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Scholarship of Teaching and Learning Grant
Final Report
Implementation of Simulation Using High Fidelity Manikins:
An Intervention to Enhance Learning and Performance for Advance Practice Nurses in Pediatrics
Marie H Thomas, PhD, FNP‐ BC, CNE
Kathleen Jordan, DNP, FNP‐ BC, ENP‐ BC, SANE-P
Colette Townsend‐ Chambers, MSN, RN
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Developing the requisite knowledge and skill set to perform as a highly competent
advanced practice nurse (APN) is an art and a science. Of utmost importance, the APN must be
able to critically appraise a clinical situation and intervene appropriately in the provision of safe
and effective care, and high-fidelity simulation is a method to enhance this ability in a protected
and nonthreatening environment. The purpose of this project was to evaluate the effectiveness of
pediatric simulation scenarios using high-fidelity manikins on student learning outcomes related
to assessment skills, clinical knowledge, clinical reasoning/decision making, and self-efficacy in
APNs.
There is a growing body of evidence that supports high-fidelity simulation as an effective
pedagogy and andragogy to promote critical thinking, problem solving, and enhancement of the
knowledge and skill set required of the APN. Multiple studies have been conducted that support
simulation as an effective method of teaching and learning leading to an improvement in
confidence, performance and clinical judgment, and reduction of medical errors (Brannan, J.D.,
White, A., & Bezanson, J.L., 2008; Jeffries & Rizzolo, 2006). In a systematic review conducted
by Harder (2010) to evaluate the effects of simulation on student learning, it was demonstrated
that clinical skills are enhanced through simulation as compared to traditional learning methods.
The most salient advantages of using high-fidelity simulation to enhance the performance
of the APN include: 1) student engagement in an active learning strategy executed during each
simulation experience that in itself has been demonstrated to promote knowledge retention;
2) exposure to realistic replications of clinical case scenarios in a safe and nonthreatening
environment which enhance quality and safety when applied to the real clinical setting,
particularly in an urgent or emergent clinical situation; 3) an opportunity for the student to
manage a medical problem while simultaneously engaging in patient and family-centered care;
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and 4) the ability for the student to engage in self-reflection and peer-review as a method to
assess and support critical thinking and clinical decision making skills (Hyland, Weeks, Ficorelli
& Vandermeek-Warren, 2012; Jeffries & Rizzolo, 2006; Ravert, 2008).
The Institute of Medicine (IOM) blueprint report, The Future of Nursing: Leading
Change, Advancing Health (2010) calls for a transformation to ensure appropriate healthcare.
The IOM supports the use of high fidelity simulation as one method to facilitate this
transformation. Student engagement in high-fidelity simulation has the potential to develop and
enhance the confidence, knowledge, skill set and self-efficacy required of the APN to meet the
increasing demands of health care environment. To date, there is limited research on the use of
high-fidelity simulation in the education of APNs, and exploratory outcome data is needed to
support this method of teaching and learning.
Methods
The Jeffries Model for Simulation (2005) was the guide used in the development of four
pediatric clinical simulations of commonly encountered health care situations by APNs and
represented situations commonly encountered by primary health care providers as identified by the
Agency for Healthcare Research and Quality (Weir, Hao & Owens, 2013). The four simulation
scenarios were developed and designed to incorporate active learning, requiring student engagement
in assessment, diagnosis, clinical decision-making, implementation of a course of treatment, and
interacting with family (Appendix A). All clinical scenarios included changes in physiologic
responses based on age, level of development, family dynamics, appropriate laboratory values, and
imaging studies as appropriate to the scenario.
All four pediatric simulation scenarios were provided to students in a small group format
allowing for focused assessment, pertinent history taking, identification of diagnosis, development of
appropriate treatment plan, and documentation. The Jeffries model (2005) supports the use of small
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student groups to allow time to gather information, diagnose, and plan a course of treatment. Eight
clinical hours were devoted to the 4 different pediatric simulation scenarios permitting each student
at least two opportunities to participate in the simulated clinical office visits.
