Nurse Education Today 31 (2011) 716–721

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Nurse Education Today

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t

The effectiveness of high fidelity simulation on medical–surgical registered nurses'

ability to recognise and respond to clinical emergencies
Thomas Buckley ⁎, Christopher Gordon
Faculty of Nursing and Midwifery (MO2), The University of Sydney, Sydney NSW 2006, Australia

a r t i c l e i n f o S U M M A R Y

Article history: Background: There is a paucity of evidence regarding the efficacy in preparing medical–surgical nurses to
Accepted 23 April 2010 respond to patients with acutely deteriorating conditions.
Study aim: The aim of this study was to evaluate registered nurses' ability to respond to the deteriorating
Keywords: patient in clinical practise following training using immersive simulation and use of a high fidelity simulator.
Simulation
Methods: This study was a follow-up survey of medical–surgical graduate nurses following immersive high
High fidelity
fidelity simulation training. Thirty eight registered nurses practising in medical–surgical areas completed the
Assertiveness
Graduate education
simulation as part of university graduate study. A follow-up survey of the graduate medical–surgical
Emergency response registered nurses conducted three months following completion of a high fidelity simulation-based learning
Clinical deterioration experience. Outcomes consisted of the number of times skills were used in practise and the usefulness of
simulation in preparing for actual emergency events.
Results: Participants reported a total of 164 clinical patient emergencies in the follow-up time period
including: 46% cardiac, 32% respiratory, 10% neurological, 7% cardiac arrest and 5% related to electrolyte
disturbances. The ability to respond in a systematic way, handover to the emergency team and airway
management were identified as the skills most improved during patient emergencies following simulation.
The most useful aspects of the simulation experience identified were scenario debriefing and assertiveness
training. Participants with less years of clinical experience were more likely to report practising the team
leader role and debriefing as the most useful aspects of simulation.
Conclusions: The skills practised in simulation were highly relevant to participants practise in medical–
surgical areas. Non-technical skills, including assertiveness skills should be considered in future emergency
training courses for nurses.
© 2010 Elsevier Ltd. All rights reserved.

Background whether simulation improves actual clinical performance (Scherer et

The use of simulation in nursing education attempts to replicate
the essential aspects of a clinical situation with the outcome focused
on the ability of nursing staff to understand and manage similar
situations in clinical settings (Alspach, 1995). In recent years there
appears to be a trend towards increased use of patient simulation in
both undergraduate and graduate education curricula. The reasons for
these may include, limited clinical placement positions, greater
acceptance of simulation as a useful adjunct to clinical teaching and
the potential for simulation to improve clinical learning (Alinier et al.,
2004; Seropian et al., 2004). Prior studies have reported that
incorporating simulation into undergraduate and graduate nursing
education increases student self-efficacy and staff satisfaction (Gee,
2006; Mole and McLafferty, 2004; Kardong-Edgren et al., 2008).
However, despite these reports, the evidence is equivocal as to
⁎ Corresponding author. Tel.: +61 2 91144043.
E-mail address: t.buckley@usyd.edu.au (T. Buckley).
al., 2007; Kuhrik et al., 2008; Wolf, 2008).
One area of clinical nursing practise that may benefit from
simulation is the assessment and early interventions necessary for
patients with acutely deteriorating conditions. Early assessment and
intervention are an important step of the “chain of survival” concept
that emphasises the need for a rapid response through early
recognition of the life-threatening event, rapid activation of appro-
priate help and commencement of interventions (Cummins et al.,
1991). To replicate these clinical situations, human patient simulators
with high fidelity responses, similar to the patient's physiological
responses, in a simulated clinical setting may facilitate educational
opportunities on clinical management of these patients. Prior
evidence suggests that training with high fidelity simulation improves
proficiency in advanced life support skills compared to clinical
experience alone (Wayne et al., 2005). Furthermore, hospital
resuscitation teams (doctors and nurses) trained in advanced life
support using simulation, improved patient outcomes following
cardiac arrest (Moretti et al., 2007). However, the majority of patients
with acute deterioration in their conditions, potentially leading to

