High Fidelity Simulation Paper

Simulation To Be or Not To Be and To What Degree That is The Question

This paper will look at the subject of high-fidelity simulation and to what degree it should or should not replace traditional clinical experiences. The current position of the state board of nursing will be queried and the literature will be reviewed for the advantages and disadvantages to students, patients, and schools for utilizing simulations. Finally, a recommendation will be given by this author, based on findings, as to what degree / percentage, clinical hours can or should be replaced with high-fidelity simulation hours.

State of Illinois Board of Nursing Regulations

The State of Illinois participated in a national summit on nursing education and TEAM ILLINOIS

developed a plan to expand the opportunity for clinical simulation (IDFPR/IL Center for Nursing, 2008). Illinois also participated in the NCSBN to determine what appropriate percentage of lab time should be used in high-fidelity simulations. I have visited the Illinois State Board of Nursing and several other sites to determine the allowable percentage of clinical time in nursing programs that can be replaced with high-fidelity simulation practice and scenarios. Unfortunately, I have not been able to find this information, so for my reference, I will go with the 10-25 % general consensus figures from the past as provided by Instructor Myers (personal communication, November 4, 2014).
How Replacing Clinical Hours with Simulation Hours Impact Patient Care
When students are allowed the opportunity to practice skills on high-fidelity mannequins they do so in an environment that is safe and controlled, with no risks for real patients. The advantage to patients is that students can practice a skill over and over again until they have achieved mastery before moving on to a live patient. Albert Bandura’s theory on self-efficacy states that self-efficacy builds from mastery experience and individuals who can practice a skill repetitively build self-efficacy or confidence (Crocetti, 2014; Hayden, Alexander, Jeffries, 2014; Hicks, Coke, & Li, 2009). A study by Hicks, Coke and Li (2009) involved students who were divided into two groups with one having clinical experiences only and the other having both clinical and simulation experiences: a statistically significant increase in the self-confidence was found in the clinical/simulation group with no change found in the group that only had clinical experience. Another study by Hicks, Coke and Li (2009) using the same group division of clinical only and clinical/simulation indicated significantly higher scores in safety and basic assessment skills in the clinical/simulation group. Another advantage to patients when it comes to high-fidelity simulations is in high-risk critical clinical situations that typically cannot be practiced by students in clinicals, such as pediatric cardiopulmonary arrest which involves respiratory management, defibrillation and cardioversion, intraosseous access and fluid bolus administration and effective team dynamics, communication, and decision making (Birkhoff & Donner, 2010). Basic assessments can be practiced and performed on live patients without adverse effects, but in a cardiac arrest timing is critical for the best patient outcomes. High-fidelity simulations can be used to practice these types of events repeatedly until students fell confident to step into a real-life situation. Patients benefit by having confident students practice on them rather that students who lack confidence and are unsure of themselves.
Learning Needs of Students and High-Fidelity Simulations
In 2009, the Boards of Nursing raised concerns about the availability and quality of clinical sites, and the amount of time nursing students were spending observing skills rather than providing patient care (Hayden, Alexander, & Jeffries, 2014).

Back when I attended a local community college for my ADN degree, there were only sixteen of us in my class. Even with having two local hospitals and several long-term care facilities for clinicals, not every student in my class was able to insert a Foley catheter in a real patient. Simulations allow for opportunities to repeatedly practice a skill such as Foley catheter insertion without endangering a real patient. It also allows the student to become proficient and develop self-confidence (Hicks, Coke, & Li, 2009). High-fidelity mannequins can be programmed with numerous case scenarios and the situation can be changed based on the student’s actions which forces the student to anticipate potential problems (Hicks, Coke, & Li, 2009). In a simulation setting, a teacher can intervene, make corrections, and give explanations to the student while they are attempting a skill without creating an awkward scene in front of a live patient or creating doubt in the patient’s mind about the quality of the school’s students, graduates, and future

