Advertisement

High-Fidelity Simulation in Undergraduate Nursing Education: A Review of Simulation Reviews

Published:April 28, 2016DOI:https://doi.org/10.1016/j.ecns.2016.01.009

      Highlights

      • Findings from simulation research and reviews revealed significant differences in design and assessment methods leading to a wide variety of measurement outcomes and limitations.
      • Standardization of implementation of high-fidelity simulation by nurse educators is essential.
      • A need for research that translates simulation outcomes to future practice.

      Abstract

      The purpose of this focused review was to provide an overview of existing high-fidelity simulation reviews in undergraduate nursing education. ​Over the last 10 years, there has been a substantial increase in the use of high-fidelity simulation in undergraduate nursing education. Six reviewers conducted a systematic literature search on existing reviews of high-fidelity simulation and undergraduate nursing education from January 1, 2009, through June 30, 2015. Using a comprehensive search of literature databases and hand searches, a total of 34 reviews were initially selected for full review with seven reviews included in the final analysis after rereview of the inclusion/exclusion criteria. Findings from simulation research and reviews revealed significant differences in design and assessment methods leading to a wide variety of measurement outcomes and a variety of limitations. Of the seven reviews, five were integrative reviews and two were reviews of the literature. No meta-analysis or systematic reviews met the inclusion criteria. The review suggests a need for methodologically sound research that translates simulation outcomes to future performance and practice. Findings from the review support the multitude of challenges in simulation research including a lack of funding, a lack of simulation training for faculty and staff, and a lack of support for faculty conducting simulation research. Limitations of prior studies include weak designs, mixed samples, and a lack of valid and reliable evaluation tools.

      Keywords

      Key Points
      • There is a need for rigorous research that translates simulation outcomes to practice.
      • Standardization of implementation of high-fidelity simulation is essential.
      • Differences in research design and assessment methods lead to limitations of findings.
      Over the last 10 years, there has been an increase in attention by the United States and other jurisdictions in developing guidelines or regulations that support simulation as a substitute for traditional clinical time for undergraduate nursing students. According to (2014), 22 Registered Nurse State Boards of Nursing support simulation at some level as a substitute for clinical. The number of clinical hours that can be replaced is variable with most State Boards of Nursing remaining silent or deciding on replacement hours on a case to case basis. A number of states are currently in the process of reviewing regulations to support replacement of clinical hours, which may be a direct response to the recent landmark study by the National Council of State Boards of Nursing (NCSBN;
      • Hayden J.K.
      • Smiley R.A.
      • Gross L.
      Simulation in nursing education: current regulations and practices.
      ).
      The 2014 NCSBN study found that up to a 50% substitution of traditional clinical time with high-fidelity simulation (HFS) yielded no statistically significant differences in outcomes from those with other more traditional methods of clinical. Importantly, National Council Licensure Examination pass rates, nursing knowledge assessments, and perceived readiness for practice postgraduation did not differ between prelicensure nursing students who spent their hours in traditional clinical as compared with a 25% or 50% replacement of those hours with HFS. The NCSBN suggests that learning through simulation is dependent on high-quality simulation. Likewise,
      • Cant R.P.
      • Cooper S.J.
      Simulation-based learning in nurse education: Systematic review.
      concluded that the use of simulation can be related to knowledge gains but only when best practice guidelines are utilized.
      The International Nursing Association for Clinical Simulation and Learning published nine guidelines for best practice of simulation designed to provide evidenced-based guidelines for the development and integration of simulation (
      • International Nursing Association of Clinical Simulation and Learning Standards Committee
      Standards of best practice in simulation I-IX.
      ). Further support for best practice of simulation can be found in meta-analyses, systematic, integrative, reviews of the literature, and other types of reviews on the practice of clinical simulation. However, findings of simulation reviews on a variety of outcomes have thus far been inconclusive, and consistent limitations of these studies have included significant differences in design and assessment methods (
      • Cant R.P.
      • Cooper S.J.
      Simulation-based learning in nurse education: Systematic review.
      ,
      • Yuan H.B.
      • Williams B.A.
      • Fang J.B.
      The contribution of high fidelity simulation to nursing students' confidence and competence: A systematic review.
      ).
      Standard I Terminology in the Standards of Best Practice (
      • Meakim C.
      • Boese T.
      • Decker S.
      • Franklin A.E.
      • Gloe D.
      • Lioce L.
      • Borum J.C.
      Standards of best practice: simulation standard I: terminology.
      ) defines HFS as: “experiences using full scale computerized patient simulators, virtual reality or standardized patients that are extremely realistic and provide a high level of interactivity and realism for the learner” (p. S6). For the purposes of this review, the definition of HFS was noted as a simulated learning experience using full-scale computerized human patient simulators. The objective of this appraisal of simulation reviews was to provide a narrative description of existing HFS reviews to assist academic nurse educators in examining simulation topics that are well studied and to identify areas that need further investigation. The results can be used to inform future research topics in simulation utilizing HFS as an effective teaching–learning strategy in the education of undergraduate nursing students.

