Teaching and Learning in Nursing (2014) 9, 120–125

www.jtln.org

Simulation in associate degree nursing education:

A literature review

Laura Skrable MSN, RNC a,⁎, Virginia Fitzsimons EdD, RNC, FAAN b

a Ocean County College School of Nursing, Toms River, NJ 08754, USAb Kean University School of Nursing, Union, NJ 07083, USA

⁎ Corresponding author. Tel.: +1 73864 3872.

E-mail address: lskrable@ocean.edu

http://dx.doi.org/10.1016/j.teln.2014.03.001557-3087/© 2014 National Organization fo

KEYWORDS:Associate degree nursing;Nursing education;Simulation

Abstract The use of simulation in nursing education is increasing in scope and popularity.Many undergraduate nursing programs have adopted high-fidelity patient simulation as aneducational tool. The effect of simulation on teaching and learning is the focus of currentresearch. The aim of this literature review is to synthesize the research findings evaluatingsimulation specifically in associate degree nursing education. The results of the review

identified the following themes: critical thinking, clinical skill performance, knowledgeacquisition, student satisfaction, self-confidence, and anxiety. Gaps in the literature arehighlighted, implications for nursing education are explored, and recommendations for furtherresearch are provided.© 2014National Organization for Associate DegreeNursing. Published by Elsevier Inc. All rights reserved.

2 255 0400x2236; fax: +1 7

1r Associate Degree Nursing. P

1. Introduction

The use of high-fidelity patient simulation (HFPS) isincreasing in all types of undergraduate nursing educa-tion. Its prevalence has been presented in the NationalCouncil of State Boards of Nursing (NCSBN) NationalSurvey (NCSBN, n.d.). Associate degree nursing (ADN)programs across the United States have reported the useof high- and medium-fidelity simulators in their program,and 54% of the survey respondents are using simulationthroughout their nursing curriculum (Hayden, 2010).However, there is little research devoted specifically toADN and simulation. This is of major concern becauseADN programs comprise the majority of programs in the

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United States. The National League for Nursing (NLN)RN program statistics reports that, in 2012, there were1,084 associate degree programs, 696 baccalaureateprograms, and 59 diploma programs in the United States(NLN, 2013). “Associate Degree Nursing (ADN)faculty is challenged by the monumental responsibilityof preparing students to function as safe, professionalnurses in a two year course of study” (Miller,Leadingham, & Vance, 2010, p. 37). Integratingsimulation into the curriculum of ADN programs canpresent many challenges, and further research is neededin order to optimize the integration and use of HFPS innursing education (Adamson, 2010; Irwin, 2011). Manynurse educators struggle with how to evaluate the effec-tiveness of simulation within the curriculum and assessstudents. Evaluation of the effectiveness of simulation asa teaching tool and its effect on learning outcomes needsto be the focus of continued research (Foronda, Liu, &Bauman, 2013).

y Elsevier Inc. All rights reserved.

121Simulation in associate degree nursing education

2. Definitions

Simulation is defined according to the level of fidelityof the manikin or scenario. HFPS uses a full-bodysimulator that can be programmed to respond to psycho-motor and affective changes, such as SimMan®, METI-man®, and Noelle®. Medium-fidelity simulation uses afull-body simulator with installed human qualities such asbreath sounds: VitalSim™ is an example (Hayden, 2010,p. 52). ADN program refers to a program of instructionthat requires 2–3 years of college academic work,generally within a junior or community college, thecompletion of which results in an associate degree with amajor in nursing and eligibility to apply for licensure as aregistered nurse (www.iconsdata.org).

3. Background

Simulation is not new to nursing education. In 1911, Mrs.Chase became the first life-size mannequin for nursingstudents to practice their skills, and low-fidelity simulators ortask trainers have been used in nursing education since the1950s (Nehring & Lashley, 2010). In the 1960s, nursingstudents used Resusci Anne® cardiopulmonary resuscitation(CPR) trainers. In the 1980s, anesthesia simulators were usedfor medical education and graduate nursing anesthesiaprograms. In the year 2000, with the debut of the SimMan®,the use of high-fidelity simulation began to sprout withinnursing education (www.laerdal.com).

