High-fidelity scenario-based simulation provides

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1 JNSD Journal for Nurses in Staff Development & Volume 28, Number 1, E1YE8 & Copyright B 2012 Wolters Kluwer Health Lippincott Williams & Wilkins Does High-Fidelity Simulation Improve Clinical Outcomes? Danielle C. Merchant, MSN, RN This literature review found that current evidence supports high-fidelity simulation as leading to enhanced teamwork and crisis management skills of healthcare providers. High-fidelity simulation should be considered as a strategy in staff development efforts to enhance safe delivery of patient interventions and professional competencies in high-risk, low-incidence clinical situations among practicing nurses. High-fidelity simulation provides objective information on individual practitioner competencies in an environment that ensures patient safety (Decker, Sportsman, Puetz, & Billings, 2008). High-fidelity simulation (see Table 1), also referred to as full-scale simulation, can be defined as learning experiences that employ highly sophisticated, interactive computer programs, which incorporate lifelike models for varying clinical situations along with practitioner reactions and interventions (Binstadt et al., 2007; Decker et al., 2008). The design and realism of this type of simulation is more likely to result in transference of learned behaviors to clinical setting, as opposed to other forms of behavior-based education, such as online course modules or didactic lecture (Fernandez et al., 2008; McGaghie, Issenberg, Petrusa, & Scalese, 2010). Danielle C. Merchant, MSN, RN, California State University, Fullerton; CHOC Children s Hospital, Orange, California. The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article. ADDRESS FOR CORRESPONDENCE: Danielle C. Merchant, MSN, RN, 455 South Main Street, Orange, CA ( dm109@csu.fullerton.edu; d3merchant@roadrunner.com). DOI: /NND.0b013e318240a728 BACKGROUND The purpose of this article is to describe the effects of high-fidelity, simulation in hospital education programs. Although the use of simulation has been widely accepted and used by the aviation and military industries to enhance outcomes in the face of highrisk, low-incidence situations, its use in health care is relatively new by comparison (Buckley & Gordon, 2011; Nagle, McHale, Alexander, & French, 2009). Furthermore, prior research focusing on simulation education has largely been concentrated on education among prelicensure nursing students, qualitative in nature, and few findings have been tied to actual clinical performance outcomes (Buckley & Gordon, 2011; Wolf, 2008). Although some healthcare organizations are using high-fidelity simulation, overall it is underused for continuing education (Wood, 2010). Several barriers may prevent employers from gaining beneficial opportunities to maximize nurse preparedness for high-risk clinical situations. The relative newness of simulation contributes to lack of knowledge regarding its benefits, especially related to clinical outcomes (Tilley, 2008). Practical barriers include required space, equipment, and training for instructors (Nagle et al., 2009). Whatever the barriers, waiting for unequivocal proof of the benefits of simulation should not occur in an industry where human lives are dependent on responsible professional caregivers (Gaba, 1992). The American Association of Colleges of Nursing (2009) and National League for Nursing (2003) both acknowledged that educators are expected to produce learning environments that facilitate critical thinking and reflection while preparing nurses for practice. The National League for Nursing (2005) also recommended that nursing educators lead the way in promoting innovative education strategies. This includes the use of high-fidelity simulation on the grounds that it integrates the core learning principles that facilitate adult learning (Nagle et al., 2009). Thus, this integrative literature review seeks to describe the documented effects of high-fidelity scenariobased simulation training on performance and clinical practice outcomes among hospital staff. FRAMEWORK Benner (2001) used a performance-based learning model to identify stages of proficiency that nurses experience in practice: novice, advanced beginner, competent, proficient, and expert (Kaakinen & Arwood, 2009; Waxman & Telles, 2009). Benner s model describes how nurse proficiency can apply to staff education; for example, clinically expert nurses begin as novices when learning how to use new technology or when put into novel situations (Waxman & Telles, 2009). However, this reversion to being a novice may lead to cognitive dissonance and discomfort in expert clinicians. Using Benner s theory, Journal For Nurses in Staff Development E1