0260-6917/$ – see front matter © 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2010.04.004
 T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721
cardiac arrest, are situated in medical–surgical ward areas (Cohn et al.,
2004; Peters and Boyde, 2007). In addition, first responders to these
patients are likely to be medical–surgical nurses who are expected to
initiate immediate treatments and recruit emergency medical
assistance. Despite this situation, there is a paucity of evidence
regarding the efficacy of high fidelity simulation in preparing
registered nurses to respond to patients with acutely deteriorating
conditions in medical–surgical environments. In fact, the effectiveness
of simulation in graduate nursing programs to improve clinical
performance is largely undocumented.
Therefore, the objectives of this study were to: a) evaluate the
frequency of use of emergency response skills in clinical practise
following high fidelity simulation learning experiences in medical–
surgical nurses; b) examine the extent that simulation-based learning
experiences improved participants' ability to respond to actual clinical
emergencies; c) to evaluate the most useful aspects of simulation in
preparation to respond to the patients with deteriorating conditions
and, d) to determine if a relationship exists between years of
experience and the most useful aspects of the simulation workshop
in improving responses during actual clinical emergencies.
Methods
The study consisted of a survey design whereby participants
reported on the usefulness of various aspects of simulation in their
ability to respond to actual patient clinical emergencies three months
after completing a simulation workshop. Ethical approval was granted
by the Human Research Ethics Committee of the university and all
participants consented to receiving follow-up surveys by mail.
Participant questionnaires were coded to maintain participant
confidentiality.
Procedures
A total of 50 students who undertook a graduate subject at an
Australian university using traditional classroom teaching combined
with a high fidelity simulation workshop agreed to participate in the
study. Thirty eight (76%) of the 50 students who participated in a
simulation-based subject participated in the follow-up survey,
completed three months after the simulation training workshop.
A description of the post-graduate level subject has been described
previously (Gordon and Buckley, 2009). Briefly, the subject consisted
of 14 h of on-campus lectures exploring theoretical aspects related to
clinical emergencies. Theory content consisted of management of the
patient in cardiac arrest, and cardiovascular, respiratory and neuro-
logical systematic assessment and management of patients with
deterioration conditions. This included pathophysiology, most com-
mon clinical presentations, and the most updated clinical manage-
ment guidelines. Following the theoretical aspects of the course,
students participated in two workshops of 3 h duration practising the
technical skills, using a Resusci Anne Simulator®, related to
assessment and initial management of patients with clinical emer-
gencies. This included advanced resuscitation skills based on the
Australian Resuscitation Council Guidelines, (2006/7).
Additionally, team-building and communication exercises were
included immediately prior to the immersive high fidelity simulation
scenarios. These exercises exposed participants to different leadership
styles, team member roles and the use of assertiveness skills that may
be relevant when working with colleagues in an emergency team.
Immersive high fidelity simulation was undertaken in a laboratory
teaching environment designed to replicate a medical–surgical
hospital setting. SimMan® was used during all immersive scenarios
with remote control of physiological variables and nurse–patient
interactions, such as talking. All participants were familiarised with
the simulation environment and provided with the necessary
information about SimMan® capabilities and the environmental
717
logistics (telephone, patient monitors, and emergency button).
Participants were assigned randomly to teams of either four or six,
and scenarios were undertaken repeatedly. Each participant partic-
ipated in a minimum of three scenarios and in various roles (for
example, first responder or team leader). Each scenario was recorded
via a two camera feed video with non-participating students viewing
the scenario live in a separate room and the scenario participants
viewing the playback followed by a facilitated debriefing session.
The simulation workshops were based on clinical case scenarios of
patients with acute illness leading to cardiac arrest. The focus on each
scenario was on both the technical skills required to perform patient
assessment and management, and decision-making skills such as:
declaring an emergency, recruiting help and working in a team. Each
scenario was allocated 45 min for both immersive simulation and
debriefing.
Data collection
Participants completed a questionnaire by mail three months
following completion of the high fidelity simulation workshop.
Participants reported on the clinical emergencies they had partici-
pated in over the previous three months and reflected on the aspects
of the simulation experience that improved their ability to respond to
these emergencies. Specifically, questions related to participants
ability to a) recognise, prioritise and recruit help, b) conduct patient
assessment and commence immediate intervention c) leadership
skills and d) team communication skills. Respondents rated their
responses on a Likert scale ranging from: “a great deal” (scored as 4)
to “not at all” (scored as 1).
Data analysis
Data were entered to an Excel data base and then imported to SPSS
version 16.0 for Windows for analysis. Descriptive statistics were used
to characterise the sample and frequencies calculated for individual
questions. The relationship between years of experience as a
registered nurse the most useful aspects of simulation in preparation
for clinical emergency responses were analysed using Spearman's
rank-order correlation due to the non-normal distribution of
participant's responses where the majority of participants scored
highly (either 3 or 4) on individual questions related to useful aspects.
Missing data were not substituted and results presented as frequen-
cies for individual item responses.
Results
Thirty eight participants responded to the survey. This represented
76% of the students who participated in the simulation workshop.
Almost 90% were female of mean age 35 years old with an average of
nine years experience as a registered nurse. Two thirds were enrolled
in a graduate certificate course, one quarter a master of nursing
degree and the remainder (8%) enrolled in a graduate diploma of
nursing. The majority of participants (71%) were classified in their
employment as registered nurses, 16% clinical nurse specialists, 10%
clinical nurse educators (10%) and one nurse manager (Table 1). All
participants had completed basic life support training in their
workplace within the previous twelve months.
Patient emergencies since completion of the simulation experience
Thirty participants (79%) reported that they responded to patient
clinical emergencies since completion of the simulation experience. In
total, participants reported 164 clinical patient events requiring early
assessment and immediate intervention as detailed in Fig. 1. Twenty
six of these participants reported between 1 to 5 clinical events, two
718 T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721