The 2010 Institute of Medicine (IOM) report, The Futureof Nursing: Leading Change, Advancing Health, recom-mends incorporation of technology, including high-fidelitysimulation, in nursing education (IOM, 2011). In theCarnegie Foundation for the Advancement of TeachingNursing Study, Benner revealed that a significant gap existsbetween current nursing practice and the education of nursesfor that practice (Benner, Sutphen, & Day, 2010). Simulationmay be one of the new educational tools that can narrow thatgap (Shinnick, Woo, & Mentes, 2011).

4. Literature review

Limited research is available devoted to the use ofsimulation in ADN programs. Because of this gap inacademic journals, most of the studies were located indoctoral dissertations. The types of studies found in theliterature included quantitative descriptive studies, mixedmethod studies, quasi-experimental, and retrospective quan-titative research. Qualitative studies were prevalent in theacademic journals. Many journal articles were descriptionsof simulation projects or recommendations for teachingstrategies (Irwin, 2011; Wolfgram & Quinn, 2012). A fewstudies included both bachelor of science in nursing (BSN)and ADN students as research participants.

4.1. Search engines and sources

The aim of the systematic review was to search the literaturethat included research on ADN programs and HFPS. Theelectronic databases used were Cumulative Index to Nursing(CINAHL), Academic Search Premier, Education ResourcesInformation Center (ERIC), Health Source: Nursing/AcademicEdition, Medline, Psycharticles, Proquest, and Science Direct.The selected databases included studies found in peer-reviewednursing journals, reviews, abstracts, full-text articles, theses, anddissertations. Search parameters included the years 2010–2013,so the most recent literature could be reviewed. Search criteriawere further limited to peer-reviewed research articles inEnglish.

CINAHL, Academic Search Premier, ERIC, HealthSource: Nursing/Academic Edition, Medline, and Psychar-ticles produced 55 references when the Boolean terms si-mulation and associate degree nursing in the title wereused. Science Direct produced 54 articles using the sameterms. ProQuest Dissertations & Theses Full Text produced12 references.

4.2. Range of perspectives

Literature chosen from the search included studies ofADN students or programs and use of medium or high-fidelity simulation. Virtual simulation and patient actorstudies were excluded. The studies chosen included 13quantitative, including two retrospective and three quasi-experimental methods, three qualitative, and two mixed-methods studies. Nine studies were chosen from academicjournals and 12 from dissertation and theses abstracts.Sample sizes ranged from 20 to 187 for individual studiesand 354 for a multisite study. Participants includedundergraduate ADN students and a combination of ADNand BSN students for the multisite studies.

5. Summary of findings

The research reviewed provides evidence that falls intothe following themes: critical thinking skills, clinical skillperformance, knowledge acquisition, student satisfaction andself-confidence, and student anxiety.

5.1. Critical thinking

Fascione, Fascione, and Sanchez (1994) define criticalthinking as the process of purposeful, self-regulatoryjudgment; an interactive and reflective reasoning processthat develops over time. Martin (2002) describes criticalthinking as the thought process used by nurses for clinicaldecision making and states that critical thinking increaseswith higher levels of clinical experience. Five recent studiesassessed the effects of HFPS on critical thinking skills ofADN students (Beebe, 2012; Goodstone et al., 2013;Melenovich, 2012; Rome, 2012; Spencer, 2011). Goodstone

122 L. Skrable, V. Fitzsimons

et al. (2013) studied 42 first-semester ADN students using atwo-group quasi-experimental design to explore the devel-opment of critical thinking for students who received HFPSversus instructor-written case studies with the same contentand learning objectives. Critical thinking was measuredusing the Health Sciences Reasoning Test (HSRT) in apretest/posttest design. Results showed a statistically signif-icant increase in critical thinking scores for both groups atposttest (p = .001); however, there was no statisticallysignificant difference in score improvement between theHFPS and case study group (p = .19). Rome (2012) also usedan experimental pretest/posttest design using the HSRT tomeasure critical thinking in relation to an 8-hour simulatedlearning experience versus a traditional clinical experiencefor 45 second year ADN students in a maternal–child course.Results indicated no significant difference in HSRT posttestscores between the simulated and traditional group. Spencer(2011) also found no significant difference in HSRT pre- andposttest critical thinking scores related to a single simulatedlearning activity.

