Chapter 51. Enhancing Patient Safety in Nursing 

Education Through Patient Simulation 

Carol Fowler Durham, Kathryn R. Alden 

Background 

The alarming rise in morbidity and mortality among hospitalized patients throughout the 

United States heightens concerns about professional competency.1 Nurses and other health care 

professionals are under increased scrutiny to provide safe, effective care. Likewise, nursing 

education programs are faced with increased pressure to produce graduates who are capable of 

providing safe patient care. Toward that end, nursing education programs develop curricula, hire 

qualified faculty, and select learning experiences for students in an effort to train and graduate 

competent, effective nurses. The instructional strategies utilized in both didactic and clinical 

components of nursing education courses are highly influential in determining critical thinking 

and clinical decisionmaking ability as well as in developing the psychomotor skill performance 

of new graduates. 

Of course, it is unrealistic to think that graduates of nursing education programs have 

received all the training they need when they depart the doors of academia. Orientation programs 

for new graduates and continuing education for nurses are essential tools to help practitioners 

improve their knowledge, skills, and expertise so that quality patient care is provided and 

outcomes are optimized while errors are minimized. Ongoing evaluation of nursing competence 

is necessary to promote patient safety. 

In the Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health Care 

System, simulation training is recommended as one strategy that can be used to prevent errors in 

the clinical setting.1 The report states that “... health care organizations and teaching institutions 

should participate in the development and use of simulation for training novice practitioners, 

problem solving, and crisis management, especially when new and potentially hazardous 

procedures and equipment are introduced”1 (p. 179). 

Nursing education has long utilized simulation in some form to teach principles and skills of 

nursing care. Models of anatomic parts, whole body mannequins, and various computer-based 

learning programs have provided educators with training tools for students seeking to become 

professional nurses. Current interest in simulation as a clinical teaching tool has largely been 

fueled by development of the human patient simulator. 

Human patient simulation is a relatively new teaching strategy that allows learners to 

develop, refine, and apply knowledge and skills in a realistic clinical situation as they participate 

in interactive learning experiences designed to meet their educational needs. Learners participate 

in simulated patient care scenarios within a specific clinical environment, gaining experience, 

learning and refining skills and developing competencies; all this is accomplished without fear of 

harm to a live patient. The use of simulation as a teaching strategy can contribute to patient 

safety and optimize outcomes of care, providing learners with opportunities to experience 

scenarios and intervene in clinical situations within a safe, supervised setting without posing a 

risk to a patient. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

The focus of this chapter is on the use of patient simulation in nursing education programs. A 

review of the various types of simulation is presented, followed by detailed information about 

the human patient simulator and its use as an instructional strategy. Specific information is 

provided about use of patient simulation in relation to prevention of medication errors, 

developing critical thinking and clinical decisionmaking skills, use of effective communication 

skills, and the importance of teamwork. The use of the METI® Human Patient Simulator (HPS) 

in a university nursing program is described, and an example of a patient care simulation that is 

used with undergraduate students is given. 

Types of Simulation 

In general terms, simulation is a technique or device that attempts to create characteristics of 

the real world. Simulation allows the educator to control the learning environment through 

scheduling of practice, providing feedback, and minimizing or introducing environmental 

distractions.2 In health care, simulation may refer to a device representing a simulated patient or 

part of a patient; such a device can respond to and interact with the actions of the learner.3 

Simulation also refers to activities that mimic the reality of a clinical environment and that are 

designed for use in demonstrating procedures and promoting decisionmaking and critical 

thinking.4 In health care education, simulation can take many forms, from relatively simple to 

highly complex. The various types of simulation are listed in Table 1, along with advantages and 

disadvantages of each. The types are briefly described in the following paragraphs. 

Part Task Trainers 

Part task trainers, also known as low-tech or static task trainers, are designed to replicate only 

a portion of the body or the environment. Many of these represent selected anatomical areas of 

the human body and are used to teach basic psychomotor skills and procedures. They range in 

complexity from an item as simple as an orange that is used to teach injection technique to an 

arm for teaching venipuncture or a mannequin for teaching cardiopulmonary resuscitation 

(CPR). These simulation tools are relatively inexpensive, and multiple models are often available 

for use within the same institution, allowing for larger numbers of learners to practice 

simultaneously. 

Simulated Patients 

Simulating patients through role play between learners and educators is commonly used in 

medical and nursing education. Physical assessment skills, history taking, and communication 

techniques are often taught using student pairs. Trained simulated patients can be used to 

simulate psychiatric interactions where the learners can try out appropriate interventions. Live 

female pelvic and male prostate models/teachers provide a dual role of allowing students to 

refine their exam techniques on the model while receiving real-time feedback about the pelvic or 

prostate exam. Expense and scheduling are challenges for this type of simulation. 

Screen-Based Computer Simulators 

Screen-based computer simulators are designed to model various aspects of human 

physiology or specific tasks or environments. Through a variety of computer programs, learners 

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Simulation and Nursing Education

use information to make clinical decisions and observe the results in action. There is often 

feedback during and after the interaction. Computer-assisted instruction programs or Web-based 

programs are relatively inexpensive and reusable and can be used individually or in groups. 

Complex Task Trainers 

Complex task trainers involve virtual reality and haptic systems, representing the highest 

level of computer-based technology. Haptic refers to technology that can sense where touch 

occurs as well as the amount of pressure being applied. This type of technology is particularly 

useful in learning environments where the faculty cannot clearly see where the student is 

assessing the patient. For example, during a pelvic exam, it is difficult for the faculty to 

determine if the learner is doing a thorough exam. With haptic technology, sensors are placed 

inside a pelvic model to provide feedback to the learner about areas assessed with touch and the 

amount of pressure applied. Complex task trainers are often combined with part task trainers so 

that a physical interaction can occur within the virtual environment. This type of simulation is 

gaining popularity for training practitioners in surgical techniques such as laparoscopy. While 

such technology is reusable, it can also be relatively expensive. 

Integrated Simulators 

Integrated simulators combine computer technology and part- or whole-body mannequins to 

provide a more realistic learning experience. The degree of sophistication of the mannequin and 

the computer that drives it determine the degree of engineering fidelity of the system. According 

to Maran and Glavin,5 fidelity can be defined as the degree to which the appearance and 

capabilities of the simulator resemble the appearance and function of the simulated system. 

Human patient simulators, therefore, are generally categorized as low, intermediate, or high 

fidelity systems (see Table 2). 

Human patient simulators. Human patient simulators are among the most recent 

technologic advances in instructional methodologies for medical and nursing education. These 

interactive mannequins are capable of realistic physiologic responses, including respiration, 

pulses, heart sounds, breath sounds, urinary output, and pupil reaction. Additionally, the more 

advanced models can communicate with the student, responding to questions posed by the 

learner in real time during the simulation exercise. 

The authors are most familiar with the Human Patient Simulator by Medical Education 

Technologies Incorporated (METI®) and SimManTM by LaerdalTM. Each company has a variety 

of portable simulators representing different patient ages to meet the educational needs of the 

learners at all levels. Both vendors have models with realistic anatomy and clinical functionality. 

The METI HPS represents the latest in state-of-the-art simulation technology. Physiological 

and pharmacological models are used as the operating platform, allowing the simulator to react 

like a live human. These unique integrated models imitate the human response in a multilayered, 

real-time manner, providing a realistic clinical presentation.6

 The HPS has a data recorder that 

records the learner’s actions, allowing precise accounts for review and debriefing. Additionally, 

the HPS interfaces with a patient monitor like those used in most hospitals. Adjustments to the 

patient scenario can be made “on the fly” as the educator deems necessary. 

Laerdal’s SimMan operates using personal computer (PC) software. The simulator displays 

patient physiologic parameters on a PC screen that emulates a patient care monitor. The SimMan 

software includes the first Integrated Video Debriefing System. The video Web camera records 

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

video and audio that is synchronized with the event log, providing a valuable tool for debriefing. 

Laerdal’s software allows ease of management of patient parameters during scenarios.7

Although most simulators owned by schools of nursing are adult males, infant and pediatric 

models are also available. The simulators have interchangeable genitalia so that the mannequin 

can present as a male or female. It is possible to adapt the appearance of the mannequin to 

represent a range of ages from young adulthood to geriatric. Additionally, with the aid of a wig, 

makeup, and female clothing, the realism can be enhanced as the male mannequin is transformed 

into a female patient. The mannequin can also be successfully outfitted to present as a pregnant 

female with the appropriate props. 

Promoting Safety Through Education With the 

Patient Simulator 

Patient safety is a multidimensional concept that is central to clinical education. Numerous 

aspects and principles of patient safety can be easily incorporated into education of nurses and 

nursing students using the patient simulator. This discussion will focus on four primary areas: 

preventing medication errors, developing critical thinking and clinical decisionmaking skills, 

promoting effective communication, and encouraging teamwork. 

Preventing Medication Errors 

The 2006 IOM report, Preventing Medication Errors, concludes that at least 1.5 million 

preventable medication errors occur each year in the United States. (This number does not take 

into consideration the errors of omission.) The report indicates that, on average, a hospitalized 

patient is subjected to more than one medication error each day.8

In the National Safety Goals for 2007 of the Joint Commission (formerly the Joint 

Commission on Accreditation of Healthcare Organizations, JCAHO),9 improving the safety of 

medication use is listed as the third goal, preceded only by improving the accuracy of patient 

identification and improving the effectiveness of communication among caregivers. Goal #8 also 

relates to medication safety: “Accurately and completely reconcile medications across the 

continuum of care.” 

Research has shown that medication errors, otherwise known as adverse drug events (ADEs), 

are most likely to occur during the prescribing and administration stages and are attributed to a 

variety of factors. ADEs commonly occur at transition points during hospitalization: admission, 

transfer between units, and discharge. Errors are often due to confusion caused by similar drug 

names. Another factor is lack of understanding by patients about their medications, including the 

risks and side effects of medications and what to do if side effects occur.8

 Medication errors 

directly related to nursing practice usually involve inappropriate medication dosage, overlooked 

allergies, giving the wrong drug, and incorrect administration site. All these errors are impacted 

by environmental distractions, miscommunication, and drug labeling problems.10 

Medication administration is a vital aspect of nursing practice and a critical component of 

nursing education curricula. Faculty in schools of nursing are concerned with teaching students 

about safe medication administration. Educating students about safe administration of 

medications is multifaceted and involves instruction about actions and uses of medications, safe 

dosage, side effects, and nursing implications. 

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Simulation and Nursing Education

A recent analysis of 1,305 medication errors by nursing students over a 5-year period showed 

that the most common medication errors were those of omission and giving the wrong dose of a 

drug. Errors were primarily attributed to students’ performance deficits with significant 

contributing factors identified as inexperience and distractions.11 

Calculation of medication dosages has been identified as a deficit for many nursing 

students.11–13 This may be related to weak math skills resulting in computational inaccuracy and 

to the lack of opportunity to utilize dosage calculation in the clinical setting. The advent of unitdose packaging has limited the need for calculation of medication dosages. 

Safe administration of medications is more than a psychomotor or mathematical skill. It also 

requires critical thinking and clinical decisionmaking. To safely administer medications, students 

must be able to assess and manage side effects and educate the patient and family about the 

prescribed treatment regimen. The patient simulator provides a realistic approach to medication 

administration in a safe setting where patient risks are eliminated. The computer technology of 

the METI HPS utilizes a barcode system in which specific medications can be scanned to 

activate physiologic responses in real or compressed time. 

Incorporating medication administration into patient simulation scenarios offers numerous 

learning opportunities and benefits to students. Understanding of the rationale for medication use 

is enhanced as students are able to see how medications fit into the treatment of selected 

conditions. They have an opportunity to identify the appropriate drugs, determine safe dosages, 

calculate dosages, properly identify the patient, administer medications by a variety of routes, 

observe for side effects, and evaluate the effectiveness of medications. The simulation presents a 

realistic simulated clinical setting with inherent distractions that may interfere with safe 

medication administration. For example, in the midst of activities surrounding a code situation, 

students are exposed to the reality of medication administration in an emergent situation and to 

the importance of providing the right patient with the right medication in the right dosage at the 

right time by the right route. Students can be taught to identify areas of potential error risk during 

patient transitions and handoffs, including shift report, transfer, and discharge. The importance of 

effective communication can be emphasized and practiced through accurate reporting of 

medications and aspects of the treatment plan through simulated handoffs. 

