Simulation as a Teaching Technology: A Brief History of Its Use in Nursing Education Free

According to Gaba (2004), simulation is a technique rather than a technology that is able to provide realistic environments or practice proxies for the purposes of learning, training, and practice. Given its application in nursing education, and its current reliance on, and amalgamation with, sophisticated computer driven machinery the argument that simulation is also a technology can be made. Simulation is effective at bringing to life representative clinical encounters in a safe educational setting where no harm can come to patients. It can—and has been—successfully applied for the teaching and training of novice learners as a way to introduce concepts or skills, as well as for seasoned providers to provide a safe environment where deliberate practice, mastery, and upkeep of skills can occur.

Simulation can be used for teaching or practicing both technical skills (insertion of intravenous catheters, or suturing for example) and non-technical skills (communication and teamwork). A combination of full body, high and low technology simulators (mannequins designed to depict humans), body part or body system-specific task trainers (models of specific body areas or systems), standardized patients (actual humans who are trained to portray illnesses for the purpose of allowing practice of taking a health history or health assessment), and virtual reality can be used as part of a simulation-based education program.

Simulation training can be immersive, where environments are set up to mimic clinical settings. These are usually replete with working medical equipment, simulated or real medications, and high-technology computer driven simulators. The use of confederates portraying healthcare providers or family members may also be incorporated into simulation encounters for the purposes of improving realism and or as scenario guides to keep learning on track (Sanko, Shekhter, Kyle, Benedetto, & Birnbach, 2013). Immersive simulation encounters allow learners to work through scripted scenarios with defined learning objectives. Alternatively, task-specific simulation encounters that utilize low-technology task trainers and usually no scripted scenario or confederate allow learners to work through complex or technically difficult skills for the purposes of practice and refinement. Hybrid techniques can also be applied (the combination of two simulation modalities: a standardized patient and a task trainer, or virtual reality and a task trainer) to provide educational opportunities where both technical and non-technical skills can be taught or practiced simultaneously. Simulation may further be used as a way to assess a learners’ aptitude, and can provide a realistic platform to measure competence prior to clinical practice or graduation from a program of study.

Simulation uses experiential learning as a foundational principle (Kolb, 1984), but has welcomed new frameworks, with the National League for Nursing-Jeffries simulation framework being the most notable nursing theory developed in simulation-based education. This framework guides the design, implementation, and evaluation of simulation-based practices in nursing education (Jefferies, 2005). Simulation-based education tends to be carried out in three distinct phases beginning with prework or briefing, followed by a hands-on/psychomotor or immersive experience, and culminating with a debriefing (Aebersold & Tschannen, 2013). The use of a phased approach allows participants to have a conceptual introduction to a topic or skill, followed by an opportunity to anchor the concept through a realistic firsthand experience where psychomotor, cognitive, and affective domains of education are utilized, and ending in a debriefing session. Debriefing is typically guided by a content expert and includes feedback, discussion, and time for learners to reflect on the experience. Simulation definitions and commonly used terminology are provided in Table 1.

Simulation as a teaching technology in nursing education has a long history spanning well over a century and a half. Some of the earliest published uses of simulation in nursing education date back to Florence Lees and Florence Nightingale (Stabler-Hass, 2012). The Handbook for Hospital Sisters by Florence Lees and Henry Acland (1874) describes the use of a “jointed skeleton” (p. 34) and models. The book also campaigns for the adoption of these in every school of nursing. Lees (1874) further describes the use of “mechanical dummies” and models of legs and arms for the purposes of teaching bandaging (p. 34). Florence Nightingale, the mother of infection control, not surprisingly used simulation in her demonstration of proper methods for infection prevention (Stabler-Hass, 2012). The use of body specific task trainers preceded the use of full body anatomical models. Published examples of pelvic models and pelvic “machines” used to train midwives can be found dating to the late 1700s (du Coudray, 1769).

