The purpose of this dissertation is to determine if participation in a repeating simulation experience has an impact on nursing students’ knowledge and clinical judgment.. A quasi-experi
INTRODUCTION
Simulation has become an integral component of nursing education, helping meet students’ educational needs and provide meaningful clinical experiences in an increasingly complex and rapidly changing health care system While not originally a necessity, simulation now addresses the challenges posed by high‑acuity, fast‑paced clinical environments where traditional practice hours are limited and securing suitable sites remains difficult Added obstacles include heightened charting security and a persistent shortage of nursing faculty, all of which make simulation a strategic tool for preparing competent, practice‑ready nurses.
Nurse educators have a duty to prepare students to care for patients within today’s complex health system With constrained clinical opportunities and shortened patient stays, students have fewer real-patient practice moments, which can undermine the development of clinical judgment and the ability to deliver safe, effective care (Yuan, Williams, & Fang, 2012) Simulation-based learning has been shown to be highly beneficial in nursing education and is now widely used across U.S programs, with both students and instructors reporting positive reactions to its expanded role in the learning process (Jeffries, 2012; Hayden et al., 2013; Mariani & Doolen, 2016).
Nursing is a practice profession, which necessitates clinical education to be a major focus of knowledge development and application (Yuan, Williams, & Fang, 2012)
Transferring knowledge and skills gained in the classroom to practice is a key factor in
Establishing clinical competence in nursing education occurs within a healthcare landscape that is complex and ever-changing, making it hard to secure adequate clinical placements for students (Bevan, Joy Keeley, & Brown, 2015; Yuan, et al., 2012) Higher patient acuity, restricted site availability, shorter patient stays, and safety concerns further complicate providing meaningful clinical experiences (Richardson & Claman, 2014) Many schools face shortages of clinical sites and low patient census, leading to student dissatisfaction and making it difficult to bridge classroom learning with practice (Tubaishat & Tawalbeh, 2015) These limitations also challenge educators in effectively evaluating students’ clinical competencies (Rizzolo, Kardong-Edgren, Oermann, & Jeffries, 2015) In response, most nursing programs now rely on simulation to meet learners’ needs (Jeffries, 2005).
Simulation-based learning has become a cornerstone across many professions, driving a transformation in education from aviation training to medicine (Wunder et al., 2014) In aviation, simulation has proven beneficial, but in medicine, outcomes research remains scattered and inconsistent, making it harder to gauge impact (Leach, 2014) While it cannot fully replace the clinical environment, simulation offers a valuable opportunity to augment clinical learning and patient care through realistic, risk-free practice (Wunder et al., 2014).
Simulation provides nursing students with a realistic yet safe environment to develop essential clinical skills, supporting active learning Professional bodies endorse simulation as a proven method for hands-on education and it is currently used in more than 900 nursing programs across the United States In nursing education, simulation encompasses a spectrum of modalities—from low- to high-fidelity mannequins and other interactive scenarios—offering diverse, practical opportunities to practice, assess, and refine competencies.
3 task-trainers, computerized simulation experiences, and standardized patients (Rourke, Schmidt, & Garga, 2010)
Simulation-based learning is a powerful modality for nursing education, enabling students to enhance knowledge and engage in deeper learning By participating in well-structured simulation scenarios, nursing students experience increased confidence and self-efficacy, better preparing them for real-world clinical practice Bevan et al (2015) emphasize that simulation fosters deeper understanding and durable learning, while Richardson & Claman report that simulation opportunities elevate students' confidence in their clinical abilities.
Bland, Topping, and Wood (2010) found that nursing students value simulation and would prefer more simulation opportunities embedded throughout the curriculum Despite this positive attitude toward simulation-based learning in nurse education, the evidence supporting its effectiveness in enhancing nursing student skills is not yet deep or comprehensive (Lin).
Current literature around 2015 shows that learning outcomes such as knowledge and clinical judgment are less studied, with many studies focusing on self-efficacy, confidence, and participants’ perceptions (Leach, 2014) More research on knowledge acquisition and the development of clinical judgment could help nurse educators leverage simulation more effectively to achieve meaningful learning outcomes.
To investigate simulation as a teaching and evaluation strategy in nursing education, this study adopts a conceptual framework grounded in Kolb’s Experiential Learning theory (1984) and Tanner’s Model of Clinical Judgment in Nursing (2006) Kolb’s theory explains the learning process through a cyclical sequence of concrete experience, reflective observation, abstract conceptualization, and active experimentation, highlighting how simulation facilitates each stage, while Tanner’s model offers a practical basis for understanding how nurses generate and test clinical judgments in real-time, decision-making, and patient assessment Together, these frameworks sit within the overarching paradigm of Experiential Learning from which both concepts derive, guiding the interpretation of simulation’s role in learning and in evaluating clinical competence.