Patient and family education related to medications can be incorporated into patient 

simulations. As part of a simulated scenario or role play, students can ask the patient or family 

member about current medications in an effort to identify medications, including over-thecounter medications and herbal medications the patient is taking, and to determine if the 

medications are being used appropriately. As students inquire about side effects of medications 

that the patient may be experiencing, they can use critical-thinking skills to determine if the 

medications may be related to the patient’s current health problems. As part of a scenario, 

students may be required to provide patient or family teaching about medications. 

Developing Critical-Thinking and Clinical Decisionmaking Skills 

Nursing educators are challenged to teach students to think critically, to go beyond simply 

“knowing,” to advance to synthesis and application of knowledge as they assess, plan, 

implement, and evaluate nursing care. Simulation provides an alternative to the traditional 

teacher-centered approach to nursing education with emphasis on the learning needs and 

preferences of contemporary nursing students. Simulated learning experiences with the patient 

simulator allow faculty to expose students to situations that they may never see in their clinical 

practicum experiences. Because students are placed in a variety of units for their clinical 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

experiences, there is a lack of consistency in learning opportunities across and among students. 

Use of the patient simulator enables faculty to provide structured simulation lab experiences 

instead of trying to find appropriate and/or rare patient care opportunities in a health care 

setting.14 

Promoting Effective Communication 

The overwhelming majority of untoward events occurring in health care settings involve 

miscommunication. The Joint Commission identifies communication as the root cause of 

approximately 70 percent of all sentinel events.15 Effective communication and teamwork are 

fundamental to quality patient care. According to the Joint Commission, patient safety is 

improved when communication is clear, accurate, complete, and timely. The significance of the 

quality of communication among team members is emphasized by the Joint Commission in one 

of its National Patient Safety Goals for 2007: “To improve the effectiveness of communication 

among caregivers.”9 Because errors often occur during times of patient transition in health care 

settings, the Joint Commission specifies that facilities must “[i]mplement a standardized 

approach to handoff communications, including an opportunity to ask and respond to 

questions.”9

Communication is an essential component of all health care curricula; however, 

intradisciplinary communication is typically the focus. Each discipline has its own terminology, 

expectations, and idiosyncrasies relative to communication, all of which can impact the 

effectiveness of communication across disciplines. Because health care involves multiple 

disciplines, a means of standardized interdisciplinary communication is needed to enhance 

quality of care and promote patient safety. 

A recently proposed model of interdisciplinary communication, known as SBAR, is gaining 

increased attention. This is a shared model for standardized communication designed to facilitate 

and improve communication between and among health care personnel. SBAR can be applied to 

both verbal and written communication. The model consists of four components: 

Situation—statement of what is happening at the present time that has triggered the SBAR 

Background—information that puts the situation into context and explains the circumstances 

that have lead to the situation 

Assessment—statement of the communicator’s ideas about the problem 

Recommendation—statement of what should be done to correct the problem, by when, and 

by whom16

Patient care scenarios using the human patient simulator provide an opportune way to teach 

students to effectively use a standardized communication method such as SBAR and to allow 

them to practice this technique. With minimal effort, SBAR can be added to each simulation, 

requiring practitioners at all levels to develop and refine their communication techniques to be 

more effective. Ideally, students representing various health care disciplines can work together in 

patient care simulations, practicing communication techniques that are representative of the 

actual health care setting. 

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Simulation and Nursing Education

Encouraging Teamwork 

The 2000 IOM report has heightened awareness about the need for system changes to 

promote patient safety and quality. The report urges organizations to develop strategies to 

improve team function, thereby increasing the quality of care for the patient.1 In an effort to 

enhance teamwork, many organizations have adopted the principles of Crew Resource 

Management (CRM), originated by NASA and used in the aviation industry in response to 

aviation disasters. The CRM training model focuses on leadership, decisionmaking, 

communication, and team training.17 It also provides training in ever-changing team structures 

for members who need to have portable skills to apply to various health care settings such as 

operating rooms, emergency departments, or intensive care units.18 Ostergaard, Ostergaard, and 

Lippert19 suggest that the individual should develop general team competencies that can be 

transferred from team to team. 

Medical and nursing educational programs train students as individuals; yet, as practitioners 

they are most often required to work in teams within organizational systems. In the practice 

setting, nurses and physicians interact on a regular basis with each other and with other personnel 

in the health care institution. Working together as a team and sharing information among team 

members can contribute to enhanced quality and safety of patient care. Research findings 

indicate that the risk of serious events seems to be reduced when team training has been 

implemented.17, 20, 21 

Simulation emphasizes the importance of teamwork in providing care for patients. It allows 

the learner to practice as a team member. Working in small groups with the simulator, students 

may be assigned specific roles such as primary nurse, secondary nurse, medication nurse, 

communicator, or recorder. They learn how to delegate tasks appropriately, to follow directions, 

and to communicate effectively with nurses and other practitioners. The simulation allows 

learners to assess the patient and the situation, identifying pertinent information that must be 

communicated to the primary health care provider. Students determine appropriate nursing 

interventions and implement orders from the health care provider. They evaluate patient 

responses and the outcomes of their assessments and interventions. 

To prepare practitioners to work as effective team members, educational programs for all 

health care personnel need to increase opportunities to work in interdisciplinary teams.22

Simulation can be used to train individuals in the context of team activities, creating a more 

realistic clinical environment. Ostergaard and associates19 state that simulation is the preferred 

educational strategy to teach teamwork skills such as leadership, communication, and 

cooperation. Students from several disciplines such as nursing, medicine, respiratory therapy, 

pharmacy, and social work can be brought together in a patient simulation scenario. This allows 

each learner to practice their patient care role and relate in real time to the other professionals 

with whom they will need to work to effectively provide safe and quality patient care. Johnson23 

states that CRM or team training needs to be introduced early and reinforced often. He further 

acknowledges that accomplishing quality teamwork requires that practitioners (crews) are trained 

as a team throughout their educational experiences. 

While patient simulation scenarios provide a means of teaching interdisciplinary teamwork 

and communication, it is important to remember that it is also an excellent strategy for educating 

students about intradisciplinary teamwork and communication. For instance, as nursing students 

participate in simulated patient scenarios, they assume a variety of nursing roles, particularly if 

they are learning in groups. Acting as a team providing nursing care, someone must assume the 

7 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

leadership role, directing other team members and delegating tasks and responsibilities. A 

primary nurse is identified as the team leader and is assisted by a secondary nurse. Other students 

may be assigned specific roles such as recorder, communicator, or resource person. Simulated 

scenarios allow students to work collaboratively as team members with the additional benefit of 

having faculty present to facilitate teamwork and observe the effectiveness of teamwork. 

Use of Patient Simulation in Nursing Education Programs 

Patient simulation is an instructional strategy that can be implemented in a variety of settings. 

The versatility and adaptability of the technology provide a broad range of uses for the patient 

simulator. 

Nursing Education Programs 

University and community college nursing education programs use patient simulators with a 

variety of learners. Patient simulators are used to teach basic assessment and psychomotor skills 

with beginning students, evolving to complex clinical scenarios as students advance in the 

curriculum.4, 15, 24–30 Graduate nursing programs utilize the patient simulator to teach advanced 

practice skills and concepts in nurse practitioner and nurse anesthesia programs.31–34 It is used by 

clinicians to teach new procedures, to validate competencies, and to transition new graduates into 

the clinical practice.35, 36 The patient simulator can be used in research concerning best practice 

for patient care and education.37 It has potential for use in master’s and doctoral-level education 

programs to train future faculty members. 

Continuing Education 

The patient simulator can be incorporated into a variety of continuing education programs, 

departing from the traditional lecture format to provide a more experiential learning experience 

for participants. Physical assessment classes, nurse anesthesia updates (e.g., airway 

management), advanced cardiac life support (ACLS) certification, critical care courses, and 

nurse refresher programs can be conducted using patient simulators.30

Nurse refresher courses typically consist of didactic and clinical components to prepare 

nurses to return to practice after an extended absence. Using patient simulators, these nurses can 

practice assessment and psychomotor skills before entering the clinical area. This helps promote 

self-confidence in the nurse refresher students as they resume hands-on care in a setting that does 

not endanger a live patient. 

Population-specific classes can also be taught using the patient simulator. For example, it can 

be utilized to teach nurses to recognize and respond to critical situations that may occur in 

geriatric patients in acute and long-term care situations. 

Staff Development 

Health care institutions can use simulators in staff development programs such as orientation 

of new graduates and continuing education programs. Orientation programs for new graduates 

can utilize the human patient simulator to present specific policies and procedures, to assess 

clinical competence, and promote communication and collaboration among the nurses. 

Simulators can be used in continuing education to introduce new equipment, to teach new 

8 
Simulation and Nursing Education

procedures, to assess competency of nurses in responding to specific clinical situations, to assess 

adherence to specific protocols, and to promote teamwork.28, 35, 36

Evidence Supporting the Use of Patient Simulation in 

Nursing Education 

Search of the literature on patient simulation reveals that the majority of research related to 

use of the patient simulator has been conducted in medical and anesthesiology settings. Evidence 

supporting the use of simulation as an instructional strategy in medical education is clear, 

although experts have pointed out that such research needs improvement in terms of rigor and 

quality.38

Issenberg and associates38 conducted an extensive review of the medical literature on 

simulation, identifying 670 articles, of which 109 were used in their analysis. Based on the 

available evidence, the researchers concluded that simulation can enhance learning by providing 

feedback (47 percent of articles), repetitive practice (39 percent of articles), curriculum 

integration (25 percent of articles), a range of difficulty level (14 percent of articles), multiple 

learning strategies (10 percent of articles), a capture of clinical variation (10 percent of articles), 

a controlled environment (9 percent of articles), individualized learning (9 percent of articles), 

defined outcomes (6 percent of articles), and simulator validity (3 percent of articles). 

An integrative review of medical and nursing literature was conducted by Ravert39 in an 

attempt to identify quantitative studies related to computer-based simulation in health care 

education and to determine the effect of simulation on learning. Nine studies out of 513 

references met the inclusion criteria; five were conducted in medical schools with medical 

students and four were done by registered nurses using samples of nurses. Seventy-five percent 

of the studies indicated positive effects of simulation on knowledge acquisition and/or skills 

training. 

Evidence in the literature related to the use of patient simulation in nursing education and 

practice is ever increasing, although still sparse in comparison to the medical literature. The 

majority of articles in the nursing literature are descriptions of how patient simulation is utilized 

in a particular setting. There is a definite paucity in actual research studies that have been 

conducted about patient simulation. 

The first reports of patient simulation in nursing education describe its use with nurse 

anesthesia students.31, 33, 40 Incorporation of the human patient simulator into nurse practitioner 

and clinical nurse specialist education programs occurred somewhat later and is described in 

articles by Hravnak, Tuite, and Baldiserri,32 and Scherer, Bruce, Graves, and Erdley.34

Numerous articles have been published describing the use of simulation and how simulation 

programs have been developed within schools of nursing, primarily with undergraduate 

students.4, 14, 24–29 There are limited reports of patient simulator use by hospitals to train 

registered nurses.35, 36 

Seropian and associates41, 42 provided detailed descriptions of simulation technology and 

guidelines related to development of a simulation program. The articles review the types of 

simulation and offer rationale for selection of the appropriate technology to fit the educational 

needs of learners. 

