Journal of Practical & Professional Nursing Category: Clinical Type: Research Article
Student Nurses Perceptions and Experiences of High Fidelity Simulation use as a Learning Strategy in a Resource Limited Setting
- Takaedza Munangatire1*, Smuts Estelle2, Ernstzen Dawn2
- 1 Paray School Of Nursing, Thaba-Tseka, Lesotho
- 2 Faculty Of Medicine And Health Sciences, Stellenbosch University, Cape Town, South Africa
*Corresponding Author:Takaedza Munangatire
Paray School Of Nursing, Thaba-Tseka, Lesotho
Received Date: Apr 25, 2018 Accepted Date: Jun 12, 2019 Published Date: Jun 19, 2019
High Fidelity Simulation (HFS) is relatively new in sub-Saharan Africa. A number of nursing colleges across a number of countries have been supported to establish HFS laboratories by the Columbia University through the Nursing Education Partnership Initiative (NEPI). The introduction of HFS is raising questions about its suitability and acceptability considering its complex technology.
The aim of this study is to explore the diploma in nursing students' perceptions and experiences of using high-fidelity simulation as a learning strategy in a resource limited setting.
The study used a qualitative descriptive design to describe nursing students’ perceptions and experiences. A purposively selected sample of sixteen students participated in three focus group discussions. Data were analysed thematically.
Five themes emerged from the data which showed that students had both positive and negative experiences of using HFS as a learning strategy. These themes were authenticity, unique learning opportunities, and accessibility, training and transfer skills.
HFS simulation can be an effective learning strategy if it is better organised, educators and students are trained and best practice guidelines on simulation use are implemented.
Existing evidence on the effectiveness of HFS in developing competence among students is currently being challenged. The argument is that existing studies and lack robustness and valid methods to conclude that there is real improvement in students' competence. Several authors contend that the improvement in competence attributed to HFS has not been extrapolated to prove any improvement in patient health outcomes [12-15]. A study by the National Council of State Boards of Nursing (NCSBN) showed that replacing clinical hours with HFS yielded similar results as traditional methods of learning . With this debate around the value of HFS, as a learning strategy, it is important for the resource limited sub-Saharan Africa to generate as much evidence to inform best practices and effective use of HFS.
According to Burch, HFS is expensive to set up and sustain in general for any institution globally . Making an example of Africa, Burch highlighted that South Africa the second largest economy and richest country in Africa took over ten years to put simulation facilities in place . Simulation in this case referred to simulation in general and not specifically HFS which is the most expensive. However since HFS has been set up in many institutions globally including a significant number of countries in the sub-Saharan Africa, research has moved on to look at the cost effectiveness of HFS rather than debate its cost in isolation . Lavoie and Clarke suggested that investing in high end simulation has no supporting evidence on its effectiveness and it’s possible that cheaper forms of simulation could be more effective . This claim is supported by a study by Lapkin and Levett?Jones which suggested that the low cost medium fidelity simulation yielded the same results as compared to high cost HFS . Evidence on effectiveness of HFS remains contentious and requiring further enquiry . Nevertheless such high level studies were not appropriate in this study setting as HFS had just been introduced and other issues like reaction to HFS and utilisation practices needed to be examined first. According to Cant and Cooper the true value of simulation can only be judged if best practice guidelines are applied . So it was the purpose of this study.
REACTION TO HFS USE
While there is abundant literature on the reaction to HFS, such literature is mainly outside Africa. There is dearth of literature on HFS in Africa which should be expected given that HFS is new in this context. HFS is a technology driven teaching strategy, and challenges with implementation are common given that nurse educators face a number of obstacles when introducing new teaching strategies . Therefore the success of using HFS in resource limited setting largely depends on proper planning and utilisation that is responsive to the challenges and opportunities presented by HFS as a an educational strategy. In addition, many studies did not consider and examining how students who are at the point of graduation perceive HFS as an educational strategy. In terms of learning, students at the point of graduation are in transition to professional nursing and they tend to perceive and experience learning differently from other students . In a meta- analysis of studies on HFS it was found that studies which involved senior students and professional nurses produced the greatest effect in evaluation studies .