Participation in the simulation scenarios were required and were counted as part of the APN
student’s designated clinical hours for the graduate nursing course Advanced Primary Care of
Children and Adolescents (NUNP 6260). Both faculty and student evaluation of the scenarios and
the student experience during the simulated office visits were collected to allow for future refinement
and modification of the process. Simulations were videotaped allowing a mechanism to review the
scenario and provide opportunities for guided reflection during debriefing. Faculty and peer feedback
was provided to encourage and reinforce performance, knowledge, and clinical decision-making.
Student-student and student-faculty interactions are designed to encourage collaboration in
evaluating the pediatric patient’s situation and implementing the appropriate plan of care as well as
promote achievement of the goals of each simulation and meet the learning outcomes for the course.
Students were evaluated on age appropriate assessment skills, clinical-decision making and
development of the differential diagnosis, planning an appropriate course of treatment, interaction
with the family, and overall integrative knowledge of the care needed including laboratory values and
pharmacology as appropriate.
Evaluation
Evaluation of the student learning outcomes was conducted through the use of the Student
Satisfaction and Self-Confidence Learning instruments developed by the National League for
Nursing (NLN) and Laerdal Medical Company (Jeffries & Rizzolo, 2006). Permission to use these
instruments was obtained from the NLN. Upon completion of the high-fidelity simulation
experience, the student participants completed three hard-copy instruments that have been previously
tested for validity and reliability by content experts in simulation development and testing. The first
tool was a Simulation Design Scale, a 20-item questionnaire using a five-point Likert scale designed
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to evaluate the design features of the simulations used in the study, and the importance of those
features to the learner (Appendix B). The second tool was an Education Practices Questionnaire,
consisting of 16-items using a five-point Likert scale designed to measure whether four education
practices are present in the simulation (active learning, collaboration, diverse ways of learning, and
expectations), and the importance of each practice to the learner (Appendix C). The third tool was a
Student Satisfaction and Self-Confidence in Leaning Questionnaire, consisting of 13-items using a
five-point Likert scale designed to measure student satisfaction with the simulation activity and selfconfidence in learning (Appendix D).
Results
Family nurse practitioner students enrolled in a pediatric clinical course completed four different
clinical simulations representing common pediatric problems seen in primary care. Twenty of the
volunteers (19 female and 1 male) completed all four simulations; one student (a female) completed two
simulations. The demographic variables of the study group were as follows: all of the students were
B.S.N. graduates, and held an active North Carolina Nursing License and were enrolled in the fifth
semester of a Family Nurse Practitioner M.S.N. program at a state university. All of the student
participants had a minimum of one year of nursing experience.
Ninety-four Jeffries/NLN simulation questionnaires were completed anonymously and submitted
for analysis. Each student was asked to complete three evaluation tools after each of the four clinical
simulations. The Jeffries/NLN evaluation tools include: Student Satisfaction and Self-Confidence in
Learning, Simulation Design Scale, and Educational Practices Questionnaire. The questionnaires use
Likert scales of 1-5 with 5 representing strongly agree and 1 representing strongly disagree. Data from the
questionnaires were analyzed using SPSS.
The Student Satisfaction and Self-Confidence in Learning Scale is a 13-item questionnaire
designed to measure student attitudes regarding the simulation experience. The first five items are
designed to elicit information about student satisfaction with simulation; the remaining questions focus on
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student self-confidence. Results from the Student Satisfaction items indicated that the students felt the
simulation was a valuable teaching tool to support their clinical education. Ninety-six percent of the
students agreed or strongly agreed that the simulation was effective in enhancing their clinical knowledge
and the simulation was an effective teaching tool. Ninety-four percent of the students felt the simulation
enhanced their self-confidence in handling common conditions presented in pediatric practice.
The Simulation Design Scale is a 20-item questionnaire focusing on the individual elements of
the simulation ranging from learning objectives to realism. On the Simulation Design Scale an average of
96.2 percent of the students agreed or strongly agreed that the simulation was effectively designed and
clinically applicable to their practice and learning needs. Ninety-two percent of students felt instructors’
questions helped them to think critically; 89.2% strongly agreed that the instructors’ effectively facilitated
the simulation experience. Eighty-two percent strongly agreed that they were challenged in their thinking
and decision-making skills and better prepared them to care for actual patients. Students commented
favorably on the instructor feedback they received during the experience; 91.8 % felt the feedback and
comments were helpful and perceived their instructors as facilitators.
