Simulation Design in Nursing Education:  The Impact of Mid-Scenario Reflection on 
Learner Satisfaction and Self-Confidence 
 
by 
 
Kimberly Harrison Raines 
 
 
 
 
A dissertation submitted to the Graduate Faculty of  
Auburn University 
in partial fulfillment of the  
requirements for the Degree of  
Doctor of Philosophy 
 
Auburn, Alabama 
December 12, 2011 
 
 
 
Keywords: high-fidelity simulation design, nursing education, reflection,  
learner satisfaction, self-efficacy 
 
 
Copyright 2011 by Kimberly Harrison Raines 
 
 
Approved by 
 
Maria Witte, Chair, Associate Professor of Educational Foundations, Leadership and Technology 
James Witte, Associate Professor of Educational Foundations, Leadership and Technology 
Bonnie Sanderson, Associate Professor of Nursing 
  
 
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Abstract 
 
While high-fidelity simulation (HFS) is used increasingly in nursing education, there is a 
dearth of quantitative evidence regarding the most effective role of the instructor in simulation.  
This descriptive correlational study examined the effect of a simulation design incorporating 
mid-scenario reflection on learning outcomes.  The results were obtained by employing 
descriptive statistical analysis (mean and standard deviation) and correlational statistical analysis 
(multiple linear regression).     
A convenience sample of 47 junior nursing students enrolled in a women?s health clinical 
course was used for this study.  Students participated in a HFS obstetrical scenario and cared for 
a laboring patient who developed an infection.  Once the students reached the point when it 
became necessary to telephone the CNM to request treatment orders, the instructor paused the 
simulation.  The group then adjourned to an adjacent classroom for a five to ten minute 
instructor-led guided reflection period that included a discussion regarding assessment findings 
and the diagnoses based on the findings.  At that time, the group mutually developed a plan of 
care and returned to the simulation lab in order to resume the scenario and begin interventions.  
Following the simulation, participants completed a demographic questionnaire, the Simulation 
Design Scale, and the Student Satisfaction and Self-Confidence in Learning Scale.   
Results from the Student Satisfaction and Self-Confidence in Learning Scale indicate that 
participants were satisfied with the simulation exercise and generally felt self-confident after the 
 
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HFS.  The participants perceived that all five design characteristics included in the Simulation 
Design Scale were incorporated into the HFS.   
The correlational analyses revealed that all five simulation design elements were 
significantly correlated with the learning outcomes of self-confidence and learner satisfaction.  A 
multiple regression analysis indicted that the simulation design elements accounted for over half 
the variance in learning outcomes.  The mid-scenario reflection did not significantly contribute to 
the level of self-confidence or learner satisfaction.  Rather, the design characteristic of Outcomes 
was the single best predictor for both learning outcomes while Support significantly contributed 
to the level of learner satisfaction.    
 
  
 
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Acknowledgments 
 
 I would like to dedicate this dissertation to my husband, John, in gratitude for his 
unending support, patience, and encouragement.  I would like to express appreciation to Dr. 
Maria Witte and Dr. James Witte for their magnanimous assistance throughout my doctoral 
studies.  Appreciation is also extended to Dr. Bonnie Sanderson for her enthusiasm, humor, and 
warm support. And thanks are due to Dr. Anita All for not only serving as a reader, but for her 
unwavering encouragement from the very beginning of my doctoral studies.  And, lastly, deepest 
thanks are due to my parents, R.L. and J.M. Harrison, whose love and support will live forever in 
my heart.       
 
  
 
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Table of Contents 
 
Abstract ........................................................................................................................................... ii 
Acknowledgments.......................................................................................................................... iv 
List of Tables ................................................................................................................................. ix 
List of Figures ..................................................................................................................................x 
Chapter 1.  Introduction ...................................................................................................................1 
 Problem Statement ...............................................................................................................1 
 Background ..........................................................................................................................2 
  History of Simulation as a Teaching Strategy .........................................................2 
  Human Patient Simulators .......................................................................................3 
  Advantages ...............................................................................................................4 
  Disadvantages ..........................................................................................................4 
 Conceptual Framework ........................................................................................................5 
 Study Purpose ......................................................................................................................5 
 Research Questions ..............................................................................................................6 
 Significance of the Study .....................................................................................................6 
 Limitations ...........................................................................................................................6 
 Delimitation .........................................................................................................................7 
 Assumptions .........................................................................................................................7 
 Definitions............................................................................................................................7 
 