According to Kirkpatrick’s model, training can be evaluated at four levels namely; reaction, learning, transfer and results. The first level was the focus of this study looking at how students perceived and experienced HFS as a learning strategy. The other levels of evaluation could not be applied in this setting because no evaluations at level one have been done before.
Second level evaluates actual learning by measuring improvement in level of competence, third level examines the extent to which competence is applied in real life situations and level four looks at the impact brought about by the improved competence level in terms of better patient health care outcomes. Looking at level one in this study was important because valid results on the effectiveness of HFS depends on best use, and studies at level one can shape and improve HFS use in learning.
Coming to the simulation model by Jeffries, it has five key components; best educational practices, student factors, educator factors, simulation design features and learning outcomes. Education practices focus on the process of teaching and learning like student-educator relationship, active learning, accommodating different learning style and feedback. The teacher and educator factors imply that the educator should facilitate learning and evaluate it while the student factors pertain to roles of being both an observer and participant in the learning activities. Simulation design feature should align to the above factors as well as promote the attainment of the learning outcomes and allow for effective debriefing. Ultimately the learning outcomes like increase in competence level and student satisfaction with the learning process should be measured against the learning objectives set at the beginning.
Putting the framework into context of this study, students are key participants in the learning process using HFS. The role they play in the learning process strongly depends on the teacher’s actions, educational practice and simulation design. This interaction yields the learning outcomes which can be viewed at four levels that correspond to Kirkpatrick’s levels of evaluation; reactions, learning, transfer and results. The purpose of HFS is to improve students learning experiences, their learning outcomes, ability to transfer learning into actual practice and ultimately improving patient care outcomes. Studies to evaluate HFS as an educational strategy have done so at these different levels even though most of them did not explicitly state that. The evidence has shown that the results on the effectiveness of HFS simulation are mixed because best practices are not constant. It becomes an important point of departure to always start evaluation of HFS at the reaction level because this can help improve the HFS utilisation making subsequent evaluations more valid and reliable. Therefore this study aimed to evaluate HFS use in a resource limited setting at level one of Kirkpatrick’s model looking at students factors related to how they perceived and experienced HFS. The students’ perceptions and experiences depict their reaction to HFS use in their learning .
In summary this study fits into the important tenets of qualitative descriptive design which are; inductive process, subjectivity, descriptive and enhance understanding of phenomenon, researcher as an active participant, groundedness in the data and naturalistic . Firstly, the study of students’ perceptions and experiences is inductive in nature since it gives more information on HFS as experienced by the participants. Secondly, perceptions and experiences are subjective and the interpretations of the researcher are also subjective. Thirdly, HFS being a new phenomenon in the study setting, the perceptions and experiences of the students helped to describe and enhance understanding of HFS as a learning strategy. Fourthly, the researcher was an active participant in the study, getting involved in designing the study, collecting data directly from participants and seeking their feedback on interpretations of the data. In addition the starting point of the data analysis was the point of view of the participants with some subjectivity applied by the interpretations of the researcher. Lastly, the study was carried out in the participants’ natural setting with data being collected in simulation rooms, after HFS activities.
There are several studies on HFS simulation and simulation in general that have applied the qualitative descriptive design. Adamson and Anderson et al., used a qualitative descriptive approach in their studies on faculty experiences of barriers and facilitators of using simulation and acquisition of simulation skills respectively . Janson et al., also applied the qualitative descriptive approach when investigating the faculty members’perceptions on barriers in using simulation . Similarly, Kaddoura et al., used the approach in exploring the undergraduate students’ perceptions on the benefits and challenges of using HFS . Consequently application of the qualitative descriptive approach in this study was justifiable and grounded in the literature.
In terms of the sample size, it was not the number of participants that mattered most but the number of focus group discussions that were required and feasible to reach data saturation. Data saturation is the point in the data collection where the participants are no longer sharing any new information compared to the already available data . Only three focus group discussions were possible, but the analysis of the data showed that acceptable saturation was reached as similar issues appeared in all the focus group discussions. Although an extra focus group would have strengthened the data saturation, it was going to require a group of students that were not exposed to HFS for any significant period of time.