      Methods

      Framework/Design

      Six reviewers conducted a systematic literature search on existing reviews of HFS and undergraduate nursing education. Integrative, best practice, reviews of the literature, and critical reviews were appraised with the Critical Appraisal Skills Programme (
      Critical Appraisal Skills Programme (CASP)
      CASP checklists.
      ). CASP is a 10-question checklist used to evaluate a variety of research studies. The CASP was a good fit because the scale offered a systematic way to evaluate reviews of simulation across six individual reviewers. Although the CASP was designed for a single review, the criterion on the scale was helpful for this review of reviews because each reviewer examined the same critical components. This provided a way to compare the quality of each review.
      Research questions were framed using a structured approach that identifies essential elements of a research question. Those elements are; the patient population (P), the intervention (I), the comparator group (C), the outcome or endpoint (O), and the study design chosen (S) (PICO) (
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      The PRISMA Group (2009) preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
      ). For this review of simulation reviews, the “patient population” was composed of review articles of HFS in undergraduate nursing education. The “intervention” was a summary in narrative form of the findings of the reviews. The “comparison” was a discussion that compared and contrasted findings, and the “outcome” was a summary of what is known and what needs more investigation in HFS in undergraduate nursing education. “Timing” was added (
      NYU Libraries
      PICO (T) Project toolkit: Welcome.
      ) because the date range for the review of simulation reviews was an important component for inclusion criteria. The date limit for the review of reviews was January 1, 2009, through June 30, 2015. The study design was a methodological review of simulation reviews. The research questions were:
      • 1.
        What topics are well studied in undergraduate nursing education and HFS?
      • 2.
        What topics in undergraduate nursing education and HFS require more investigation?

      Search Strategy

      An initial search was conducted in the Joanna Briggs Institute and the Cochrane Library databases to determine if a review of simulation reviews had already been completed. There were no reviews of simulation reviews found. A systematic search and retrieval method was used by the reviewers to search the following databases: PubMed, Academic Search Premiere, Cumulative Index to Nursing and Allied Health Literature, Scopus, Medline, ProQuest Nursing Journals, Excerpta Medica database, and PsycINFO. Journal searches included Clinical Simulation in Nursing, Simulation in Healthcare, Nursing Education Perspectives and the National League for Nursing's database. Hand searches of bibliographies did not produce new reviews. Dissertation databases for published or unpublished dissertations and unpublished works were excluded. Approximately 2,309 review articles were identified that had the word “review” in the title. After 632 duplicates were eliminated, abstracts were scanned to exclude simulation reviews that did not focus on undergraduate nursing students and HFS. Most of the review articles did not meet inclusion criteria (Figure; Table 1). Thirty-four review articles were selected for full read. Twenty-seven of these reviews were excluded because they either contained individual studies where the samples were a mix of undergraduate and others, such as practicing nurses and physicians or they were not purely HFS. A sample of seven reviews was included in the final review. Of those, one review was from Australia, and those remaining were from the United States. All six reviewers were in 100% agreement on the final selection of HFS reviews in undergraduate nursing education.
      Table 1Summary Critical Appraisal Skills Programme Results
      QuestionsBerndtBlumFisherShearerWeaver
      1. Review addressed a clearly focused question?11110
      2. Authors looked for right type of articles?11111
      3. Important, relevant studies were included?11111
      4. Authors assessed the quality of included studies?01110
      5. If results of review are combined, was it reasonable to do so?10110
      6. What are the overall results of the review? (cannot be answered by a 1 or 0)See belowSee belowSee belowSee belowSee below
      7. How precise are the results? (cannot be answered by a 1 or 0)See belowSee belowSee belowSee belowSee below
      8. Can results be applied to a local population?01101
      9. Were all important outcomes considered?00110
      10. Are the benefits worth the harms/costs?11111
      Total56874
      Summary Responses for Questions 6 and 7
      6. What are the overall results of the review? (cannot be answered by a 1 or 0)If yes/no7. How precise are the results? (cannot be answered by a 1 or 0)If yes/no
      BerndtThe results are reported as qualitative summary vs. statistical results. No statistical data provided for the results.

      Results:

      “The evidence supports the use of simulation to teach patient safety competencies”

      Simulation is effective in teaching prelicensure nursing students

      Simulation can be used to educate prelicensure nursing students on patient safety.
      1They lack precision. They are qualitative or a summary rather than statistical.0
      BlumOverall results are reported, but not numerically. There is a lack of unequivocal evidence to support a change in the nursing education toward simulation-based education for prelicensure safety competencies. Evidence is still lacking to support simulation as a method to improve patient safety.1Not precise at all0
      FisherResults were expressed clearly through coding of themes that emerged through thematic analysis of the findings. These themes were: “transferability of simulation skills to clinical practice,” “exposure to broader range of experiences,” “confidence levels in relation to simulation training,” “competence/performance,” “clinical judgment and knowledge,” and “student perceptions of preparedness for practice after simulation.”1Both authors reviewed studies and performed thematic analysis. Then, a comparison of coding was performed. The thematic analysis was performed with color coding and numbering of codes.1
      ShearerThe results were summarized according to subheaders: medication errors, patient identification, hand hygiene, communication and knowledge, and skills and attitudes. Articles were analyzed by outcome and coded and scored. Only those with a score more than four were analyzed in matrix. Two studies provided evidence for effectiveness of high-fidelity simulation on outcomes of safety. Effect of communication was inconsistent.1This is difficult to tell. The data table is helpful, but the matrix of scores is not available in table format to indicate which studies had the higher scores.0
      WeaverConcepts of confidence, knowledge, knowledge transfer, value, realism, and stress emerged from the review on the effects of HFPS in nursing education. More research is needed because of large gaps in literature.

      The question posed in second paragraph (does the evidence support HFPS as an alternative to clinical experience with real patients?) was never addressed. The narrative also questioned if the benefit of HFPS outweighed the cost for equipment and faculty training. This question was also never addressed.

      Results expressed in narrative form only.
      0Results were expressed in narrative form only. It is unknown how precise the results are.0
      *Can question #6 say “overall results clear?” to make it a yes/no question?
      *Can question #7 say “results are precise?” to make it a yes/no question?