vi 
 Study Organization ..............................................................................................................9 
Chapter 2.  Review of Literature....................................................................................................11 
 Introduction ........................................................................................................................11 
 Research Questions ............................................................................................................12 
 Theoretical Framework  .....................................................................................................12 
  The Nursing Education Simulation Framework  ...................................................12 
  Model Description  ................................................................................................13 
  Novice-to-Expert Theory .......................................................................................15 
  Model Description .................................................................................................16 
  Novice-to-Expert Theory and Simulation Design .................................................17 
  Social Cognitive Theory ........................................................................................18 
 Self-Efficacy and High-Fidelity Simulation ......................................................................20 
  Successful Performance .........................................................................................20 
  Observation of Others ............................................................................................21 
  Positive Feedback ..................................................................................................21 
  Minimizing Anxiety ...............................................................................................22 
  Effect of HFS on Undergraduate Nursing Student Self-Efficacy ..........................23 
 Learner Satisfaction and High-Fidelity Simulation ...........................................................25 
 The Role of Reflection in Learning ...................................................................................28 
 The Role of Reflection   .....................................................................................................32 
 Levels of Facilitation .........................................................................................................36 
 Literature Support for Mid-Scenario Reflection  ...............................................................37 
            Chapter Summary ..............................................................................................................41 
 
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Chapter 3.  Methods .......................................................................................................................43 
 Introduction ........................................................................................................................43 
 Research Questions ............................................................................................................43 
 Research Design.................................................................................................................44 
 Setting  ...............................................................................................................................44 
 Sample................................................................................................................................46 
 Ethical Considerations  ......................................................................................................46 
 Data Collection  .................................................................................................................46 
 Instrumentation  .................................................................................................................55 
  Simulation Design Scale (SDS) .............................................................................55   
  Student Satisfaction and Self-Confidence in Learning   ........................................56 
 Data Analysis .................................................................................................................... 57 
 Chapter Summary ..............................................................................................................58 
Chapter 4.  Results .........................................................................................................................60 
 Introduction ........................................................................................................................60 
 Participants .........................................................................................................................60 
 Data Analysis  ....................................................................................................................61 
 Research Question One  .........................................................................................61 
 Research Question Two and Three ........................................................................64 
  Correlation between Design Characteristics and  
  Student Self-Confidence ............................................................................66 
  Correlation between Design Characteristics and Learner Satisfaction ......66 
 Research Question Four  ........................................................................................67 
   Self-Confidence .........................................................................................67 
 
viii 
   Learner Satisfaction ...................................................................................69 
 Additional Findings ...........................................................................................................71 
 Summary  ...........................................................................................................................72 
Chapter 5.  Conclusions, Implications and Recommendations..................................................... 73 
 Introduction ........................................................................................................................73 
 Summary of Findings .........................................................................................................73 
 Conclusions  .......................................................................................................................75 
 Implications........................................................................................................................77 
 Recommendations ..............................................................................................................79 
 Summary ............................................................................................................................81 
References ......................................................................................................................................83 
Appendix A Permission to Use Nursing Education Simulation Framework ??????? 99 
Appendix B Institutional Review Board Approval ..................................................................101 
Appendix C Informed Consent.................................................................................................103 
Appendix D Permission for Use of NLN Instruments .............................................................106 
Appendix E Simulation Design Scale and Student Satisfaction and  
  Self-Confidence in Learning Instruments ............................................................108 
 
 
 
 
  
 
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List of Tables 
 
Table 1. Simulation Objectives of the Obstetrical Scenario ......................................................47 
 
Table 2. Scenario Outline...........................................................................................................48 
 
Table 3. Design Characteristics of the Obstetrical Scenario ......................................................50 
 
Table 4. Descriptive Information for the Simulation Design Scale (n = 47) .............................62 
 
Table 5. Descriptive Information for the Student Satisfaction and  
 Self-Confidence in Learning ........................................................................................65 
 