The early 1900s introduced perhaps the most famous initial full-body mannequin, Mrs. Chase. Mrs. Chase was introduced in 1910 and was described as a full-body, static mannequin with realistic structures including jointed hips, elbows, and knees (Herrmann, 1981). The mannequin was modeled after its creator, Martha Chase (Herrmann, 1981). Chase, of Pawtucket Rhode Island, was a children's doll maker who was asked by Lauder Sutherland, the principal of the Hartford Hospital Training School, to make an adult-sized mannequin for her use in training nurses at Hartford Hospital. She had become tired of using straw filled “dummies” to train her students and welcomed the new addition of an adult-sized mannequin to train them and allow for the practice skills learned in the classroom (Nehring, Lashley, & Ellis, 2002). In 1914 Mrs. Chase created “Arabella,” an upgraded version of the mannequin that allowed student nurses to practice arm injections (Weir, 2012). Although the name “Arabella” never stuck, with the help of a number of further makeovers and updates, Mrs. Chase was used well into the 1950s for training student nurses, and could be found in use in research settings to study the effects of accidents on the human body as recently as the 1970s (Herrmann, 2008).

Full-scale simulation labs in schools of nursing emerged in the mid-1930s. The first published description of a simulation lab comes from the Indiana University Training School for Nurses. The description depicts the use of mannequins for the purposes of teaching students to give injections in a dedicated “skills” lab space (Davis, 1932). By the 1970s there were the first efforts to pull together the leaders of nursing skills labs to share knowledge and engage in a dialogue (International Nursing Association for Clinical Simulation and Learning [INACSL], 2015). These first collaborative efforts led to some of the first nursing-focused “simulation” meetings and would eventually lead to the development of the INACSL.

In 1995 the organization (Health Education Media Association) held the first National Conference on Nursing Skills labs, which was held biannually until 2009 (INACSL, 2015). In 2002 the organization was named INACSL (INACSL, 2015). Today INACSL has a robust membership of over 1500 nurse simulationists from around the world. They also hold an annual meeting focused on simulation-based education in nursing. Thanks in part to these early leaders, simulation/skills labs are now nearly ubiquitous in schools of nursing in the United States. The simulation labs found in nursing schools are state-of-the-art centers ranging in size from a single room to a full-scale multifloor hospital and encompass a variety of high- and low-technology simulators, and dedicated staff.

Human patient simulators were adopted for use in nursing education around the mid-1990s (Nehring & Lashley, 2004). Although they had already been in use in medical education for nearly 3 decades, nursing did not incorporate them into practice till much later. These high-technology computer controlled simulators were first introduced in the late 1960s, with SimOne being the first of its kind.

SimOne was developed at the University of Southern California and was described as lifelike in appearance, featuring plastic skin and configured as a male patient lying on an operating-room table (Abrahamson, 1997). His left arm was able to receive injections of intravenous fluids, while his right was able to generate a blood pressure (Abrahamson, 1997). SimOne also breathed, had a heartbeat, as well as temporal and carotid pulses that synchronized with his blood pressure and heart rate (Abrahamson, 1997). Another notable early computer-controlled simulator was “Harvey.” Although not able to really be called a full-body simulator because he did not have full arms and legs, Harvey was invented to teach cardiology. Harvey was developed at the University of Miami by Michael Gordon and was introduced in 1968. Harvey's features included physical findings related to the cardiopulmonary system (Cooper & Taqueti, 2004). A unique feature of Harvey was the inclusion of an accompanying curriculum.

Despite its early use, simulation only became widely used and accepted as an effective teaching modality in nursing education in the last 2 decades (Aebersold & Tschannen, 2013). This modern trend began on heels of the landmark Institute of Medicine Report To Err is Human (Kohn, Corrigan, & Donaldson, 1999), which reported that more than 90,000 deaths each year were attributed to preventable medical error.

Nursing literature in the late 1990s began to describe the use of more sophisticated simulators, standardized patients for health assessment practice, and the development of comprehensive simulation-based programs in an effort to improve safety in healthcare (Nickerson & Pollard, 2010). In an effort to respond to the issues noted in the 1999 Institute of Medicine report simulation programs of the early 2000s focused on error mitigation, critical thinking, crisis management, and professional competencies such as communication and teamwork (Nickerson & Pollard, 2010). Nursing, like medicine, began to look to other high-reliability organizations and learn from their use of simulation.

