Zacharias Capstone final

Running head: HIGH FIDELITY SIMULATION 1

High Fidelity Simulation in Undergraduate Nursing Education:

Communication and Critical Thinking Skills

Elizabeth K. Zacharias BSN, RN

Lourdes University

IMPACT OF HIGH FIDELITY SIMULATION 2

Abstract

The problem identified in this paper is that improved techniques must be utilized to ensure that

graduate nurses are able to effectively transition to nursing independently with professional

communication and critical thinking skills. When nurses feel more confident and competent in

their skills, patient care improves. Being able to communicate with all members of the healthcare

team allows a registered nurse to better advocate for their patient needs. An extensive literature

review has been performed to determine themes. The focus of this literature search was to

determine whether high-fidelity simulation improves competence and confidence in the new

graduate nurse. This information was then used to develop a curriculum tool to be presented to

baccalaureate nursing programs to improve the utilization of high fidelity simulation throughout

their programs.


High Fidelity Simulation in Undergraduate Nursing Education:

Communication and Critical Thinking Skills

Many graduate nurses have difficulty with communication and utilizing their knowledge

in the practice setting. High fidelity simulation exercises provide a more realistic approach to

nursing care and its challenges. Opportunities to use critical thinking skills, interact with the

multidisciplinary team, and develop communication with physicians are all able to be explored

with high fidelity simulation (Richardson and Claman, 2014). It is believed that extensive

immersion in this learning technique will allow for better transition to independent nursing

practice.

High-fidelity simulation is the use of mannequins and equipment within a controlled

educational practice environment. High-Fidelity Simulation is supported by the Cognitive

Learning Theory: Assimilation Theory. This theory states that students make experiences fit

what they already know and develop that “Aha Moment.” Students have more control over what

occurs in these simulations and learn from their decisions (Candela, 2012; Bradshaw, 2014; and

Braungart, Braungart, and Gramet, 2014). Fidelity refers to how close to reality a simulation is.

High-Fidelity simulation refers to simulations that are extremely realistic and contain a high

level of interactivity and realism (Jeffries and Clochesy, 2012). Some strengths of Mid to High-

Fidelity Simulation are active involvement of students, effectiveness as a competency check,

correction of errors can be discussed immediately, and it creates a standardized experience for all

students (Jeffries and Clochesy, 2012). Some limitations of Mid to High-Fidelity Simulation

include the time commitment of faculty, the need for faculty to design all aspects of simulation,

the time to experience the simulation and reflect, faculty orientation to equipment, and expense

for the facility (Jeffries and Clochesy, 2012). The mannequins are able to ‘speak’, simulate vital


signs and disease processes. Students are able to perform skills, work on communication with

each other and the patient, and learn confidence in their skills.

Problem Statement and Research Question

The problem identified is that improved techniques must be utilized to ensure that

graduate nurses are able to effectively transition to nursing independently with professional

communication and critical thinking skills. This problem specifically relates to new graduate

nurses in the acute care setting. Graduating nurses that are better prepared for the challenges of

the acute care setting will allow them to transition easier to independent, competent, and

confident care. Learning to communicate well with colleagues, whether physicians, fellow

nurses, or support therapies will improve patient satisfaction and care. The use of high fidelity

simulation has been shown to increase student’s confidence, technical skills and their ability to

reflect on their experience (Negrão Baptista, Amado Martins, Carneiro Ribeiro Pereira, and

Mazzo, 2014). The research question pertaining to this problem is, “Does the use of high fidelity

simulation improve nursing communication and critical thinking skills for the graduate nurse in

the acute care setting?”

Significance to Nursing Practice

When nurses feel more confident and competent in their skills, patient care improves.

Being able to communicate with all members of the healthcare team allows a registered nurse to

better advocate for their patient needs. The ability to practice scenarios in the safety of high

fidelity simulation allows for improvement of skills and allows room for errors to improve the

learning experience. Reflection following simulation is a great technique to foster improvement.


Literature Review

Communication and critical thinking are essential to the development of the professional

nurse. With increased acuity of patients, the nurse is required to have a firm grasp of this skill in

order to effectively care for his/her patient (Grant, Dawkins, Molhook, Keltner, and Vance,

2014). Critical thinking is a vital component of nursing education and should be incorporated

throughout the curriculum (Smith and Roehrs, 2009; Kaddoura, 2010; Smithburger, Kane-Gill,

Kloet, Lohr, and Seybert, 2013). Use of this simulation experience provides a safe learning

environment for students to improve their skills (Kaddoura, 2010).