Data collection procedures
‘And the way we handle Susie (name of the high fidelity simulator) is just the way you can handle a real patient or human. [P1-FGD]
For the students, performing as if they were in the clinical areas was a motivator for them to learn. The realism of HFS created positive learning experiences for students that helped them to improve their knowledge, understanding, practical skills and confidence.
“It is helping us because we can build confidence” [P1-FGD3]
“With Susie it’s like a human being and you are motivated to practice and this is how it improves our competence” [P-4; FGD2]
On the other hand, few students were scared off by the high level of realism in HFS. This created feelings of fear and anxiety compromising students learning. Students either failed to recognise the responses by the high fidelity simulators because of fear or some were frightened by the response hence failed to act appropriately.
“Sometimes we are panicking because we think it’s a real patient…” [P6-FGD2]
“Sometimes I am scared of Susie… [P7-FGD1]
Fear expressed by students can be expected in students who lacked exposure to complex technology.
Unique learning opportunity
“That was a satisfying experience because I could make mistakes and see where I needed to improve”. [P5-FGD3]
In addition majority of the students described how the high fidelity simulators could be manipulated to mimic many real clinical situations as a result allowed them to expand their set of skills. Skills such as critical thinking, problem solving and practical skills are generally difficult to learn in real clinical practice without risks but it’s possible to learn such skills with HFS.
“Susie can be manipulated to any condition we have to manage so it gives us more skills”. [P3-FGD 3]
Access to HFS
“With Susie we have little access on her” [P4-FGD 1]
“We were given the rules and I find them much more complicated than when we were using the old demonstration room with the other simulators”. [P6-FGD2]
Secondly, not all students appreciated or perceived supervision by the educators as good. The students felt that the continuous presence of educators compromised their opportunity to learn experientially and self-directed learning. Presence of the educators although required and rated as good was not always accepted by students.
“Sometimes we think we should do it alone without the presence of supervisors although their presence is helpful “. [P4-FGD3]
“It affects our learning negatively because we don’t have access to practice… [P5- FGD1].
“I wish we can be taught how to manipulate Susie” [P7-FGD1]
“Our educators some of them do not know how to manipulate Susie because sometimes they have to wait for that one”. [P1-FGD3]
HFS was being used for the first time at the college so it’s not surprising that both students and educators struggled to use it in teaching and learning. This lack of training could be another explanation of why there was excessive restriction on the high fidelity simulators.
Transfer of learning
“I think it is more important to practice on real patients than on Susie because the challenges you can meet with a real patient differ from challenges you can from Susie”. [P5-FGD3]
“Susie, I can see her veins are visible, but when I get to the real patient, sometimes I struggle”. [P4-FGD1]
Only a few students reported a different experience with regard to transfer of learning. These students reported finding it easy in real practice to apply skills learnt through HFS. Such a positive experiences need further investigation because they offer hope for better use of HFS in learning and possibly better health care outcomes.
“The procedures we have practiced on Susie, we found it better when practicing on real patients”. [P4-FGD-3].
In summary, this study revealed that nursing students perceived and experienced HFS a useful learning strategy that made learning of nursing skills realistic in a safer learning environment as well as learning certain unique skills that are not possible to learn in real practice. The perceptions and experiences of students also suggested that the effectiveness of HFS use as a learning strategy was affected by limited access and lack of competence in using HFS as a teaching and learning strategy among both students and educators.
This study indicated that through HFS simulation students could experience learning in an environment where mistakes were considered as part of learning. This finding supports the studies of Johannesson et al., and Au et al., who reported that HFS allowed deliberate practice and making mistakes without fear of harming patients [1,44]. Similarly Sears et al., found that HFS is a safe environment for students to practice . However the making of mistakes made possible by using HFS could be a draw back because students can develop a bad attitude of making mistakes and carry it over to real practice .