Melenovich (2012) used Elsevier's Health EducationSystems, Inc. (HESI) Critical Thinking Difference scoresand California Critical Thinking Disposition Inventory scoresto evaluate the impact of additional HFPS experiences oncritical thinking. Although not statistically significant, theexperimental group had higher mean score differences frompretest to posttest compared with the control group. One study,Beebe (2012), used an ex-post-facto design to examine ifdifferences existed in critical thinking of 187 ADN graduatesfrom six cohorts who were exposed to different amounts ofsimulation exposure and fidelity. Scores from the students' exitHESI critical thinking subscore were used. Results revealed astatistically significant difference in critical thinking skillsbetween the cohorts (p = .003) and a positive linear trend inHESI critical thinking mean scores (p b .001) as exposure toand number of clinical hours substituted with simulationincreased. No significant differences were identified in criticalthinking based on the fidelity of simulation used. Conflictingstudy results necessitate further research on the effects ofHFPS on the acquisition of critical thinking skills.

5.2. Clinical skill performance

Three studies (Gantt, 2010; Garneau, 2012; Sportsman,Schumacker, & Hamilton, 2011) evaluated clinical perfor-mance of ADN students following high-fidelity simulation.Gantt (2010) describes a pilot study of 69 ADN studentswhose performance was evaluated and scored in a randomlyassigned manikin-based obstetrical or newborn simulationusing the Clark Simulation Evaluation Rubric. The evalua-tion tool was found to be useful for evaluation ofperformance but lacked interrater reliability. Garneau(2012) conducted a quantitative experimental study toexamine the effectiveness of delegation performance of 51fourth semester ADN students. The experimental groupcompleted an HFPS experience and a case study on

delegation as compared with the control group exposed tothe case study only. Pretest and posttest scores werecompared using the Nursing Assessment Decision Grid(NADG). Results indicated the experimental group NADGscores improved significantly more than the control group(p = .0092). Sportsman et al. (2011) performed a descriptive,longitudinal study with both ADN and BSN students todetermine if participation in high-fidelity simulation for aportion of clinical practicum would influence studentoutcomes. They found “no significant difference in meanscores for the Clinical Competence Appraisal Scale (CCAS)”(p. 264), a 6-point Likert scale to assess students' perceptionsof their own clinical competency. “There appears to be a lackof studies comparing student performance in simulation totheir performance in the clinical area” (Norman, 2012, p. 26).

5.3. Knowledge acquisition

In three of the studies examining knowledge acquisition(Beebe, 2012; Sportsman et al., 2011; Valente, 2010),standardized exit examination scores of multiple graduatingADN cohorts were analyzed to evaluate the effect ofexposure to varying amounts of simulation on scores.When six cohorts where compared, Beebe (2012) reporteda statistically significant improvement in HESI compositescores between the cohorts (p = .001). Sportsman et al.(2011) found no significant differences on exit examinationscores or graduating grade point averages when 3 years ofseniors were compared. Valente's (2010) study exploredstudent competency in the application of the nursing processusing the Assessment Technologies Institute exit examina-tion. Those results indicated a statistically significantdifference between scores for overall nursing processapplication between groups.

One study explored the impact of simulation on NationalCouncil Licensure Examination for Registered Nurses passrates. Terwilliger's (2013) study examined pass rates for the2 years before and 2 years after the addition of simulationinto ADN programs. Results of the study indicated anincrease of 3.69% in National Council Licensure Examina-tion pass rates after the implementation of simulation, adifference of p = .0001 level of significance.

