art & science research

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Investigating the use of simulation as a teaching strategy
Shepherd CK et al (2010) Investigating the use of simulation as a teaching strategy. Nursing Standard. 24, 35, 42-48. Date of acceptance: December 11 2009.

Abstract
Aim To compare the performance of two groups of pre-registration nursing students exposed to two different methods of simulation as a teaching strategy, with the aim of providing an evidence base to assist in the selection of appropriate teaching methods, and to inform resource allocation with regard to teaching clinical skills. Method A longitudinal, comparative quasi-experimental design, including a validated and piloted assessment tool, was used to evaluate students’ performance within three domains: cognitive (knowledge and decision making), motor and affective. Students also completed self-assessments of confidence and anxiety levels. Data were statistically and thematically analysed. Results Students who had been exposed to different forms of simulated teaching, showed no significant difference in performance within the cognitive and motor domains. However, one form of simulation was more effective in enabling students’ learning in the affective domain (students’ interpersonal, communication and professional nursing skills). An unexpected finding was students’ inability to measure vital signs manually. Conclusion Simulation as a teaching strategy contributes to students’ learning. Education providers and clinicians need to recognise that overuse of automated equipment may potentially de-skill future generations of nurses.

Author
Chew Kim Shepherd, Margaret McCunnis and Lynn Brown, lecturers, School of Health, Nursing and Midwifery, and Mario Hair, lecturer, School of Science, University of the West of Scotland, Paisley. Email: kim.shepherd@uws.ac.uk

Keywords
Nursing students, patient assessment, simulation, skills These keywords are based on subject headings from the British Nursing Index. All articles are subject to external double-blind peer review and checked for plagiarism using automated software. For author and research article guidelines visit the Nursing Standard home page at www.nursing-standard.co.uk. For related articles visit our online archive and search using the keywords.

clear, comprehensive and exhaustive guidance covering the required standards of proficiency for pre-registration nursing. These standards stipulate the overarching principles necessary to practise as a nurse. The NMC’s (2005) review raised concerns regarding the variation in competence of newly qualified registered nurses in certain fundamental and essential nursing skills, for example communication, medication administration and decision making (Wilford and Doyle 2006). However, the NMC (2005) indicated that students must be fit for practice at the point of registration, and employers are asking educators to do a better job of preparing students for the real world of nursing (Jeffries 2005). Following this review (NMC 2005), support for the use of simulation as a pre-registration teaching and learning strategy has gained momentum (Prescott and Garside 2009). Simulation assists a student by consolidating his or her skills and addresses skills deficits (Wilford and Doyle 2006). Billings and Halstead (2005) defined simulation as: ‘A near representation of an actual life event; may be presented by using computer software, role-play, case studies, or games that represent realities and actively involve learners in applying the content of the lesson.’ Simulation is the promotion of understanding through ‘doing’ (Billings and Halstead 2005). In response to the concerns raised by the review, the NMC implemented a simulation and practice project, which consulted on how best to ensure competence in practice and indicated the need to look more closely at how simulation could support the development of direct care skills needed for safe and effective nursing practice. The findings of the project were positive and suggested that simulated learning achieves the following (NMC 2007): Helps students to achieve clinical learning outcomes. Provides students with learning opportunities that are not possible in a clinical setting. Increases students’ confidence in the clinical environment. NURSING STANDARD

THE NURSING AND MIDWIFERY COUNCIL (NMC) (2005) carried out a review to assess if nursing students are ‘fit to practise’ at the point of registration. This was in spite of the NMC’s (2004) 42 may 5 :: vol 24 no 35 :: 2010