An interesting finding of this study was students’ perceived restricted access to HFS which students considered as limiting to their learning. Lack of trust and fear that students could damage the high fidelity simulators can explain why the educators closely guarded the simulators but in the process compromising learning. The issue of cost of HFS cannot be ruled out as the other driving force to provide extra care to HFS although this has not been discussed in any available literature. One student even highlighted;
“May be Susie is too expensive”. [P1-FGD2]
Another issue raised in this study was how continuous presence of educators in HFS sessions affected the students’ learning. Evidence related to these findings by other researchers showed that issues of being watched either directly or through cameras in HFS caused anxiety and feeling of being overwhelmed [39,46,47].
Findings of this study revealed that low level of skills in using HFS among students and educators negatively affected students’ experiences of learning using HFS. These findings are congruent with evidenced which showed that the technology in HFS is challenging . When used by educators without getting sufficient training as is in a number of cases students learning experiences were not good and their perceptions of HFS were negative [48,49]. The evidence from this study further supports the report by Al-Ghareeb and Cooper which indicated that training and support is required when working with HFS . Students in this study had no training or prior experience of using HFS as a learning strategy, therefore the students had to learn how to trying to learn clinical skills.
The nursing students’ perceptions and experiences on the transfer of learning into the clinical area confirmed the existing evidence which showed a mixed reaction. Some students could practice competently on high fidelity simulators but encountered difficulties in doing the same skills on real patients. This confirms the findings of Welman and Spies who found that students felt they could not be as proficient in using skills gained in simulation in real practice . Transfer of learning remains a major issue in the use of HFS with no valid evidence to support that skills gained in simulation can be easily transferred to the real world and result in improvement in quality of health care [14,15]. In addition the failure to transfer skills can be explained by the lack of best practice guide and the lack of skills among educators in using HFS as experienced by students in this study. On the other hand, the other group of students were of the perception that learning through HFS helped them to have a better clinical experience and were able to transfer their skills into the real practice. This supports some evidence which suggested that HFS learning improves application of skills in practice and improves clinical competence [22,24,39].
Overally, the students’ perceptions and experiences of using HFS as a learning strategy were mixed. HFS was viewed positively because of its ability to closely mimic real clinical situations, provided opportunities for deliberate practice and making mistakes as well as improving students’ skills. On the other hand, lack of understanding of HFS use, restrictions in its use and failure to transfer skills into real practice created negative perceptions and experiences of HFS as a learning strategy. By maximising the positives brought about by HFS and eliminating the negatives there is a good chance HFS will be an effective learning strategy in resource limited settings.
Based on these findings it can be suggested that orientation and training should be provided to students and educators on how to use HFS before using it in teaching and learning. It should be accepted that current educators may have not experienced HFS as students and in their training to be educators, and some students in resource limited settings have limited access to technology. Therefore, the technology of HFS if it is new to both the educators and students, proper training will help to improve the use of HFS.
The cost of HFS is high and it is expected that proper care and use is taken to protect the simulators from improper use and possible damage. Strict rules and regulations while necessary, they should not instil fear in students and compromise accessibility of HFS to students. Doing so will be defeating some of the purposes of HFS as a learning strategy which is to promote self-directed learning and allow deliberate practice. It is proposed that models on simulation use can be adapted to ensure best practice guidelines on simulation are used and at the same time the high fidelity simulators are protected. In some settings there are dedicated technicians who operate and guide users of HFS, availability of such will allow students to access to HFS at their own time and recreate clinical scenarios and help them learn better.
- Au ML, Sao Lo M, Cheong W, Wang SC, Van IK (2016) Nursing students' perception of high-fidelity simulation activity instead of clinical placement: A qualitative study. Nurse Educ Today39: 16-21.
- Duphily NH (2014) Simulation education: A primer for professionalism. Teaching and learning in nursing9: 126-129.
- Welman AM, Spies C (2016) High fidelity simulation in nursing education: considerations for meaningful learning. Trends in Nursing 3: 42.
- Middleton L, Howard AA, Dohrn J, Von Zinkernagel D, Hopson DP, et al. (2014) The Nursing Education Partnership Initiative (NEPI): innovations in nursing and midwifery education. Academic Medicine 89: 24-28.