On the 16-item Educational Practices Questionnaire, 94.5% of students felt the simulation
experience was effective. A goal of the research study was to investigate student-student and studentfaculty collaboration in assessment, diagnosis and treatment of pediatric patients in primary care. Ninety
one percent of the students agree or strongly agree that simulation supported active learning, 87.4% felt
the experience encouraged collaboration and 89.5% felt simulation was a unique method of teaching.
Eighty nine percent of students felt the learning outcomes, goals and expectations were clear for the
simulation. The following chart indicates the overall results of the study.
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Discussion
Overall, the students reported the simulation experiences as very helpful and a good preparation
for clinical. Students also stated they would have benefited from an orientation to simulation as
experiences with simulation varied from none to having extensive experience with simulation in their
Baccalaureate program. The ability to ask questions and collaborate with peers was considered very
positive experience. The majority felt the use of simulation should continue and be part of the future
curriculum. Simulation can and should be developed to support clinical experiences for APN students.
Future plans are incorporating simulation experiences in the advanced adult health curriculum and the
women’s health curriculum. Continued research is needed to identify the type and amount of simulation
need to maximize patient safety and quality of care.
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Appendix A
Pediatric Clinical Scenarios
#1. Simulation Design Template: Asthma
Expected Simulation Run Time: 30 minutes
Client Name: Michael Davis
Gender: Male
Age: 8 years
Historian: Mother and patient
CC: Cough and wheezing
Weight: 30 kg
Height – 52 inches
Vital Signs: P – 128 RR – 36 T 99 oral SaO2 – 92%
Allergies: No known drug allergies
Medications: Zyrtec, Albuterol
Immunizations: Current per CDC recommendations
Past Medical History: Diagnosed with asthma three years ago. History of seasonal allergies,
and intermittent wheezing with change of seasons. Last episode of wheezing was several
months ago. RSV in infancy x2.
History of Present Illness: Michael Davis is an 8-year-old male who is brought into your
pediatric primary care office with the chief complaint of cough and wheezing for 2 days. He
has a history of asthma but it is very well controlled and he rarely has to use his Albuterol. He
has both a nebulizer and a MDI with spacer and mask. His mother states that since the weather
has changed and the pollen has appeared he has been having watery eyes, a stuffy nose, and a
mild cough. Over the past 2 days he has started wheezing and coughing more. His mother
reports that she has been administering Albuterol via nebulizer his nebulizer every four hours.
Last night he woke up during the night coughing and wheezing and he had to have an albuterol
treatment. His teacher also said that he has had to go to the nurses’ office at school yesterday for
a treatment after playing outdoor during recess.
Social History: Lives with mother and father. He has two older school-age siblings, ages 5 and
10. His 10-year-old sibling has asthma. He is in the third grade at school, plays baseball and
soccer.
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Objectives:
1. Perform a comprehensive history and physical examination on the patient.
2. Correctly diagnose the clinical condition and acuity level of the patient.
3. Order the appropriate interventions. Order appropriate diagnostic tests if needed.
4. Reevaluate the patient after implementing interventions and modify plan of care as needed.
4. Accurately diagnose and implement a plan of care for the patient (intermittent asthma) using
the asthma action plan. Include discharge teaching and discussion of follow-up and return
precautions. Write prescriptions for needed medications.
Scenario Progression Outline
TIME
2 Minutes
MANIKEN ACTIONS
Sitting in high-fowlers position on
stretcher
EXPECTED INTERVENTIONS
Wash hands
Introduce self to mother
Initiate history
5 minutes
Tachypnea with RR 36, tachycardia
with heart rate 128, Sa02 – 92%,
inspiratory and expiratory
wheezing, coughing frequently,
intercostal retractions
PEFR - 175
5 minutes
Unchanged
Complete a history and physical
examination (Findings: Pt. is in mild
respiratory distress, moist mucous
membranes, pharynx without
erythema, boggy nasal mucosa, normal
skin turgor, brisk capillary refill, lungs
with inspiratory and expiratory
wheezing bilaterally, abdomen with
normal bowel sounds, soft, non-tender,
moves all extremities equally)
Assess Peak Flow
Explain concerns of physical
examination findings to mother and
patient. Discuss plan of care. Verify
allergies. Order Albuterol 2.5 – 5 mg
and Atrovent 0.5 mg HHN. Order
steroids – loading dose with 2 mg/kg
of Orapred (15 mg/5 ml = 20 ml or
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two 30 mg ODT’s)
5 minutes
5 minutes
Pt. reports that he is feeling better.