Table 1 Table 2
Characteristics of study participants (n = 38). Participants responses to the question: “during the emergency events, to what extent
has the workshop improved your ability to:”.
Number
A great To some A little Not at
Age in years mean (range) 35.1 (23–54)
deal N (%) extent N (%) N (%) all N (%)
Years as registered nurse (SD) 8.9 (7.9)
Female 24 89% Non-technical skills
Recognise an unstable patient 19 (64) 10 (33) 1 (3) 0 (0)
Course enrolment Respond to an unstable patient 26 (87) 3 (10) 1 (3) 0 (0)
Graduate certificate in nursing 25 66% in a systematic way
Master of nursing 10 26% Coordinate immediate 23 (77) 7 (23) 0 (0) 0 (0)
Graduate diploma in nursing 3 8% responders
Handover to the emergency team 26 (87) 3 (10) 1 (3) 0 (0)
Position classification
Clinical RN 27 71% Technical skills
Clinical nurse specialist 6 16% Assess responsiveness 23 (77) 5 (17) 2 (6) 0 (0)
Clinical nurse educator 4 10% Assess the airway 22 (73) 6 (20) 2 (7) 0 (0)
Nurse unit manager 1 3% Assess for breathing 24 (80) 5 (17) 1 (3) 0 (0)
Assess circulation 22 (74) 7 (23) 1 (3) 0 (0)
Workplace specialty Manage the airway 21 (72) 6 (21) 7 (2) 0 (0)
Medical/surgical ward 28 73% Manage breathing difficulties 23 (79) 4 (14) 2 (7) 0 (0)
Oncology/haematology 4 11% Manage circulation problems 18 (62) 9 (31) 2 (7) 0 (0)
Othera 3 8% Manage the unresponsive patient 20 (69) 7 (24) 2 (7) 0 (0)
Operating department 2 5%
Mental health 1 3%
a
Other: critical care, paediatric, and spinal nursing. following simulation training. Debriefing after immersive scenarios (87%
of participants rated “a great deal”) and assertiveness skills (80%) were
the aspects of simulation most highly rated. Practising patient handover
participants reported 6 to 20 events and two participants reporting (53%) was the least rated aspect of simulation (Table 3). The relationship
more than twenty clinical emergencies in the follow-up period. between years of experience and the most useful aspect of simulation are
presented in Table 4. A lower number of years experience was associated
Improvement in non-technical and technical skills with a higher likelihood of reporting practising the team leader role and
debriefing as highly useful aspects of simulation.
Overall, participants reported that the simulation workshop
improved their performance in both non-technical and technical
skills. Of the non-technical skills, 87% of participants reported that Discussion
since completion of the workshop their ability to respond in a
systematic way and ability to hand over to the emergency team had The main findings of this study are that both non-technical and
improved “to a great deal”. Less highly rated were coordination of the technical skills acquired and practised in the simulation workshop
immediate responders (77% of participants) and recognition of an were relevant to participants' practise, with the majority of partici-
unstable patient (64%), (Table 2). pants (79%) utilising the skills between one and five times in the three
Of the technical skills surveyed, assessment of breathing (80%) and month follow-up period. Participants reported that responding in a
managing breathing difficulties (79%) were most highly rated to have systematic manner, management of airway and breathing and
improved, while the simulation workshop was considered to have been handing over to the team were considered to have improved during
least helpful at improving ability to manage patients with circulation actual patient clinical emergencies since completion of the workshop.
problem (62%) and the unresponsive patient (69%) (Table 2). Additionally, debriefing and assertiveness training were considered
the most important aspects of the simulation experiences.
Most useful aspects of simulation
Clinical emergencies experienced
Participants rated the most useful aspects of the simulation workshop
in assisting their ability to respond to the real patient emergencies In this study, patients with acute deterioration related to cardiac
origin (hypotension or rhythm disturbance) were the most frequently
reported followed by respiratory problems (airway or breathing
difficulties), altered consciousness and electrolyte disturbances. The
type of emergencies reported by participants are consistent with prior