Henrichs, Rule, Grady, and Ellis43 explored perceptions of nurse anesthesia students about 

the use of a human patient simulator in their first year of clinical training. Analysis of data 

collected through observations, student journals, and focus groups indicated that students felt the 

9 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

simulation experience was educational, although they experienced feelings of apprehension, 

uneasiness, or fear during the sessions.

In another study of nurse anesthesia students, Farnsworth and colleagues44 examined the 

efficacy of the human patient simulator in teaching conscious sedation skills. A sample of 20 

nurses completed pretests and then experienced a training session consisting of 4 patient 

simulation scenarios followed by a practical exam. They were asked to complete post-tests and 

evaluations of the patient simulation training sessions. Overall scores on the post-test were 

significantly higher than pretest scores. As part of the evaluation, students were asked to rate the 

training session on a scale of 1 to 4 with 1 = poor and 4 = excellent. The mean rating score was 

3.75, indicating that the participants found the training session to be both beneficial and 

enjoyable. 

Nehring and Lashley30 conducted an international study of human patient simulation in 

nursing education. They examined the use of the METI HPS by nursing schools and associated 

simulation centers. The researchers mailed surveys to 66 nursing programs and 150 simulation 

centers, hospitals, and other institutions of higher education that were located near nursing 

programs. Thirty-four nursing schools (18 universities and 16 community colleges) and 6 

simulation centers throughout the world responded by completing the 37-item closed- and openended survey designed by the researchers. Results were categorized and reported as follows: 

(1) Curricular use: Greater use of the HPS was reported by community college programs for 

more hours in all courses with the exception of the maternal newborn course. In 

university programs, the HPS was most often used in basic skills courses, while 

community colleges reported the greatest use in advanced medical-surgical nursing 

courses. Most schools used the HPS as part of required clinical time. 

(2) Faculty use: Ninety-three percent of schools indicated that 25 percent or less of their 

faculty used the simulator; more than half of the sample states that their faculty was 

generally receptive to HPS use in their courses. 

(3) Student views: Twenty-one schools reported collecting information on student 

perceptions of the HPS. In relation to use of the HPS for competency evaluation of 

undergraduate students, 42 percent of schools stated that it should be used, 36 percent 

agreed it should be used in some circumstances, and 22 percent indicated it should not be 

used. 

(4) Other uses of HPS: Only six institutions indicated that they were conducting research 

about HPS use. Six nursing programs and four simulation centers reported use of the HPS 

in continuing education programs. 

Feingold, Calaluce, and Kallen45 conducted a study to evaluate nursing student and faculty 

perceptions about patient simulations using the Laerdal SimMan Universal Patient Simulator. 

Using a 20-item tool, the researchers surveyed 65 students who had participated in simulations 

during 2 consecutive semesters. Four faculty members were surveyed using a similar 17-item 

tool. Findings showed that while the majority of students and faculty felt the simulations were 

realistic and valuable, only half of the students agreed that skills learned in the simulation were 

transferable to a real patient care setting. Faculty indicated that simulations reinforced clinical 

objectives and adequately tested clinical and decisionmaking skills. Concerns of faculty 

members relative to patient simulator use included extra preparation time and lack of faculty 

support to use the technology. 

Bearnson and Wiker46 explored the benefits and limitations of using the METI HPS as a 

substitute for a clinical day in a junior-level nursing course. Each student had a 2-hour session 

10 
Simulation and Nursing Education

involving three preprogrammed scenarios. Following the scenarios, the students completed a 

brief survey instrument (four items) consisting of a Likert-type scale (1 = strongly disagree to 4 

= strongly agree) and three open-ended questions. Responses indicated that the HPS increased 

knowledge of medication side effects (mean = 3.13), increased knowledge of differences in 

patients’ responses (mean = 3.31), increased ability to administer medications safely (mean = 

3.06), and increased confidence in medication administration skills (mean = 3.00). Responses to 

the open-ended questions were overwhelmingly positive.

Alinier and colleagues47 demonstrated the effectiveness of scenario-based simulation training 

on nursing students’ clinical skills and competence. A sample of 99 undergraduate nursing 

students in the United Kingdom was divided into control and experimental groups, with the 

experimental group being exposed to patient simulation training using the Laerdal SimMan. 

Students in both groups completed a pretest and post-test as well as a questionnaire. There was a 

statistically significant difference in the mean scores of the two groups from pretest to post-test, 

with the experimental group demonstrating higher overall scores. 

In a recent study, Bremner and associates48 examined the value of using the human patient 

simulator as an instructional strategy with novice nursing students. A sample of 41 students 

completed a questionnaire about their learning experiences with the human patient simulator. 

The simulator session was rated as good to excellent by 95 percent of the students, and 68 

percent recommended it as a mandatory component of their educational program. Over 60 

percent of the students indicated that the patient simulation experience increased their confidence 

in physical assessment skills. Limitations of the technology identified by students included not 

having enough time to work with the simulator, initial anxiety when first encountering the 

patient simulator, and a lack of realism. 

Advantages of Patient Simulation in Nursing Education 

The major advantage of using the patient simulator as an instructional strategy in nursing 

education is that it provides opportunity for active and interactive learning without risk to an 

actual patient.3 Learners can be permitted to make mistakes without fear of harming a live 

person. 

Use of the patient simulator allows for an immersive, experiential learning activity.50

Students are active participants, not merely recipients of didactic content as in a lecture class. 

Small numbers of students are typically involved in each scenario, with each student having a 

role in the simulation. The patient simulator provides a hands-on experience in which students 

are able to witness the results of their actions in real time. 

Clinical simulation with the patient simulator is consistent with adult learning theory. It is a 

learner-centered approach to education, building on previous knowledge and experiences. The 

patient simulator provides opportunities for self-study as well as group interaction.50

The sophisticated computer technology of the patient simulator has appeal for contemporary 

learners. Although increasing numbers of nontraditional students continue to enter nursing 

programs, the majority of learners currently enrolled are younger than 25 years of age. They 

represent the computer-savvy Generation X and Generation Y, having grown up with gaming 

systems such as Nintendo®, computers, and the Internet. Individuals from these generations 

typically possess an inherent fascination with technology and are accustomed to fast-paced 

communication through means such as instant-messaging. They always want to be in touch; 

cellular phones, MP3 players, and personal digital assistants (PDAs) have become a way of life. 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Effective educational strategies must capture the learners’ aptitude with and desire to use 

technology as they gain and apply necessary skills and knowledge. 

Patient simulation scenarios provide a bridge between theory and clinical practice. Working 

with the patient simulator, students are able to visualize physiological responses that may be 

difficult to understand simply through didactic classes or readings. Critical thinking and clinical 

decisionmaking skills are developed and refined as students apply previous knowledge in 

simulated patient situations. Synthesis learning experiences can be provided through patient 

simulations. Knowledge and skills attained from classroom and clinical experiences can be 

applied in patient care situations 

Scenarios can be selected or designed to meet specific course objectives and in accordance 

with learning needs of the students. Simulations allow faculty to expose students to situations 

that they may never see in their clinical practicum experiences. 

The instructor is in control of the events and timing of the scenario and can pause the action 

as needed for reflection or correction. Scenarios can be repeated to provide consistency of 

learning experiences across student groups. 

Skills and procedures can be practiced in a realistic situation, and immediate feedback is 

provided as learners observe patient responses and interact with faculty facilitators. If needed, 

students can be allowed to repeat skills and procedures until proficiency is achieved. 

Working in small groups with patient simulation scenarios, learners benefit from each other’s 

successes and mistakes. They also learn to work as a team and can experience a variety of roles 

as team members. 

Learning experiences with the human patient simulator can boost students’ self-confidence 

and help reduce anxiety in the actual patient care setting. Students are able to practice assessment 

and psychomotor skills and implement nursing interventions under the supervision of faculty so 

that they feel more confident and competent when they enter the practice setting and are assigned 

care for patients. 

Learning experiences with the patient simulator help students to identify gaps in their 

knowledge and experience base. The following comments from baccalaureate nursing students 

illustrate this point (note: “Stan” or “Stan the Man” refers to the human patient simulator): 

♦ Stan stimulates me to want to learn more. I found that when I was in the situation 

and didn’t know what to do, I wanted nothing more than to be able to go and look up 

what was going on and gain an understanding. After the first day of working with 

Stan, I went back and read about the specific illnesses that we had encountered in our 

practice. I found that while we had done many things right, there were many things 

we had missed.

♦ During my work with Stan the Man, I realized that my knowledge of normal ranges 

for central venous pressure, pulmonary pressure, and pulmonary wedge pressure was 

lacking. Also I realized that I didn’t have a firm grasp of the ABCs of emergency 

care. Stan showed me what happens when these things (airway, breathing, 

circulation) are not taken care of and in that order. We had a simulation where a 

spontaneous pneumothorax (which is commonly treated in the ED) resulted in Stan 

crashing, and ultimately we lost him. This happened mainly because we didn’t get a 

chest tube inserted in time, but had we paid more attention to the ABCs at the 

beginning of the simulation, we might have been able to avoid him coding on us. 

12 
Simulation and Nursing Education

♦ I think the most valuable thing I learned was what I do not know. For example, 

while my group was working with Stan, I discovered that my ability to apply what I 

thought I had learned in pharmacology is lacking. In several cases I had no idea 

which drug to use or why. If it had not been for the suggestions from the instructors, I 

would not have been able to figure out which drugs to use. Thus I have identified 

pharmacology as a topic that I need to study more.

A major benefit of using the simulator in nursing education is that most students and faculty 

enjoy this type of learning experience. The dynamic and interactive nature of simulation provides 

learning experiences that are stimulating and beneficial.43–45 

Teaching with the patient simulator provides opportunity for faculty development and 

increased job satisfaction. Nursing educators who enjoy interactive teaching methods may 

welcome the use of patient simulation into the curriculum and volunteer to participate in training 

programs and implementation of this technology with students. 

As nursing education programs are seeking to hire new faculty, the patient simulation may 

serve as a recruitment tool. Those schools of nursing that own or have access to patient 

simulators may be able to attract faculty members who desire to teach using creative and 

innovative strategies. 

Limitations of Patient Simulators 

Limitations or disadvantages of the patient simulator are primarily related to its cost, which is 

prohibitive for many schools. The cost of the equipment can range from approximately $30,000 

to $200,000, depending on the manufacturer and features of the patient simulator. Additional 

expenses include physical space to house the equipment, supplies and equipment needed to 

simulate the desired clinical environment, the cost of training faculty to utilize the technology, 

and faculty time involved in developing scenarios.14, 27 

While a justifiable argument against the use of the human patient simulator is the expense 

involved in purchase and maintenance, there are ways to make its use more affordable.27, 30

Educators and administrators need to carefully examine what is the best fit for their agency. They 

need to identify a plan to integrate the simulator into their curriculum, develop the complexity of 

the simulated cases, and determine the degree of realism required. As educators become more 

adept at using the simulator, higher-level performance will be desired of the simulator, so longterm usability and adaptability of the simulator should be weighed against its initial cost. Nursing 

education programs may procure the simulator through their annual budget, grants, special 

allocations, or private donations. To help recover some of the costs, some schools of nursing rent 

the simulator to a variety of groups and agencies, charging an hourly or daily rate.30 

The portability of the simulators facilitates multicenter sharing. Schools of nursing can 

partner with hospitals to share the costs of the simulator and training. Realistic clinical 

environments for simulation can be more easily created through shared props such as intravenous 

(IV) pumps, dressing supplies, etc. Nursing faculty can collaborate with expert clinicians to 

develop realistic scenarios that reflect current practice. The two groups can cooperatively teach 

with the patient simulator. For example, in a university setting, two clinical specialists from the 

intensive care units at a local hospital lectured to a group of senior students about how to respond 

in a “code” situation (cardiopulmonary arrest); these two clinical experts provided case studies of 

actual situations that were developed into scenarios for use with the human patient simulator. 

The scenarios were used with the seniors and, later, with a group of new intensive care unit staff 

13 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

nurses. The faculty and the two clinical specialists worked together to facilitate the scenarios for 

both groups of learners. 