Wheezing is increased, however air
exchange is improved. SaO2 – 95%
PEFR - 225
Inquire as to how pt. is feeling.
Auscultate lungs. Assess peak flow.
Explain that a second Albuterol 2.5 –
5.0 mg will be administered. Order
treatment.
Pt. reports that he is feeling much
better. Lungs with minimal
wheezing, RR: 20 Sa02 – 98%.
Confirm success of therapy with pt.
and mother. Discuss home care to
include:

PEFR - 230





Equipment Needed:
Pulse Oximeter
Peak flow meter
Stethoscope
Albuterol 2.5 mg HHN every 4
hours as needed
Orapred @ 1 mg/kg for 4 more
days (10 mg or one thirty
ODT).
Continue Zyrtec
Discuss possibility of needing
an inhaled steroid if symptoms
are difficult to control
Review asthma plan and
provide to pt. and mother
Discuss return precautions:
worsening wheezing, coughing,
chest tightness or SOB. Advise
to return to the ED or office
during office hours. Use
asthma action plan.
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Nebulizer for Albuterol/Atrovent administration
Peak Flow Meter Chart
Asthma action plan form
Blank Prescription
Debriefing / Guided Reflection Questions for This Simulation
1. What assessment data is important in determining degree of respiratory distress in children?
2. What were your priorities for this patient?
3. How did the team determine who would do what? How did you communicate?
4. What did you do well? Were your interventions effective?
5. To Observers: What questions or comments do you have for the team?
#2. Simulation Design Template: Child Maltreatment
Expected Simulation Run Time: 30 minutes
Client Name: Steven Morrison
Gender: Male
Age: 6 weeks
Historian: Mother
CC: Fussy, and ? pain in left leg
Weight: 4.2 kg
Vital Signs: P – 136 RR – 32 T 100.8 ®
Allergies: No known drug allergies
Immunizations: Current per CDC recommendations
Past Medical History: Patient was a full-term vaginal delivery @ 39 weeks gestation. Mother
was a G1P1. There were no complications during pregnancy, labor or delivery. Apgar’s were 8
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and 9. Birth weight was 3.2 kg.
History of Present Illness: “Patient appears to be fussy since he woke up this morning. He is
bottle-fed (Gerber Gentle) and normally takes about 4 ounces every 3-4 hours. This morning he
only drank 2 ounces of formula. He is normally not a fussy baby and this morning has been very
fussy, doesn’t want to be put down and cries especially hard when I change his diaper or dress
him. He acts like his left leg might be hurting him. My husband got up to feed him during the
night and told me that he drank his whole 4 ounce bottle”.
Social History: Lives with mother and father. He is an only child. Mother is a stay at home
mom, and he does not attend daycare
Objectives:
1. Perform a comprehensive history and physical examination on the patient, identifying left leg
pain.
2. Identify a list of differential diagnoses.
3. Order the appropriate diagnostic tests.
4. Accurately diagnose and implement a plan of care for the patient.
Scenario Progression Outline
TIME
2 Minutes
MANIKEN ACTIONS
Being held by mother
EXPECTED INTERVENTIONS
Wash hands
Introduce self to mother
Initiate history
5 minutes
Cries with movement and palpation
of left leg
Complete a history and physical
examination
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5 minutes
Lying on exam table
Explain concerns of physical
examination finding to mother, discuss
plan of care and order x-ray of left
femur
10 minutes
Lying on exam table
Review x-ray findings
Inform primary nurse of plan of care
Consult with pediatric orthopedics
Notify law enforcement and DSS
Contact EMS for transfer
Discuss x-ray findings and plan of care
with mother
TIME
2 Minutes
MANIKEN ACTIONS
Lying on exam table
Seizure activity – lasting 1 minutes
and spontaneously resolves
5 minutes
Lying on exam table
EXPECTED INTERVENTIONS
Place infant on side, maintain open
airway, administer oxygen, monitor
vital signs
Initiate peripheral IV
Gives report to EMS
Notify orthopedic surgeon
Notify emergency department (ED) as
patient will now go to the ED
Transfer of patient to the ED
Critical Behaviors
1. Preform a complete head to toe exam, identifying fussy infant with full anterior fontanel, and
tenderness on palpation of left femur.
