Nursing Student Simulation: A Three-Tiered Model Approach

Friday, 28 July 2017

Kristina L. Leyden, PhD
Peavy School of Nursing, University of St. Thomas, Houston, TX, USA
Nakisha S. Paul, MBA
Peavy School of Nursing - Simulation Lab, University of St. Thomas, Houston, TX, USA
Katherine D. Simpson, MSN
Peavy School of Nursing, University of St. Thomas - Houston, Houston, TX, USA


Simulation has long been used as training in nonmedical facilities1. In nursing, it has had many definitions. The oldest definition found is using models to teach basic skills 1. As simulation technology grows, changes, and improves, so does the need to clearly define terms and how we use them. Simulation, presently, includes varying degrees of interaction. Examples include low-fidelity models (LFM) which has limited function/interaction (task-trainer intravenous (IV) arms for IV insertion); medium-fidelity mannequin (MFM), (chest model illustrating heart rhythms); high-fidelity mannequin (HFM), (full-bodied mannequin, fully functioning, mimicking a living patient)2,3; and standardized patients (SP), (live persons participating in a scenario)4.

Technologically-enriched learning through simulation lab activity enhances personal and professional confidence. Simulations promote teamwork through communication and collaboration5. Students stated they enjoy the simulation lab activity and prepares them for the real world clinical environment. Students enter their roles with explored senses of patient care needs, and clinical expectations. This produces confidence and decreases situational anxiety6. Patient safety has improved since the seeds of critical thinking skills have been planted and sprouted in the real clinical environment. Medication errors are identified and corrected during simulation learning7.

Usefulness of differing simulation mediums in student education needs to be fully explored, well-documented, and clearly defined. Recommendations for use of differing simulation methods are dependent on learning objectives and the level of the student 8. The purpose of this research is to disseminate how one baccalaureate-nursing program in a highly diverse, liberal-arts university with novice simulation technicians and faculty defined various methods of simulation, students’ response to various methods, and recommendations for use.


Partnership with a senior baccalaureate-nursing program with expert simulation technicians and faculty occurred so lab facilitators/faculty could shadow simulations and explore laboratory function to enhance simulation development and experience with novice users. A hospital clinical rotation preparation simulation was developed in Fall 2015, it was well received by students; however, technical limitations warranted close examination for modifications. High-intensity simulations were used in Spring 2016. Categorization, definitions, and learning objectives for simulation was needed for clarity across the program.


Faculty developed an introductory simulation, Fall 2015 for the adult/older adult medical surgical course, in addition to already existing laboratory skills with LFM. Introductory simulation included students assigned to one-on-one care to HFM with adult/older adult medical/surgical scenarios. This simulation mimicked a general medical/surgical hospital unit. Objectives included hospital unit preparation, setting expectations, understanding the routine of a hospital unit, beginning clinical reasoning, and effective communication to facilitate patient care. One student acted as charge nurse, other students assessed, medicated, and called the “provider” if needed and performed many other tasks, critical thinking, and prioritizing orders. Students carried out orders, documented findings, called laboratory and radiology for results, if needed. Students performed this simulation over 6-hour periods with pre- and post-briefing. Debriefing included asking the students to describe how they can use this experience going forward to their clinical experience, discuss their perceived limitations, and their perceived needs for clinical success.

Faculty extended simulation Spring 2016 for the Pediatric course. This simulation was increased in intensity and performed in a shorter period in small groups of 2-3 students and completed in phases. This simulation included two higher acuity patient scenario and a focus on clinical reasoning. Students participated in two scenarios. Pre- and post-simulation testing completed to measure effectiveness and meeting of learner objectives.

Students’ positive feedback and request for more simulations prompted the faculty to develop a step-approach to simulation in courses. Resources and technological restrictions needed to be evaluated.


HFM require the most consideration. HFM are manufactured and programed by commercial companies and try to resemble life-like situations. Battery life varies between brand, gender, and mass. Males are more efficient because of automated features. The power source is located below the waist. Females use more power. They are used for general simulations and maternity. In maternity simulations, automation requires total body manipulation which requires greater power. Longevity of the mannequin’s battery life may determine scenario length. Learning objectives may depend on mannequin type.