Good communication is necessary to work with patients, families, and the

multidisciplinary team. Lack of communication greatly influences employee morale, turnover,

and employee satisfaction, which can effect patient care (Di Delupis, Pisanelli, Di Luccio,

Kennedy, Tellini, Nenci, Guerrini, Pini, and Gensini, 2014; Holtschneider, 2007). Experience

with development of this skill is important in nursing curricula (Kameg, Clochesy, Mitchell, and

Suresky, 2010). The use of high-fidelity simulation aids in assessment of skills, improves

communication, and improves patient care (Kaddoura, 2010).

Debriefing following simulations allows students and educators to evaluate performance

and improve skills (Kaddoura, 2010). Facilitating this discussion is a primary role for nurse

educators (Holtschneider, 2007). While best debriefing practices are being assessed, the use of

high-fidelity simulation with debriefing has proven to increase patient safety, improve

assessment skills, develop critical thinking skills, and improve communication among the team

members (Smith and Roehrs, 2009; Grant et al., 2014; Kaddoura, 2010). Blum, Borglund, and

Parcells performed a study comparing students within a traditional learning environment versus

students using high-fidelity simulation in their education (2010). Their study determined that


there was no statistical significance in self-confidence scores between these two groups (Blum et

al., 2010). It was decided that further development of the simulation experiences required repeat

evaluation.

Kaddoura performed a literature review, as well as a study, to determine how new nurses

perceived their simulation experiences after a new training program was developed. He primarily

focused on their critical thinking skills and confidence in their new practice setting (Kaddoura,

2010). Interviews of these nurses were completed and the qualitative data revealed three main

themes. The realistic patients allowed the nurses to narrow their theory to practice gap

(Kaddoura, 2010). The new graduate nurses also reported feeling they improved their critical

thinking skills and communication skills, both during the simulation and with reflection during

debriefing (Kaddoura, 2010). The third theme that surfaced was the feeling of safety in the

simulation environment. The nurses felt they were able to improve their confidence level when

they knew they were performing in a safe environment (Kaddoura, 2010).

Kameg, et al., studied how high-fidelity simulation enhanced student self-efficacy of

communication skills. Following simulation experiences, it was determined that their perceptions

of improved skills were significant (Kameg et al., 2010). The students reported increased

understanding of nursing concepts, improved critical thinking skills, narrower theory to practice

gap, and improved confidence (Kameg et al., 2010).

Smithburger, et al., developed a multidisciplinary team approach to high-fidelity

simulation. Following a series of scenarios, the pharmacy, medical, nursing, social work, and

physician assistant students were given a survey to evaluate how high-fidelity simulation

improved team communication (Smithburger et al., 2013). The students reported improved


communication and increased confidence, as well as an interest in interprofessional

communication (Smithburger et al., 2013).

Theoretical Framework

The focus of this research is to determine whether high-fidelity simulation improves

competence and confidence in the new graduate nurse. Benner’s model of Novice to Expert

(1984) fits well with this topic. As educators, it is important that our teaching guides students

through the novice to expert stages while utilizing various teaching methods. Benner’s model

separates into five levels of competency. The first level is the novice nurse, who concentrates on

concrete information, such as vital signs and weight (Waldner and Olson, 2007). This level does

not focus on any outside information. The second level is the advanced beginner, who is able to

recognize that these vital signs are related to a disease process. The third level is the competent

nurse. This nurse is able to recognize symptom management in the long term care of the patient.

This nurse feels a sense of responsibility to the patient (Waldner & Olson, 2007). The fourth

level is proficiency, where this nurse is able to notice changes in the patient condition and

determines her actions based on that decline. Lastly, the expert level is where a nurse has

developed an intuition that allows him/her to perform at a more efficient level than the previous.

This nurse has extensive knowledge and experience to assess situations (Waldner & Olson,

2007).

It has been discussed that the new graduate nurse should perform, at minimum, in the

advanced beginner role. Performance at the competent level is preferred (Waldner & Olson,

2007). The use of simulation in nursing programs is useful in advancing through these levels

(Waldner & Olson, 2007). Novice nurses are able to enhance their clinical skills using

simulation. The ability to debrief will allow these students to see the bigger picture to make


connections with their classroom learning. The challenge to the novice and advanced beginner’s

confidence allows them to grow and improve their critical thinking skills (Waldner & Olson,

2007). More complex simulations can be created as a student reaches competence. Pushing them

out of their comfort zone allows them to expand their knowledge and requires them to adapt their

care (Waldner & Olson, 2007).

Project Design

The aim of this research was to determine the relationship between clinical simulation

and communication, confidence and competence. An extensive literature review was performed

to determine themes. This information was utilized to formulate an outline for nursing curricula

that incorporates simulation. A recommendation will be made to baccalaureate nursing programs

in order to improve simulation experiences and effectiveness. Future research will hopefully

implement and evaluate this analysis for improvement.