2 TABLE 1 Definitions for Terms Term Definition Medical simulation High-fidelity, or full-scale simulation Competency Teamwork Crew resource or composite risk management training Crisis management Educational strategy that mimics actual environmental and patient situations and compels learners to demonstrate clinical competency. Highly sophisticated, interactive computerized programs that incorporate lifelike model interfaces for varying clinical situations along with practitioner reactions and interventions. Interpersonal, decision-making, and technical skills that meet practice standards within health care. Includes aspects of behavior (e.g., communication, prioritization) that in turn affect clinical performance. Skill comprised of core competencies, including problem solving/planning/preparation, action processes, and interpersonal factors (e.g., collaboration, mutual respect, and conflict resolution), supporting mechanisms (such as shared goal recognition and closed-loop communication), and reflection (e.g., debriefing and feedback). Simulation-based training programs that use high-fidelity, simulation to help team members achieve maximum group effectiveness under time restraints in stressful environments and situations. Task- and cognitive/behavior-oriented skill setsvincluding teamwork, decision making, resource handling, and situation awarenessvused during an urgent or high-risk situation to successfully organize, control, and resolve the situation. Refences used in the table are as follows: Binstadt et al., 2007; Cross & Wilson, 2009; Decker et al., 2008; Fernandez et al., 2008; Galloway, 2009; Knudson et al., 2008; Messmer, 2008; Shapiro et al., 2008; Tilley, high-fidelity simulation can be modified to meet the needs of nurses who fall within any stage of clinical competency. Furthermore, high-fidelity simulation facilitates adult learning through experiential learning strategies, which encompass real-time experience, reflection, abstract conceptualization, and active experimentation (Kaakinen & Arwood, 2009; Nagle et al., 2009; Waxman & Telles, 2009). Experiential learning provides learners with opportunities that allow them to work together to solve problems and use critical thinking within a safe environment. With simulation, a clinical event (real-time experience) with debriefing (reflection), reviewing and understanding (abstract conceptualization), and learning on the simulator (active experimentation) epitomizes experiential learning (Waxman & Telles, 2009). METHODS Studies that evaluated educational strategies using highfidelity simulation to measure performance and practice outcomes among nurses in hospital settings were analyzed and synthesized. Other studies reviewed were those that recognized conditions where simulation was most effective in enhancing learning. Search Methods The computerized data bases such as Academic Search Premier, CINAHL Plus, Cochrane Library, OmniFile, PsycINFO, PubMed, and Wiley InterScience were searched using the following key words: nursing education, simulation, high fidelity, learning, clinical outcomes, teamwork, and crisis management. Research studies were selected if they were published in peer-reviewed journals between 2004 and 2010, assessed clinical outcomes of high-fidelity simulation-based educational interventions, and focused on nursing or medical samples in clinical settings. Excluded were articles that were pure literature reviews, studies that solely addressed the use or outcomes of simulation with prelicensure or undergraduate nursing students, studies that used simulation solely to evaluate competencies, and studies that only used participant surveys or self-evaluations to measure clinical performance outcomes. FINDINGS The search yielded eight published studies regarding the effect of simulation on performance and clinical practice outcomes, specifically within staff training programs (see Table 2). Teamwork Studies demonstrated the feasibility of using high-fidelity simulation as an effective method for learning and practicing teamwork (see Table 1) and organizational skills in a variety of critical medical scenarios (see Table 2). The effect of simulation training on teamwork skills among nurses, physicians, doctor of medicine (MD) residents, and respiratory therapists was measured. In one study, DeVita, Schaefer, Lutz, Wang, and Dongilli (2005) found that critical care nurses, physicians, and respiratory therapists increased simulator patient survival from 0% to 89% after completion of a Web-based tutorial E2 January/February 2012

3 TABLE 2 Summary of Studies Including High-Fidelity Simulation in Hospital Staff Education Author (Year)/Study Design Sample/Setting Simulation Studied Abrahamson et al. (2006) 275 healthcare workers (including 225 intensive care unit [ICU] nurses, physicians, and respiratory therapists) High-fidelity, on crisis management and teamwork Study Focus and Outcomes Purpose: Test the effectiveness of using simulation to teach a new protocol for treating cardiac patients with severe acute respiratory failure (SARS) Findings Errors for existing and initial protocols were noted and corrected. Simulation allowed for assessment and correction of participant skills performance during crisis scenarios. Education program implementation and evaluation Classroom and empty, negative pressure hospital room Major outcomes: individual/team performance in crisis scenario (cardiac arrest in SARS patient), time to complete tasks (for infection control and cardiac arrest management), and ability to correctly perform tasks (per policy). Also identified errors and changes needed in protocol for cardiac arrest in SARS patients. Simulation was effective in evaluating treatment protocols and teamwork training during low-incidence, high-risk crisis situation scenarios Andreatta et al. (2011) 228 junior and senior pediatric doctor of medicine (MD) residents in various pediatric specialty areas; pediatric ICU nurses, pharmacists, and hospitalists (exact number was unclear) High-fidelity, on crisis management Purpose: Test the effectiveness of using simulation-focused mock code training program for successfully resuscitating pediatric patients with various clinical presentations using evidence-based interventions over 4 years Pediatric cardiopulmonary arrest patient survival rates increased from 33% to 50% within the first year after initiation of the program (p G.0001). Survival rates correlated with increased frequency of mock codes (r =.87). The same trend continued over the remainder of the study, but survival rates did not increase as much. Simulation center at the University of Michigan Tertiary Care Academic Medical Center Major outcomes: learner perceptions of ability to manage a pediatric code (postsimulation program training), open-ended and 6-point Likert-scale items, relationship between clinical survival rates for pediatric patients who have experienced cardiopulmonary arrest and simulated mock code training Continued Journal For Nurses in Staff Development E3