Table 3
The most useful aspects of the simulation workshop in improving responses during
clinical emergencies.

A great To some A little Not at

deal N (%) extent N (%) N (%) all N (%)

Debriefing after immersive 26 (87) 4 (13) 0 (0) 0 (0)

scenarios
Assertiveness skills during 24 (80) 5 (17) 1 (3) 0 (0)
an emergency
Managing cases on the patient 22 (74) 7 (23) 1 (3) 0 (0)
simulator
Viewing performance on video 22 (73) 5 (17) 3 (10) 0 (0)
Practising the team leader role 19 (63) 11 (37) 0 (0) 0 (0)
Practising patient handover during 16 (53) 12 (40) 2 (7) 0 (0)
Fig. 1. The distribution of the 164 patient clinical emergencies reported by participants an emergency
since completion of the simulation workshop.
 T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721
Table 4
The relationship between years of experience and the most useful aspects of the
simulation workshop in improving responses during clinical emergencies.
r p
Debriefing after immersive scenarios − 0.36
Practising the team leader role − 0.45
Managing cases on the patient simulator − 0.26
Viewing performance on video 0.29
Assertiveness skills during an emergency − 0.06
Practising patient handover during an emergency − 0.14
findings where respiratory distress, neurological derangements and
hypotension have been reported to accounted for three quarters of
hospital Medical Emergency Team (MET) calls in one study
(Calzavacca et al., 2008) and 92% of hospital MET calls in another
(Crispin and Daffurn, 1998). This demonstrates that the patients cared
for by the graduate nurses in this study were representative of
patients requiring emergency team responses. Furthermore, the skills
acquired and practised during the high fidelity simulation workshops
were highly relevant to the patient cohort. Therefore, the graduate
nurses experienced a range of patients with clinical emergencies, and
their ability to implement the technical and non-technical skills
required for these events were able to be assessed.
The technical skills associated with performing assessment of
breathing and managing breathing difficulties were highly rated to
have improved in clinical practise after completing the simulation
workshop. It would appear simulation is a valued educational tool for
improving these skills which are highly technical and difficult to
master. Similar to this finding, reports from medical training have
demonstrated repeatedly that simulation improves technical skill
acquisition during emergency procedures (Gaba et al., 2001;
McLaughlin et al., 2002).
The simulation workshop was considered to have been less helpful
at improving the ability to manage patients with circulation problems
during clinical emergencies. This was surprising and may have resulted
as many of the cardiac emergencies reported were secondary to cardiac
rhythm disturbance and chest pain. The classroom and simulations were
based on the Australian Resuscitation Council Resuscitation Guidelines
for cardiac arrest and did not explicitly refer to guidelines for
management of chest pain or non-cardiac arrest arrhythmias. Although
management of non-cardiac arrest arrhythmias and chest pain
presentation were discussed during debriefing, it may be important to
reinforce this content using written guidelines, as was done with other
aspects of resuscitation. This is an area for future development of
simulation workshops and reference may need to be made to other
guidelines that provide guidance for assessment and management of
different arrhythmias, other than those related to cardiac arrest.
It was surprising that only 64% of participants considered that the
simulation workshop improved their ability to recognise an unstable
patient. As all participants were graduate students with several years
of clinical nursing experience, and all had previously completed basic
life support training, it is likely that they were already proficient in
recognising the unstable patient. Participants rated the individual
assessment of responsiveness, airway, breathing and circulation more
highly, which suggests that overall recognition of the unstable patient
should have been more highly rated as an acquired skill. However, this
was not observed in this cohort. Possibly, the participants considered
that overall recognition of the unstable patient was a more
sophisticated assessment than the individual assessments of airway,
breathing and circulation. Alternatively, this may relate to the
limitation of the high fidelity simulation mannequins, where more
subtle signs, such as changes in skin colour and body temperatures are