The cost of the simulator can be shared by a variety of health care disciplines. The simulator 

can be used in a multidisciplinary environment where medical, nursing, and other health care 

specialists work as a team to assess, intervene, and evaluate care provided to simulated patients 

in specific situations. Collaboration among schools of nursing, medical schools, and other health 

care disciplines can result in the development of scenarios designed to incorporate the 

knowledge, skills, and experience of all the related professions. 

Schools of nursing and health care institutions can partner with community agencies in 

purchasing the patient simulator. Community agencies that wish to utilize the patient simulator 

may be able to barter with schools or hospitals, trading other services for personnel and time to 

use the human patient simulator. Although use of the human patient simulator began in inpatient 

health care, its use has extended into the field for training programs that prepare first responders, 

military, and health care professionals to respond to natural disasters or acts of bioterrorism. 

The complex nature of the technology requires a commitment to training educators in the use 

of patient simulation. This means that faculty time and energies are involved in learning to 

operate and incorporate simulation into existing curriculum. Since faculty workloads are already 

heavy, this may seem to be an additional burden. Faculty time involved in actual teaching with 

simulation has been cited as a potential disadvantage of its use.45 Student/faculty ratios are 

typically lower when teaching with a patient simulator. While traditional clinical groups may 

consist of 8–10 students, the maximum number of students that can be accommodated in a 

patient simulated learning experience is 5 or fewer, depending on the scenario. 

Another potential disadvantage or limitation of the patient simulation that has been identified 

is lack of realism in the scenarios and patient responses. The realism of any simulation depends 

upon multiple factors, including the fidelity of the simulator, the environment, props, and the 

description of the scenario. Realism is also affected by the facilitator’s expectation of students to 

suspend disbelief and treat the simulator as a patient. As realism is enhanced, the effectiveness of 

the scenario as a learning tool is increased.41

Student anxiety related to the use of patient simulation is a potential limitation to its 

effectiveness.43, 48 Unfamiliarity with the simulator and fear of the unknown may evoke anxiety. 

Students may worry about their ability to manage a critical care situation. They may experience 

some discomfort about working under the direct supervision of faculty facilitators. If students are 

being evaluated and assigned grades for their participation in scenarios, anxiety may be elevated. 

The authors’ experience with undergraduate nursing students demonstrates that although students 

may be somewhat anxious when they first encounter the simulator, this anxiety is not necessarily 

a negative influence. Having participated in scenarios using the METI® HPS, one student 

commented, “The experience was outstanding! I was terrified, but teamwork got us through. This 

forced me to deal with my fear of what do I do when a patient comes in. I was proud of myself 

and the group. Together we did it.” 

Patient Simulation and Undergraduate Nursing Education 

The use of human patient simulators for undergraduate nursing education and evaluation 

offers an excellent means by which to provide learning experiences and to measure competency 

of knowledge and skills.14 In the simulation lab, students collaborate in patient care as they 

conduct assessments; monitor physiologic parameters such as vital signs, heart sounds, breath 

sounds, and symptoms; perform nursing interventions; obtain and carry out physician’s orders; 

14 
Simulation and Nursing Education

administer medications; and evaluate patient responses. This type of learning activity allows the 

learners to synthesize and apply knowledge they have gained from structured courses and/or 

clinical experiences. 

The use of human patient simulation as an instructional strategy can enhance patient safety 

and optimize outcomes, providing a means of allowing nursing students to “practice” critical 

thinking, clinical decisionmaking, and psychomotor skills in a safe, controlled environment, 

without potential risk to a live patient. Errors can be allowed and corrected without concern for 

patient safety. 

Simulation allows a condensing of vital learning experiences that assists the learner in 

developing clinical reasoning and decisionmaking skills. Additionally, a simulation can be 

repeated to allow students to correct misconceptions, fill in knowledge gaps, and hone clinical 

skills. This can be beneficial in boosting self-confidence and self-esteem as students are learning 

to think and act like nurses. 

The patient simulator is intended as an adjunct teaching strategy to complement—not to 

replace—the traditional clinical practicum. It may be an addition to clinical hours or may be 

utilized as a means of remediation for students who encounter difficulties in the clinical setting. 

Scenarios using the patient simulator can be useful for students who may have been away from 

the clinical setting for a period of time; for example, students who must drop out of the program 

temporarily may benefit from patient simulations to refresh clinical knowledge and skills before 

they return to the clinical area. 

The patient simulator provides an alternative to traditional clinical experiences. As 

enrollments in schools of nursing are rising, there is increased competition for clinical sites. The 

use of the human patient simulator is one means of providing clinical learning experiences 

outside the health care institutional setting. Faculty may elect to send students through care 

scenarios with patient simulation in lieu of a day or portion of a day on the clinical unit in the 

hospital. The simulation experiences may be used instead of a clinical conference. The time 

spent in a well-structured simulation experience can be powerful and far outweigh what can be 

accomplished in a traditional clinical conference. 

The patient simulator can help faculty address problems related to lack of consistency in 

students’ clinical experiences. The traditional model of undergraduate clinical education dictates 

that students are assigned to groups of 8 to 10, supervised by a clinical faculty, working in a 

health care setting for several hours at a time. Students are placed throughout hospitals and 

community agencies, working on a variety of units. There is inevitably lack of consistency in 

student learning experiences. Even students assigned to the same unit will encounter individual 

patients with unique problems and needs. It is impossible to assure that every student who 

graduates from a nursing education program will have had the same opportunity to provide care 

for any specific type of patient. Many variables influence student learning experiences in the 

clinical setting. These include such things as patient acuity and diagnosis, facility access, time of 

day, as well as clinical and teaching expertise of clinical instructors and nursing staff. Use of the 

human patient simulator allows for greater consistency in learning experiences. Learning occurs 

in a controlled environment where groups of students are exposed to the same scenarios, under 

the same conditions. Simulation is an efficient way to offer “standardized [experiential] learning 

in concentrated periods of time”51 (p. 13). 

The versatility of the technology means that patient simulation can be incorporated into 

courses throughout the nursing education curriculum. It can be used in beginning nursing courses 

to demonstrate such things as pathophysiological and pharmacological principles, normal and 

15 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

abnormal physiologic parameters, and responses to interventions. Faculty can utilize the patient 

simulation with beginning students in physical assessment courses to demonstrate principles and 

techniques of systematic assessment. Students can hone their assessment skills with the simulator 

as they practice assessment of specific body systems and as they learn the head-to-toe 

examination. The simulator can be used to help students understand the concept of doing an 

initial patient assessment, assist them to understand how to approach a patient, and provide them 

with introductory interaction skills. 

Patient simulation is an instructional strategy that bridges theory and practice in a variety of 

courses throughout the undergraduate curriculum (e.g., medical-surgical nursing, pediatrics, 

obstetrics, community health, psychiatric nursing, geriatric nursing). Undergraduate nursing 

faculty often employ the patient simulator as part of a synthesis learning experience with 

students enrolled in “capstone” medical-surgical nursing courses.30 Students are expected to 

apply theory from current and previous didactic courses and to draw from their previous clinical 

experiences as they respond in the various scenarios. In the last semester prior to graduation, 

students enrolled in the nursing program at the University of North Carolina at Chapel Hill 

participate in a series of medical-surgical simulations cases: congestive heart failure that has 

progressed to pulmonary edema, tension pneumothorax, and ventricular tachycardia that leads to 

a full “code.” These three cases are presented in a 1-hour time frame. The congestive heart 

failure/pulmonary edema case takes approximately 30 minutes and is provided as an example in 

Appendix A. The next two cases move more rapidly due to the emergent status of the patient and 

the necessary interventions. Later in the semester the students return to the simulation lab for a 

second hour where they encounter a hyperglycemic hyperosmolar nonketotic coma case that 

incorporates factors such as cultural issues, use of herbs, use of an interpreter for a non-English 

speaking patient, regulations under the Health Insurance Portability and Accountability Act 

(HIPAA) regarding family communications, and issues related to access to care. 

Teaching with simulation offers opportunities to experience and act in common situations 

that students are likely to encounter in the clinical setting. Likewise, simulation can be used to 

teach students how to respond in situations that are relatively uncommon, yet warrant prompt 

action to prevent deleterious consequences. 

The patient simulator allows for purposeful exposure to critical care scenarios that the learner 

may not encounter in the clinical practicum. Acquisition of this type of experience is important 

because the nurse needs to intervene promptly to prevent adverse patient outcomes. Simulation 

allows students to be immersed in critical care scenarios, requiring them to be active participants 

identifying pertinent changes in patient status and intervening appropriately, in a timely manner, 

to effectively treat the changes or to limit adverse outcomes. Even if they do not intervene 

appropriately or quickly enough and the simulated patient dies, there is educational value to be 

gained through debriefing. 

Most nursing students have minimal opportunities to work in a critical care setting during 

their clinical practicum, yet it is important that they recognize signs of deterioration in patient 

status and are knowledgeable about appropriate assessments and interventions. Students on the 

clinical unit have limited opportunities to participate in emergent situations. If a patient develops 

cardiac or respiratory arrest and a “code” is called, the team of experts rushes in; the student is 

typically pushed to the periphery to act as an observer. Students can be taught how to respond in 

a “code” situation. A cardiopulmonary arrest can be simulated and students are expected to 

intervene, calling the “code” team and participating in the resuscitation. Students can actually 

use the portable defibrillator to “shock” the mannequin.52 

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Simulation and Nursing Education

Communication with the team and the health care provider is an important element of any 

patient simulation scenario. As student nurses working on a clinical unit, there is typically little 

opportunity for students to contact health care providers directly to discuss concerns or questions 

about their patients. For example, students do not make calls to physicians to report a patient’s 

declining health status. In simulation, they may be asked to notify the provider, conveying 

pertinent information in a concise, professional manner and acting as an advocate for the patient. 

As orders are received from the provider, the student must document and communicate 

accurately to the team so that they may proceed with implementation. 

Scenarios using simulation also provide important lessons about the importance of 

documentation, particularly in fast-moving critical care cases. One student may be assigned to 

record everything that is happening, ranging from the patient’s vital signs to steps in 

cardiopulmonary resuscitation. The old adage, “if it is not documented, it was not done,” can be 

emphasized and important lessons reinforced. 

Role of the Educator in Patient Simulation 

Just as the construction industry emphasizes the importance of using the “right tool for the 

job,” so it is with the choice of an instructional strategy in nursing education. While the uses for 

the human patient simulator are broad, it is not intended as a panacea that can be implemented 

effectively at any place and time within a nursing curriculum. There must be careful thought in 

selecting patient simulation as the instructional method of choice to meet specific learning 

objectives. 

Benner53 (p. xiv) states that “providing nursing care involves risks for both nurse and patient, 

and skilled nursing requires well-planned education programs. Experience-based skill acquisition 

is safer and quicker when it rests upon a sound education base.” When planning an educational 

activity, it is helpful to consider what type of tool will be most appropriate to teach the task at 

hand and to optimize the situation for the learner. Beaubien and Baker2 dispel the myth that 

simulation is a unidimensional concept that has been used to describe the capabilities of the 

equipment such as high or low fidelity. It is not the level of the simulation fidelity that 

determines the effectiveness as an educational tool, but rather the faculty who designs the 

educational experience. Simulation is a multidimensional concept requiring the educator to 

examine not only the equipment, but also the environment and the psychological perceptions of 

the learner and educator.2

 

The patient simulation is only as effective as the faculty who are using it. The creativity, 

clinical knowledge, teaching expertise, and technological abilities of the faculty are highly 

influential in the effective use of patient simulation. A combination of standardized patients, part 

task trainers, and static mannequins can be coupled with the mannequin-based high-fidelity 

simulator to provide a more comprehensive learning experience. Patient simulation is a learnercentered instructional strategy where faculty act primarily as facilitators. The role varies 

somewhat, depending on whether the patient simulation is utilized for student learning or as a 

means of evaluating student performance.4 

It is important to acknowledge that the patient simulator is a highly sophisticated, 

technologically advanced teaching tool. Training is required to enable faculty to effectively 

utilize the simulator. In most institutions, one or two faculty members are initially trained and are 

subsequently charged with training other faculty members in use of the patient simulator. It is 

helpful to have a “champion” who can present the patient simulator to faculty in a positive way, 

17 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

citing the advantages to be gained in educating students with this teaching tool. Faculty who are 

unfamiliar with the simulator can be invited to orientation sessions where they can have handson experience with the mannequin and witness the capabilities of the technology. They can also 

be invited to observe teaching sessions in which students are involved in patient care scenarios 

using the simulator. Faculty who see the potential benefits of patient simulation may be more 

likely to want to use the simulator in their teaching. Those who are innovative, creative, and 

enjoy learning through active participation may be more apt to try the patient simulator as a 

teaching strategy. 