4 TABLE 2 Continued Author (Year)/Study Design Sample/Setting Simulation Studied Carroll and Pignataro (2009) Surgical staff nurses at Children s Hospital Boston (exact number was unclear) Scenario-based simulation and sporadic use of low-fidelity simulator facilitators; focused on crisis management Study Focus and Outcomes Purpose: Prepare nurses for low-incidence, high-risk patient presentations to optimize/ improve clinical outcomes and reduce incidence of reported performance anxiety during crisis situations Findings Hospital reported noticeable improvement in communication skills, patient outcomes, and staff confidence during emergency situations in both mock and actual codes in the hospital Education program implementation and evaluation Children s Hospital Boston s simulation laboratory, surgical units Major outcomes: staff nurse attitudes, opinions, role confidence, communication techniques regarding education after participation in mock/actual codes; exact methods used to determine outcomes vague DeVita et al. (2005) 138 experienced staff (69 critical care nurses, 48 physicians, 21 respiratory therapists); 11 were advanced cardiac life support trained with experience responding to cardiac arrests High-fidelity on crisis management and teamwork Purpose: Study the effectiveness of simulation training to improve group team skills/performance during medical emergencies Simulated survival (following predetermined criteria for death**) increased from 0% to 89%; initial team task completion rate was 10%Y45%, which rose to 80%Y95% during the third session Single Large training center at university- affiliated tertiary care hospital Major outcomes: (1) crisis management goals (manage airway, breathing, circulation, and neurological problems [ABCD] effectively); (2) use of appropriate interventions for crisis management; (3) acceptability of time for identification of problems and interventions. Also organizational goals (communication, teamwork) and task completion. **Simulator survival depended on supporting oxygenation, ventilation, and circulation within 60 seconds and delivering the definitive treatment within 3 minutes. Knudson et al. (2008) 18 midlevel surgical MD residents High-fidelity on crisis management Purpose: Evaluate the effect of simulation-based trauma curriculum training on actual performance The intervention group s (simulation-trained participants) overall performance and crisis management skills were higher than those of the control group, especially for the teamwork component (p =.04). E4 January/February 2012

5 TABLE 2 Continued Author (Year)/Study Design Sample/Setting Simulation Studied Randomized, Simulation center and emergency department (ED) Study Focus and Outcomes Variables: independent variable (IV)Vsimulation-based curriculum for trauma surgical training; dependent variables (DVs)Vevaluation and treatment skills, crisis management skills, and overall performance in ED patient management Findings Messmer (2008) 50 nurses (medicalysurgical, ambulatory, ED, and ICU nurses) and 55 pediatric MD residents Scenario-based training with human patient simulator focused on teamwork Purpose: Determine the effect of simulation training on nurseyphysician collaboration With increased exposure to and participation in critical pediatric simulation scenarios, participants improved competency, levels of collaboration, and group cohesion scores. Single Setting not described Major outcomes: individual/team competency among nurses and physicians using the Kramer and Schmalenberg NurseYPhysician Scale, Group Cohesion, and Collaboration and Satisfaction With Patient Care Decisions tools Shapiro et al. (2004) 20 participantsv4 randomly selected teams of 8 ED physicians (4 attending and 4 residents) and 12 nurses High-fidelity on teamwork Purpose: To determine if high-fidelity simulation-based team training can improve clinical team performance when added to an existing didactic teamwork curriculum Main findings: (1) no significant differences between the experimental and comparison groups at baseline; (2) experimental team showed a trend toward improvement in quality of team behavior (p =.07); (3) comparison group showed no change in team behavior during the two observation periods (p =.55). Single, crossover, prospective, blinded, and controlled Simulation center (Level 1 trauma center and academic emergency medicine training program) at teaching hospital Experimental group: 8 hours of simulation training; comparison group worked together in ED for 8 hours Variables: IVVsimulation teamwork training; DVVteamwork behavior as measured by Team Dimensions Rating formybehavioral anchored rating scale Continued Journal For Nurses in Staff Development E5