      Inclusion and Exclusion Criteria

      The inclusion and exclusion criteria were reviewed at regular intervals to maintain rigor and standardization (Table 2). The criteria appeared straightforward when the abstracts were initially appraised, yet on review of the full article, it became clear that many abstracts did not clearly define the sample population or the type of simulation studied. For example, some of the titles and abstracts that were initially screened indicated that the review was limited to undergraduate nursing education and HFS, but on further review, it was found that other health care professions were included in the review with low and medium fidelity and other types of simulation that were not manikin based. To determine if the article met inclusion and exclusion criteria, a thorough review of the full articles were completed by multiple reviewers. A decision was made not to include studies that used mixed modalities, such as medium or low fidelity and/or varied participant samples, such as interprofessional disciplines, graduate and undergraduate students, as this would have strayed from the aim of this review and altered the findings (
      • Shin S.
      • Park J.H.
      • Kim J.H.
      Effectiveness of patient simulation in nursing education: Meta-analysis.
      ). The reviewers determined that it was imperative to adhere to the inclusion and exclusion criteria, so that the findings of this review of reviews would inform the practice of HFS in undergraduate nursing programs.
      Table 2Inclusion and Exclusion Criteria
      Inclusion CriteriaExclusion Criteria
      • High-fidelity simulation
      • Any review (review of the literature, critical review, best practice, integrative, systematic, meta-analysis)
      • Reviews from January 1, 2009, to June 30, 2015
      • English language
      • Low- to mid-fidelity simulation
      • Interprofessional simulation reviews
      • Standardized patients
      • Other health care professions
      • Foreign language
      • Computer-based simulation
      • E-learning
      • Virtual simulation/avatar
      • Web-based simulation
      Articles before 2009

      Developing Keywords

      The initial development of search terms began with the following: simulation; simulation and meta-analysis; simulation and systematic; simulation and integrative; simulation and review of the literature; simulation and critical review; and simulation and best practice review. These were further refined to include nurse. The keyword “simulation” was further refined to “high-fidelity simulation.” Final keywords were meta-analysis and high-fidelity simulation (or simulation) and nursing; systematic review and high-fidelity simulation (or just simulation) and nursing; and integrative review and high-fidelity simulation (or just simulation), review of the literature and high-fidelity simulation (or just simulation) and nursing. Additional searches with the same keywords were conducted accepting the word “review” in the abstract or in text.
      The terms prebrief and debrief were cross matched with all final keywords to investigate whether there were any published reviews focused on the prebrief and debrief as these are considered critical components of the simulation experience (
      • International Nursing Association of Clinical Simulation and Learning Standards Committee
      Standards of best practice in simulation I-IX.
      ). To further refine, “ing” was added to prebrief and debrief which broadened the search and yielded more articles for debrief; however, no additional articles were found for prebrief.

      Results

      Meta-Analysis

      A meta-analysis is a statistical methodology used to combine findings from several independent studies and in particular provides a way to systematically conduct a scientifically valid review of multiple primary research studies on a common research problem (
      ). Statistical methods are used to combine evidence from these studies to provide one overall effect size. To conduct a meta-analysis, each primary study should have a common research problem and be similar or identical in methodological design (
      • Whittemore R.
      • Knafl K.
      The integrative review: Updated methodology.
      ). Consequently, a meta-analysis can provide researchers one overall effect size of an intervention and potentially provide a more precise treatment effect estimate given that meta-analysis results are based on an overall increased sample size owing to combining studies. However, if the primary studies within the meta-analysis are not similar or are not methodologically sound, the findings may not be valid (
      • Gall M.D.
      • Gall J.P.
      • Borg W.R.
      Educational research: An introduction.
      ). As an example, when researchers include individual studies that conduct simulation education differently (i.e., high fidelity to low fidelity, virtual reality) as compared with traditional education (i.e., lecture, power point) for evidence that one is more effective than the other; the differing methods used in the studies may invalidate the overall effect size estimate and hence the estimate of the treatment effect. This review suggests that users of simulation research are not clear on the evidence provided by multiple studies.
      Three meta-analyses were identified from the initial literature search but were excluded. These were excluded because participant samples included new novice nurses, nurse practitioner graduates, and a variety of participants in health care professions; and fidelity was not limited to HFS but included low- and medium-fidelity simulation in their analyses.

      Systematic Reviews

      A systematic review is a review that examines the evidence for a clinical problem or is meant to establish an evidence base for clinical practice. This requires a succinct and specific clinical question, a systematic search methodology with a thorough search for pertinent primary studies (
      • Whittemore R.
      • Knafl K.
      The integrative review: Updated methodology.
      ). If the primary studies included in a systematic review are similar or identical than a meta-analysis, as defined previously, may be appropriate to provide the strength of the evidence, or an effect size, for an intervention (
      ). However, if statistical findings cannot be pooled, then a narrative analysis can be completed. For example, studies in a systematic review that are quasi-experimental cannot be combined in a useful way with randomized controlled trials (
      ).
      An initial search resulted in seven systematic reviews on HFS and undergraduate nursing education. Individual research studies within the reviews included interprofessional samples and included low- and medium-fidelity simulation. The systematic reviews also examined other methods of simulation that were part of the exclusion criteria, including, peer-to-peer learning, virtual reality, and standardized patients. Novice nurses and graduate nursing students (i.e., midwifery education) as well as medical students and residents were also included in participant samples; therefore, all seven articles were excluded because they did not meet the inclusion criteria.