While the novelty and versatility of patient simulation technology can be very appealing, 

learning to use the equipment can be daunting. This may be especially true for older faculty who 

have grown accustomed to traditional teaching methods, while younger faculty who have grown 

up with computer technology may be more interested and adept at learning to use patient 

simulators. Teaching assistants, who are often graduate students, are utilized in some settings to 

operate the patient simulator and to assist faculty in writing and running scenarios. 

The time factor associated with use of patient simulation may be seen as a disadvantage.30, 45

Typically, the student/faculty ratios are lower than in classroom or clinical settings, which means 

that more faculty time is required to offer the simulation experience to students. Faculty may be 

unwilling to commit more of their time, particularly if they already feel stretched. Those faculty 

who see the value of the learning experience for the students may be more likely to commit to 

using the simulator. Using patient simulated scenarios in place of clinical hours may enhance the 

appeal of this technology; substituting a day of clinical practice for equivalent time in the 

simulation lab may be an option. In many curricula the credit hours allotted to labs and clinical 

are the same and allow for 1:1 hour exchange between the two learning environments. 

Developing and Using Patient Simulation Scenarios 

Manufacturers of patient simulators provide a variety of predefined scenarios for use in 

health care education. Both METI HPS and Laeradel’s SimMan have preprogrammed patient 

care scenarios. These standardized cases serve as the foundation for other scenarios that can be 

created by the user to fit curricular and learning needs. The METI Program for Nursing 

Curriculum IntegrationTM focuses on nursing educational concepts and competencies. It provides 

a strategy for implementing simulation use across a 4-semester nursing curriculum. The 90 

clinical simulations include objectives, pre-scenario questions, evidence-based references, and 

more. 

Faculty members may choose to adapt or create their own patient simulator scenarios to be 

more consistent with specific learning objectives and student needs. When adapting an existing 

simulated program or developing a case scenario, there are important considerations: 

• Q: Are there preprogrammed scenarios that can be used, or is it necessary to 

develop a scenario? 

A: Even if an existing program is used, it is likely that the faculty will choose to elaborate 

and embellish it, including information to make it seem more realistic, framing the 

scenario with patient background and history. The patient simulator may be used in 

conjunction with other instructional strategies such as unfolding case studies or problembased learning activities. Other types of simulation such as part task trainers may be used 

in conjunction with the patient simulator. If faculty choose to create their own simulated 

scenarios, they may draw ideas and data from previous experiences, from staff members, 

18 
Simulation and Nursing Education

or from students. As a course assignment, students may be asked to write a critical 

incident paper that can provide ideas for simulated cases. Students may be asked to create 

cases that can be adapted to the simulator. Of course, patient anonymity must be 

protected. 

• Q: What are the goals of the experience? 

A: It is important to identify specific learning objectives. There may be primary and 

secondary objectives. For example, one of the primary goals may be for students to 

identify physiologic responses to hemorrhage, while a secondary objective may relate to 

recognition of cultural and religious beliefs related to use of blood products. Beyond the 

major objectives, the educator should think about what other teaching points can be 

incorporated into the case, such as family dynamics, cultural issues, use of alternative 

therapies, HIPAA regulations, working with an interpreter, etc. 

• Q: Is there an evaluation component to the simulation? 

A: Students tend to be less anxious in working with the simulator when their performance 

is not being evaluated. Prior to beginning the case, it should be made clear to the students 

whether or not any type of evaluation would be done during the simulation. If there is 

evaluation involved, students should be provided with clear information about the criteria 

used for evaluation. 

• Q: What is the context of the patient simulation learning experience? 

A: If used within a specific course, it is important to consider didactic and clinical 

content that precedes use of the patient simulator. Additionally, previous courses or 

clinical experiences that students have had should be considered. The patient simulator 

provides an excellent opportunity for a synthesis experience in which students can apply 

what they have learned previously to the current situation. 

• Q: What is the level of the students? Are these beginning students who have not yet 

started the first clinical practicum, or are these advanced students who will be 

graduating in a few weeks? 

A: Cases are developed to match the level of the learners. Ideally, students can be 

introduced to the simulator early in the curriculum as they practice assessment and other 

basic psychomotor skills. Then, as they progress through the program, they can be 

involved in patient simulation scenarios that increase in complexity as their knowledge 

level increases. Ultimately, the patient simulator can be used as a synthesis experience in 

which students are expected to apply knowledge, experience, and skills that they have 

acquired up to that point in the program. 

• Q: How much time is allotted for the scenario? 

A: In general, the more complex the scenario, the greater the time required for 

completion. It is reasonable to think that most scenarios can be conducted in 30 minutes. 

It is important to allow time for debriefing when the scenario is over. 

• Q: How many students will be assigned to each scenario? 

A: Generally, small groups of no more than five students work well together in a 

simulated scenario. The case is designed with consideration of the number of roles that 

students can assume and the tasks that are to be accomplished during the case. Although 

19 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

there is benefit to having students act as observers if space allows, there is greater 

learning potential when there is hands-on participation in the scenario. 

• Q: Have the students had previous experience with the patient simulator? If so, how 

much? 

A: Orientation to the equipment and the technology is essential prior to having students 

participate in an actual case scenario. There is some anxiety associated with encountering 

a new teaching method, particularly when it is novel and unfamiliar. Both students and 

faculty need the opportunity for hands-on orientation to the mannequin, doing such things 

as listening to breath and heart sounds, being informed of the capabilities of the system, 

viewing the bedside computer display, and identifying the location of supplies and 

equipment within the environment. 

• Q: How many faculty/staff are available to assist with the scenario? 

A: Ideally, there are at least two to three persons involved in running a patient simulated 

case. It is advantageous to have a coordinator or team leader who is familiar with all 

aspects of the simulation. This person is responsible for assigning and delegating tasks to 

other team members, checking the setup and equipment, directing, and troubleshooting as 

the scenario progresses.41 The team leader may also be involved in facilitating the 

scenario, although there are usually one or two other faculty members serving in that 

capacity. There must be an operator who runs the computer and makes the simulation 

happen in real time, making adjustments as necessary according to learning needs and 

actions of the participants. The operator, facilitator, or other staff assistants may 

periodically move into acting as family members, friends, or other health care personnel 

who may be involved in the scenario. All faculty/staff who are serving as facilitators will 

need to be flexible to also assume such roles intermittently as needed during the case. 

• Q: What type of environment is needed to represent the clinical setting for the 

scenario?

A: The educator needs to examine the situation, props, and environment to determine if 

they are as realistic as possible. Realism of the situation is critical to the learning 

experience for the student during the scenario. Suspending disbelief by creating a 

situation as realistic as possible encourages learners to immerse themselves in the 

experience with minimal distractions. Gaba3

 suggests that learners who are immersed in 

experiential learning are more able to suspend disbelief and perform as they would in a 

real-life situation. Additionally, it may enhance the ability to transfer what has been 

learned in the scenario to an actual patient situation. While the patient simulator is 

typically housed in a particular room or space, it may be possible to adapt the 

environment to increase the realism of the simulated case. Real patient care equipment 

should be used whenever possible. Visual and auditory props may be as simple as a 

telephone that can be used to simulate phoning the health care provider. Gather the props 

and equipment and have the environment prepared in advance of the case. For example, 

intravenous fluids or blood products may need to be mixed and hung. Depending on the 

patient being simulated, the mannequin may need transforming with makeup, masks, or a 

wig. 

20 
Simulation and Nursing Education

• Q: What audiovisual equipment is needed and available? 

A: A whiteboard, blackboard, or flipchart is needed for recording patient data and 

nursing interventions during the scenario. Video recording of a simulation session is 

useful in providing feedback for the participants. Video playback can be a powerful 

teaching tool as participants are able to observe and critique the scenario. The video 

recording is also helpful for the operator and others to see the simulation from all 

angles.41

• Q: Is there time for debriefing? 

A: The debriefing is a critical part of the patient simulated scenario, providing 

participants with an opportunity to reflect on their learning experience. During this time, 

participants may be asked to consider key questions such as: “What went well?” “What 

could have been done better?” “How did you feel in the role of _____?” (See 

Postsimulation.) The debriefing is also a time to review key concepts and knowledge 

related to the scenario. Important points can be discussed; pathophysiology of patient 

symptoms and responses to interventions can be reviewed; rationale for interventions can 

be identified; actions, dosages, side effects, and administration of medication can be 

discussed. 

Presimulation 

Presimulation Faculty 

Prior to use of the simulator with students, faculty must be fully prepared to facilitate the 

learning experience. This means familiarity with the equipment and with the particular scenarios 

that are to be used. The computer operator needs to be skilled in the technology of the simulator. 

They need to know how to set up the equipment, connecting the mannequin to the computer, and 

initiating the program to be used. If a preprogrammed scenario is used, the operator starts the 

program and allows it to run. However, if the scenario allows physiological parameters to change 

outside of the program, the operator must be knowledgeable about how to make the necessary 

adjustments as students are in the midst of the scenario. For example, if students do not intervene 

promptly and appropriately in recognizing and treating hemorrhage, the “patient” may progress 

to hypovolemic shock and subsequently arrest. The operator can determine how quickly the 

patient’s condition deteriorates and the patient’s response to interventions. 

It is important to provide all involved in the case with a script a few weeks prior to the 

simulation so that they can prepare adequately to be a facilitator. You might color code each role 

in the script to allow ease of following the case. The script should be in a large font and doublespaced, allowing quick referencing during the case. It is helpful to rehearse the simulation 

scenario before utilizing it with students. This allows for refining and adjusting the scenario 

and/or roles as needed prior to implementation to promote its effectiveness as a learning strategy. 

Because this is an unfamiliar educational method for most nursing educators, faculty may benefit 

from in-service classes about teaching with the simulator. Additionally, they need the 

opportunity for hands-on learning with the simulator so that they are better able to assist students 

and facilitate their learning experiences. Having faculty participate as students in scenarios can 

be very effective in increasing their comfort level with the patient simulator. 

Using clinical faculty as facilitators of patient simulator scenarios can be very effective, 

particularly with their own clinical groups. This can provide opportunity for faculty to gain 

21 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

insights into how the students function as team members; to identify leadership qualities; to 

assess communication, critical thinking, and skill performance; and to observe how students 

react under pressure if a critical situation occurs. 

Using the METI HPS With Baccalaureate Nursing Students 

The following paragraphs describe how the METI HPS is used with senior students in the 

baccalaureate nursing education program at the University of North Carolina at Chapel Hill. 

Simulation is used to provide students with a synthesis learning experience in which they have 

the opportunity to utilize previous knowledge and experiences as they assess, intervene, and 

evaluate the care of a rapidly deteriorating patient. This critical care experience requires that 

students demonstrate competency in assessment, critical thinking, communication, teamwork, 

skill performance, and documentation. It is an excellent means of reviewing important concepts 

as students prepare to take the National Council Licensure Exam for Registered Nurses 

(NCLEX-RN) and enter practice within a few months. 