Table 6. Correlation (r2) between Design Characteristics and Self- 
 Confidence/Satisfaction (n = 47) .................................................................................66 
 
Table 7. Model Summary of Design Characteristics as Predictors of Self-Confidence ............67 
 
Table 8. Multiple Regression Analysis of Design Characteristics as  
 Predictors of Self-Confidence ......................................................................................68 
 
Table 9. Coefficients ..................................................................................................................69 
 
Table 10. Model Summary of Design Characteristics as Predictors of Satisfaction ...................70 
 
Table 11. Multiple Regression Analysis of Design Characteristics as  
 Predictors of Satisfaction .............................................................................................70 
 
Table 12. Coefficients ..................................................................................................................71 
 
 
  
 
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List of Figures 
 
Figure 1.  Nursing Education Simulation Framework ????????? ???????.. 15 
Figure 2.  Nursing Process for the Mid-Scenario Debriefing ........................................................54 
 
 
 
  
  
  
  
 
CHAPTER 1. INTRODUCTION 
 
The nursing shortage in the United States continues to grow while the acuity of 
hospitalized patients increases and medical technology becomes more sophisticated (Buerhaus, 
Donelan, Ulrich, Norman, & Dittus, 2006; Heller & Nichols, 2001; Rhodes & Curran, 2005).  As 
a result, nursing graduates enter a demanding healthcare environment - one that requires greater 
responsibility and accountability by its nurses than ever before.  New nursing graduates often 
report feeling unprepared to face the complex challenges and high expectations of the healthcare 
system (Candela & Bowles, 2008; Kilstoff & Rochester, 2004).   
Finding clinical experiences that prepare undergraduate students to practice in an 
increasingly demanding workplace is a challenge for nurse educators.  Moreover, while 
enrollment into nursing programs has increased, availability of clinical education sites has 
declined (American Association of Colleges of Nursing, [AACN], 2005).  During this 
challenging time, nurse educators must employ creative teaching strategies based on research 
findings in order to prepare students for successful practice (Institute of Medicine [IOM], 2007; 
National League for Nursing [NLN], 2005).  High-fidelity simulation (HFS) is one such 
innovative instructional technique.  
Problem Statement 
The use of HFS is relatively new in nursing education and its use is growing (Katz, 
Peifer, & Armstrong, 2010; Nehring & Lashely, 2004).  However, there is a dearth of knowledge 
regarding best HFS practices (Kardong-Edgren, Adamson, & Fitzgerald, 2010; Prion, 2008).  
 
2 
 
Moreover, the current literature lacks specific recommendations regarding the role of the 
facilitator in simulation (Jeffries, 2005).  And while the effects of post-simulation debriefing 
have been studied, the effectiveness of mid-simulation learner reflection has not been studied or 
described in the literature.   
Background 
Gaba (2007) defines simulation as a technique ?to replace or amplify real experiences 
with guided experiences that evoke or replicate substantial aspects of the real world in a fully 
interactive manner? (p. 126).  In healthcare, a medical simulation endeavors to ?replicate some 
or nearly all of the essential aspects of a clinical situation so that the situation may be more 
readily understood and managed when it occurs for real in clinical practice? (Morton, 1995, p. 
76).   
History of Simulation as a Teaching Strategy 
The use of simulation as a teaching strategy began prior to World War I with airplane 
pilot training (Rolfe & Staples, 1986).  Human patient simulators (HPS) were first used in 
medical education in the late 1960s for anesthesiology training (Abrahamson & Denson, 1969).   
Other high-stakes industries using simulation-based education include the military, space 
programs, and the nuclear power industry (Issenberg, Mcgaghie, Petrusa, Gordon & Scalese, 
2005).        
The use of simulation in nursing education is not new.  In 1911, a life-size mannequin 
was produced by the doll manufacturer, M.J. Chase Company, for the purpose of student nurse 
training (Nehring & Lashley, 2010).  For the past century, nurse educators have continued to 
integrate simulation into clinical instruction.   
 