      Integrative Reviews

      Data Collection

      An integrative review is a broad search of the literature on a topic of interest that includes experimental, quasi-experimental, and qualitative studies (
      • Whittemore R.
      • Knafl K.
      The integrative review: Updated methodology.
      ). A wide range of topics, such as examining the definition of a concept, a review of a nursing or learning theory, and the use of HFS in undergraduate nursing education, can be addressed by an integrative review (
      • Whittemore R.
      • Knafl K.
      The integrative review: Updated methodology.
      ). Findings are reported in descriptive or narrative form rather than statistically. However, integrative reviews benefit from an explicit search methodology that strengthens the validity of the narrative description of a phenomenon of interest (
      • Whittemore R.
      • Knafl K.
      The integrative review: Updated methodology.
      ).
      Five integrative reviews were identified from the search (Table 3). The five integrative reviews (
      • Berndt J.
      Patient safety and simulation in prelicensure nursing education: An integrative review.
      ,
      • Blum C.A.
      • Parcells D.A.
      Relationship between high-fidelity simulation and patient safety in a prelicensure nursing education: A comprehensive review.
      ,
      • Fisher D.
      • King L.
      An integrative literature review on preparing nursing students through simulation to recognize and respond to the deteriorating patient.
      ,
      • Shearer J.E.
      High-fidelity simulation and safety: An integrative review.
      ,
      • Weaver A.
      High-fidelity patient simulation in nursing education: An integrative review.
      ) included studies that were quantitative, qualitative, and mixed methods.
      • Berndt J.
      Patient safety and simulation in prelicensure nursing education: An integrative review.
      and
      • Fisher D.
      • King L.
      An integrative literature review on preparing nursing students through simulation to recognize and respond to the deteriorating patient.
      used a systematic method of appraisal to rate the studies in their review. Of the five integrative reviews, three focused on simulation related to safety (
      • Berndt J.
      Patient safety and simulation in prelicensure nursing education: An integrative review.
      ,
      • Blum C.A.
      • Parcells D.A.
      Relationship between high-fidelity simulation and patient safety in a prelicensure nursing education: A comprehensive review.
      ; and
      • Shearer J.E.
      High-fidelity simulation and safety: An integrative review.
      ); one included articles that reviewed simulation in nursing education (
      • Weaver A.
      High-fidelity patient simulation in nursing education: An integrative review.
      ); and one focused on responding to the deteriorating patient (
      • Fisher D.
      • King L.
      An integrative literature review on preparing nursing students through simulation to recognize and respond to the deteriorating patient.
      ).
      Table 3Review Article Grid
      CitationType of ReviewThe Objective of This Review Was to:Findings/ResultsConclusionLimitationsImplications/Future Research
      Berndt, J. (2014). Patient safety and simulation in prelicensure nursing education: An integrative review. Teaching and Learning in Nursing 9, 16-22.Integrative reviewCritically analyze the evidence on the use of simulation as an educational intervention to teach patient safety competenceIncluded studies focused on simulation, patient safety and simulation, and patient safety in prelicensure nursing education. Found 13 studies that investigated simulation as an educational intervention, and five studies that studied simulation as the outcome of patient safety.The authors concluded that simulation is an effective educational intervention to teach patient safety competencies in prelicensure nursing education.The review included all types of studies including qualitative and quantitative. It is surprising that given this lack of exclusion that they only found 13 studies examining simulation as an educational intervention in prelicensure nursing education.Review suggests that studies focusing on patient safety and simulation effectiveness of simulation in interprofessional simulation, knowledge retention, and the National Council Licensure Examination will evolve and will bolster the incorporation of simulation into curricula as a standard educational intervention to improve patient safety.
      Blum, C. A., & Parcells, D. A. (2012). Relationship between high-fidelity simulation and patient safety in a licensure nursing education: A comprehensive review. Journal of Nursing Education, 51(8), 429-35. doi:10.3928/01484834-20120523-01Comprehensive reviewEvaluate the current quantitative evidence from preintervention–postintervention and control–experimental research studies related to the use of simulation in prelicensure nursing education directed at enhancing safety in nursing practiceThis review of 18 studies found that evidence is still lacking on measuring outcomes of simulation related to patient safety.The authors concluded that simulation is essentially equal to traditional methods of teaching safety in nursing education.The review did not list limitations to the review but discussed limitations to methodology as each study was critiqued.The review suggests a reevaluation of clinical training paradigms and on best practice in teaching. One recommendation is to continue research on the use of simulation to cultivate safety competency in undergraduate nursing students. The use of simulation should be validated in longitudinal studies using safety-based educational models.
      Fisher, D., & King, L. (2013). An integrative literature review on preparing nursing students through simulation to recognize and respond to the deteriorating patient. Journal of Advanced Nursing, 69(11), 2375-2388.Integrative reviewTo review current research studies on the effectiveness of simulation to prepare nursing students to recognize and respond to a patient in decline and to inform future undergraduate nurse educators and researchers in simulationThis review of 18 research studies found that Thematic analysis identified six main themes: “transferability of simulation skills to clinical practice”; “exposure to broader range of experiences”; “confidence levels in relation to simulation training”; “competence/performance”; “clinical judgment and knowledge”; and “student perceptions of preparedness for practice following simulation.”The authors concluded that confidence, clinical judgment, knowledge and competence, all vital in the care of a deteriorating patient, were enhanced due to simulation learning. However, evidence of simulation used specifically to prepare nursing students to recognize and respond to the deteriorating patient appeared limited.The review listed limited sample size, single locations, and limited statistical rigor.This review describes the need for more robust research, longitudinal studies to explore skill transferability, clinical judgments, knowledge, confidence, competence, performance, and effective preparation of nursing students.
      Shearer, J. E. (2013). High-fidelity simulation and safety: An integrative review. The Journal of nursing education, 52(1), 39-45. doi: 10.3928/01484834-20121121-01Integrative reviewTo evaluate the evidence that the use of high-fidelity simulation (HFS) in nursing education may improve patient safety outcomes. Safety was operationalized as self-efficacy, perceptions of abilities, knowledge, attitudes, and safety competencies observed as safety behaviors and nursing skills that were thought to avoid patient harmThe results were summarized according to the following outcomes: medication errors, patient identification, hand hygiene, communication and knowledge, skills, and attitudes. Two studies provided evidence for effectiveness of HFS on outcomes of safety. The effect of communication was inconsistent.From this review, the author concluded that two studies provided evidence HFS was effective on the outcome of avoiding medical errors and patient identification. The other 18 studies did not provide equivocal evidence that HFS as a learning strategy has an impact on patient safety behaviors.The review listed limitations: as a limited time range 2007-2012, search terms may not have been optimal; fidelity of simulation was assumed in some of the studies to be HFS, timing during the semester students went into clinical rotations, In addition, bias by the author for positive findings for a published work.This review recommends more research on safety outcomes with comparison groups and based on a simulation model or theory to advance nursing science in HFS.
      Weaver, A. (2011). High-fidelity patient simulation in nursing education: An integrative review. Nursing Education Perspectives, 32(1), 37-40.Integrative reviewTo evaluates the findings of recently published researchFrom this review of 24 articles, the outcomes of confidence, knowledge, knowledge transfer, realism, value, and stress were discussed.From this review, the author found that HFS benefits nursing students in terms of knowledge, value, and realism. More research is needed to support the use of HFSThe review did not list limitations.This review recommends further research in the areas of communication, feedback and support during the implementation of simulation. Student satisfaction is listed but is not needed. New theories and models, knowledge acquisition compared with traditional findings. Knowledge transfer, debriefing and vidoetaping, since this article was published in 2011, some of these topics have been addressed in research studies. Confidence is considered a topic that is well studied in HFS.
      Neill, M. A. & Wotton, K. (2011). High-fidelity simulation debriefing in nursing education: A literature review. Clinical Simulation in Nursing, 7(5), e161-e168. doi:10.1016/j.ecns.2011.02.001Review of the literatureTo analyze the literature on the use of simulation debriefing in nursing education. In addition, to make recommendations for further research.Thematic analysis revealed six themes: structured and unstructured debriefing, faculty debriefing demeanor, a safe and trusting environment, the use of probing and cueing questions, the best time to debrief and allocation of adequate time for debriefing.This literature review confirmed that debriefing is central to successful HFS education strategies. However, the review identified the scarcity of nursing research exploring debriefing (this may not be so true anymore).No real limitations noted. Since this has been published, there has been a great deal more done on debriefing.The identified themes of the review revealed that much is still in debate on the foundations for a recognized debriefing framework. Further research is required to guide refinement of best practices leading to a debriefing environment more conducive to reflection and experiential learning. Also, missing comparison studies
      Page-Cutrara, K. Use of Prebriefing in Nursing Simulation: A Literature Review. Journal of Nursing Education, 53(3), 136-141.Review of the literatureTo comprehensively review available nursing simulation literature on the phenomenon of prebriefing and to critically evaluate its current role as a component of undergraduate nursing simulationNarrative findings for the review were organized into themes: the definition and purpose of prebriefing, alternate learning structures used in prebriefing, and it uses in relation to learner outcomes.This literature review concluded prebriefing is an important role as one component of HFS. Prebriefing should be leveled to the learner. Prebriefing may have a positive effect on the development of clinical judgmentOne study of 15 was specific to prebriefing. Some of the articles did not fully describe simulation experiences of participants or the prebriefing activities. There were undefined time frames and differences the content and complexity of prebrief.Prebriefing is an understudied component of HFS. Further research is needed to validate its practice. Recommend replicating small sample studies using larger sample sizes; investigate if more time in prebrief and orientation to simulation has an impact on learning; does prebriefing have an impact on the development of clinical judgment.