not evident. However, despite recognition of an unstable patient been
rated less than other skills, and the fact that participants were
experienced registered nurses, it is still encouraging that 64% reported
that the simulation improved this skill in clinical practise. This is an
719
important outcome as delayed recognition may result in delayed
medical emergency team activation, an independent predictor of
patient outcome (Calzavacca et al., 2008).
Of the non-technical skills surveyed, responding in a systematic
0.05 way and handing over to the emergency team were most highly rated
0.01 to have improved during actual emergencies since completion of the
0.17 workshop, The Australian Resuscitation Council Guidelines for
0.16
management of cardiac arrest promote the use of the Danger,
0.77
0.47 Response, Airway, Breathing and Circulation, also known as
the “DRABC” approach to patient assessment and management
(Australian Resuscitation Council Guidelines, 2006/7) and this is
widely advocated in emergency response guidelines (Handley et al.,
2005). Patient handover is a critical aspect of emergency response and
not always conducted accurately in emergency situations (Carter et
al., 2009).The absence of a structured and complete handover can lead
to fragmentation in patient care and omissions in the care being
delivered, although there appears to be lack of research based
literature relating to the process in emergency situations. In the
simulation workshop, handover was practised as a two step approach
with essential information given immediately and again thereafter to
provide further information once initial treatments were given. This
was based on previous evidence which advocates this approach in
emergency situations (Jenkin et al., 2007).
Most useful aspects of simulation
Participants, particularly those with less years experience as a
registered nurse, rated debriefing after immersive scenarios and
assertiveness skills as the most useful aspects of simulation in
assisting their ability to respond to the actual patient emergencies.
Debriefing, a critical component of simulation experiences, provides
clinicians with the opportunity to reflect and discuss their experience
immediately after the immersive simulation experience. Research has
consistently demonstrated that debriefing is an essential component
of simulation training, and has been highly rated by medical trainees,
undergraduate and new-graduate nurses (Abrahamson et al., 2004;
Rhodes and Curran, 2005; Ackermann et al., 2007). Furthermore,
evidence is emerging that debriefing may be particularly important in
fostering the non-technical skills associated with emergency response
(Engel et al., 2008) as observed in the study reported here. This is an
aspect of simulation training that requires further investigation.
While there is a scarcity of literature relating to the use of
simulation to improve assertiveness during patient clinical emergen-
cies, the level of education attained by practising registered nurses has
been associated with perceived assertiveness (Kubsch et al., 2004).
Assertiveness skills were introduced to participants during the team-
building and communication exercises and then integrated into the
immersive scenarios and debriefing sessions. The focus was on the use
of language in communicating the degree of urgency associated with
the simulated scenarios. The improvement in assertiveness reported
during actual clinical emergencies suggests that simulation may be an
effective educational tool in developing assertiveness. The authors
suggest that non-technical skills taught and practised during
simulation, such as assertiveness during emergency scenarios, could
be expanded to include a range of other clinical situations where
assertiveness would be appropriate.
An aspect of the simulation workshop considered to have been
less useful during actual patient emergency responses was practis-
ing handover during the emergency. This was interesting as 87% of
participants reported improved ability to handover to the emer-
gency team as a result of completing the learning experience, yet
only 53% attributed this to the simulation workshop. It may be that
simulation is not as effective at improving social or communication
skills as traditional-based teaching methods or clinical experience
(Leigh, 2008). This may especially be the case in relation to social
and communication skills during simulated emergencies where the
720 T. Buckley, C. Gordon / Nurse Education Today 31 (2011) 716–721