- van Vuuren VJ, Goon DT, Seekoe E (2018) The perceptions of nurse educators regarding the use of high fidelity simulation in nursing education. Africa Journal of Nursing and Midwifery20: 1-20.
- Al-Ghareeb AZ, Cooper SJ (2016) Barriers and enablers to the use of high-fidelity patient simulation manikins in nurse education: an integrative review. Nurse Educ Today36: 281-286.
- Bussard ME (2015) High-Fidelity Simulation to Teach Accountability to Prelicensure Nursing Students. Clinical Simulation in Nursing11: 425-430.
- Shearer JE (2013) High-fidelity simulation and safety: An integrative review. Journal of Nursing Education 52: 39-45.
- Munangatire T, Naidoo N (2017) Exploration of high-fidelity simulation: Nurse educators’ perceptions and experiences at a school of nursing in a resource-limited setting. African Journal of Health Professions Education 9: 44-47.
- Chapelain P, Morineau T, Gautier C (2015) Effects of communication on the performance of nursing students during the simulation of an emergency situation. J Adv Nurs 71: 2650-2660.
- La Cerra C, Dante A, Caponnetto V, Franconi I, Gaxhja E, et al. (2019) Effects of high-fidelity simulation based on life-threatening clinical condition scenarios on learning outcomes of undergraduate and postgraduate nursing students: a systematic review and meta-analysis. BMJ open 9: 025306.
- Doolen J, Mariani B, Atz T, Horsley TL, O'Rourke J, et al. (2016) High-fidelity simulation in undergraduate nursing education: A review of simulation reviews. Clinical Simulation in Nursing12: 290-302.
- Okuda Y, Bryson EO, DeMaria Jr S, Jacobson L, Quinones J, et al. (2009) The utility of simulation in medical education: what is the evidence? Mt Sinai J Med 76: 330-343.
- Burch V (2014) Does simulation-based training have a future in Africa? African Journal of Health Professions Education6: 117-118.
- Kunst EL, Henderson A, Johnston AN (2018). A scoping review of the use and contribution of simulation in Australian undergraduate nurse education. Clinical Simulation in Nursing 19: 17-29.
- Hayden JK, Smiley RA, Alexander M, Kardong-Edgren S, Jeffries PR (2014) The NCSBN national simulation study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation 5: 3-40.
- Lavoie P, Clarke SP (2017) Simulation in nursing education. Nursing management 48: 16-17.
- Lapkin S, Levett?Jones T (2011) A cost–utility analysis of medium vs. high?fidelity human patient simulation manikins in nursing education. J clin nurs 20: 3543-3552.
- Cant RP, Cooper SJ (2010) Simulation?based learning in nurse education: systematic review. J Adv Nurs 66: 3-15.
- Shin S, Park JH, Kim JH (2015) Effectiveness of patient simulation in nursing education: meta-analysis. Nurse Educ Today 35: 176-182.
- Silvia S (2013) Faculty perceptions of simulation on student learning for safe clinical nursing practice (Doctoral dissertation) Available from ProQuest Dissertations and Theses.
- Mills J, West C, Langtree T, Usher K, Henry R (2014) ‘Putting it together’: Unfolding case studies and high-fidelity simulation in the first-year of an undergraduate nursing curriculum. Nurse Educ Pract 14: 12-17.
- Tawalbeh L, Tubaishat A (2014) Effect of simulation on knowledge of advanced cardiac life support, knowledge retention, and confidence of nursing students in Jordan. J Nurs Educ 53: 38-44.
- Bultas MW, Hassler M, Ercole PM, Rea G (2014) Effectiveness of high-fidelity simulation for pediatric staff nurse education. Pediatr Nurs40: 27-32.
- Benner P, Sutphen M, Leonard V, Day L, Shulman LS, et al. (2010) Educating Nurses: A Call for Radical Transformation. John Wiley & Sons, USA, Pg no: 288.
- Jeffries PR (2005) A framework for designing, implementing, and evaluating: Simulations used as teaching strategies in nursing. Nurs Educ Perspect 26: 96-103.