      Findings

      Three of five integrative reviews validated simulation is an effective teaching-learning strategy in prelicensure nursing education (
      • Berndt J.
      Patient safety and simulation in prelicensure nursing education: An integrative review.
      ,
      • Blum C.A.
      • Parcells D.A.
      Relationship between high-fidelity simulation and patient safety in a prelicensure nursing education: A comprehensive review.
      ,
      • Weaver A.
      High-fidelity patient simulation in nursing education: An integrative review.
      ). A CASP review was scored on each of the five articles (Table 3). Of the 10 questions on the CASP review, eight questions were answered as a yes/no question and received a point value of one for yes and zero for no for a total possible points of eight. Two of the questions were answered by summarizing the results and are included as part of this review. For the five articles reviewed, the range of scores was from four to eight.
      The concepts and themes that emerged from the analysis of the integrative reviews of simulation included the following: confidence, satisfaction, attitudes, interdisciplinary experiences, skills, knowledge, anxiety, safety, situational awareness, and fidelity. A few of these concepts and themes were further subdivided. For example, safety was subdivided into medication safety, handwashing, and communication, and knowledge was subdivided into knowledge acquisition and knowledge transfer.
      The integrative reviews concluded that simulation is as effective as other educational approaches and is an excellent interactive teaching–learning strategy in prelicensure nursing education in which there is a high degree of student satisfaction. Although there were several recommendations for further research exploring outcomes of simulation, there was an increasing focus on patient safety as an outcome of simulation. Overall, HFS is being used for multiple learning opportunities, and it is seen as a safe-learning environment.
      Some limitations of the integrative reviews were noted. First, only two of the five reviews specified a specific appraisal system (
      • Berndt J.
      Patient safety and simulation in prelicensure nursing education: An integrative review.
      ,
      • Fisher D.
      • King L.
      An integrative literature review on preparing nursing students through simulation to recognize and respond to the deteriorating patient.
      ). The two reviews that did use a specific appraisal system were published most recently, so perhaps the process for reviews is becoming more rigorous over time. The second limitation noted was the inability to ascertain the quality or rigor of the studies that these particular reviews included in their analysis. Third, for most of the reviews, there was a gap in the time frame from when the reviews were completed to publication time and again from when they were published to when this review was performed. Although the findings and conclusions of the integrative reviews were relevant at the time of publication, some of the conclusions and recommendations may currently be dated.