2. Preform neurovascular assessment of left leg.
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3. Identify and treat acute pain.
4. Order x-ray. Interpret x-ray.
5. Consult with orthopedics and arrange for transfer. Notify Police and DSS.
6. Order splint. Discuss plan of care with patient’s mother.
7. Identify seizure. Protect airway. Reevaluate pt. after seizure.
8. Notify ED. Monitor pt. until EMS arrives for transfer.
Equipment Needed:
Gauze (to place over anterior fontanel)
O2 with tubing
Pulse Ox
Splint for leg
Debriefing / Guided Reflection Questions for This Simulation
1. How did you feel taking care of Steven and his mom?
2. What were your priorities for this patient?
3. How did the team determine who would do what? How did you communicate?
4. What did you do well? Were your interventions effective?
5. To Observers: What questions or comments do you have for the team?
#3. Simulation Design Template: Gastroenteritis with Dehydration
Expected Simulation Run Time: 30 minutes
Client Name: Brittany Smith
Gender: Female
Age: 18 months
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Historian: Mother
CC: Vomiting, diarrhea and fever
Weight: 10.9 kg
Vital Signs: P – 136 RR – 32 T 100.5 ® SaO2 – 99%
Allergies: No known drug allergies
Immunizations: Current per CDC recommendations
Past Medical History: Otitis media x 1, 6 six months ago that cleared with one course of
Amoxicillin. No previous hospitalizations or surgeries.
History of Present Illness: 10:00 AM Brittany Smith is an 18 month old who is brought into
your pediatric primary care office with the chief complaint of vomiting and diarrhea. Her
mother states that for the past 2 of days she has had vomiting, diarrhea, and a low-grade fever
with T max of 101.4. Her mother reports that Brittany has been unable to keep anything down
all day today, and vomits even after sips of Pedialyte. She also reports that she has not changed
a wet diaper since last night.
Social History: Lives with mother and father. She has two older school-age siblings who are
healthy. She attends daycare and mother reports that several children in her daycare have had
similar symptoms this week.
Objectives:
1. Perform a comprehensive history and physical examination on the patient, identifying mild
dehydration.
2. Identify a list of differential diagnoses.
3. Order the appropriate interventions. Order appropriate diagnostic tests.
4. Accurately diagnose and implement a plan of care for the patient.
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Scenario Progression Outline
TIME
2 Minutes
MANIKEN ACTIONS
Being held by mother
EXPECTED INTERVENTIONS
Wash hands
Introduce self to mother
Initiate history
5 minutes
Cries when approached by
examiner (tears present). Easily
consolable by mother.
Complete a history and physical
examination (Findings: pt is in NAD,
nontoxic, but does not appear to feel
well, positive tears, mildly dry mucous
membranes, normal skin turgor, brisk
capillary refill, lungs CTA bilaterally,
mild tachycardia, abdomen with
hyperactive bowel sounds, soft, nontender, diaper moist with urine)
5 minutes
Lying on exam table
10 minutes
Following po challenge of 30 ml of
Pedialyte, pt is sitting on mothers
lap looking at a book. NO further
vomiting or diarrhea.
Explain concerns of physical
examination findings to mother: mild
dehydration; discuss plan of care
(Zofran 0.15mg/kg po followed by a
po challenge in 20 minutes). If pt is
able to tolerate po then we will
discharge to home, if unable to tolerate
po challenge then we will give IV
bolus and check UA and BMP. Offer
mother opportunity to verbalize
questions and concerns.
Discuss plan of care for discharge to
include:
Self-limited viral gastroenteritis
Symptomatic home care: oral
replacement of fluids 5 ml every 5
minutes. Goal is 50 ml/4 hours. As
vomiting decrease offer larger amounts
of fluids more frequently
No fruit juice, sorts drinks or sugary
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drinks
Advance diet slowly as tolerated to full
diet
Return to office or ED if pt is unable
to keep fluids down, abdominal pain,
blood in stools
Debriefing / Guided Reflection Questions for This Simulation
1. What assessment data is important in determining degree of dehydration in children? At what
point do you initiate IV fluids? What fluid would you start with and at what rate?