The aviation industry discovered years before healthcare that simulation is uniquely suited for crisis management and team-based training. The era of primarily team-based healthcare delivery and a seemingly pandemic medical error rate has helped to bring more focus on the use of simulation to bridge the gap between theory and practice (Cioffi, 2001), as well as a way to provide much-needed interdisciplinary and multidisciplinary training. Interprofessional education endeavors, usually with a simulation component, are becoming requirements of healthcare education, and the 2011 interprofessional collaborative practice competencies are helping to provide benchmarks for education in this area (Interprofessional Education Collaborative Expert Panel, 2011). These insights and discoveries have helped to forge a path for more interprofessional education and a broadening use of simulation-based education.

The full adoption of simulation in nursing education was a slow process, with a 2004 survey (Nehring & Lashley, 2004) finding that simulation was still very much in a developmental phase, with simulation faculty still learning to use the equipment and figuring out how to integrate it into the curriculum. By 2008, however, things seemed to have picked up “steam,” with boards of nursing beginning to change regulations to allow simulation to be counted as substitution for clinical hours (Nehring, 2008). Following on this, a 2010 National Council of State Boards of Nursing national survey of simulation use in nursing education found that simulation was used by 87% of the responding schools (N = 1,060) of nursing, with over half of these reporting using simulation in at least five clinical courses (Hayden, 2010). More recent publications and recommendations from leading educational organizations continued to further support the use of simulation-based education throughout the first decade of the 21st century (Benner, Sutphen, Leonard, & Day, 2010; Irby, Cooke, & O'Brien, 2010).

Today simulation in nursing education includes the use of a variety of modalities that have been incorporated into nursing curricula including, anatomical models, task trainers, role playing, games, computer-assisted instruction, standardized patients, virtual reality, and both low- and high-fidelity simulators (Gore, Van Gele, Ravert, & Cedric, 2012; Nehring & Lashley, 2009).

The educational paradigm of “do one, see one, teach one” no longer pervades nursing education; rather, “see one, practice many, do one” is the rule of the day. Despite simulation's widespread use and acceptance in prelicensure education, a gap still exists in the adoption of simulation for the purposes of skill development among practicing nurses (Aebersold & Tschannen, 2013). However, given the current focus on patient safety and the growing evidence that simulation has patient outcome benefits, it is likely that this gap will close in the near future. Overall, the growth of simulation has been explosive. The number of organizations, publications, and resources presently available is a testament to the pervasive and upward use and demand of simulation in nursing education. In 2001 at the first International Meeting for Simulation in Healthcare there were about 150 people in attendance; however, in 2016 there were over 3,000. The 2016 meeting not only had a record number of attendees, but over 325 courses were taught by 750 faculty. From an economic perspective, simulation is estimated to be a $1.5 billion industry, with projected growth to over $2 billion by 2020 (Sanko, 2016). Even with an estimated startup cost of close to $880,000 for a simulation center and average fixed costs of nearly $400,000 (McIntosh, Macario, Flanangan, & Gaba, 2007) annually, programs are growing. The costs seem to be at least anecdotally worth the efforts and some argue the value unquestionable (National Council of State Boards of Nursing, 2009).

Technological advances and reductions in the costs of simulators can in part be attributed to by the rising demand for these educational adjunctive modalities. Simulation equipment has become more attainable as its use in education has grown. Moreover, innovation is giving rise to less expensive and more realistic models for use. The “high-fidelity” mannequin of today does not always mean high technology. While smaller and smaller computers have allowed high-technology simulators to more closely approximate real patients, low-technology mannequins made from synthetic tissues are providing realistic alternatives for learning anatomy and invasive procedures. The availability of simulated durable and large-scale medical equipment has also grown exponentially. The evidence is in the number of vendors displaying their products at the most recent International Meeting for Simulation in Healthcare. Over 98 companies displayed products ranging from simulated medication to large scale computer run simulators.

Educational opportunities for those wishing to be trained to carry out simulation-based education have increased in number as well. Centers like the Center for Medical Simulation and the WISER Center have been offering courses to prepare educators to carry out high quality simulation-based education for over a decade. Today, they are far from the only ones; organizations, institutions, universities, and industry leaders now offer courses worldwide. These courses can vary from several-hour online webinars to multiyear degree- or certificate-awarding programs, with many offered by major universities.