more research is needed to identify the ‘hallmarks’ of good simulation (Jeffries 2006). Clinical decision making is where discriminative thinking is used to choose a specific course of action (Cioffi 1998). Jeffries 2005. to help clinicians develop new skills NURSING STANDARD as well as assess existing skills (NHS Education for Scotland 2005). The literature suggests that there is confusion and ambiguity regarding definitions of competence (Eraut 1988. Harlow and Sportsman 2007). may 5 :: vol 24 no 35 :: 2010 43 . Literature review Clinical skills laboratories are widely used to help integrate theory and practice. Critical thinking. With simulation technology. Haskvitz and Koop (2004) recognised that there was no quantitative evidence to prove that clinical simulation using manikins was more effective than alternative teaching methods. and to address problems associated with insufficient practice placements (Morgan 2006). however. The experimental group was exposed to simulation training. This study seeks to establish if simulation promotes effective learning. Many studies are subjective.Nurses of today must be critical thinkers (Nehring et al 2002. It is important. It is also recognised that higher education affects the quality of decision making and the intellectual maturity of the student (Glen 1995). the studies did not measure if learning had taken place. Mayne et al 2004). Ramsay et al 2008. Simulation is a fast moving trend in nursing education. Following the use of electronic patient simulators. and to practise in a professional context using appropriate interpersonal and communication skills (Baillie 2005). Fletcher (2005) indicated that simulation increased confidence levels. Alinier et al (2006) critically appraised the value of simulation in nurse education by comparing the performance of two student groups using an objective structured clinical examination (OSCE). qualitative and only consider the students’ perspective of simulation (Henrichs et al 2002. As the use of simulated learning continues to increase. Dickerson 2005). critical thinking and team building (Medley and Horne 2005). Larew et al 2006. In addition. Even though these evaluations were positive. Various studies have examined the effect of a variety of simulation techniques on student learning (Jeffries et al 2003. McMullan et al 2003). Comer (2005) also identified that role play increased students’ understanding and improved their examination performance. Prescott and Garside (2009) also found that confidence gained during simulation was disseminated into clinical practice. Comer 2005. explores what is known in relation to the outcome. managers and those responsible for staff development find that many students and newly qualified nurses lack the critical thinking skills needed to work in the increasingly complex clinical environment (Aronson et al 1997). In this study. The researchers found that the experimental group’s performance significantly improved in the second OSCE (Alinier et al 2006). including simulation. motor skills and affective skills. incorporates data collection and analysis. understanding. it could be suggested that equipment is often purchased without a plan or idea about implementation of appropriate learning practices. Experienced nurses. to acknowledge that identical OSCE stations were used at the time of re-testing and that global scores using a checklist were realised rather than individual components of competence. It has been suggested that confidence may improve if simulation is used (Alinier 2003. competence in relation to effective nursing skills involved knowledge and understanding. but did not provide any evidence to support this assumption. when applied to nursing. it intends to inform resource allocation with regard to teaching clinical skills to assist in the selection of appropriate teaching methods. Qualified nurses must use effective decision-making skills to provide safe nursing care (Paul 1993). non-threatening experiential environment that also provides opportunities for decision making. the ability to solve problems and make decisions. Haskvitz and Koop 2004. Comer (2005) found that role play techniques can be an effective substitute for clinical simulation when teaching clinical skills. effective decision makers (Bakalis and Watson 2005) and competent. and is essential to the future of professional nursing practice (Tschikota 1993). only half of the students in Harlow and Sportsman’s (2007) study thought that the skills could be transferred to real life situations. but again with no supporting evidence. However. The authors’ study intends to establish if a specific method of simulation is more effective in assisting learning in relation to practical nursing skills (knowledge. undergraduate students can gain and improve skills in a safe. and examines the individual and determines the best course of action (Dickerson 2005). Universities in Scotland use various methods. decision making and problem solving). Considerable funds are being invested in the development of sophisticated clinical simulation rooms to help create a variety of healthcare environments from critical care areas to general wards and community healthcare settings. Prescott and Garside 2009).