Power source can be a great limitation, as well as varying sizes of simulation laboratories. When the lab size is small, the radioactivity space is limited. This causes a voided transfer of data between mannequins. This cancels programmed scenario data and will not allow use of multiple mannequins in one setting; this can create limited teaching capabilities at one time.

Instructors must monitor mannequin vitals at all times. If abnormal vital signs are set in a scenario and go untreated by the student, mannequins will decompensate like live patients would. Mannequins will overheat and shut down.

Facilitator knowledge and ability varies and facilitators must learn the technology in order to allow the student to gather the most benefit. This facility uses an ultraportable recording system, so the ideal simulation includes one-facilitator recording/annotating student observations, one facilitator changing mannequin settings, vital signs, one answering the students’ questions as the “patient”, and one facilitator acting as the provider on-call, laboratory, or other departments the student may need to call upon.


In Fall 2016, faculty developed a three-tiered model approach to simulation for students entering the adult/older adult medical surgical clinical rotation in order to classify and define simulation exercises for students. The first tier, coined “Sim-Skill”, included needed laboratory skills training. The second tier, “Sim-Shift”, is an introduction into the hospital unit and patient care during a shift. The third tier, “Sim-Care”, is a high-acuity patient scenario.

Sim-Skill included learning new skills on LFM. For example, nasogastric tube insertion, central line dressing change, and injections were a few of the skills learned. In addition, students view equipment orientation and procedures via faculty-made videos.

Sim-Shift included students assigned to HFM as if in a general medical/surgical nursing unit, like in the previous year. However, shifts were shortened to morning and afternoon sessions allowing for technical considerations, and the students to report to one another between shifts. Session changes allowed the students to develop their communication skills nurse-to-nurse while giving report on the patient. Students in both sessions reported to the class on the following day their experience. These changes allowed the mannequins to reset between sessions. Most importantly, it allowed the students to transfer patient care and learn what was essential in communicating for transfer of care. Students got a sense of what it is like to work on a medical/surgical unit, fully manage patient care, communicate for continuation of care, and be accountable to others for that patient. Furthermore, students were able to put into practice fundamental safety concerns. For example, if a student left a side-rail down, simulation facilitators would place mannequin on the floor for the student to find. Sim-Shift was useful in identifying immediate safety and prioritization student needs.

Sim-Care included HFM and SP (acting as mannequin’s family member) with high-acuity adult/older adult and pediatric scenarios performed in groups of 2-3 students. Expectations included assessment, prioritization, and interventions appropriate to scenario stages. The simulated patient’s family may also be in the scenario adding another dimension to the simulation. They were also expected to communicate findings to the patient’s provider. Learning objectives in this tier include synthesizing theory learned in classroom and skills learned in the previous tiers. In addition, faculty assessment of students included clinical judgment and critical indicators. Pre-/post-simulation testing occurred.


Students consistently request more time spent in the lab to develop technique and facilitate practice for the clinical setting. Students report a freedom in lab practice without risk of causing harm to a live patient.

Students participating in Sim-Shift reported better understanding of clinical expectations/role and helped to link theory to actual patient care. They reported seeing symptoms displayed by mannequins helped make disease clinical manifestations concrete. Learning these elements in simulated environment helped students feel safe in practice when clinical began. Students especially liked mannequins who were placed on contact/respiratory isolation. This helped make aware of needing to prioritize and prepare nursing interventions. Students learned importance of communication and preparedness before talking to the simulated-provider of the patient in order to receive orders or request the patient to be seen. Students reported an over-all positive experience and a desire for more Sim-Shifts.

Students participating in Sim-Care reported positive, stressful experiences. Post-simulation testing improved knowledge base in 57% of students for both scenarios and 83% of students for one scenario. One student had poor performance in post testing of both scenarios. All students identified own needs in order to think, prioritize, communicate, and implement patient care. All students requested more Sim-Care scenarios to translate didactic content into practical environment.


Simulation definitions helped facilitators communicate needs and student expectations to faculty and students. In addition, the clear definitions helped students understand a step-approach to clinical preparedness. This three-tiered model approach assists faculty in deciding simulation levels appropriate to student ability of for meeting set objectives. Technical limitations help form simulation type, length, and intensity. Faculty will continue to use this three-tier model to facilitate learning.