Further evidence of the growth of simulation is in the movement toward certification and accreditation of centers and the publication standards of practice. The Society for Simulation in Healthcare offers certification for both simulation educators (basic and advanced) and technicians. Additionally, The Society for Simulation in Healthcare is one of the few organizations offering accreditation of simulation centers.

INACSL spearheaded the publication of the standards of best practice for simulation-based education. These standards are widely used to guide practice and have been adopted by many other organizations. The standards provide evidence-based guidelines for simulation-based education and are designed to advance the science of simulation.

Peer-reviewed publications devoted to simulation in healthcare disciplines are also growing. Since 2014 the number of journals focused on simulation in healthcare has doubled. There are also a number of textbooks dedicated to simulation. An Amazon search for healthcare simulation books identified 576 books available. In addition to publications as a forum for dissemination of research and knowledge there are scientific conferences worldwide focused on simulation in healthcare. Online resources are increasing and provide yet another a place where information can be shared and obtained. The use of social media including LinkedIn, Facebook, and organizational mailing list servers, blogs, and online communities are also contributing to the world wide sharing of ideas around the use of simulation.

The future of healthcare simulation and the use of simulation in nursing education seem to be limitless. New landmark studies such as the one conducted by the National Council of State Boards of Nursing that provided the first evidence demonstrating that high quality simulation can safely replace up to 50% of clinical hours with no untoward effects to learning outcomes (Hayden, Smiley, Alexander, Kardong-Edgren, & Jefferies, 2014) is helping to pave the way for new and more varied use of simulation in nursing education. Consumers of healthcare and healthcare education know about simulation and have come to expect it as part of educational coursework. Schools and hospitals are responding to the demand. Nursing schools are expanding the use of simulation and building bigger and better centers to carry out not only simulation-based education but also research. New technologies such as augmented reality will further change simulation-based education. Continued innovation will surely spur new curricular programing and fuel new and unexplored benefits and impacts of learning using simulation. It is hard to predict exactly what simulation-based education will look like in a decade; no one could have predicted it would be where it is today.

Despite all of its advancements, availability, and successes, a gap still exists in proving that simulation makes a difference at patients’ bedsides where the efforts of education and training make the most difference. The discipline continues to struggle with demonstrating unequivocal evidence of its effectiveness (Lapkin, Levett-Jones, Bellchambers, & Fernandez, 2010). The number of confounding factors and human variability make doing such research challenging. A small number of studies have successfully demonstrated the positive impacts of simulation training on patient outcomes (Riley et al., 2011; Zendejas et al., 2011); however, a 2013 systematic review of the literature showed that the pooled results of 50 studies exploring the impact of simulation training on patient outcomes demonstrated only small to moderate patient benefits (Zendejas, Brydges, Wang, & Cook, 2013). Further, these studies have primarily focused on physician training rather than nurse training.

Simulation as a pedagogic approach is not fully developed (Moule, 2011); therefore, nurse scientists and educators will need to continue to expand on and contribute to what is known about the impacts of simulation-based training on both learning and patient outcomes. Anecdotally, those who use simulation as a teaching technique/technology believe in its ability to develop safer practitioners with stronger critical thinking skills and improved competence and confidence, but will continue to need to defend its use until the research evidence catches up to the anecdotal sentiment. Certainly, patients—as do airline passengers—feel safer knowing time has been spent in the simulation lab, and perhaps that is all that is required.

As time is a testament, these first humble beginnings led the way for more ambitious goals and current knowledge; continued efforts will give way to new uses and discoveries. The old psychomotor skills laboratories filled with simple task trainers and static mannequins paved the way for the modern-day large-scale simulation centers teeming with computer-run mannequins depicting multiple age groups, races, and genders. Without these early innovators and collaborators nursing education may look quite different today. Given the increasing pressures in the healthcare system and increasing technological advances in healthcare, it is likely that simulation will gain further popularity and even wider adoption (Moule, 2011). With the foundation set and quick commercialization of new technologies, as well as a global community of simulationists, the next decade is sure to be filled with exciting advancements that will benefit students and patients alike.