6 TABLE 2 Continued Author (Year)/Study Design Sample/Setting Simulation Studied Wolf (2008) Sample: 13 ED nurses; 6 of 13 in simulation group Scenario-based simulation using high-fidelity human patient simulator to supplement classroom didactic focused on crisis management Study Focus and Outcomes Purpose: Develop an orientation education model incorporating human patient simulation in nurse-driven ED environments, particularly in smaller community hospitals; study the effect of simulation training on triage skills among nurses in ED Findings After classroom portion, nurses averaged 20-point increase from pretest. Education program implementation and evaluation; retrospective Setting: classroom/ simulation laboratory Variables: IVVsimulation-supplemented training; DVVcrisis management/triage performance using retrospective chart audits Simulation participants demonstrated a 30% to 60% improvement in triage accuracy, with the greatest improvement among nurses new to triage. and participation in three high-fidelity, team-based, critically simulated scenarios. The initial team task completion rate also increased from 10%Y45% to 80%Y95% after the third simulation. After each case presentation, participants received feedback through debriefing. Simulator patient survival was achieved when respiratory interventions were applied within 1 minute and appropriate treatment was delivered within 3 minutes (DeVita et al., 2005). Aggregate results across the studies also demonstrated significant improvements in the times it took the teams to complete simulated tasks (Abrahamson, Canzian, & Brunet, 2006; DeVita et al., 2005; Messmer, 2008; Shapiro et al., 2004). In a crossover, blinded, and controlled observational study, Shapiro et al. found improved teamwork in emergency department (ED) teams of physicians and nurses who received simulation training; the control group demonstrated minimal evidence of improved teamwork. In addition, Abrahamson et al. (2006) found that highfidelity simulation allowed medical personnel to identify and correct for individual and team errors in infection control and transport protocols. In a study assessing nursey physician collaboration during three pediatric life-threatening mock codes using fully simulated scenarios, Messmer (2008) found both nurses and physicians improved their communication skills and developed mutual respect for one another s contributions; the author posits that this allowed them to act more quickly and efficiently for the benefit of the patient (human simulator). These teamwork-focused findings did not include direct clinical outcome measures (Abrahamson et al., 2006; DeVita et al., 2005; Shapiro et al., 2004). That is, completion of the simulation training was not directly associated with improved staff performance in the hospital or in clinical outcomes. Conclusions such as those of Messmer (2008), as to what specifically leads to changes in teamwork behaviors, were also untested. Teamwork-focused studies also included crew resource management training methodologies (see Table 1), which can be defined as cognitive/behavioral training programs, commonly used in the aviation and military industries, that use high-fidelity simulation to help team members achieve maximum group effectiveness under time restraints in stressful environments (Cross & Wilson, 2009; Knudson et al., 2008; Messmer, 2008; Shapiro et al., 2008). However, Shapiro et al. (2004) was the only study that employed validated instruments from crew resource management training to determine teamwork-related outcomes (see Table 2). Crisis Management Studies demonstrated the practicality of using highfidelity, simulation as an effective method for learning and practicing crisis management (see Table 1) in a variety of healthcare settings. Crisis management outcomes were measured among nurses, physicians, MD residents, and respiratory therapists (see Table 2). Wolf (2008) introduced triage training to 13 ED nursing staff members. Retrospective chart audits demonstrated that, at baseline, ED nurses triaged approximately 40% of patients. Nurses were divided into two groups that received didactic training; six nurses were also exposed to several high-fidelity, simulations. The E6 January/February 2012

7 nurses who completed the simulation training triaged 70%Y100% of patients appropriately (Wolf, 2008). Although the chart audits did not provide a direct link between the simulation training and accurate triage (Galloway, 2009), the nurses who experienced simulation training stated that their training helped them to better anticipate and manage patient care interventions. Andreatta, Saxton, Thompson, and Annich (2011) retrospectively evaluated hospital data and found that pediatric cardiopulmonary arrest patient survival rates (defined to include patients who were subsequently discharged from the hospital) increased from 33% to 50% within the first year after initiation of an evidence-based simulationfocused mock code program ( p G.0001). Survival rates correlated with increased frequency of mock codes (r =.87). While this trend continued over the remainder of the 4-year study, survival rates did not increase significantly. Study participants included 228 MD pediatric residents in various specialty areas and pediatric intensive care unit nurses, pharmacists, and hospitalists; the exact number of these participants was unclear. Participants were selected to respond to random simulated mock codes at progressively higher frequencies over the course