Experiential learning rests on the premise that knowledge arises from concrete experiences, making experience and learning essentially inseparable in adult education Merriam and Bierema (2014) emphasize the intimate, mutually reinforcing relationship between experience and learning, arguing that they go hand in hand and one is often not found without the other They capture this dynamic with the assertion that “the heart of adult learning is engaging in, reflecting upon, and making meaning of our experiences” (Merriam & Bierema, 2014, p 104), highlighting that meaningful learning occurs when adults actively participate in experiences and thoughtfully reflect to construct new understanding.
Experiential learning theory provided a much-needed theoretical base for learning through experience
Experiential learning happens when learning and new experiences occur in conjunction with one another, reflecting a holistic, integrative approach to education (Merriam & Bierema, 2014) It combines experience, cognition, and behavior into a single, dynamic process, capturing Kolb’s view of learning as a holistic perspective that links doing, thinking, and acting (Kolb, 1984).
Kolb's experiential learning theory, described by Merriam & Bierema, frames learning as a cyclical process that begins with a concrete experience It then moves through reflective observation, abstract conceptualization, and active experimentation, with the cycle repeating as learners engage in new experiences.
Kolb’s Theory of Experiential Learning
Kolb (1984) introduced experiential learning theory as a foundational model for learning and development, outlining a four-stage cycle that governs how people learn The cycle comprises concrete experience, reflective observation, abstract conceptualization, and active experimentation, guiding learners from direct engagement to thoughtful analysis, conceptual understanding, and practical testing In Kolb's view, the learning process is continuous, with each stage informing the next, enabling individuals to apply insights from real-world experiences to new challenges and to refine knowledge through ongoing experimentation.
First the student learns through an experience, in the case of this study, students will participate in a cardiac code simulation at the beginning of the day The students then
Experiential learning through reflection and debriefing enables students to gain insight and apply knowledge to new situations, using reflective journaling, debriefing, post-conferences, and other reflective practices Insight is generated during the debriefing of the morning simulation and again as students repeat the simulation, allowing them to extend their understanding in similar scenarios In the afternoon, a second cardiac code simulation gives learners the opportunity to build on what they gained from the first run, while active experimentation in the second simulation expands their knowledge base and broadens their horizons Experiential learning provides a direct medium for students to participate in learning, reflect on the experience, and construct new abstractions and applications for knowledge (Waldner & Olson, 2007; Chiang & Chan, 2013).
Figure 1 Kolb’s Theory of Experiential Learning
There are several strengths to Kolb’s theory of experiential learning This theory explains student learning as a process driven by critical reflection (Merriam & Bierema,
Critical reflection has proven to be an excellent method for helping students gain and retain knowledge This theory acknowledges that learners are not all the same, with some spending more time in certain stages than others (Merriam & Bierema) By allowing for unequal time across the stages, it reinforces the cyclic nature of the theory and strengthens its applicability to diverse learners.
REVIEW OF THE LITERATURE…
This chapter surveys the current state of the science of simulation in nursing education and examines whether participation in repeated simulation experiences enhances senior nursing students’ knowledge and clinical judgment during simulated cardiac arrest scenarios, while providing a focused literature review on how simulation affects knowledge and clinical judgment in nursing education; the findings from this literature review informed a concept analysis manuscript, which is included at the end of the chapter.
Simulation-based learning now permeates nursing education across the United States, offering realistic patient scenarios within a safe environment where students actively learn by demonstrating care and reflecting on practice While medicine has used simulation since the 1960s, nursing did not widely adopt this teaching modality until the turn of the century, despite its success in other disciplines.
Simulation has become a core component of nursing education, as noted by McGovern, Lapum, Clune, and Martin (2012) The International Nursing Association for Clinical Simulation and Learning (INACSL) has developed the Standards of Best Practice for Simulation to provide evidence-based guidelines for the implementation of simulation and the training associated with it.
(INACSL, 2016) These guidelines cover simulation design, outcomes and objectives, facilitation, debriefing, participant evaluation, professional integrity, simulation-enhanced interprofessional education, and a simulation glossary
It is important for schools that use simulation to follow these best practices
Simulation-based education can be a reliable teaching, learning, and assessment method only when it is grounded in prior research and evidence Developing standardized terminology and guidelines improves communication between facilitators and learners and provides a solid foundation for simulation education (INACSL, 2016) When these best practices are not followed, students may not achieve the intended learning outcomes or experiences.
Simulation in nursing education is increasingly utilized, yet its effectiveness remains incompletely understood (Hayden et al., 2014; Leach, 2014) Much of the literature focuses on student confidence and attitudes toward simulation as a learning modality (Chiang and Chan, 2014) In exploring new areas or concepts, initial research often employs qualitative analysis to describe and interpret the phenomena, and once a knowledge base is established, researchers move to quantitative analysis that quantifies findings through tests and statistical methods (Melnyk & Fineout-Overholt).