      Reviews of the Literature

      Data Collection

      Two reviews of the literature were found using the search and inclusion criteria. One review of the literature was on debriefing and met the inclusion criteria for this review.
      • Neill M.A.
      • Wotton K.
      High-fidelity debriefing in nursing education: A literature review.
      searched the literature between 2000 and 2010 to identify current HFS debrief practices in nursing education. Because the search results were small, the authors included two literature reviews and a discussion paper for a total of nine articles (
      • Neill M.A.
      • Wotton K.
      High-fidelity debriefing in nursing education: A literature review.
      ). The review yielded a narrative analysis of the debrief experience.
      A second review of the literature (
      • Page-Cutrara K.
      Use of prebriefing in nursing simulation: A literature review.
      ) on prebriefing was found to initially meet the search and inclusion criteria. Page-Cutrara completed a literature review of research that included scholarly works on the use of prebriefing in nursing simulation. On further review, it was noted that despite the review's inclusion of participant samples of undergraduate nursing students, Page-Cutrara also included emergency department nurses, health care professionals, and graduate nurses. Because there was no more than the
      • Neill M.A.
      • Wotton K.
      High-fidelity debriefing in nursing education: A literature review.
      review on prebrief, the authors addressed the review by Page-Cutrara here but caution readers that when combining mixed participant samples, it is difficult to isolate those factors that have an impact on the use of HFS with undergraduate nursing students. After careful consideration, the authors decided to keep this article in the review as prebriefing is not specific to any health care discipline or level of nursing education.

      Findings

      Thematic analysis of the review on debriefing (
      • Neill M.A.
      • Wotton K.
      High-fidelity debriefing in nursing education: A literature review.
      ) disclosed the following six main themes: structured or unstructured debriefing, faculty debriefing demeanor, a safe and trusting environment, use of probing and cuing questions, the best time to debrief, and allocation of adequate time for debriefing (
      • Neill M.A.
      • Wotton K.
      High-fidelity debriefing in nursing education: A literature review.
      ) with an expanded discussion of the six themes that supported effective debriefing strategies. Effective debriefing is achieved through linking the patient care situation to learning objectives (
      • Neill M.A.
      • Wotton K.
      High-fidelity debriefing in nursing education: A literature review.
      ). However, this review provided evidence that debriefing practices vary greatly (
      • Dufrene C.
      • Young A.
      Successful debriefing-best methods to achieve positive learning outcomes.
      ,
      • Levett-Jones T.
      • Lapkin S.
      A systematic review of the effectiveness of simulation debriefing in health professional education.
      ).
      The findings from the
      • Page-Cutrara K.
      Use of prebriefing in nursing simulation: A literature review.
      review found that prebriefing prepares the participant for simulation activities and creates relevance to learning objectives. It was posited that prebriefing may increase the engagement level of the learner in simulated experiences (
      • Page-Cutrara K.
      Use of prebriefing in nursing simulation: A literature review.
      ). This phase of simulation may benefit the learner by initiating clinical thinking that will enhance the development of clinical judgment.
      One unique finding identified in the
      • Page-Cutrara K.
      Use of prebriefing in nursing simulation: A literature review.
      review was the relatively recent introduction of the term prebrief (
      • Page-Cutrara K.
      Use of prebriefing in nursing simulation: A literature review.
      ). This phase of the simulation experience is not well identified in the literature (
      • Page-Cutrara K.
      Use of prebriefing in nursing simulation: A literature review.
      ). The themes synthesized from the two reviews captured elements applicable to both prebriefing and debriefing (
      • Page-Cutrara K.
      Use of prebriefing in nursing simulation: A literature review.
      ,
      • Neill M.A.
      • Wotton K.
      High-fidelity debriefing in nursing education: A literature review.
      ). These themes included the purpose and structure of the experience, time allotment for the activity, linkage of objectives to the experience as well as faculty skill and effect to engage the learner.
      Prebriefing prepares the participant for simulation activities and creates relevance to the learning objectives. This phase of simulation may benefit the learner by initiating clinical thinking that will enhance the development of clinical judgment. Effective debriefing is achieved through linking the patient care situation to learning objective (
      • Neill M.A.
      • Wotton K.
      High-fidelity debriefing in nursing education: A literature review.
      ). However, this review provided evidence that debriefing practices vary greatly (
      • Dufrene C.
      • Young A.
      Successful debriefing-best methods to achieve positive learning outcomes.
      ,
      • Levett-Jones T.
      • Lapkin S.
      A systematic review of the effectiveness of simulation debriefing in health professional education.
      ).
      An important finding for this review was that prebriefing and debriefing are understudied. As an example,
      • Dufrene C.
      • Young A.
      Successful debriefing-best methods to achieve positive learning outcomes.
      review on debriefing started with just undergraduate nursing students, but when the search yielded only two studies related to undergraduate nursing students, the authors subsequently expanded the search to include medical and emergency room residents, anesthesiology residents, and practicing anesthetists.
      Some limitations of the reviews are due to the lack of standardized terminology adopted by educators to describe what occurs in advance of the simulation. Language encountered in the literature included briefing and presimulation. The review by
      • Neill M.A.
      • Wotton K.
      High-fidelity debriefing in nursing education: A literature review.
      scanned 10 years from 2003 to 2009; however, debriefing literature has grown immensely since the time of this review. Consequently, it does not reflect the recent research that has been completed on this concept or the evidence-based educational practices that have been implemented to support student learning.