Three recent studies reported statistically significantknowledge gains in groups exposed to HFPS using apretest/posttest design (Beyer, 2012; Fluharty et al., 2012;Schlairet & Pollock, 2010). Beyer (2012) examined use ofsimulation in the classroom with 45 ADN students. Resultsshowed that significant learning occurred (p = .0001).Student perceptions of the classroom simulation were alsomeasured using a Likert scale, along with open-endedcomments. Overall, the students perceived their knowledgehad increased by integrating the simulation into theclassroom. Schlairet & Pollock (2010) compared posttestscores between an HFPS group and a traditional clinicalgroup in a fundamentals course. Both groups indicated asignificant knowledge gain between pretest and posttest, but

123Simulation in associate degree nursing education

the knowledge scores of the simulated and traditional groupwere determined to be statistically equivalent. A multisitequasi-experimental study including 370 ADN students byFluharty et al. (2012) reported significant knowledge gainsfrom pretest to posttest in the total sample of students,regardless of the students' role in an end-of-life simulation.The highest change scores were found for students in theobserver role. Self-reported communication scores were alsohigh in this study, “reflecting the students' perceptionsthat they learned how to communicate with this type ofclient” (p. e141). Conflicting evidence exists on the impact ofsimulation on knowledge acquisition, an area requiringfurther research.

5.4. Learner satisfaction/confidence

Learner satisfaction and confidence were commonlydescribed themes in the literature related to simulation. Thestudies used survey tools developed by the NLN or othervalid and reliable instruments to measure learner satisfactionand confidence. Eight studies reviewed verified a positiveassociation with simulation and student confidence andsatisfaction (Conejo, 2010; Dougherty, 2011; Fluharty et al.,2012; Heston, 2010; Miller et al., 2010; Partin, Payne, &Slemmons, 2011; Re, 2011; Sportsman et al., 2011). In onequalitative study, students expressed that they “enjoyed thesimulation experience and felt that it facilitated theirlearning” (Partin et al., 2011, p. 188). Fluharty et al. (2012)concluded that “students felt more confident about caring fora particular client after experiencing the situation in asimulated, safe environment” (p. e141) as a result from theirmultisite quasi-experimental study. Although all studiesreviewed measured increased confidence and satisfactionlevels, the Heston (2010) experimental study of confidencelevels between students enrolled in traditional courses andstudents enrolled in courses incorporating HFPS in thecurriculum showed no statistical significant differences inconfidence levels between the two groups. The author of thestudy suggested that traditional instructional methodologiesare equally as effective in promoting self-confidence as thatof HFPS methodologies. The study results by Dougherty(2011) reported that students were satisfied and felt self-confident after a simulation interaction; however, there was aweak positive correlation between the two variables.

5.5. Anxiety

Two studies examined stress levels of ADN studentsinvolved in simulation. In the Partin et al. (2011) qualitativestudy exploring perceptions of associate in science students,a main theme identified was the nonthreatening environment.“A relaxed, nonthreatening atmosphere was found to reduceanxiety, increase confidence, and control external influencesthat distract from learning” (p. 187). The Todd (2011) studyused quantitative measures to investigate the effect of HFPSon the stress levels of novice ADN students prior to their first

clinical experience. A quasi-experimental pretest–posttestdesign was used to examine self-reported stress levels on theStudent Stress and Coping Inventory (SSCI) subscale. Theintervention group received practice on a high-fidelitysimulator prior to their first clinical day, the control groupdid not. Results revealed that the intervention participantsidentified significantly lower levels of stress on their SSCIposttests compared with the control group whose posttestscores increased. Findings confirmed a significant differencein overall mean stress scores between the two groups. Morequantitative research is needed to determine the relationshipbetween anxiety levels and effect on learning in a simulatedclinical environment.