2011) More research is needed on the effect simulation has on learning outcomes in nursing education
Although several studies have explored the effect of simulation on student learning outcomes, a gap in the literature persists that warrants a focused literature review to synthesize what is known about this dimension of simulation The goals of this review are to map the current empirical evidence on the impact of simulation on learning, assess study quality and methodological diversity, identify enduring gaps and unanswered questions, and articulate implications for classroom practice, curriculum design, and future research directions in simulation-based education.
This literature review examines the impact of simulation on nursing students' learning outcomes, synthesizing evidence on clinical knowledge gain, the application of knowledge in clinical practice, and the development of clinical judgment It also identifies emerging themes and knowledge gaps to guide future research and practice in simulation-based nursing education.
To determine whether simulation has an effect on nursing students’ learning outcomes, a comprehensive literature review was conducted using a broad search strategy A computer-assisted search of databases including CINAHL, OVID, ERIC, ProQuest, and Cochrane identified studies relevant to the aim by using search terms that combined nurse or nursing with assess or evaluate and simulation with knowledge or clinical judgment English-language studies published in 2010 or later were included, with dissertations and non-English articles excluded After screening, ten relevant studies were found and included in the literature review.
In this review, studies that included a population of nursing students who participated in a simulation experience with medium- or high-fidelity human patient simulators were included
Primary studies evaluating the effect of simulation on student learning outcomes were included in this review The included research spanned diverse study designs, including experimental, quasi-experimental, descriptive, qualitative, and mixed-methods approaches, and the synthesis also incorporated meta-analyses and systematic reviews Studies were excluded if they did not address learning outcomes, did not meet predefined methodological criteria, or were not primary empirical investigations.
19 they only utilized case study, role-play simulation, simulated interviews, or only examined student confidence or satisfaction
20 Figure 4 Literature Review Search Figure
Databases: CINAHL, OVID, ERIC, ProQuest, and
Search Terms: (used in varying combinations) nurse, nursing, assess, evaluate, simulation, knowledge, clinical judgment
Limits: Non-English studies, published before 2010, not full text, and dissertations were excluded.
137 articles excluded: duplicates, tool-focused, non-related
A summary of the literature utilized in the review can be found in the evidence table after the Findings section
Two major concepts emerged in the literature review: knowledge acquisition and clinical judgment For knowledge acquisition, the identified themes are skills, cognitive processes, and subject matter For clinical judgment, the analysis revealed sub-themes of actions and thought processes.
Assumptions underpin every study and review of the literature, defined as beliefs accepted as true even without proof (Gray, Grove, & Sutherland, 2017) In this literature review, three major assumptions are identified The first defines simulation as a dynamic process that creates a hypothetical opportunity with an authentic representation of reality, fosters active student engagement, and weaves together practical and theoretical learning with opportunities for repetition, feedback, evaluation, and reflection (Bland, Topping, & Wood, 2011, p 668) The second posits that interdisciplinary simulation occurs when two or more healthcare professions autonomously participate in highly realistic scenarios to learn with, from, and about each other in a safe and controlled manner (Gough, Hellaby, Jones, & MacKinnon, 2012, p 154) A third assumption is acknowledged but not described in the provided excerpt.
Knowledge in nursing, as Webber (2002) defines it, is a cumulative, organized, and dynamic body of scientific and phenomenological information used to identify, relate, understand, explain, predict, influence, and/or control nursing phenomena (p 17) In this review, knowledge thus refers to the application of cognitive knowledge Clinical judgment is the conclusion about a patient’s needs, concerns, or health problems, and the decision to take action (or not), to use or modify standard approaches, or to improvise new ones as deemed appropriate by the patient’s response (Billings & Halstead, 2012).
Several methodological perspectives emerge in this literature review Some studies rely solely on pre-test/post-test designs or questionnaires, producing data from the student perspective Other investigations are observational and reflect the instructor's or researcher’s viewpoint Only one study among those reviewed combines multiple data collection methods and examines simulation from both the student and the instructor/researcher perspectives Including both approaches in this review enhances its scope, since the planned study will integrate pre-test/post-test design with observational methods to collect data.
Bias can infiltrate even the most thorough literature reviews (Gray et al., 2017), with potential sources including publication bias, time-lag bias, and language bias Publication bias occurs when studies with positive findings are more likely to be published and thus captured in a literature search, potentially skewing conclusions Time-lag bias arises when favorable results are published more quickly than null or negative findings, affecting the timeliness and completeness of the evidence base Language bias can further limit the evidence if non-English studies are underrepresented in search results, shaping the overall view of the research landscape.
Bias may have influenced the conclusions of interdisciplinary simulation research involving nursing students, which remains in its early stages and where negative results are often published only years later (Gray et al.) Additionally, language bias is likely, given that only English-language studies were included.
It is important to include the strengths of the studies as well as the weaknesses Discussing strengths aids in the dissemination and use of research findings (Gray et al,