      Discussion

      This review of simulation reviews did not produce new knowledge but supported previous findings in the literature. There is an abundance of literature on simulation, and it is interesting to note that for the seven articles included in the review, there were a total of 212 reference articles used in these seven articles, and only 38 (17.9%) of the references in these articles were referenced more than once. Having pointed out the large body of knowledge related to HFS, there is still a need for a robust pool of research that can establish a cause-and-effect relationship between HFS and learning in undergraduate nursing education (
      • Blum C.A.
      • Parcells D.A.
      Relationship between high-fidelity simulation and patient safety in a prelicensure nursing education: A comprehensive review.
      ,
      • Fisher D.
      • King L.
      An integrative literature review on preparing nursing students through simulation to recognize and respond to the deteriorating patient.
      ,
      • Foronda C.
      • Liu S.
      • Bauman E.B.
      Evaluation of simulation in undergraduate nurse education: An integrative review.
      ,
      • Yuan H.B.
      • Williams B.A.
      • Fang J.B.
      • Hong Ye Q.
      A systematic review of selected evidence on improving knowledge and skills through high-fidelity simulation.
      ). What was supported from this review of reviews was that there remains a variety of significant challenges faced by nurse scientists engaging in simulation research to move the science forward.
      There are methodological challenges in conducting simulation research. For example, although there is a large body of knowledge related to HFS, there is a general paucity of properly controlled randomized trial research establishing a direct cause-and-effect relationship between HFS and learning in undergraduate nursing education (
      • Blum C.A.
      • Parcells D.A.
      Relationship between high-fidelity simulation and patient safety in a prelicensure nursing education: A comprehensive review.
      ,
      • Fisher D.
      • King L.
      An integrative literature review on preparing nursing students through simulation to recognize and respond to the deteriorating patient.
      ,
      • Foronda C.
      • Liu S.
      • Bauman E.B.
      Evaluation of simulation in undergraduate nurse education: An integrative review.
      ,
      • Yuan H.B.
      • Williams B.A.
      • Fang J.B.
      • Hong Ye Q.
      A systematic review of selected evidence on improving knowledge and skills through high-fidelity simulation.
      ). Valid and reliable measurement tools are lacking in simulation, and the use of proxy measures such as confidence, perception, and competence has been criticized (
      • Cant R.P.
      • Cooper S.J.
      Simulation-based learning in nurse education: Systematic review.
      ). Other challenges with respect to methodological issues identified in this review of reviews included less rigorous study designs, lack of randomization, and the use of small heterogeneous samples. Even the recent NCSBN simulation research that utilized a robust design and a large sample size noted some limitations to the study commented on the need for standardization and best practice in simulation.
      This review of reviews supported additional challenges faced by nurse scientists engaging in moving the science of simulation research forward. These challenges include a lack of funding, proper training of ancillary personal and research assistants, and support from within some schools of nursing for simulation research. Funding of simulation is essential to support methodologically sound research. These costs include simulation technicians who program, set up, break down, and implement the HFS scenarios, as well as faculty training, statisticians, and research assistants (
      • Dufrene C.
      • Young A.
      Successful debriefing-best methods to achieve positive learning outcomes.
      ,
      • Hallenbeck V.J.
      Use of high-fidelity simulation for staff education/development: A systematic review of the literature.
      ). All these items are crucial to designing robust simulation studies and are challenging without appropriate funding (
      • Shinnick M.A.
      • Woo M.A.
      • Mentes J.C.
      Human patient simulation: State of the science in prelicensure nursing education.
      ). These details and support for simulation facilitate stronger simulation designs, standardization of the process from prebrief to debrief, and faculty training (
      • Hallenbeck V.J.
      Use of high-fidelity simulation for staff education/development: A systematic review of the literature.
      ,
      • Levett-Jones T.
      • Lapkin S.
      A systematic review of the effectiveness of simulation debriefing in health professional education.
      ,
      • Yuan H.B.
      • Williams B.A.
      • Fang J.B.
      • Hong Ye Q.
      A systematic review of selected evidence on improving knowledge and skills through high-fidelity simulation.
      ).
      Another challenge to overcome in simulation research is recruiting undergraduate nursing students for studies that are not a normal part of the curriculum. This takes time away from standard curricular activities. This problem might be the reason reviews of simulation included individual studies with mixed cohorts or participant samples (
      • Dufrene C.
      • Young A.
      Successful debriefing-best methods to achieve positive learning outcomes.
      ). Multisite studies may be a solution to small sample sizes and the difficulty in recruiting nursing students, but the cost increases and the time for collaboration to develop a rigorous research study make it challenging to conduct multisite studies.
      Standardization in the implementation of HFS by nurse educators is essential. The Standards of Best Practice: Simulation developed by the International Nursing Association of Clinical Simulation and Learning standards committee (
      • International Nursing Association of Clinical Simulation and Learning Standards Committee
      Standards of best practice in simulation I-IX.
      ) were not available for earlier studies. As a result, there was minimal literature to support evidence-based best practice. The Standards should raise the benchmark and increase the rigor of simulation research. It is now an expectation that simulation educators and researchers will use these standards.

      Limitations

      There were several limitations noted to this review. An overall limitation is the exclusion of articles that were not in English, low to medium fidelity, and mixed participants studies. This yielded a small sample of which to analyze. Another limitation was that the search included articles from January 2009 to June 2015. This excluded articles that have been published more recently and may have addressed some of the issues discussed here.

      Implications for Future Research

      Implications for future research from this work include the following: (a) transferability of knowledge and skills to clinical practice; (b) the components of prebriefing; (c) the effect of prebriefing and debriefing strategies as a learning outcome of simulation; (d) integration of simulation across curricula; (e) inclusion of more experimental studies with a more rigorous design (varying student characteristics to avoid bias, mixed-methods approaches and multisite studies); (f) interprofessional simulations; (g) National Council Licensure Examination readiness; and (h) the effect of HFS on patient outcomes. Until there is strong evidence on outcomes of simulation, it may be difficult to properly implement high-stakes testing.