2. What were your priorities for this patient?
3. How did the team determine who would do what? How did you communicate?
4. What did you do well? Were your interventions effective?
5. To Observers: What questions or comments do you have for the team?
#4. Simulation Design Template: Supracondylar Fracture
Date: April 2015
Course: NUNP 6460
Expected Simulation Run Time: 30 minutes
Setting: Urgent Care Center
Brief Description of Client Name: Christopher Johnston
Gender: Male
Age: 6 years
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Historian: Mother
CC: Fell off monkey bars and injured right arm
Weight: 24 kg
Vital Signs: P - 128 RR - 28 BP - 116/78 T – 99.2 SaO2 – 99%
Allergies: No known drug allergies
Immunizations: Current per CDC recommendations
Past Medical History: Patient is healthy with no medical history. No previous hospitalizations.
Does not take any medications on a daily basis.
History of Present Illness: As per pt’s mother, Christopher was at school during recess
swinging on the monkey bars and fell off and landed on his right arm on a dirt covered ground
surface. Her mother reports that the teacher assistant (TA) was standing there and saw him fall.
The TA informed her mother that he did not lose consciousness, and cried immediately and was
complaining of right arm pain. The teacher assistant reported that it was difficult to console
him. The teacher assistant stated that she asked Christopher if anything else hurt and he reported
“just my arm”. The TA carried him into the nurses office. Ice and a splint were applied and the
nurse called Chistopher’s mother.
Social History: Lives with mother and father. He has two younger siblings and everyone at
home is healthy. Mother is a stay at home mom.
Objectives:
1. Perform a comprehensive history and physical examination on the patient, identifying any
other areas of injury. Perform a detailed neurovascular assessment of the right arm.
2. Identify a list of differential diagnoses.
3. Order the appropriate diagnostic tests.
4. Accurately diagnose and implement a plan of care for the patient.
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Scenario Progression Outline
TIME
2 Minutes
MANIKEN ACTIONS
Lying on the stretcher
EXPECTED INTERVENTIONS
Wash hands
Introduce self to mother
Initiate history
5 minutes
5 minutes
Crying and stating “don’t touch my
arm, it hurts”, sobs with palpation
of right arm; and states that her left
knee abrasion hurts. States that
nothing else hurts. Continues
sobbing in pain.
Lying on exam table
Complete a head–to-toe history and
physical examination
Discuss plan of care with pt and
mother. Explain that pain medication
will be given IV to maintain NPO
status, in case pt. needs surgical
intervention, and an x-ray will be
ordered. Orthopedics will be
contacted after the x-ray.
Verify that the patient does not have
any allergies and verify stable vital
signs. Order IV morphine at 0.1 mg/kg
= 2 - 2.4 mg morphine IVP
Order a long arm splint with arm in
position of comfort. Elevate extremity
on a pillow. Perform neurovascular
assessment before and after splint is
applied.
Order a PA and lateral view of the
right elbow.
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10 minutes
Lying on exam table
Review x-ray findings and consult
orthopedics.
Inform primary nurse of plan of care
Notify emergency department as pt
will be transferred to the ED.
Evaluate pt’s pain level and assess
neurovascular status of right arm/hand
Discuss plan of care with mother
Contact EMS for transfer
5 minutes
Lying on exam table
Gives report to EMS
Transfer of patient to the ED
Critical behaviors:
1. Preform a complete head to toe exam, identifying right elbow injury and left knee abrasion.
2. Preform neurovascular assessment of right distal arm. Apply splint and reassess
neurovascular status of distal right arm.
3. Identify and treat acute pain.
4. Order x-ray. Interpret x-ray.
5. Consult with orthopedics and arrange for transfer.
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6. Discuss plan of care with pt’s mother.
7. Reevaluate neurovascular status and level of pain.
Equipment Needed:
Splint
IV for pain medication (can use intranasal fentanyl), or IM
X-ray
Vital sign machine
Ice and pillow for elevation of extremity
Debriefing / Guided Reflection Questions for This Simulation
1. What were the priorities of care for Jennifer?
2. How did the team determine who would do what? How did you communicate?
4. What did you do well? Were your interventions effective?
5. To Observers: What questions or comments do you have for the team?
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Appendix B