Technology-enhanced simulation-based learning has become prevalent in nursing education; however, learners often do not complete traditional presimulation preparation activities such as assigned readings and are therefore not adequately prepared to actively participate and benefit from clinical simulation (Tyerman et al., 2016). Presimulation preparation refers to content provided in advance of a simulation experience to provide learners with the necessary knowledge and skills to participate successfully in a clinical simulation (Luctkar-Flude, 2019).Thus, presimulation preparation is critical to the learning that occurs with simulation. Virtual simulation games are proposed as an innovative and engaging presimulation preparation activity for nursing students.
Virtual simulation comprises a variety of emerging simulation-based activities that are accessed by computer, tablet or smartphone technologies (Luctkar-Flude, 2019). Virtual simulation may be used to enhance lecture or web-based courses, replace a portion of traditional simulations or clinical hours, replicate high-risk or low-frequency clinical experiences, and for formative or summative assessments (Foronda & Bauman, 2014). Although there may be considerable upfront costs to develop virtual simulations whether avatar-based or video-based, these costs may be offset by the ability to share these resources across countries and continents, even reaching remote educational settings where funding for live simulations may be limited. Virtual simulation incorporates aspects of experiential learning, problem-based learning, self-directed learning, and adult learning theory (Foronda et al., 2013). Web-based simulation has been shown to be highly acceptable to nursing students, augments face-to-face teaching, provides increased accessibility and repeatability, allows learners to learn at their own pace, and appears to provide learning benefits that align with other simulation approaches (Cant & Cooper, 2014). Results of a systematic review and meta-analysis even suggest that computer-based simulation was the most effective strategy on nurses’ knowledge when compared to other simulation strategies (Hegland et al., 2017).
Virtual simulation games are virtual simulations that incorporate principles of gamification. In healthcare simulation, “serious games” are accessed by computer for educational purposes rather than entertainment (Verkuyl et al., 2016). Virtual simulation games can be used to supplement learning in the classroom and simulation lab, and provide opportunities for clinical decision-making that may not be available in clinical practice (Cant & Cooper, 2014). Research has demonstrated similar gains in learner knowledge, self-efficacy and satisfaction from participation in virtual simulation games as participation in traditional laboratory simulations (Verkuyl et al., 2017). Using virtual simulation games as presimulation preparation may additionally reduce learner anxiety and promote achievement of learning outcomes during the subsequent live clinical simulations (Gantt, 2013; Nielsen & Harder, 2013).
In keeping with principles of adult learning and self-regulated learning theories we provided nursing students with a variety of presimulation preparation activities that could be completed depending on their self-determined learning needs. Four bilingual virtual simulation games were previously created as part of a multi-site randomized controlled trial investigating the cost utility of using virtual simulation games for presimulation (Tyerman et al., 2018). Our user friendly approach to virtual simulation game design and production involved the use of a Go-Pro camera and a game template created using Articulate software, and can be easily replicated by other nurse educators to add to a growing repository of virtual simulation games; however, further research is required to establish best practices in design and implementation of virtual simulation games in nursing education, and to evaluate its impact on learning outcomes. In this study, we proposed that learners would find a virtual simulation game to be more engaging than traditional presimulation preparation activities such as a case study. Thus the purpose of the study was to determine which presimulation preparation activities would appeal to and be completed by senior nursing students prior to participating in a live simulation. The specific research questions are the following: Which presimulation preparation activities will senior nursing students complete prior to participating in a live simulation: case study, virtual simulation game, lecture notes and readings, self-assessment rubric, and/or scenario summary/patient profile? Which activities are associated with greater learner confidence and performance? Which aspects of presimulation preparation are perceived as most/least helpful?
Methods:
A quasi-experimental, pre-test/post-test research design was used to evaluate learner preferences for presimulation preparation activities and perceived competence A live deteriorating patient simulation scenario focused on care of an elderly patient with urosepsis was implemented in April 2018 with 4th year BNSc nursing students (n=76) and in Aug 2018 with 2nd year students in a 2-year BNSc Accelerated Standing Track (AST)(n=39). Prior to participating in the live scenario learners were provided with several presimulation activities to choose from: case study, virtual simulation game, lecture notes, textbook readings, self-assessment rubric, scenario summary and patient profile. All students in the course were invited to complete a pre and post-simulation survey in which they indicated which activities they had completed, rated their pre- and post-simulation competence using a learning outcomes assessment rubric, and rated the case study and virtual simulation game in terms of usability, engagement and impact on learning using a modified ClassRoom Instructional Support Perception (CRISP) survey which measures learner perceptions of educational technologies (Richardson et al., 2015). Learners also provided qualitative feedback on their choice of presimulation preparation activities.
Results:
One hundred and fifteen senior nursing students consented and completed a pre and post-simulation survey. Of these 60% reported reviewing the scenario and patient profile; 57% completed the paper-based case study; 37% played the virtual simulation game; 45% completed the self-assessment rubric; 7% reviewed their lecture notes or textbook readings; and 12% completed no preparation. Interestingly 30% of learners chose to complete both the case study and the virtual simulation game. Time spent on the case study was an average of 8.8 minutes, whereas learners reported spending 11.5 minutes on the virtual simulation game, 15 minutes reviewing the scenario and patient profile, 5 minutes completing the assessment rubric, and 8.3 minutes reviewing lecture notes or textbook readings. Learners from the 4 year track BNSc program were more likely to complete any presimulation preparation activity than learners from the 2 year accelerated track, and participation in any preparation resulted in significant improvements in perceived competence (t=2.3; p=.02). Learners rated the virtual simulation game higher than the case study in terms of usability (t=2.6; p=.01), engagement (t=2.8; p=.01) and impact on learning (t=2.4; p=.02). Qualitative feedback suggested the virtual simulation game supported clinical decision-making and reduced learner anxiety during simulation, as well as increased opportunities for accessibility and deliberate practice.
Conclusion:
Results revealed that senior nursing students have different preferences for presimulation preparation activities. Although more students completed the case study than the virtual simulation game, those who played the game rated it more highly. This supports the feasibility and acceptability of using virtual simulation games as an engaging presimulation preparation activity. Further qualitative study may help to explain the different choices made by the students. However, providing a choice in presimulation preparation activities resulted in the vast majority of students completing some type of preparation, which contributed to learner perceptions of competence. Future research could investigate presimulation preparation preferences and outcomes with other groups of learners and other types of presimulation preparation activities. Simulation facilitators should design presimulation preparation activities that align with the simulation learning outcomes, the level of the learner, and learner preferences in order to support optimal learner preparation for simulation.