of the study (Andreatta et al., 2011). Mock codes were videotaped, and residents participated in debriefing exercises with clinical faculty immediately after the simulated code. Simulated scenarios varied based on common pediatric clinical presentations. Andreatta et al. also examined various confounding variables that could have affected the findings. The effect of these variables, which included the number of cardiopulmonary arrest events, staffing, patient acuity, average length of stay, and patient census, was not significant (Andreatta et al., 2011). Knudson et al. (2008) completed the only study that presented actual clinical outcome measures related to crisis management skills. These researchers randomized 18 midlevel surgical MD residents to one of two groups participating in resuscitation training. Groups included training with (a) didactic lecture (control group) or (b) simulation (intervention group). After training, residents first four trauma resuscitations were videotaped. Whereas the two groups performed similarly initially, after training, the intervention group received higher scores for crisis management skillsvincluding teamwork, decision making, and situation awareness (Knudson et al., 2008). However,thesescoreswerenotsignificantlydifferentfrom residents in the control group; this was possibly because of the small sample size. DeVita et al. (2005) found that healthcare providers who participated in simulation training demonstrated improvement in achieving crisis management goals, which included managing airway, breathing, circulation, and neurological problems (ABCD), effectively. Critical care nurses, physicians, and respiratory therapists in this study achieved a simulator patient survival increase of 0%Y89% after a Web-based tutorial and participation in three high-fidelity, team-based, critically simulated scenarios (DeVita et al., 2005). Abrahamson et al. (2006) also found that high-fidelity simulation allowed the assessment and correction of skills performance among healthcare providers during crisis scenarios. Carroll and Pignataro (2009) reported on implementation of a simulator, mock code training that was well received by nursing staff. The hospital also found noticeable improvement in communication skills, patient outcomes, and staff confidence during emergency situations in both mock and actual codes (Carroll & Pignataro, 2009). DISCUSSION This review demonstrates the usefulness of simulation training to improve teamwork and crisis management of hospital staff, including nurses. Generally, simulation is most effective in enhancing learning under certain conditions. These conditions include use of teaching methods that (a) provide valuable and timely feedback, (b) allow for repetitive practice, (c) capture clinical variation, and (d) establish controlled and safe learning environments (Issenberg, McGaghie, Petrusa, Gordon, & Scalese, 2005). These conditions also set the stage to allow educators to measure outcomes related to specific learning objectives. Nurse educators should consider use of high-fidelity simulation as a teaching strategy that meets these conditions and can optimize and enhance learning outcomes. Simulation is an effective means for measuring clinical performance across many aspects of nursing care and represents an integrative approach to understanding the risks or potential risks to patient safety and the effectiveness of nursing interventions (Binstadt et al., 2007; Weinger, Slagle, Jain, & Ordonez, 2003). Furthermore, effective teamwork and crisis management are key components in positive clinical outcomes, which include error reduction, decreased mortality rates, cost reductions, and increased patient safety in high-risk circumstances. Lack of teamwork-related competencies, particularly communications, have been identified as a potential cause for approximately 70% of sentinel events (Cross & Wilson, 2009; Messmer, 2008). Therefore, effective use of simulation training to improve teamwork and other clinical skills will likely result in enhanced patient safety. More high-quality research is needed to measure the effect of simulation-based education on actual provider behaviors and clinical outcomes. Well-designed studies that use meaningful outcome measures such as those used by Andreatta et al. (2011), Knudson et al. (2008), and Shapiro et al. (2004) could help nurse researchers establish a solid evidence base for the use of high-fidelity, Journal For Nurses in Staff Development E7

8 simulation in continuing nursing education. As more evidence accrues about the effects of simulation on clinical outcomes, researchers can begin to improve educational strategies by determining the method and frequency at which simulation training should occur to achieve and maintain quality, evidence-based clinical skills. References Abrahamson, S. D., Canzian, S., & Brunet, F. (2006). Using simulation for training and to change protocol during the outbreak of severe acute respiratory syndrome. Critical Care, 10(1), 1Y6. American Association of Colleges of Nursing. (2009). Setting a high standard. In Advancing higher education in nursing (p. 8). Washington, DC: Author. Retrieved from Andreatta, P., Saxton, E., Thompson, M., & Annich, G. (2011). Simulation-based mock codes significantly correlate with improved pediatric patient cardiopulmonary arrest survival rates. Pediatric Critical Care Medicine, 12(1), 33Y38. Benner, P. (2001). From novice to expert. 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