A pilot study was carried out in January 2008 with a sample of five students from a different cohort of students to those in the main study. Participants were allocated to a site: site A (n=18) and site B (n=10). Recordings were randomly assigned to the external assessors and both received recordings from both sites. If students chose to take part. and decision making and problem solving) motor and affective domains (University of the West of Scotland 2008). Participants were in their final year of a three-year pre-registration adult nursing programme. Qualitative data were analysed thematically by the researchers. In phase 2. In April 2008. which was the third year of a Bachelor of Science adult nursing programme. Data analysis The study sought to establish whether there were any significant differences in performance between the two sites.art & science research Aim The main aims of this study were to: Compare the performance of two groups of pre-registration nursing students exposed to two different methods of simulation: role play versus the use of manikins. Problem solving nursing scenarios were used to compare students’ performance in relation to measuring and assessing vital signs in a simulated environment. participants were reassessed using a similar scenario to that used in phase 1. and decision making and problem solving. These recordings allowed the students’ performance to be viewed remotely and negated the need for an assessor to be present in the room. and descriptive and inferential statistics were realised. At site B. even if they had decided to participate. The total score possible equalled 100% (knowledge and understanding: 25%. Data collection A validated and piloted assessment tool was used to evaluate the students’ performances within the cognitive (knowledge and understanding. Following approval. Provide an evidence base to assist in the selection of appropriate teaching methods within pre-registration nursing programmes. Students also completed self-assessments of confidence (Schwarzer 1992) and anxiety (Spielberger 1983) levels before and following the simulation exercise. This allowed the researchers to assess the feasibility of the study and to test the data collection tools for validity and reliability. The first phase took place in the middle of year three (June/July 2008) and the second phase towards the end of the programme (January 2009). they were asked to sign an opt-in form at recruitment and to sign a consent form before participation. decision making and problem solving: 25%. 24 students continued to participate (site A (n=15) and site B (n=9)) and four students declined to participate any further . without having to provide an explanation. It also allowed the researchers to trial the recording equipment. potential participants were approached regarding their participation in the study. This provided an opportunity to test whether there were any changes in the students’ performance following an extensive period of practice. Quantitative and qualitative data were realised. Participants were informed that all data collected NURSING STANDARD . relating to measuring and assessing vital signs. On completion of the patient assessment. Quantitative data were analysed by a statistician. The study was carried out between January 2008 and February 2009. Ethical issues Ethical approval was sought from the university’s ethics committee. They were informed that they could withdraw from the study at any stage. All participants were examined within a specified time frame and their performances were recorded. at the end of their programme. At these recruitment sessions. the principal investigator and research team approached the cohort of students to be studied at both sites to recruit them for the study. a volunteer patient was recruited and briefed to act as a patient in the role play simulation. These recordings were sent to two external assessors experienced in the assessment of clinical skills. Sample All third-year students were invited to participate. specific questions were asked to assess students’ knowledge and understanding. of which 28 students agreed to take part. & Method This longitudinal study used a quantitative quasi-experimental design. students were issued with an information pack containing details of the study and what would be required of them should they choose to participate. Each student was awarded a percentage to enable comparisons to be made. Inform resource allocation with regard to teaching clinical skills. No automated equipment was used at either site to measure vital signs. Phase 2 Following six months of clinical practice. Inter-marker reliability was addressed by each assessor cross-marking five performances. At site A. 44 may 5 :: vol 24 no 35 :: 2010 Phase 1 Participants at both sites were assessed in the skills laboratory using a clinical scenario appropriate to the stage of their programme. a high-fidelity manikin that simulates vital signs and verbal sounds was used. motor: 25% and affective: 25%).