Presimulation logistics. The course coordinator for the senior-level capstone medical 

surgical nursing course assigns students to groups for the simulation experience. Each clinical 

group is divided into two groups of five students. (Five seems to be the maximum number for 

effective use of the HPS.) Each clinical faculty member assists with the simulation experience 

for his or her group. Students spend a total of 2 hours in the simulation lab during the semester as 

they encounter four simulation scenarios involving care of an acutely ill adult patient. The cases 

that are typically used include congestive heart failure progressing to pulmonary edema, tension 

pneumothorax, hyperglycemic hyperosmolar nonketotic coma, and cardiac arrest. These cases 

were adapted from preprogrammed HPS scenarios. 

The HPS is located in a room that is dedicated to its use. The room houses the mannequin on 

a stretcher, the patient monitor display, a cart with medications and emergency supplies (oxygen, 

IVs, syringes, etc.), a set of cabinets that includes a countertop and sink, a white erase board, 

resource books, and a telephone. There is an adjoining control room that houses the operating 

tower and computer interface. A one-way mirror enables the computer operator to observe the 

students and faculty as they participate in the scenario. An infant sound monitor is placed near 

the head of the mannequin and the receiver is placed in the control room so the operator can hear 

what is being said in the simulation room. 

Two nurse educators who act as facilitators and a graduate teaching assistant who operates 

the computer usually conduct the simulation scenarios. The nurse educator who is most 

knowledgeable and experienced with the HPS takes the lead and directs the simulation. The 

other nurse educator (usually the clinical faculty) assists and supervises students’ performance. 

Both faculty members assume additional roles as needed, such as a family member and physician 

or nurse practitioner. The graduate teaching assistant operates the computer from the control 

room, initiating and managing the physiologic responses of the mannequin in accordance with 

each particular scenario or simply starting and stopping a preprogrammed scenario. The teaching 

assistant also is the voice of the patient (the HPS mannequin has a voice box in his neck), 

responding to the students’ history and assessment questions. The infant sound monitor allows 

the teaching assistant to hear the students’ questions. 

Presimulation student instructions. In an effort to promote realism in the cases, students 

and faculty dress as they would for the clinical experience in the hospital. In addition, they are 

asked to wear identification badges and to bring their stethoscopes. It is made clear to students 

that the HPS simulation is a required experience. Students are expected to come to the HPS 

22 
Simulation and Nursing Education

simulations with some background knowledge and experience. They may have assigned readings 

or written assignments to complete prior to the simulation. A completed written assignment (e.g., 

study questions) may be used as a student’s admission ticket to the scenario. 

Presimulation briefing. All simulation scenarios begin with a presimulation briefing (see 

Simulation Box 1). During this time, students are oriented to the mannequin and the learning 

environment. A faculty member who will be assisting with the subsequent scenarios conducts 

this session. 

Each group of students enters the simulation room, accompanied by one of the nursing 

educators who will facilitate the cases. The first time students encounter the human patient 

simulator, the technology and equipment involved with the mannequin are explained (see 

Simulation Box 2). Students are encouraged to uncover and examine and touch the mannequin, 

listen to the heart and breath sounds, palpate the pulses, and observe pupil response. The voice of 

the mannequin is demonstrated. It is important to remind students that they are to treat the 

mannequin as they would a patient in the scenarios. Students are oriented to the environment, 

including the computer display and the location of equipment and supplies. After each student 

has had an opportunity to become acquainted with the mannequin and the environment, the 

group of four or five is escorted outside the simulation lab where they receive instructions about 

how the scenarios will proceed. Each student is assigned a specific role during the scenario: 

primary nurse, secondary nurse, communicator, recorder, and resource/medication nurse (see 

Simulation Box 3). The students draw 5” × 7” index cards to determine their assigned roles. Each 

card identifies the responsibilities of that particular role. In subsequent scenarios, role 

assignments are changed so that no student repeats a role they have already performed. During 

the briefing, students are given a concise report on the patient they will meet in the scenario. The 

setting (e.g., emergency department, intensive care unit), patient history, presenting problem, 

family situation, and other pertinent details are described to the students. 

The use of index cards to assign specific student roles evolved after conducting a few 

simulations in which students appeared disorganized and confused about what each one should 

be doing. For example, one student would think of something to do and all the students in the 

group would set about attempting to perform that intervention. There was no evidence of 

teamwork. In an attempt to remedy this problem, students were asked to volunteer for a role in 

the scenario (primary nurse, secondary nurse, communicator, recorder, and resource/medication 

nurse). Students were hesitant and took too long deciding who would perform each role. 

Subsequently, faculty developed index cards to identify each role and the associated 

responsibilities of that role. During the presimulation briefing, a faculty facilitator shuffles the 

cards and asks students to draw their roles prior to each scenario. In addition to saving some 

time, this technique provides the students with some direction as they begin the scenario. 

 

Simulation Box 1. Presimulation Student Preparation 

Instructions to the student: 

• Prior to simulation, complete assigned readings, case materials. 

• Be prompt to your assigned simulation time. 

• Dress as in clinical. 

• Wear name badge. 

• Bring stethoscope. 

• Address and treat mannequin as though a patient. 

23 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Simulation Box 2. Presimulation Briefing—Orientation to Simulator & Learning Environment 

Orientation to the mannequin: 

• Heart and lung sounds 

- Instruct students to listen to the heart and lungs sounds so that they are be able to differentiate 

from normal, which is what they are hearing during orientation, and abnormal, which is what 

they will hear when the scenario begins. Help students to adapt to the mechanical sounds 

associated with the heart and lung sounds. 

• Palpate peripheral pulses (no posterior tibia pulse). 

• Perform PERRL (no A or accommodation). 

• Explain to students what mannequin does not do/have: 

- Bowel sounds 

- Sweat 

- Seizure 

- Change color such as cyanotic, flushed, or pale 

• Demonstrate how to connect mannequin to monitor. 

• Inform students that patient data is located on the patient care monitor. Detail the data as presented so 

that they can interpret later in a case. 

• Differentiate for them what data they can expect to get from the monitor and what will require their 

assessment. 

Orientation to the learning environment: 

• Monitor 

• Mannequin on stretcher or hospital bed 

• Oxygen and delivery devices 

• Defibrillator 

• Medications 

• Suction 

• Patient chart 

• Realistic lab values, chest x-rays, EKGs 

• Phone to call physician/nurse practitioner and labs 

Simulation Box 3. Role Assignment Cards 

Position: Role: 

Primary RN Team leader, assessment, history, sets priorities, and 

 delegates. 

Secondary RN Assists with assessment, performs nursing skills and 

 medication administration as directed by primary nurse. 

Recorder Writes down pertinent information on whiteboard. 

Communicator Speaks to family, health care provider, lab, radiology, etc. 

Resource/Medication RN Looks up needed information for team (e.g., safe medication dosage, rate of 

administration of medications) and administer medications as needed.

*The roles are printed on colored 5” X 7” index cards with the role name on one side and the responsibilities of role 

on the other side. These cards are laminated and used over and over for each simulated case. 

24 
Simulation and Nursing Education

Intrasimulation 

The actual simulation begins as students enter the simulation room. If it is their first 

encounter with the simulator, they may need some assistance and encouragement in getting 

started. The faculty facilitators coach the students as needed. The students acting as primary and 

secondary nurses are expected to introduce themselves to the patient and family. The 

communicator assumes the position near the telephone, the recorder goes to the whiteboard, and 

the resource/medication nurse locates the reference materials. The primary nurse begins the 

assessment and directs the secondary nurse to assist or to do other tasks as needed. Based on the 

assessment findings and any physiologic changes that may occur, the primary nurse determines 

the interventions that are needed. He or she may collaborate with the secondary nurse or other 

team members as necessary. The recorder documents all assessment findings on the whiteboard. 

At the point it is determined that a call to the health care provider is warranted, the 

communicator gathers the necessary data and contacts the provider by telephone. Using the 

SBAR communication method, pertinent information is relayed to the provider and orders are 

obtained. The communicator documents the orders. As soon as she or he is finished, the 

facilitator uncovers a foam board with the orders prewritten large enough that they are visible to 

the entire team. The orders are implemented at the direction of the primary nurse, who is also 

involved in carrying out the orders. The resource nurse looks up any medications that are ordered 

to identify the type of drug, the actions, dosage, administration, and potential incompatibilities 

with other medications. This information is communicated to the team prior to administering any 

medications. The primary nurse can delegate some of the medication administration to the 

resource nurse. 

The faculty facilitators may be involved in numerous aspects of the simulation. One may be 

assisting with medications, while another may be helping with skills such as applying oxygen or 

testing blood sugars on the patient. If the students do not intervene appropriately, the patient may 

go into respiratory arrest and/or experience cardiac arrhythmias. Faculty assist the students as 

they perform CPR and administer emergency medications. The simulation ends at the 

predetermined “end” of the case, when the patient “expires,” or as determined by the faculty. 

Postsimulation 

Debriefing is used to correct any misinformation or improper practice techniques the students 

may demonstrate. Beaubien and Baker2

 stress the importance of feedback to enhance the ability 

of students to integrate correct behaviors into their skill set. Through the simulation, gaps in 

knowledge are identified in individual students that would otherwise go undetected. 

Additionally, in the debriefing students are asked to reflect on their own skills and knowledge. 

They identify what they have done well and areas that warrant improvement. Because there are 

multiple activities occurring throughout the simulation and students may be focused only on their 

specific roles, debriefing can be used to review key points about the simulation. This includes 

discussion of the events that occurred, psychomotor skills such as setup of a chest tube drainage 

system, selection of oxygen delivery method and application, rate and technique for IV push 

medications, etc. (see Simulation Box 4) 

25 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Simulation Box 4: Postsimulation Debriefing and Discussion 

Ask students:

• What do they think they did well? – Validate what they know and affirm what they are currently doing well. 

• How did this case make them feel? 

• What would they do differently if they had to do it again? – Critique their performance as a group and assist 

them to identify additional learning needs. 

• How did they like working with the HPS? 

Review key concepts:

• Describe and interpret scenario. 

• Students will 

- Discuss roles of team members – point out teamwork, communication, and use of appropriate and 

inappropriate delegation. 

- Highlight areas for potential patient safety issues – communication with each other, transcription of 

orders, handoff and transfer of patient. 

- List what signs and symptoms Mr. Jones exhibited. 

- State how Mr. Jones’ presenting signs and symptoms varied from the textbook picture. 

- Identify what precipitated Mr. Jones’ CHF and pulmonary edema – past medical history and 

pathophysiology. 

• Discuss pathophysiology of CHF and pulmonary edema. 

• Review lab reports, x-ray, EKG. 

• What should be immediate interventions? (Focus on ABCs.) 

• Review communication with health care provider: 

- SBAR 

- Key points to include 

• Discuss rationale for each of the health care provider’s orders. 

• Identify important nursing considerations: 

- Conserve Mr. Jones’ energy – do not ask complete history while he has dyspnea. 

- Explain to Mr. Jones what you are doing – be brief, concise. 

- Communicate with Mrs. Jones – provide information, but do not offer false reassurance; have staff 

member escort her out of room. 

• Do a skill review: 

- Non-rebreather mask and why it is best choice for oxygen delivery 

- Insertion of IV: choice of angiocath size, insertion site, fluid, rate of administration 

- IV push medications and technique for administration 

- Foley catheter to straight drainage (urometer for hourly outputs) 

It is important to provide students with an opportunity to evaluate their experiences and the 

use of the patient simulator as an instructional strategy. This is done as part of the debriefing, but 

should also be part of a computerized or written evaluation. It may be part of a course evaluation 

or a separate evaluation tool specific to the patient simulation experience. 

Student Evaluations of HPS Scenarios 

The students who have participated in METI HPS simulations in the baccalaureate of science 

in nursing and continuing education programs have given overwhelmingly positive evaluations 

of the simulator as an instructional strategy. This is consistent with other reports of student 

evaluations in nursing43–45, 48 and medical education.51, 54, 55 One student commented, “Simulation 

was very effective. It took into account many facets of care, for example, assessment, 

communication with family, doctor’s orders, medications, including herbs.” 