focus at the bedside is frequently directed towards technical skill
accomplishment. Interestingly, less experienced participants were
more likely to report practising the team leader role as a useful
aspect of the simulation suggesting that simulation may be more
useful in improving leadership skills in registered nurses who have
had less opportunity to develop these skills in the clinical area.
Future research is needed to determine the number of times
participating in immersive simulation will result in optimal self-
efficacy in these skills.
This study builds on an earlier report that graduate medical–
surgical nurses reported increased confidence in their ability to
respond to patients with deteriorating conditions immediately
following participation in immersive simulation (Gordon and Buckley,
2009). Developing confidence is a major component of clinical
decision making (White, 2003). The use of human patient simulators
has been demonstrated previously to improve participant confidence
in responding to different clinical situations (Leigh, 2008; Wolf, 2008).
Advantages of using immersive simulation educational experiences in
management of the deteriorating patient are the ability to practise
patient management in a safe, less stressful environment compared to
clinical settings. In this study, graduate nurses highly rated technical
and non-technical skills during clinical emergencies up to three
months following simulation training. However, the length of time
that this increased confidence continues remains unknown. It is likely
to be highly dependent of the type of clinical environment with
presumed better retention rates in registered nurses exposed to more
acutely ill patients.
The finding that participant's ability to respond to patient
emergencies has clinical importance. The importance of nurse
education focussing on immediate responses to acute deterioration
in patients was highlighted in a study that demonstrated that patients
initially assessed and managed by nurses trained in advanced life
support (ALS) had a four-fold increase in survival. In this study, Dane
et al. (2000) observed that the emergency team arrived on average
within 60 s, suggesting that early recognition and immediate
interventions by ALS-trained nurses may have been the critical
element in patient survival. The finding that the majority of
participants in the study here had used the skills practised in the
simulation workshop in clinical practise highlights the need to ensure
a post-graduate curriculum includes learning experiences are realistic
and similar to actual clinical situations. Moreover, documentation of
the most frequent clinical emergencies provides guidance for future
planning of similar simulation experiences for nurses working in
medical–surgical areas.
Limitations
In the current study, technical performance during emergency
events was not directly assessed but rather the graduates' perceived
ability of their performance was evaluated. It may be that simulation
only increases confidence to cope during the patient clinical
emergency, rather than increasing actual technical performance.
However, to adequately assess overall performance, both technical
and non-technical as well as teamwork during emergency events,
variables such as response times associated with critical elements, like
time to first defibrillation and recruitment of assistance following
recognition of abnormal vital signs may be more appropriate
measures.
Additionally, this study evaluated the effect of immersive
simulation blended with both classroom and workshop learning
activities making it difficult to identify what aspect of the learning
resulted in improvements reported clinically. However, the authors
recommend this approach to learning, where immersive simulation is
used to complement traditional learning methods, rather than a
standalone activity.
Conclusion
These findings suggest that immersive simulation combined with
classroom teaching, improves medical–surgical nurses' perceived
ability to respond to patient clinical emergencies. Furthermore, it
appears that technical and non-technical skills during patient clinical
emergencies appear to be equally important to medical–surgical
nurses and relevant to nursing practise. In graduate students, greater
use of simulation may result in more clinically confident and
proficient nurses who can respond accurately and appropriately to
patients who require emergency responses and are appropriate to be
included in post-graduate nurse education.
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