nurses.
High-Fidelity Simulation in Place of Clinical Hours
So what can a high-fidelity mannequin do? According to Smith (2011) he can “cry, sweat, bleed, blink his eyes, foam at the mouth, vomit, moan and groan, make lifelike breath and abdominal sounds, and pee.” (p.1). Everything can be programmed and operated by the instructor without being in the room and the instructor can even tell what medications are given and if CPR is performed correctly. The best part of using high-fidelity mannequins, according to Smith (2011) is that when a student kills the mannequin, they can sit down, discuss what went wrong and try it again. Mistakes made in simulations can be turned into learning opportunities.
In a normal clinical environment, students practice skills on real patients under the careful watch of their instructors after receiving classroom instruction, watching videos and practicing in the lab. The Boards of Nursing have expressed concerns about the number and quality of clinical sites available for students in addition to patient safety initiatives, liability and HIPPA concerns institutions have that restrict student access to medical records and their activity and numbers on patient unis (Hayden, Alexander, & Jeffries, 2014).
The study done by Hayden, Alexander and Jeffries (2014) gave substantial evidence that high-quality simulation substituted for up to half of traditional clinical hours produces graduates ready to practice who have met end-of-program educational outcomes. Haden, Alexander and Jeffries (2014) acknowledged a study by Lapkin et al. that demonstrated improvement in knowledge, critical thinking, and the ability to recognize when a patient is deteriorating. Simulations can provide numerous opportunities to practice case scenarios in the lab that students will never get to experience in a clinical setting and there is the advantage of instructors modifying the experiences to add in “what if” scenarios, such as changing cardiac rhythms and lung sounds to further students’ opportunities to experience and work through problems they may encounter in real life (Birkhoff & Donner, 2010).
Position on Using High-Fidelity Simulation in Place of Clinical Hours
Clear advantages to using high-fidelity simulation have been discussed: mainly the ability to practice with no risk of harm to living patients; the opportunity to practice repeatedly until a skill is mastered; and the ability to work through various scenarios as a team. The disadvantages and reasons why students still need to experience actual clinical time are that of equipment, environmental, and psychological fidelity; negative transfer, which can occur when instructors fail to explain the differences between the mannequin and real patients; and that certain assessments cannot be experienced using a simulator (Hicks, Coke, & Li, 2009). Schools can make great attempts to make simulation mannequins life-like by dressing them in gowns, putting on makeup and using wigs, but they are still mannequins. The environment can also be made to resemble a real hospital or exam room, but psychologically it is hard for students to think of the mannequins as real patients in a real hospital. Mannequins cannot be made to feel and react like real patients for example, a real patient may press their knees together while a catheter is being inserted so a student needs to be aware that they may also need to use their arms to keep the patient’s legs apart while handling the catheter and maintaining a sterile field.
Summary
This paper has discussed clear benefits to patients of affording students the opportunity to practice repeatedly skills on high-fidelity mannequins before practicing on real patients, mainly to allow the students to mater skills, thereby reducing errors and avoiding harm. The advantage to students run along the same lines as far as allowing them to develop self-efficacy and confidence in addition to experiencing scenarios not available in traditional clinical settings and experiencing teamwork during escalating cases. .
Based on the study by Hayden, Alexander, and Jeffries (2014) I would recommend anywhere from 10 to 50 % of clinical hours be allowed to be replaced with high-fidelity simulations due to the makeup and characteristics of each school of nursing and program of study. High-fidelity mannequins are expensive and not only may some schools not have the budget to purchase them, they may not have space available to set up labs or the faculty trained to run them. The location, size of the school and number of students competing for clinical sites to practice in are also determinants of how many hours of quality traditional clinical time can be scheduled. Each school needs to justify their curriculum, specifically their traditional clinical and high-fidelity simulation hours based on their unique needs and program level: Associate Degree Program versus Bachelor Degree Programs. A strategic plan using SWOT analysis to measure strengths, weaknesses, opportunities, and threats should be used to develop a plan which can be revised on a yearly or semi-yearly basis to evaluate the progression towards their specified goals (Gantt, 2010). The ultimate goal of which is to provide learning opportunities to students to best prepare them to practice safely and confidently in the real world.