Many students feel that the simulation experience taught them all they know. This concept is 

evident in the following student evaluative comment: 

26 
Simulation and Nursing Education

The simulator was awesome and so realistic. We were required to do rapid 

assessments of a critically ill patient and to pull it all together to provide care. 

Now I better know what I do not know and can work on improving. I learned 

more in this hour than I have my whole curriculum. 

Students do not recognize that the simulation provides a synthesis experience in which they 

draw from previous knowledge and experiences. The didactic and clinical components of their 

educational experience to date have been instrumental in preparing them to think and act like 

nurses. The “aha!” experience of patient simulation promotes student confidence in their criticalthinking and clinical-decisionmaking skills and in their ability to practice as safe, competent 

nurses as they enter the workplace.46, 48

Practice Implications—The Future of Patient Simulation in 

Nursing Education 

Use of the patient simulator as an instructional strategy holds great promise for nursing 

education. Simulation can become an integral part of nursing education because of its ability to 

improve patient care and patient safety. No live patients are placed in jeopardy at the expense of 

the learner. Simulation provides standardization of cases, promotes critical thinking, allows 

mastery of patient care, provides immediate feedback, and helps students integrate knowledge 

and experience. It is an ideal synthesis learning experience. 

Because the patient simulator is a relatively new educational tool, nursing educators must 

become acquainted with the technology, its potential uses, and benefits to learners. Toward that 

end, it is important that the nursing literature on patient simulation is increased, both in 

descriptive articles and in research reports. As faculty become more aware of the advantages of 

educating students with patient simulation, its utilization in educational programs should 

increase. 

Because of the investment of money and faculty time associated with patient simulation, it is 

imperative that administrators and educators see the value of teaching with simulation. 

Administrators need to commit financial resources to procuring patient simulation equipment 

and training faculty in its use. Faculty time must be dedicated to the development and 

implementation of simulation programs. 

Nursing faculty need to look for new ways to utilize the patient simulation technology with 

all types of learners. Schools of nursing can optimize the use of a patient simulator and increase 

its cost effectiveness by incorporating it into undergraduate, graduate, and continuing education 

programs. 

Research Implications 

The paucity of nursing research on the use of patient simulation demonstrates the need for 

further study. Studies are needed to investigate the best ways to utilize patient simulation in 

nursing education.39 Evaluative studies are needed to examine the success and effectiveness of 

patient simulation in all types of nursing education programs. Research is also needed to 

demonstrate that knowledge and skills acquired in a simulated environment are transferable to 

actual patient care situations. The cost effectiveness of using simulation also needs to be 

explored.47, 56–58

27 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Conclusion 

The use of patient simulators in nursing education is a relatively new instructional 

methodology. The rationale for using simulation as an educational strategy includes the absence 

of risk to a live patient; the ability to provide standardization of cases; the promotion of criticalthinking, clinical-decisionmaking, and psychomotor skills; the provision of immediate feedback, 

and the integration of knowledge and behavior. Through patient simulation scenarios, essential 

elements of patient safety can be emphasized, such as prevention of medication errors, 

promotion of effective communication, and the importance of teamwork. Learners can be 

exposed to critical care scenarios and have the opportunity to respond without fear of harming a 

live patient. 

By providing students with exposure to a variety of clinical situations through clinical 

practicum experiences and patient simulations, they can be better equipped to provide safe, 

effective care and work as contributing members of the health care team. 

The challenge is for faculty to embrace patient simulation as an instructional strategy and to 

seek its effective implementation in nursing education programs. The exciting technology of 

patient simulation is only as good as the faculty who use it. The potential benefits to learners 

outweigh the costs of the equipment and faculty training. 

Acknowledgments 

Acknowledgments to Lindsay Allen, R.N., M.S.N., clinical instructor for collaboration on 

simulation cases, and to Darlene Baker, R.N., M.S.N., assistant director of the Clinical Education 

& Resource Center for editorial assistance at the University of North Carolina School of 

Nursing, Chapel Hill, NC. 

Author Affiliations 

Carol Fowler Durham, M.S.N., R.N., University of North Carolina at Chapel Hill. E-mail: 

Carol_Durham@unc.edu.

Kathryn Rhodes Alden, M.S.N., R.N., I.B.C.L.C., University of North Carolina at Chapel 

Hill. E-mail: alden@email.unc.edu.

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Table1. Teaching/Learning Strategies Using Simulation 

Type of Simulation59 Description59 Advantages60, 61, 62 Dis

Low-tech (static) task trainers e.g., food items: oranges for injections, chicken breast for biopsy, pigs feet for suturing, injecta pads, adult/child/infant mannequins, breast and gyn/prostate models, eye/ear models, IV arms, CPR mannequins, case studies, etc. Props, models, or mannequins used to practice skills and procedures No threat to patient safety Readily available Reusable Develop role memorization Allows for return demonstration of skills Large groups of learners Low to moderate cost Task traini

ConsistencLearner – Lower veraReturn dem

Simulated patients e.g., standardized patient (trained actors), learner/learner, educator/learner, patients playing role of patient, female and male human models for pelvic and prostate exams, unfolding case studies Role-play patients for training, simulates assessment of history taking, physical exams, communication, and therapeutic psychiatric interventions No threat to patient safety Great tool for high communication skills Provides relatively consistent experience for all students Moderate t

Limited lea

Screen-based computer simulators e.g., computer-assisted instruction (CAI), virtual reality excursions (VRE), Web-based programs Programs to train and assess clinical knowledge and decisionmaking. No threat to patient safety Provides relatively consistent experience for all students Reusable Variable am

Moderate c

Complex task trainers e.g., virtual reality devices such as bronchosocpy, laparoscopic surgery, IV access (Cath SimR), haptic (touch cue) simulators such as pelvic exam, cardiac catheterization and stent placement, respiratory intubation, neonate (umbilical artery, lumbar, intubation) 

models 

High-fidelity visual, audio, touch cues with interfaces with computers 

No threat to patient safety Provides relatively consistent experience for all 

students 

Promotes realism Improves psychomotor skills 

Moderate tLimited lea

32
33

Type of Simulation59 Description59 Advantages60, 61, 62 Dis

Human Patient Simulators Low-fidelity e.g., Noelle birthing mannequin – uses 

compressor to birth newborn every 7 minutes Moderate-fidelity e.g., LaerdalTM SimManTM 

High-fidelity e.g., METI Human Patient SimulatorR

Full-length human mannequins Simulated anatomy and physiology Computer-driven scenarios that responds as programmed Computer-driven physiologically based that responds in real time to interventions

No threat to patient safety High degree of realism and veracity Low educator/learner ratio (1:5) Active involvement of learner Decreases emphasis on memorization Consistent experience for all students: serious or 

uncommon clinical problems can be presented to all learners 

Creates a standardized setting for honing and 

enhancing critical-thinking, problem-solving, and decisionmaking skills 

Enhances ability to assess variations in patient 

responses and the learners’ ability to pick up important assessment data 

Increases competence and ability to formulate a 

strategy for a specific situation 

Learners are better prepared for clinical practicum Practice communication with multidisciplinary team 

members. Teamwork and leadership skills can be practiced 

Communication and delegation skills can be fine 

tuned 

Psychomotor skills can be applied and refined Increased organization of patient care 

High cost (MaintenanResource 

faculty 

Limited leaHigh staffinNo validati

to clinic

Learner’s dHypervigila

observ

Anxiety of 

perform

Lack of kn

simulat

Physical sp

associaneeded 

Lack of co

teachin

59 Adapted from Ziv A, Wolpe PR, Small SD, Glick S. (2003). Simulation-based medical education: an ethical imperative. Academic Med60 Gordon JA, Wilkerson W, Shaffer DW, Armstrong EG. (2001). Practicing medicine without risk: students’ and educators’ responses to 

simulation. Academic Medicine, 76, 469-472. 

61 Rauen C. (2001). Using simulation to teach critical thinking skill: you can’t just throw the book at them. Critical Care Nursing Clinics of 

103. 

62 Weis PA, Guyton-Simmons J. (1998). A computer simulation for teaching critical thinking skills. Nurse Educator, March-April, 23, 30-3
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Table 2. Key Terms and Definitions 

Terms and Acronyms Definitions 

ABCs airway-breathing-circulation 

ABG arterial blood gases 

ACLS advanced cardiac life support 

ADE adverse drug event 

ASA aspirin 

BSN baccalaureate of science in nursing 

BP blood pressure 

CAI computer-assisted instruction 

Capstone A course occurring at the end of a curriculum allowing students to synthesize what they 

have learned. 

CBC complete blood count 

Champion A person who will be a leader in the use of a new technology, helping to bring 

additional faculty along in their implementation of the technology across the curriculum. 

Chem 7 Blood work that is done on serum examining seven chemical tests: blood urea nitrogen 

(BUN), serum chloride, carbon dioxide, creatinine, glucose, potassium, and sodium. 

CHF congestive heart failure 

Code Respiratory and/or cardiac arrest 

Complex task trainer Highly sophisticated computer technology that provides training on specific skills or 

procedures; includes virtual reality and haptic systems. 

CPR cardiopulmonary resuscitation 

CRM Crew Resource Management 

CXRs chest x-rays 

ED emergency department 

EKG electrocardiogram 

Fidelity The degree to which the appearance and function of the simulator resemble the 

simulated system; low, intermediate, or high5

FiO2 fraction of inspired oxygen 

Generation X Refers to the generation of people born between 1961 and 1981 (dates vary among 

different sources) and describes behaviors in terms of life experiences. 

Generation Y Refers to the generation of people born between 1977 and 2003 (dates vary among 

different sources) and describes behaviors in terms of life experiences. 

GYN gynecological 

Haptic Technology that interfaces with the user via the sense of touch. 

High-fidelity patient 

simulators 

Highly sophisticated computerized mannequins, capable of realistic physiologic 

responses. 

HHNC hyperglycemic hyperosmolar nonketotic coma 

HIPAA Health Insurance Portability and Accountability Act 

HOB Head of bed 

HPS human patient simulator; high-fidelity computerized mannequin, produced by Medical 

Education Technologies Incorporated (METI®

). 

HR heart rate 

Hypovolemic Decreased circulating blood volume. 

ICU intensive care unit 

I/O intake and output 

Integrated simulators Simulators that combine computer technology and part- or whole-body mannequins. 

Injecta pad Gel-filled pad used to teach and practice giving intramuscular and subcutaneous 

injections. 

IVs intravenous line or intravenous fluid 

K-Dur Oral form of potassium chloride, a potassium supplement. 

JCAHO Joint Commission on Accreditation of Healthcare Organizations (now known as the 

Joint Commission) 

Laparoscopy Minimally invasive surgery in the abdomen or pelvic area where thin instruments are 

used to view, remove, or repair areas through small incisions. 

mEq milliequivalents 

METI Medical Education Technologies Incorporated 

mg milligram(s) 

34 
Simulation and Nursing Education

Terms and Acronyms Definitions 

MD medical doctor 

ml milliliter(s) 

MP3 player MPEG-1, Audio-3, a portable, compressed, digital encoding device that allows a person 

to listen to music and/or watch video. 

MSO4 morphine sulfate 

NASA National Aeronautics and Space Administration 

NRB mask non-rebreather mask for delivery of oxygen 

NCLEX-RN National Council Licensure Exam for Registered Nurses 

NS @ KVO normal saline (intravenous fluid) at keep-the-vein-open rate (30 ml per hour) 

O2 oxygen 

Part task trainers Low-tech or static task trainers, designed to replicate a portion of the body or the 

environment; many represent selected anatomical areas of the human body and are 

used to teach basic psychomotor skills and procedures. 

Patient simulators High-fidelity computerized mannequins. 

PC personal computer 

PDA personal digital assistant, a hand-held data device. 

Pedal edema Excessive fluid in the extremities. When the tissue is pressed with a finger over a bony 

prominence, the depression remains, and the amount of depression is graded from 0 to 

3+ to indicate severity of the fluid overload. 