      Conclusion

      This review of the literature included seven simulation reviews that met our inclusion criteria. The focus of this review was to examine simulation reviews on the use of HFS in undergraduate nursing education. Although this is a narrow focus, it was purposeful. This project broadened awareness of the importance of creating a culture of prioritizing simulation research to meet educational outcomes for undergraduate nursing education. The NCSBN suggests that learning through simulation is dependent on high-quality simulation. Therefore, educators and researchers in undergraduate education programs need to have evidence to inform best practice strategies for the design and implementation of HFS. Future research efforts should include adherence to the Standards of Best Practice: Simulation (
      • International Nursing Association of Clinical Simulation and Learning Standards Committee
      Standards of best practice in simulation I-IX.
      ). In this way, multisite studies with larger sample sizes can be implemented in a standardized manner with reliable and valid tools to produce evidence of learning because of HFS.

      References

        • Berndt J.
        Patient safety and simulation in prelicensure nursing education: An integrative review.
        Teaching and Learning in Nursing. 2014; 9: 16-22
        • Blum C.A.
        • Parcells D.A.
        Relationship between high-fidelity simulation and patient safety in a prelicensure nursing education: A comprehensive review.
        Journal of Nursing Education. 2012; 51: 429-435https://doi.org/10.3928/01484834-20120523-01
        • Cant R.P.
        • Cooper S.J.
        Simulation-based learning in nurse education: Systematic review.
        Journal of Advanced Nursing. 2009; 66: 3-15https://doi.org/10.1111/j.1365-2648.2009.05240.x
        • Critical Appraisal Skills Programme (CASP)
        CASP checklists.
        CASP, Oxford2014 (Retrieved from)
        • Dufrene C.
        • Young A.
        Successful debriefing-best methods to achieve positive learning outcomes.
        Nurse Education Today. 2014; 34: 372-376https://doi.org/10.1016/j.nedt.2013.06.026
        • Fisher D.
        • King L.
        An integrative literature review on preparing nursing students through simulation to recognize and respond to the deteriorating patient.
        Journal of Advanced Nursing. 2013; 69: 2375-2388
        • Foronda C.
        • Liu S.
        • Bauman E.B.
        Evaluation of simulation in undergraduate nurse education: An integrative review.
        Clinical Simulation in Nursing. 2013; 9: e409-e416https://doi.org/10.1016/jecns.2012.11.003
        • Gall M.D.
        • Gall J.P.
        • Borg W.R.
        Educational research: An introduction.
        8th ed. Pearson Publishing, New York2007
        • Hallenbeck V.J.
        Use of high-fidelity simulation for staff education/development: A systematic review of the literature.
        Journal for Nurses in Staff Development. 2012; 28: 260-269https://doi.org/10.1097/nnd.0b013e31827259c7
        • Hayden J.K.
        • Smiley R.A.
        • Gross L.
        Simulation in nursing education: current regulations and practices.
        Journal of Nursing Regulation. 2014; 5: 25-30https://doi.org/10.1016/S2155-8256(15)30084-3
      1. Higgins J.P.T. Green S. Cochrane handbook for systematic reviews of interventions. Version 5.1.0. The Cochrane Collaboration, 2011 (Retrieved from)
        • International Nursing Association of Clinical Simulation and Learning Standards Committee
        Standards of best practice in simulation I-IX.
        Clinical Simulation in Nursing. 2013; 2015; 9: S1-S35
        • Levett-Jones T.
        • Lapkin S.
        A systematic review of the effectiveness of simulation debriefing in health professional education.
        Nurse Education Today. 2014; 34: e58-e63https://doi.org/10.1016/j.nedt.2013.09.020
        • Meakim C.
        • Boese T.
        • Decker S.
        • Franklin A.E.
        • Gloe D.
        • Lioce L.
        • Borum J.C.
        Standards of best practice: simulation standard I: terminology.
        Clinical Simulation in Nursing. 2013; 9: S3-S11
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        The PRISMA Group (2009) preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
        PLoS Medicine. 2009; 6: e1000097https://doi.org/10.1371/journal.pmed.1000097
        • Neill M.A.
        • Wotton K.
        High-fidelity debriefing in nursing education: A literature review.
        Clinical Simulation in Nursing. 2011; 7: e161-e168https://doi.org/10.1016/j.ecns.2011.02.001
        • NYU Libraries
        PICO (T) Project toolkit: Welcome.
        2015 (Retrieved from)
        • Page-Cutrara K.
        Use of prebriefing in nursing simulation: A literature review.
        Journal of Nursing Education. 2014; 53: 136-141
        • Shearer J.E.
        High-fidelity simulation and safety: An integrative review.
        Journal of Nursing Education. 2013; 52: 39-45https://doi.org/10.3928/01484834-20121121-01
        • Shinnick M.A.
        • Woo M.A.
        • Mentes J.C.
        Human patient simulation: State of the science in prelicensure nursing education.
        Journal of Nursing Education. 2011; 50: 65-72https://doi.org/10.3928/01484834-20101230-01
        • Shin S.
        • Park J.H.
        • Kim J.H.
        Effectiveness of patient simulation in nursing education: Meta-analysis.
        Nurse Education Today. 2015; 35: 176-182https://doi.org/10.1016/j.nedt.2014.09.009
        • Weaver A.
        High-fidelity patient simulation in nursing education: An integrative review.
        Nursing Education Perspectives. 2011; 32: 37-40
        • Whittemore R.
        • Knafl K.
        The integrative review: Updated methodology.
        Journal of Advanced Nursing. 2005; 52: 546-553
        • Yuan H.B.
        • Williams B.A.
        • Fang J.B.
        • Hong Ye Q.
        A systematic review of selected evidence on improving knowledge and skills through high-fidelity simulation.
        Nurse Education Today. 2012; 32: 294-298
        • Yuan H.B.
        • Williams B.A.
        • Fang J.B.
        The contribution of high fidelity simulation to nursing students' confidence and competence: A systematic review.
        International Nursing Review. 2012; 59: 26-33