- Kirkpatrick DL, Kirkpatrick JD (2006) Evaluating training programs: the four levels. Berrett-Koehler Publishers, Inc. USA.
- Samawi Z, Miller T, Haras MS (2014) Using high-fidelity simulation and concept mapping to cultivate self-confidence in nursing students. Nursing Education Perspectives 35: 408-409.
- Adamson K (2015) A Systematic Review of the Literature Related to the NLN/Jeffries Simulation Framework. Nurs Educ Perspect 36: 281-291.
- Kirkpatrick DL, Kirkpatrick JD (1998) Evaluating training programs: the four levels. Berrett.
- Polit DF, Beck CT (2014) Essentials of nursing research: Appraising evidence fornursing practice. Wolters Kluwer Health, USA.
- Neergaard MA, Olesen F, Andersen RS, Sondergaard J (2009) Qualitative description-the poor cousin of health research?. BMC Med Res Methodol 9: 52.
- Sandelowski M (2000) Whatever happened to qualitative description?. Res Nurs Health 23: 334-340.
- Sandelowski M (2010). What’s in a name? Qualitative description revisited. Res Nurs Health 33: 77-84.
- Doody O, Bailey M E (2016) Setting a research question, aim and objective. Nurse Res 23: 19-23.
- Bradshaw C, Atkinson S, Doody O (2017) Employing a Qualitative Description Approach in Health Care Research. Glob Qual Nurs Res4.
- Adamson K (2010) Integrating Human Patient Simulation into Associate Degree Nursing Curricula: Faculty Experiences, Barriers, and Facilitators. Clinical Simulation in Nursing6: 75-81.
- Jansson M, Kääriäinen M, Kyngäs H (2013) Effectiveness of simulation-based education in critical care nurses’ continuing education: A systematic review. Clinical Simulation in Nursing, 9: 355-360.
- Kaddoura M, Vandyke O, Smallwood C, Gonzalez KM (2016) Perceived benefits and challenges of repeated exposure to high fidelity simulation experiences of first degree accelerated bachelor nursing students. Nurse Educ Today 36: 298-303.
- Onwuegbuzie AJ, Dickinson WB, Leech NL, Zoran AG (2009) A qualitative framework for collecting and analyzing data in focus group research. International Journal of Qualitative Methods, 8: 1-21.
- Kitzinger J (2005) Focus group research: using group dynamics. Qualitative Research in Health Care 56: 70.
- Arthur C, Levett-Jones T, Kable A (2013) Quality indicators for the design and implementation of simulation experiences: a Delphi study. Nurse Educ Today 33: 1357-1361.
- Lucas AN (2014) Promoting continuing competence and confidence in nurses through high-fidelity simulation-based learning. J Contin Educ Nurs 45: 360-365.
- Johannesson E, Silén C, Kvist J, Hult H (2013) Students’ experiences of learning manual clinical skills through simulation. Adv Health Sci Educ Theory Pract 18: 99-114.
- Sears K, Goldsworthy S, Goodman WM. (2010) The relationship between simulation in nursing education and medication safety. J Nurs Educ 49: 52-55.
- Gantt LT (2013) The effect of preparation on anxiety and performance in summative simulations. Clinical Simulation in Nursing 9: 25-33.
- Willhaus J, Averette M, Gates M, Jackson J, Windnagel S (2014) Proactive policy planning for unexpected student distress during simulation. Nurse Educ 39: 232-235.
- Davis AH, Kimble LP, Gunby SS (2014) Nursing faculty use of high-fidelity human patient simulation in undergraduate nursing education: A mixed-methods study. J Nurs Educ 53: 142-150.
- Dowie I, Phillips C (2011) Supporting the lecturer to deliver high-fidelity simulation. Nurs Stand 25: 35-40.
Citation: Takaedza M, Estelle S, Dawn E (2019) Student Nurses Perceptions and Experiences of High Fidelity Simulation use as a Learning Strategy in a Resource Limited Setting. J Pract Prof Nurs 3: 011.
Copyright: © 2019 Takaedza Munangatire, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.