3 
 
The use of HFS in nursing education is increasing in large part due to lack of available 
clinical sites.  According to Medley and Horn (2005), the dwindling availability of clinical sites 
is directly attributable to shorter lengths of stay, higher patient acuity, increased enrollment in 
nursing programs, and shortages of nursing staff.  Other factors influencing the use of simulation 
are public concerns for safety and quality in healthcare delivery, ethical considerations inherent 
in practicing skills on patients, and the pressure on students to become competent as quickly as 
possible (Boller & Jones, 2008; Nehring, 2010; Patel & Gould, 2006).      
Human Patient Simulators 
Steady advances in technology have lead to the development of integrated simulators that 
offer a continuum of complexity from low-fidelity to high-fidelity HPS.  Low-fidelity simulators 
are static mannequins traditionally used in teaching specific psychomotor skills such as 
injections.  Low-fidelity simulators are limited to simple, gross body movements and do not 
provide a realistic context for patient-nurse interaction (Seropian, Brown, Gavilanes, & Driggers, 
2004).  It has been proposed that low-fidelity instruction may improve performance through 
repetition of a specific skill (Nagle, McHale, Alexander, & French, 2009). 
Moderate-fidelity simulators possess some physiological properties of human patients 
that allow the learner to, for example, listen to breath and heart sounds and palpate pulses; 
however, these models are unable to exhibit chest expansion when breathing or eye movement 
(Nehring & Lashley, 2010).  While moderate-fidelity simulators offer more realism than the low-
fidelity models, these simulators are most useful in introductory courses that teach specific 
physical assessment competencies (Seropian et al., 2004).        
High-fidelity simulators, used in nursing education since the 1990s (Solnick & Weiss, 
2007), are computer-integrated models that have the ability to breathe, talk, move, and blink.  
 
4 
 
These models have programmable physiological functions such as heart, breath, and bowel 
sounds and can simulate patient responses to student actions (Nehring & Lashley, 2010).   High-
fidelity simulators provide students an opportunity to ?? demonstrate their ability to establish 
priorities, make decisions, take appropriate action, and work successfully as part of a team? 
(Jeffries, 2007, p. 4).   
Advantages      
The advantages of using simulation in nursing education are numerous, varied, and well- 
documented in the literature.   Undoubtedly, the most important benefit is the student?s ability to 
make mistakes in a safe environment without threat to patient safety.  Moreover, errors that are 
made can be corrected and discussed immediately (Fletcher, 1995).  The use of simulation also 
eliminates random learning opportunities instead providing standardized clinical experiences for 
all (LeFlore, Anderson, Michael, Engle, & Anderson, 2007).  Furthermore, simulated scenarios 
can be designed to meet course objectives (Rhodes & Curran, 2005; Vessey & Huss, 2002) and 
can be repeated in order to build competence more quickly (Beyea & Kobokovich, 2004).  The 
complexity of scenarios may increase along with students? level of knowledge (Seropian, 2003) 
and simulation may also serve as a strategy for clinical remediation (Haskvitz & Koop, 2004).  
Lastly, simulation provides an active learning environment that is consistent with adult learning 
theory (Feingold, Calaluce, & Kallen, 2004).   
Disadvantages 
Despite simulation?s many advantages, there are disadvantages associated with the use of 
HFS.  Cost is the biggest challenge.  Simulation equipment ranges in price from $50,000 to 
$300,000 (Adamson, 2010).  Additional expenses include the cost of operation, maintenance and 
repair of the equipment, and the need for additional space in which to operate and store the 
 
5 
 
equipment (Rauen, 2001).  The time required to both develop and implement HFS is also a major 
challenge for faculty.  Rauen (2001) found that the faculty time required to create a HFS scenario 
is comparable to the time needed to create a complex lecture.  In addition, the HFS technology is 
intricate and requires a significant time commitment for faculty technical training.  Simulation 
can also be time-intensive due to the need for a limited number of students participating in a 
session at one time (Nehring & Lashley, 2004).  
Conceptual Framework 
 The conceptual framework used for this study was developed by Jeffries (2005) and is 
based on adult educational theory.  The Nursing Education Simulation Framework (NESF) was 
created in order to guide nurse educators in the design, implementation, and evaluation of HFS.  
The NEFS describes the relationship of the simulation components (educational practices, 
student, and instructor) and simulation design characteristics (objectives, fidelity, problem 
solving, student support, and reflection) and their effect on learning outcomes (knowledge, skill 
performance, learner satisfaction, critical thinking, and self-confidence).  The NESF is based on 
the proposition that a well-designed simulation improves learning outcomes.  Jeffries (2007) 
found that design factors had a significantly positive effect on learner satisfaction and self-
confidence.          
Study Purpose 
The purpose of this study was to evaluate the effect of a partial instructor-driven 
simulation design incorporating mid-scenario reflection on learning outcomes.  Learning 
outcomes were measured by post-simulation reports of student self-confidence and student 
satisfaction with the simulation experience.  The relationship between the features of a partial 
instructor-driven simulation design and learning outcomes were also explored.     
 
