Simulation is an accepted pedagogical adjunct to clinical exposure to facilitate knowledge transfer and encourage praxis in healthcare education. Research has indicated that simulation can be an acceptable methodology to enhance clinical learning (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). The use of simulation across the curriculum blends theory and practice, increases self-efficacy and self-confidence in a time as new graduates enter nursing practice and are expected to respond to the complexities of healthcare (Hayden et al., 2014). However, criticism of the use of technology-enhanced simulation such as the high costs of the technology, support staff and faculty time have been identified (Ker & Hogg, 2010). Research has shown that despite the criticisms, novice nurses do find simulation to be effective in increasing their self-efficacy, which in turn decreases anxiety in practice (Franklin, Gubrud-Howe, Sideras, & Lee, 2015).
As a precursor to the actual simulation event, pre-simulation preparation is often created, and expected, by faculty but is not always used by students. Pre-simulation preparation is identified as the content provided at an unspecified time before the simulation event and is used to optimize learning (Tyerman, Luctkar-Flude, Graham, Coffey, & Olsen-Lynch, 2016). Accordingly, the challenge for educators to explore innovative pedagogies to enable students to prepare for simulation activities. Best practices in simulation-based learning (SBL) indicate that preparation prior to the simulation event enhances trust, integrity and respect in the simulation event, and thereby, create a positive learning space (International Nursing Association for Clinical Simulation in Learning [INASCL], 2016). Virtual simulation scenarios are a new methodology within simulation-based learning and are beginning to be used in nursing education to engage students in preparation for simulation activities in innovative ways. The use of gaming in nursing education is not new but application to simulation preparation is. By engaging in research on the effectiveness of the use of virtual simulation gaming in pre-simulation preparation, the science of simulation-based learning is advanced, and student-centered learning is enhanced. The integration of theory, with real-life experiences combined with simulation continues to have importance in practice education (CASN, 2015).
The purpose, therefore, of this research was to determine the impact of two instructional design approaches of pre-simulation preparation, in-person delivery and blended delivery, on nursing students’ ability to achieve learning outcomes, and as well the cost-effectiveness of the use of virtual pre-simulation preparation for clinical simulation teaching and learning in the context of undergraduate nursing education. The in-person delivery consisted of a traditional paper-based preparation which was assigned by the faculty; and the blended consisted of the developed virtual simulation game used as pre-preparation.
Methods:
A prospective, randomized controlled observational design was used in this study. Appropriate ethical approval was obtained. Each site developed a pre-simulation virtual game to be used as preparation, and as well, additionally ran one other scenario game. The site being presented developed on one on urosepsis in the elderly and ran the scenario with another scenario created on the mental health suicide ideation. The videos were filmed from the perspective of the nurse. There were decision points embedded in each game, where students were expected to select the most appropriate action to address the situation. Students were able to identify if their action was right or not through a button on the screen that explained why the choice made by the student was correct or incorrect.
Data was collected from the control and experimental groups at the following times for students and instructors:
Student Data: Student learning outcome data will be collected at three points during the simulation: (1) at the end of pre-simulation preparation (T1); (2) at the end of the simulation (T2); and, (3) at the end of the post-simulation debriefing (T3). Student clinical knowledge will be tested at three times: (1) at the end of pre-simulation preparation (T1); (2) at the end of the simulation (T2); and, (3) at the end of the post-simulation debriefing (T3).
Instructor Data: Instructor assessment of students’ learning outcomes will be collected at two points: (1) at the end of the simulation (T2); and, (2) at the end of the post-simulation debrief (T3).
Data analysis was done to assess the extent to which the e-preparation virtual simulation (i.e. experimental group) enhanced the students’ learning outcomes, the student self-assessment of learning outcomes (T1 compared to T2 and T3) within and between both experimental and control groups. In addition, the instructor assessment of learning outcomes was compared to student assessments (Instructor T2 compared to student T1; instructor T3 compared to student T3). Second, the impact of the pre-virtual simulation on improved clinical knowledge, the clinical knowledge scores for the experimental group were compared to the traditional groups’ scores at T1 and at T3.
Results:
Four bilingual (French and english) games were created between all sites, with each game meeting the legislated requirements for Accessibility for Disabled Persons Act.
Results indicated that no statistically significant difference was seen in the scores of the students pre and post scenario in the two groups. With respect to cost analysis, the virtual game required a larger initial cost upfront for development and creation, once the cost is measured to a manual preparation of selecting and assigning required preparation, the cost of virtual preparation does provide a lower cost per student under all scenarios developed, including the one being presented.
Other results were related to the development of skills in multi-site research for all researchers, especially the faculty at the institution being presented. As new researchers, the learning moments related to research skills, understanding the research process and collaboration with other institutions.
Conclusion:
Due to the smaller size and limits with analysis, this study cannot be generalized but provides important information about the use of pre-simulation preparation in simulation-based learning. Pre-simulation preparation and pre-simulation practices in general are new concepts in simulation education science that requires further research (Tyerman et al., 2016). Research should focus on all components of the simulation event, from conceptualization to evaluation and impact on student learning and patient health outcomes. This study adds to the knowledge of the broader use of simulation preparation as a venue to better prepare students to learn in simulation-based education, as well as informs determination of the cost-effectiveness of simulation education, often a difficult construct to measure. Better informing educators of this economic evaluation can ensure best results for efforts expended (Maloney & Haines, 2016).