PERRLA pupils equal round and reactive to light and accommodation 

PERRL pupils equal round and reactive to light 

PMH past medical history 

PO Per os, Latin for “by mouth” 

Pulmonary edema Fluid collecting in the lungs primarily due to left-sided heart failure but may occur with 

right-sided heart failure. 

QD every day 

Q 5 min every 5 minutes 

RN registered nurse 

RR respiratory rate 

SBAR Situation, background, assessment, recommendation: A model of communication that 

is clear, concise and to the point. Sharing key information about situation, background, 

and assessment, and providing a recommendation. 

Screen-based computer 

simulators 

Computer programs designed to model various aspects of human physiology, specific 

tasks, or environments; learners use information to make clinical decisions and observe 

the results in action; feedback is provided during and/or after the interaction. 

SimManTM High-fidelity patient simulator produced by LaerdalTM 

Simulated patients Live persons acting as patients through role play; student partners practicing 

assessment skills or procedures; live actors as trained patients. 

Simulation A technique or device that attempts to create characteristics of the real world; in health 

care, a device representing a patient or part of a patient that can respond and interact 

with actions of the learner;3

 activities that mimic a clinical environment, designed for 

use in demonstrating procedures and promoting decisionmaking and critical thinking.4

SL sublingual 

SOB shortness of breath 

Stat Statim, Latin for “immediately” or “now” 

T Temperature 

Tension pneumothroax A patient care emergency where air enters the pleural cavity but cannot exit, causing 

increased pressure in the pleural space and leading to the collapse of the lung on the 

affected side. This change in pressure will eventually compress the heart and major 

vessels, and the lung on the affected side will not be able to expand. 

TV television 

VRE virtual reality excursions 

35
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Appendix A: Simulation Case Presentation 

Simulation Scenario: CHF Pulmonary Edema 

Simulation participants: 

• Lead faculty: director and facilitator

• Clinical faculty: facilitator, assume additional roles (wife, MD), assist students with 

psychomotor skills, etc. 

• Computer technician: (in control room, behind two-way mirror): “patient” voice and 

computer operator 

• Students 

Note: To facilitate ease of role identification, when we prepare scripts for the faculty, we color 

code all the different roles, double space, and highlight key points. The case is then bound and 

distributed to all the facilitators. 

Facilitator: Role context is an RN who has worked the night shift in a busy emergency 

department (ED). Students are told they are coming reporting to work on the day shift in the ED. 

It is 7:00 a.m. and time for report. 

Thank goodness you all are here. We have had a terrible night. There is a code going on 

down the hall, so I’ll be quick. I need for you to take over care of the patient in room 1. 

His name is Alex Jones; he is a 62-year-old Caucasian male, just brought in by his wife. 

He is complaining of shortness of breath and chest pain. He says he has been up all 

night, and his wife finally made him come to the ED because it had gotten so bad. His 

wife has gone to park the car and has all of his meds. I’m sorry; all we have done so far 

is get him in a room. He hasn’t been connected to the monitor, and no one has assessed 

him yet. Thanks for taking him over! I’ll check on you later. I have to run back to the 

code. 

Facilitator: Escorts students into the simulation room. Direct communicator to area where 

phone (phone is a prop and is not connected) is located; direct recorder to white erase board and 

resource nurse to reference materials. If students are hesitant to begin their assessment, provide 

encouragement. 

Students: 

Primary and secondary nurses should introduce themselves to Mr. Jones and begin to do the 

following: 

• Connect patient to the monitor. 

• Obtain vital signs. 

• Auscultate heart and lungs. 

• Administer O2 – 100 percent non-rebreather (be sure to fill bag with O2 before putting 

mask on patient). 

• Start IV – NS @ KVO. 

• Elevate HOB. 

36 
Simulation and Nursing Education

• Assess pain (rate and describe). 

• Assess for peripheral edema (he has on puffy socks to simulate 3+ pedal edema). 

• Obtain history – recognize the need to limit questions due to his SOB. 

Facilitator: Students need to ask patient appropriate questions. If they seem like they are getting 

off track, give redirection and guidance to their assessment and history. (The primary and 

secondary nurses may take directions/suggestions from the other team members.) 

Computer technician: (Computer operator on other side of one-way mirror is the voice of Mr. 

Jones, voice is transmitted through microphone). 

Voice of Mr. Jones: Make voice sound very anxious, keep repeating until nurse intervention, “I 

just can’t catch my breath,” “It hurts all over my chest,” “I can’t take lying down like this,” and

“You’ve got to help me.” 

When asked by the students, Mr. Jones gives the following responses: 

3⁄4 Pain: “10” on a scale of 1–10, all over my chest, feels different from when I had heart 

attacks. 

3⁄4 PMH: I’ve had four heart attacks. When? The first one was when I was 36 and my last 

one was 2 years ago. I’ve never had open-heart surgery. 

3⁄4 Medications: “Oh, honey, I can’t keep track of all of them. My wife is bringing them in.” 

“I took all of them this morning at about 3:00 a.m. before we came in.” 

3⁄4 Social history: No alcohol, quit smoking 20 years ago. 

3⁄4 Recent changes: “When I take my socks off, my leg looks like they are still on,” “I tell my 

wife that I fall asleep watching TV every night in the recliner, because I don’t want her to 

worry. But, the truth of the matter is, I just can’t sleep lying down anymore,” and “I 

thought maybe I just ate too much at (fill in appropriate holiday), because I’ve gained 10 

lbs in the past 2 weeks.” 

Faculty facilitator: (One of the faculty facilitators acts as wife of Mr. Jones.) At some point, 

preferably when the students are engaged with the patient, a concerned wife runs into the room, 

anxiously asking about her husband, trying to get to him to hold her hand. Ask the nurses, “Is he 

okay? What is going on? Is he having another heart attack?” Continue to be “in the way” until 

one of the students responds to you and takes you aside to talk to you. 

Give the paper bag full of his medication bottles from home to one of the students. 

List of meds:

• Nitrostat 0.3mg SL prn chest pain Q 5min x 3 doses 

• Ramipril 2.5 mg PO QD 

• K-Dur 20 mEq PO QD 

• Furosemide 20mg PO QD 

• Tenormin 50mg PO QD 

• Lanoxin 0.25mg PO QD 

• ASA 81mg PO QD 

37
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Student: The student acting as communicator should take the wife out into the hall and identify 

herself/himself and explain who she/he is and what role they have in the care of Mr. Jones. 

Use therapeutic communication to explain that Mr. Jones’s heart rhythm is regular, which is a 

good sign, but that you will have to do an EKG and additional tests to determine if he is 

having/has had another heart attack. Assure her that the team is doing everything they can for 

him. Attempt to calm the wife down and give her no more than two tasks. Tell her that the 

secretary will accompany her to registration/admitting and then she should come back to the 

waiting room. Tell her your name again, and explain that you will be here for the next 12 hours. 

Tell her you will be out very soon to update her on her husband’s condition. Thank her for 

bringing in his meds and reassure her that she did the right thing by bringing him to the ED. 

Note: Since the “wife” is a faculty/facilitator she/he can come out of role and give the student 

feedback and direction as needed during or after the interaction. 

Computer technician: When you think that the students are starting to pick up on the diagnosis 

of congestive heart failure [can be cured by lead faculty], begin coughing (as Mr. Jones). 

Facilitator: Once Mr. Jones starts coughing, hand the students the emesis basin with pink, frothy 

sputum. 

Recipe: Pink, frothy sputum can be simulated by mixing a small amount of red powdered Jell-O, 

ivory dish detergent, and water, shaking it vigorously, pouring off liquid, and putting pink suds 

in emesis basin.

Students: The students should recognize this as a cardinal sign of pulmonary edema. If they feel 

that they have enough data, they need to anticipate the following orders: 

• Diuretic 

• Narcotic analgesic 

• Nitroglycerine 

• EKG 

• Chest X-ray 

• Blood gases 

• CBC, Chem 7, cardiac enzymes 

• Foley catheter (strict I/O) 

• Continue 100 percent oxygen per 

non-rebreather mask 

Students: When the students feel they are ready, the communicator places a call to the health 

care provider. A prop telephone is available for the student to use. The student is expected to do 

the following: (If student is having difficulty, they can use the script that follows. Faculty hands 

card with script to communicator.) Using principles of SBAR (situation, background, 

assessment, recommendation), student accomplishes the following: 

• Introduce yourself and state where you are located. 

• State who the patient is and describe him. 

• State chief complaints and relevant signs and symptoms. 

• Provide brief history with relevant information for current status. 

• Give quantitative vital signs, always include FiO2 with pulse ox. 

• Identify interventions that have been done. 

• State what you think is going on with the patient. 

• Ask health care provider for further orders. 

38 
Simulation and Nursing Education

Figure 1. Communication With Health Care Provider 

“Dr. ________________, This is [state your name], one of the nurses in [state your 

department]. 

We have a new patient, [patient’s name], a [age] year-old, [race], [gender]. He came in 

with complaints of________________________ 

_____________________________, which started at [time of onset]. 

His vital signs are [HR], [RR], [BP], [T], and [pulse ox, amount of O2 and type of 

delivery]. 

He has a history of ___________________________________________. 

On assessment, we found______________________________________. 

So far, we have [tell what interventions you have done so far]. 

I think he may have ________________________________________. 

I think he needs some________________________________________. 

What else you would like for us to do?” 

Restate what needs to be done, including reading back the orders. 

Confirm when the health care provider will arrive to assess the patient. 

Facilitator: (One of the faculty facilitators acts as the health care provider responding to the 

student’s call.) The health care provider gives the following orders and states she/he will be 

down to see the patient shortly. The student should write down the orders and read them back to 

the health care provider. After this is done, the orders are displayed on a prewritten foam board 

so that they can be seen by all the students simultaneously. 

The orders are as follows: 

• Lasix 40mg IV stat 

• Morphine 4mg IV stat 

• Nitroglycerine 0.4mg/spray 2 

sprays SL stat 

• Normal saline at 30 ml per hour 

• Stat ABG 

• Stat EKG and serial EKGs 

• Stat CBC and Chem 7 

• Stat cardiac enzymes 

• Stat portable CXR 

• Foley catheter to straight 

drainage 

• Hourly intake and output 

• Continue 100 percent NRB mask 

39
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

Students: 

The primary nurse delegates tasks to secondary nurse (med administration, Foley, etc.) and 

directs communicator to call lab, x-ray, and EKG. 

The resource nurse needs to look up the proper rate of administration for Lasix and MSO4. The 

primary and secondary nurses administer the Lasix and morphine IV push through the peripheral 

IV that they placed earlier. 

The communicator places a call to lab, radiology, and EKG to request stat testing. 

Facilitator: State “After about 15 minutes, you get the test results on Mr. Jones.” 

• EKG: Sinus tachycardia, indicative of old MIs (Give students EKG.)

• CXR: Enlarged heart, enlarged hila with indistinct margins (perivascular edema), and 

prominence of veins draining the upper lobes (cephalization of flow) (Show students 

CXR.)

• Lab results: respiratory acidosis (Show students ABG.)

Students should recognize and state need to call results to the health care provider as soon as 

possible. 

Facilitator: “Where do you think Mr. Jones should be transferred?” 

Students should state that Mr. Jones will likely go to an intensive care unit. 

SCENARIO ENDS

Debriefing 

This is one of the most important aspects of simulation. It is imperative that it is done well in 

order to help students have the best possible synthesis experience. 

Take the students outside the simulation room. Begin debriefing (see Simulation Box 4) while 

other simulation staff reset the room and mannequin for the next case. Distribute handouts with 

key points and materials for the student to take with them and review. 

Remind students they are not to share information with their fellow students because 

• All students should have the same opportunity to learn. 

• It is best for the student to move through the case as they did, experiencing the hot 

seat as they did. 

• To discuss the case is similar to sharing answers from a test and would be considered 

an Honor Code violation. 

40