6 
 
Research Questions 
1. What are the perceived characteristics of a simulation design incorporating mid-
scenario reflection?   
2. What is the effect of a simulation design incorporating mid-scenario reflection on 
student self-confidence? 
3. What is the effect of a simulation design incorporating mid-scenario reflection on 
learner satisfaction? 
4. What is the relationship between perceived simulation design characteristics and 
learning outcomes? 
Significance of the Study 
 High-fidelity simulation is changing the landscape of nursing education as virtual clinical 
experiences are replacing actual clinical experiences.  Given the increased use of this costly 
teaching method, nurse educators must examine how simulation design characteristics contribute 
to learning outcomes.  Leaders in the field of HFS in nursing education have called for studies 
that determine the most effective role of the facilitator in simulation (Jeffries, 2005; Leighton, 
2010; Prion, 2008) and, more specifically, that explore the effectiveness of incorporating guided 
reflection into simulation experiences (Decker, 2007).  Findings from this study may add to the 
body of evidence needed to guide nurse educators in the development of successful simulation 
design.  
Limitations 
 There are several limitations to the study.  The study used a convenience sample of 
junior-level nursing students.  The results rely on self-reported data.  There was some variability 
in communication during each mid-session reflective period due to differing student responses 
 
7 
 
and questions.  Lastly, the results of this study may not be generalizable since the sample for the 
study was obtained from one public university in the southeastern United States.           
Delimitation 
 The study was limited to one high-risk obstetrical scenario. 
Assumptions 
 Each simulation participant will be willing to engage in active learning and will prepare 
for the simulation experience as assigned by faculty.  Each participant will respond honestly to 
instrument items and be able to identify and self-report the level of learner satisfaction and self-
confidence.  Finally, the human patient simulator (HPS) will perform reliably throughout the 
study.   
Definitions 
 In this study, the following terms were used: 
1. Active Learning ? a process whereby instructors become facilitators and students 
become engaged in a dialog with their colleagues (Modell, 1996).  
2. BSN Students ? enrollees in a four-year academic nursing degree program in a 
nationally accredited school. 
3. Chorioamnionitis ? an infection of the chorionic and amniotic membranes of the 
uterus and placenta that is potentially life-threatening to the pregnant woman and the 
fetus.  A major complication of pregnancy. 
4. Feedback ? an evaluative response given by the instructor to the student regarding 
learner actions in order to develop knowledge (Jeffries, 2005).  
5. Fidelity ? the degree to which the simulated clinical experience replicates reality 
(Jeffries, 2005).  
 
8 
 
6. High-Fidelity Simulation (HFS) ? a teaching methodology that closely mimics reality 
using a simulator that displays physiological reactions such as breathing, speaking, 
and eye movement (Seropian et al., 2004).  The operational definition of HFS for this 
study was an obstetrical nursing care scenario using a manikin, NoelleR, manufactured 
by Gaumard ScientificR.   
7. Human Patient Simulator (HPS) ? ?a computerized, full-body mannequin that is able 
to provide real-time physiological and pharmacological parameters of persons of both 
genders, varying ages, and with different health conditions? (Nehring, Ellis, & 
Lashley, 2001, p.195). 
8. Instructor-Driven Simulation ? a simulation design incorporating frequent direction, 
immediate cueing and prompting by the instructor who is present at the bedside 
during the simulation (Dubose, Sellinger-Karmel, & Scoloveno, 2010).  
9. Learner Satisfaction ? the extent to which the learner believes the educational activity 
provides a relevant learning experience.   
10. Learner Self-Efficacy ? a self-judged perception about whether one can successfully 
perform required actions (Bandura, 1977).  
11. Mid-Scenario Reflection ? a brief hiatus during a simulation exercise in which 
simulation participants engage in an instructor-guided reflective discussion period.  
An opportunity for students to take a ?time out? in order to consider the obtained 
assessment information and develop a plan for nursing care.   
12.  Partial Instructor-Driven Simulation ? a method of simulation instruction that 
provides prompting by the patient or family member only.  The facilitator is not 
 