and decision making and problem solving).56 Phase 2 Table 2 shows the mean and standard deviation of scores at each site for the overall total mark and the three separate domains that may 5 :: vol 24 no 35 :: 2010 45 . a significant negative correlation (r=-0.2 Effect size 1.8 0.67 14. The mean difference between sites for each score was formally tested using an independent sample t-test.20 11. Those students who showed the greatest increase in confidence following simulation also showed the least increase in anxiety. Once again there was a similar pattern in both sites. however. The more anxious students were before the test.56 27.47 12. NURSING STANDARD FIGURE 1 Post hoc power analysis 1. There was also a significant negative correlation between change in confidence and change in anxiety after the test (r= 0. The greater the change in confidence after the test.94 12.44 Standard deviation 8. an analysis of covariance was undertaken with total score as the dependent variable.8 0.70 12. In this case.10 3.60 8. 24) = 0.863).683.27 5.53 4.60 Standard deviation 11.03.9 Power (1 – prob type 2 error) TABLE 2 Results of phase 2 Site Totals Cognitive domain: knowledge and understanding Cognitive domain: decision making and problem solving Total for cognitive domain Motor domain Affective domain A B A B A B A B A B A B Number of participants 15 9 15 9 15 9 15 9 15 9 15 9 Mean 55. There was no evidence to suggest that any site achieved better results than the other site.01) between pre-test anxiety and change in anxiety. the smaller the change in anxiety after the test.2 0. TABLE 1 Results of phase 1 Site Totals Cognitive domain: knowledge and understanding Cognitive domain: decision making and problem solving Total for cognitive domain Motor domain Affective domain A B A B A B A B A B A B Number of participants 18 10 18 10 18 10 18 10 18 10 18 10 Mean 55.would be anonymised and all results would be kept securely by the principal investigator.99 3.39 5.20 27.00 12.23 2.54 2.86 2.16 2.7 0.83 1.50 3.33 27.78 15.6 0.72 2.89 14.30 13. The probability that the test could detect a real difference is called the power of the test.0 0. the smaller the change in anxiety. P< 0.6 0.75 Results Phase 1 Table 1 shows the mean and standard deviation of scores at each site for the overall total mark and the three separate domains that make up the total (cognitive is the sum of both cognitive elements: knowledge and understanding. A difference of 10% equates to an effect size of one and gives a power of 70%.87 51. However. Anxiety and confidence Both pre-test anxiety and confidence were higher in participants at site A than site B.78 14.77 3.35 3.01).67 13.4 1. Mean scores for the overall total and for each domain are similar.60 14. The pattern was similar in both sites. the site as the fixed factor and both pre-test anxiety and confidence levels as covariates.17 55. However. the power of the test is such that it can be reasonably concluded that any real difference between sites in excess of 10% could be determined by these tests (Figure 1).10 13. There was.5 0.81 2.19 3. with any statistical test there is always a possibility that the test is not sufficiently powerful to detect a real difference.572.80 5.45 2.60 13. A post hoc power analysis was conducted to determine the likelihood that the test could determine a real difference.38 8.69 2.3 0. with no site being consistently better or worse. P=0. neither of these differences were statistically significant. To confirm whether anxiety or confidence had any significant effect on test scores.80 14. There was no significant difference between sites (F(1. Those who were least anxious before the test experienced the biggest increase in anxiety after the test.14 3.40 27.56 13.4 0. P<= 0.