A systematic literature search was performed using the Academic Search Complete,

CINAHL Plus with Full Text, Health Source: Nursing/Academic Edition, MEDLINE with Full

Text databases and ProQuest Nursing & Allied Health Source databases. The searches performed

used the search terms: simulation, high fidelity, confidence, competence, communication,

undergraduate, nursing, novice, multidisciplinary, interdisciplinary, graduate, and nurse.

The search was narrowed to articles that were peer-reviewed and used evidence based

practice, including the dates of January of 2005 through November of 2015. A total of 32 articles

reviewed, with 21 being utilized to reach saturation on the topic. Quality of the search articles

was evaluated using a hierarchy. Studies were scored as high, medium, and low quality with low

quality articles being omitted. The Critical Appraisal Skills Programme (CASP) tool for

Systematic Reviews, CASP tool for qualitative articles, and CASP tool for Cohort Studies were


used to evaluate the articles for quality ratings. The research focused on communication and

confidence related to high fidelity simulation versus skills. Articles that focused on skill-based

evaluation were excluded.

Themes

Safe Learning Environment

Four main themes were discovered while evaluating the research materials. The first

theme was that simulation can be used to provide a safe learning environment. This allows

students the freedom to practice their skills and use critical thinking in a controlled environment

(Candela, 2012; Bradshaw, 2014). These students are able to practice their skills without fear of

injuring a real patient. The simulations are used to guide the critical thinking of the students and

they drive the experience and outcomes. They experience a realistic acute care environment,

complete with equipment and supplies. Simulation experiences are able to be created based on

different clinical presentations, communication scenarios, or to practice delegation. It has been

shown that confidence improves greatly in this environment without fear of making mistakes

(Braungart, Braungart, & Gramet, 2014).

Employee Turnover, Morale, and Satisfaction

The second theme that emerged was the overwhelming link to employee turnover,

morale, and satisfaction. Students who experienced high fidelity simulation during their

undergraduate education were shown to feel more confident and competent in their nursing

practice (Di Delupis, Pisanelli, Di Luccio, Kennedy, Tellini, Nenci, Guerrini, Pini, & Gensini,

2014). This allowed them to feel more comfortable in their work environment and allowed them

to gain the acceptance of their coworkers. These new graduates were found to be more satisfied

at their jobs and remain in their entry nursing positions for longer periods of time (Holtschneider,


2007). This has been a known issue in our local health care system. We have new graduate

nurses that attend a nursing residency program for the 20-40 weeks, and then transfer on to

another position, or rarely leave nursing altogether. There is now a contract in place to retain

these new registered nurses for a minimum of 18 months. With the amount of money that goes

into financing these nursing residency programs, this certainly seems like an important aspect to

review.

High Fidelity Simulation with Debriefing

The third theme was the importance of debriefing following the simulation experience.

This debriefing has been proven to increase patient safety and improve assessment skills

(Kaddoura, 2010). The videotaping of the simulation allows for the students and instructors to

review the chain of events. Students are able to see the areas they performed well and are able to

correct their weaker areas. This way they are able to view their mistakes and discover their own

solutions. Simulation allows the students to improve their communication skills and develop

their critical thinking skills (Holtschneider, 2007). This experience allows the students to be

more in control of their learning while remaining in a safe learning environment. Their errors in

this learning environment will not cause harm to patients and will hopefully improve their future

patient care. The students are able to discover issues that they will be more aware of in the

future, and often seeing these mistakes is what sticks in their mind.

Interprofessional Communication Skills

The fourth theme revealed an improvement in interprofessional communication skills

(Smithburger et al., 2013). Students can role play as different members of the healthcare team in

order to improve their communication skills. This allows them to practice requesting patient

orders, updating physicians on patient condition, communicating with pharmacy staff, hand-off


reporting, etc. These communication skills were reported to be lacking from many undergraduate

nursing curricula (Smithburger et al., 2013). Working toward better communication skills will

improve patient care. It would be excellent to incorporate students from all disciplines into

simulation experiences to benefit all. Often the first time these disciplines meet is during a

critical patient situation.

Conclusion

Simulation experiences should be an essential part of the undergraduate nursing

curriculum. They are currently used to promote skill development, but are not utilized to their

full potential. Communication skills are so important in nursing practice. Teaching our students

these skills throughout nursing school will allow them to be more confident upon graduation.

The included simulation experiences are just a few examples to help incorporate communication,

critical thinking, and confidence in the learning environment.


References

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