9 
 
present at the bedside but is instead available to redirect students during a pause 
when, and if, redirection is required (Dubose et al., 2010).   
13. Reflection ? an active process that occurs during or after an experience (Dewey, 
1933). 
14. Simulation Scenario ? a sequence of possible events in the care of an imaginary 
patient. 
15. Simulated Clinical Experience (SCE) ? ?a realistic enactment of a clinical situation in 
which the student is able to step into the role of the nurse? (Schoening, Sittner, & 
Todd, 2006).   
16. Student Support ? assistance provided by the facilitator to the student during the 
course of a simulation exercise.  Such assistance may take the form of a verbal cue by 
the patient, a phone call from the physician, or a laboratory report (Jeffries, 2007).  
For the purposes of this study, student support also includes mid-scenario reflection.   
Study Organization 
 Chapter 1 introduces the study and includes a statement of the problem, purpose of the 
study, limitations, delimitations, and assumptions.  Research questions are identified, definitions 
of terms are provided, and the significance of the study is discussed. 
Chapter 2 includes a literature review exploring the use of simulation in nursing 
education, the Nursing Education Simulation Framework, learning theories related to self-
efficacy, learner satisfaction, reflection, and design characteristics of HFS.  The link between 
HFS, learner satisfaction, self-efficacy, and reflection are also discussed.   
Chapter 3 describes the population and sample along with the instruments used for data 
collection.  The data collection and data analysis process are explained.  Chapter 4 presents the 
 
10 
 
study findings.  Chapter 5 contains a summary of the study along with conclusions and 
recommendations for further practice and research.    
 
  
 
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CHAPTER 2.  REVIEW OF LITERATURE 
 
Introduction 
This chapter presents the review of the literature regarding simulation in nursing 
education along with the philosophical underpinnings of simulation design.  Current literature 
regarding the relationship between simulation design and learning outcomes was reviewed along 
with the role of guided reflection in experiential learning.   
The use of high-fidelity simulation (HFS) is relatively new in nursing education and its 
use is growing (Katz, Peifer, & Armstrong, 2010; Nehring & Lashely, 2004).  However, there is 
a dearth of knowledge regarding best HFS educational practices (Kardong-Edgren, Adamson, & 
Fitzgerald, 2010; Prion, 2008).  Moreover, the current literature lacks specific recommendations 
regarding the role of the facilitator in simulation (Jeffries, 2005).  And while the effects of post-
simulation debriefing have been studied, the effectiveness of mid-simulation guided reflection 
has not been studied or described in the literature.   
The purpose of this study was to evaluate the effect of a partial instructor-driven 
simulation design incorporating mid-scenario reflection on learning outcomes.  Learning 
outcomes were measured by post-simulation reports of student self-confidence and student 
satisfaction with the simulation experience.  The relationship between the features of a partial 
instructor-driven simulation design and learning outcomes were examined.     
 
12 
 
Research Questions 
The following research questions were used in this study: 
1.  What are the perceived characteristics of a simulation design incorporating mid-
scenario reflection?   
2.  What is the effect of a simulation design incorporating mid-scenario reflection on 
student self-confidence? 
3.  What is the effect of a simulation design incorporating mid-scenario reflection on 
learner satisfaction? 
4.  What is the relationship between perceived simulation design characteristics and 
learning outcomes? 
Theoretical Framework 
The Nursing Education Simulation Framework 
Jeffries (2005, 2007) described the Nursing Education Simulation Framework (NESF), a 
theory-based framework developed specifically for the design, implementation, and evaluation 
for clinical simulation in nursing education.  Recognizing the many unanswered questions 
regarding effective simulation practices, Jeffries proposed a framework for the purpose of 
identifying best teaching practices using a consistent model based on the theoretical literature 
and empirical knowledge related to learning outcomes in higher education (Chickering & 
Gamson, 1987).   
Jeffries further recognized the need for an organizing framework to provide a consistent 
measurement of influencing variables related to simulation design.  A review of nursing and 
other healthcare literature along with related literature from non-healthcare disciplines guided the 
development of the framework (Jeffries, 2006).  The NESF was developed and tested in a multi-
 
