Integrating simulation based learning into nursing education programs: Hybrid simulation

1. Background

Advances in education and technology have combined the two fields. The use of simulations is becoming increasingly widespread in nursing education. “Simulation is a technique, not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion” [1].

As simulation provides a secure learning setting and safe treatment, the use of simulation in nursing education has attracted interest. In recent periods, simulation has been integrated into nursing education programs to prepare students for clinical training, to improve students’ self-confidence in clinical practice and to provide a secure learning environment. The World Health Organization [2, 3] recommends the use of simulation-based education programs to improve patient safety, as the treatment of patients by nursing students who are not fully competent in patient management may result in various risks to patient safety. Research has indicated that simulation improves students’ skills in relation to clinical practice, communication, decision making and critical thinking, as well as their self-confidence and team work [4, 5, 6, 7, 8, 9].

Simulation technologies include various forms, from low to high technologies. One of the methods used in simulation is hybrid simulation. Hybrid simulation is the combination of more than one simulation modality in a single teaching or evaluation exercise. Hybrid simulation can be developed with mannequins of any fidelity and tabletop simulators with a standardized patient to create a complex, high-level learning activity [10]. Hybrid simulations allow for the training of technical skills combined with communication proficiency [11]. They have many benefits to students and faculty in the health profession, including higher skill performance, increased knowledge, expanded critical thinking, and strong self-confidence. Kneeboneve et al. have argued that the integration of real persons in scenarios adds a unique reality dimension to the simulation. They have also stated that hybrid simulation has invaluable contributions to improving students’ communication and decision-making skills [11].

Research has indicated that nursing students experience stress before their involvement in clinical practice [12, 13, 14]. Simulation-based learning makes it possible for students to combine their learning and technical skills before entering clinical practice [15]. It has been reported that simulation-based learning methods are useful in reducing student stress before clinical practice [7]. On the other hand, the disadvantages of simulation training are rarely discussed in the literature. There are some disadvantages. Some of these are stressful situation for students, risk of blurring reality with simulation, risk of reducing professional development and standards of practice, and heavy financial burden of material and human resources invested in simulation [16]. It is important for trainers or faculty members to employ various teaching and learning methods to make it possible for students to adapt to the clinical setting [17, 18]. The aim of this study is to analyze the effects of a hybrid simulation technique used with nursing students in a scenario about the emergency setting.

2. Methods

3. Results

The participants were all female, and the mean age was 19.21 ± 0.52 years (min. = 19 – max = 21). Table 1 presents the views of the participants on the hybrid simulation activity. All of the participants reported that the simulation made it possible to develop a connection between their education and real world situations, that through it they identified topics that they should learn further, and that their motivation improved. They also stated that through the simulation, they recognized the significance of communication with team members and cooperation and that they found an opportunity to improve their knowledge base in the follow-up session. The participants liked the practice and suggested that it should be used in other clinical practices. Nearly all participants reported that the simulation improved their critical thinking, decision-making skills, and self-confidence before the clinical activity and that they felt as though they were real nurses during the activity (94.7%, 97.3%, 84.2%, and 92.1%, respectively). The majority of the participants (70.3%) stated that through the simulation activity, they were given an opportunity to combine their theoretical learning and applied knowledge.

Table 2 indicates that the total score of the participants on the patient intervention self-confidence/ competency scale was 75.23. Their scores on the subscales, namely clinical implementation, psychological support and knowledge of the health care system, were found to be close to the maximum scores (45.73, 16.71 and 12.78, respectively).

Table 3 presents the students’ statements during the debriefing session that was conducted after the simulation activity. More specifically, the students reported that during the activity, they recognized deficiencies in themselves and in their knowledge base. Positive remarks were mostly related to experiencing the situation before treating a real patient. The points they identified as needing improvement included the feelings of panic, being rushed, fear, and not knowing what to do. In addition, they reported that their communication with the patient’s relatives was weak.

All participants reported that the simulation made it possible for them to develop a connection with real world scenarios. Similarly, Siassakos et al. [20] and Higham et al. [21] found that the participants in their studies considered hybrid simulations to be realistic.

The participants also stated that through the simulation, they recognized the significance of communication with their team members and cooperation (Table 1). The scores of the participants on the subscale of psychological support in the Patient Intervention Self-Confidence/Competency Scale were very high (Table 2). However, the Δ statements of the participants during the debriefing session were mostly about the lack of effective communication (Table 3). In the teaching of basic psychomotor, procedural and technical skills, tutorials with low fidelity mannequins are employed. In the teaching of basic skills, both psychomotor skills and communicative skills were perceived to need improvement. Siassakos et al. [20] found that hybrid training resulted in better communication skills with patient actors than standard methods that lacked specific communication training. Additionally, hybrid simulations can be offered to students to cover complex scenarios and can help ensure patient safety, respect, and dignity during real-life encounters [22]. Tun et al. employed a hybrid simulation technique to assess the competency of emergency physicians. The participants in their study reported that the simulations allowed them to adequately demonstrate the range of skills and attributes (such as technical ability, communication, and professionalism) required to perform the procedure competently [23].

Another significant finding of the study was that through the simulation education, the participants identified topics that they should learn further (Table 2). During the debriefing session, the Δ statements of the participants also supported this finding. In debriefing sessions, deficiencies in performance based on the learning outcomes should be identified [24]. As the participants recognized that they needed to have much more information about certain points, it can be stated that the debriefing session achieved its goal.

Nearly all participants reported that the simulation improved their critical thinking, decision-making skills, and self-confidence (Table 1). Other research has suggested that simulation-based learning improves students’ critical thinking and decision-making skills, as well as their self-confidence [25].

The scores of the participants on the clinical implementation subscale of the Patient Intervention Self-Confidence/Competency Scale were very high (Table 2). The participants reported that the hybrid simulation activity improved their self-confidence in relation to clinical implementation, psychological support and knowledge of the health care system. The participants liked the practice and suggested that it should be used for other clinical practices and courses. Wagner et al. [26], Bambini et al. [27] and Kuznar [28] reported that simulation had a positive effect on self-confidence. Abdo and Ravert [29] found that simulation improved the self-confidence and clinical competence of half of their participants. Sun-yeun and Mi-ye concluded that hybrid simulation improved students’ knowledge and their performance in delivery nursing care [30].

5. Conclusions

Research has shown that simulation-based education allows for the combining of theoretical information and technical skills before the implementation of clinical activities [23, 31, 32, 33] Simulation should be an integrated part of nursing education programs to apply theoretical information in practice [34].

The results of this study support the integration of hybrid simulation experiences throughout the nursing curriculum, as evidenced by positive responses from students through the simulation evaluation questionnaire. However, many more studies are needed to identify how simulation can be integrated into nursing education programs [35]. In this study, it was found that simulation improved student nurses’ self-confidence in caring for patients.