6. Gaps in the literature

Although use of simulation is gaining momentum in ADNeducation, there are few studies on how to integratesimulation into the curricula of an ADN program. Adam-son's (2010) descriptive study offered recommendations forintegration based on survey responses from ADN facultyinvolved in the on-line survey. Results of the surveyindicated that schools are spending very little money onsupport and training past the initial simulator investment.Research regarding the underuse of simulation in nursingeducation is lacking. More evidence-based research isneeded on the efficacy of HFPS. Most of the studiesreviewed were based on learner self-perception or descrip-tive quantitative analysis. Experimental studies with largesample sizes need to be conducted to measure learningoutcomes. Most of the studies reviewed used smallconvenience samples. The literature also revealed that thereis a lack of valid and reliable tools specifically designed forhigh-fidelity simulation to measure learning outcomes. Agap in the literature also exists on the effects of simulation-based learning on clinical judgment or the transfer ofoutcomes to the clinical setting in ADN education.

7. Summary

The literature in this review suggests that exposure toHFPS increases standardized critical thinking test scores,although not significantly higher than other teachingmodalities. The impact of simulation on students' ability touse critical thinking is still not known. HFPS has beenreported to increase knowledge acquisition and skillperformance, although there is a need for valid and reliabletools to evaluate the effectiveness of simulation and learningoutcomes. Numerous studies reported that HFPS experiencesincreased student confidence levels. High satisfaction levelswith simulation experiences and integration into clinicaleducation were also reported. Engagement in a simulatedclinical environment has been reported to reduce stress levels

124 L. Skrable, V. Fitzsimons

of students and is identified as a nonthreatening environmentin which to learn.

8. Implications for nursing education

The use of simulated learning in ADN programs isemerging, although there is little research dedicatedspecifically to these programs. The NLN recommendsuse of simulation integration into undergraduate nursingcurricula. Competition for clinical sites is tremendous, soHFPS has been used to replace clinical in varyingpercentages, although there is little evidence basedresearch to support this pedagogy. The NCSBN iscurrently conducting a 3-year multisite nationwide studyincluding ADN and BSN programs to evaluate theeducational outcomes of 25% and 50% simulation use inplace of traditional clinical hours. After the cohorts ofnursing students graduate, they will be followed into theirclinical practice for 1 year to examine how well graduatenurses are prepared for practice. The study cohortsgraduated in May 2013, and data collection is scheduledfor completion December 31, 2014. “Study findings willprovide evidence for State Boards of Nursing as theydecide the acceptable level of simulation use within theirrespective states” (Hayden, Jeffries, & Kardong-Edgren,2012, p. e407). The results of this study will have atremendous impact for the future of simulation use in ADNprograms. Ongoing support and resources will be requiredfor improving integration into the curriculum and to meetthe curriculum's learning objectives. Integrating simulationis more than just purchasing expensive equipment.Educators need to be properly trained in order to guidethe simulation experience for effective learning. Simulatedlearning is an innovative way for students to practice in asafe environment without harm to actual patients. High-fidelity simulation can expose students to rare and criticalsituations that they may not see in traditional clinical.Technology will have a tremendous influence in bothhealth care and educational institutions.

9. Research recommendations

It is evident that more research is required to advance thepractice of simulation in ADN education. Continued researchefforts are needed in the following areas:

• Effects of simulation on acquisition of critical thinking skills• Comparison of student performance in simulation to their

performance in the clinical area• Students' knowledge acquisition through simulation as

compared with traditional clinical• The relationship between anxiety levels and effects on

learning in a simulated clinical environment• Effects of simulation on clinical judgment and transfer of

learning outcomes to clinical

• Development of valid and reliable measurement tools tomeasure learning outcomes of simulation

• The underuse of high-fidelity simulators in nursing education

10. Conclusion

The available literature on simulation and ADN educationindicates that high-fidelity simulation has the potential to bea highly effective teaching and learning strategy thatcontributes to knowledge, skills, and confidence. Successfulintegration into the curricula and ongoing faculty support andtraining is crucial for a successful simulation program.Further evidence-based research is required to fully evaluatethe influence of this technology on ADN education.

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