while others focused on procedural conversation. the scores achieved in these domains were relatively low (between 27. Also. This is of concern as these students had previously been exposed to two years of practice placements.’ In general. As the sample sizes were small the difference was retested using a non-parametric Mann-Whitney test. and decision making and problem solving. Some participants were able to initiate reasonable conversation. A similar post hoc power analysis was conducted as for phase 1 and gave similar results. Furthermore.80 to 11. P<0. The lowest scores in phase 1 were in the motor domain (between 12. The mean overall total scores were higher in site A compared with site B. students’ anxiety and confidence scores did not appear to affect their performance. all third-year adult branch students at the university could be included.05). At site B.94 out of 25). site A scored higher in both the motor and affective domains. Cognition and motor The majority of students demonstrated indecision when choosing the equipment required to measure vital signs. for example: ‘I am going to take your blood pressure.4 and 5. there was a significant difference in the mean affective scores (t(22)=2.44). neither type of simulation was shown to be more effective than the other in phase 1. Furthermore. although the monitor was switched off. Education providers must therefore be mindful. The 95% confidence interval for the difference in mean affective scores shows that the mean at site A is between 0. In phase 2.39.80 and 12. Discussion Although the results for performance in the cognitive domain in phase 1 were not significantly different between sites. However. would improve with further clinical experience. However. The mean difference between sites for each score was formally tested using an independent sample t-test. Despite the large difference in mean scores between sites the difference was not significant because of the large variability in overall scores. all students recognised that the changes in the patient’s vital signs were significant and that they demonstrated deterioration in the patient’s condition. Motor scores fell even further at one site (12. students using role play achieved greater scores in the affective domain in phase 2 (15. Site B students did not demonstrate either competence or confidence in these domains.70 out of a possible score of 50).56 out of a possible 50). students demonstrated poor manual dexterity when using NURSING STANDARD Qualitative findings of phase 1 and phase 2 Cognition On questioning. In this study. the total cognitive scores fell even further at both sites (27. In addition. Furthermore. it would be advantageous to carry out a comparative study at another school of nursing in a different higher education institution. several students exposed the manikin’s chest to obtain a respiratory rate. to select the most appropriate method of simulation. In this study. students did not communicate well with the manikin.47 versus 12. Rationale for participants’ evaluation of confidence and anxiety pre and post-simulation was to ensure that these factors did not unreasonably affect performance. Affective Communication varied between students. Nonetheless.art & science research make up the total. These results for anxiety concur with Spielberger’s (1983) research regarding anxiety levels before sitting examinations. It would be useful to replicate this study with more participants. This concurs with Ramsay et al’s (2008) assertion that role play was useful when rehearsing communication. This is a concern as it could be assumed that knowledge and understanding. The test confirmed that the difference between the sites was significant. with continual back and forth movement observed. Nehring et al (2002) recommended that students’ comfort with simulation should be measured. 46 may 5 :: vol 24 no 35 :: 2010 .78) and there was a lack of awareness regarding what equipment was required to assess patients. The mean affective score at site A was significantly higher than the mean score at site B. manual dexterity differed between sites. when teaching communication and interpersonal skills. all students suggested appropriate interventions that must be taken. & Limitations It is recognised that the sample size in this study was small. some students continued to pay a great deal of attention to it. The cognitive scores were similar. the tests could detect a real difference of 10% with a power of 62%. Although there was a slight improvement in psychomotor scores at one site these results remained poor. In this case.64 greater than the mean at site B.33 and 27.20 versus 27. Affective scores in phase 2 were significantly different and at one site they dropped even further when compared with phase 1 scores. for example.

but depend on accurate measurements of vital signs. 101. 1. 3. Anfinson J. Cooke WH. Rosa JM. Nurse Education Today. 24-29. Jootun D. 68-72. This resulted in a marked decrease in patients experiencing cardiac arrest – the number of arrests dropped by two thirds. 25. 23. 2. with some unable to apply the blood pressure cuff correctly or demonstrating incorrect use of the stethoscope. 27. 357-361. Second Edition. London. 26. Holcomb et al (2005) identified the importance of manually establishing pulse characteristics. 33-39. such as volume. Comer SK (2005) Patient care simulations: role playing to enhance clinical understanding. 70-74. A hands-on approach to patient References Alinier G (2003) Nursing students’ and lecturers’ perspectives of objective structured clinical examination incorporating simulation. Ellis W (2002) Nurse anesthesia students’ perceptions of the anesthesia patient simulator: a qualitative study. students still looked at monitors that were switched off. 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NHS Education for Scotland (2005) Clinical Skills Units – Improving Patient Safety through Simulated Practice. All nursing students should be fully versed in manual observation and measurement skills as well as being sufficiently conversant with the use of automated equipment. Nursing Standard. ongoing need for educators to be trained in the purpose and use of simulation resources. 31-34. Nursing and Midwifery Council (2007) Supporting Direct Care through Simulated Practice Learning in the Pre-Registration Nursing Programme. Foundation for Critical Thinking. Redwood City. 15. London. Wilford A. Journal of Advanced Nursing. California. 22. 128-132. Lashley FR. Educators therefore should select the appropriate type of simulation depending on the learning outcome they are striving to achieve. NHS Education for Scotland. Ker JS (2008) Use of simulated patients for a communication skills exercise. 37. Educators should be aware that learning within different domains requires different forms of simulated teaching. is essential to enable early recognition of patient deterioration. Edinburgh. Nicol M. 1. 9. Nursing Education Perspectives. Elsevier. 48 may 5 :: vol 24 no 35 :: 2010 NURSING STANDARD . because there is an over reliance on automated equipment in clinical areas. Ellis WE (2002) Critical incident nursing management using human patient simulators. Ramsay J. Third edition. an unexpected and concerning finding was the inability of many senior nursing students to assess patients’ vital signs manually. Cronin P. London. Paisley. A ‘hands on’ assessment of patients’ status. Parish C (2008) Hands-on pulse monitoring sees cardiac arrests cut by two thirds. 41. and decision making and problem solving – vital components of a registered nurse’s practice. and patient safety is being compromised. Scottish Government (2009) The Healthcare Quality Strategy for Scotland: Draft Strategy Document. Nehring WM. 3. 155-161. Rawlings-Anderson K (2008) Essential Nursing Skills. Edinburgh. Paul RW (1993) Critical Thinking: What Every Person Needs to Survive in A Rapidly Changing World. now and for the future’ (Scottish Government 2009). where role play achieved significantly better results. Keith G. NMC. 3. Nursing and Midwifery Council (2005) Consultation on Proposals Arising from A Review of Fitness for Practice at the Point of Registration. but vital. Bavin C. Conclusion This study demonstrated that both forms of simulation – role play and the use of manikins – realised similar outcomes in terms of students’ scores. Doyle TJ (2006) Integrating simulation training into the nursing curriculum. 32. 22. McMullan M. Endacott R. 389-398. Schwarzer R (Ed) (1992) Self-Efficacy: Thought Control of Action. Scottish Government. following six months of clinical practice. 44. 39-44. 17. except in the affective domain. 7. 15. Nursing and Midwifery Council (2004) Standards of Proficieny for Pre-Registration Nursing Education. British Journal of Nursing. Portfolios and assessment of competence: a review of literature. safe and clinically effective care for everybody. 19. The Journal of Nursing Education. including pulse characteristics. Prescott S. Garside J (2009) An evaluation of simulated practice for adult branch students. NMC. It must also be recognised that automated equipment is for single patient use and should be recalibrated if used for multiple patients. Horne C (2005) Using simulation technology for undergraduate nursing education. 926-930. Edinburgh. 23. Washington DC. However. 23 . & IMPLICATIONS FOR PRACTICE It should be the concern of all educators and healthcare providers that nursing students and qualified nurses are potentially becoming deskilled. Mind Garden. Furthermore. Spielberger CD (1983) State-Trait Anxiety Inventory for Adults. every time. Medley CF. The Journal of Nursing Education. Third edition. 283-294. These procedures can only assist ‘person centred. Those in control of the budget in higher education institutions should consider carefully what type of simulation resources to purchase in view of how students learn. Hand-in-hand with selective purchasing is the often neglected. London. Nursing Standard. Tschikota S (1993) The clinical decision-making processes of student nurses. Journal of Clinical Nursing. Morgan R (2006) Using clinical skills laboratories to promote theory-practice integration during first practice placement: an Irish perspective. Nursing Standard. 2. participants’ performance in this study did not improve NS Acknowledgement The authors would like to thank Rosemary Mullen and Marie Robertson for their assistance. Hemisphere. University of the West of Scotland (2008) Expected behaviours and assessment criteria (Level 9). 22. Santa Rosa CA. NMC. Gray MA et al (2003) Integrative Literature Reviews and Meta-Analyses. Participants’ cognitive scores were relatively poor in relation to knowledge and understanding.art & science research assessment uses manual equipment and a full minute of pulse recording to include pulse characteristics and not just rate. 35-40. University of the West of Scotland.

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