13 
 
site research project jointly organized and funded by the National League of Nursing (NLN) and 
the simulator manufacturer Laerdal Corporation.  The NESF is used by many nursing education 
programs nationwide (Nehring & Lashley, 2010).  The premise of the NESF is that well-
designed simulations improve learning outcomes. 
Model Description  
The NESF is based on several assumptions: the learning needs of the student determine 
the nature of the simulation design, the student must be a motivated and self-directed participant, 
and the teacher?s role will vary according to the purpose of the simulation and faculty perception 
of best educational practices.   
 The five conceptual components of the framework, as seen in Figure 1, are design 
characteristics, educational practices, teacher characteristics, student characteristics, and learning 
outcomes.  The model examines how teachers, students, and educational practices affect 
simulation design characteristics and attempts to explain the relationship of these concepts to 
learning outcomes.  
 Simulation design characteristics recognized in the NESF include objectives, fidelity, 
complexity, student support, and reflection/debriefing.  Jeffries (2005, 2007) proposes that 
clearly articulated objectives are essential in simulation design.  Simulation objectives should 
include enough detail for optimal learner participation in addition to specific learning outcomes 
for the clinical simulation experience (CSE).  It is essential that the objectives match the 
student?s skill and knowledge level (Jeffries, 2005, 2007).  Fidelity refers to the authenticity of 
the CSE.  In a HFS design, the environment must be as realistic as possible (Medley & Horne, 
2005).  Problem Solving refers to the number of problems the human patient simulator (HPS) 
exhibits; the complexity will vary depending on the knowledge and skill level of the student.  
 
14 
 
This complexity allows the student to determine underlying relationships and prioritize planned 
care.  Student support refers to the assistance provided to the student by the facilitator.  This 
support can be defined as cues or hints built into the scenario such as a doctor?s telephone call, a 
patient?s remark, or a family member?s question.  The degree of support should not interfere with 
the student?s ability to make independent decisions and yet should offer enough information to 
enable the student to continue the scenario.   
Finally, reflective thinking/debriefing traditionally refers to the period immediately after 
the CSE when faculty and students critically examine the simulation experience.  This is the time 
when theory and practice are linked and the relevant teaching points are explored.  Debriefing, 
considered a vital component of effective simulation design, may have a role in the development 
of critical thinking skills (Bruce, Bridges & Holcomb, 2003).  For the purposes of this study, 
reflection and student support included the mid-scenario guided reflection incorporated into the 
CSE.    
The final component of the NESF is learning outcomes consisting of knowledge, skill 
performance, learner satisfaction, critical thinking, and self-confidence.   The evaluation of 
learning outcomes is essential to verify what students have learned in order to validate the 
effectiveness of the CSE (Jeffries, 2005, 2007; Kirkpatrick, DeWitt-Weaver, & Yeager, 2005). 
The NESF was chosen for this study because it was developed in order to explore the 
relationship between simulation design and learning outcomes.   
 
  
 
15 
 
 
Figure 1.  The Nursing Education Simulation Framework 
 
Note.  From Simulation in Nursing Education: From Conceptualization to Evaluation (p. 23), 
edited by P.R. Jeffries, 2007, New York: National League for Nursing.  Copyright 2007 by the 
National League for Nursing.  Reproduced with permission (Appendix A).   
 
Novice-to-Expert Theory 
 Another theoretical framework suitable to this study is Benner?s Novice-to-Expert 
Theory (1984) which is based on the Dreyfus and Dreyfus (1980) Model of Skill Acquisition in 
students.  Benner?s framework serves as a model for the development of expertise in both 
nursing education and nursing practice and has often been the basis for HFS research and design 
(Nehring, 2010).  For example, it has been suggested that simulation design (objectives, level of 
fidelity, degree of student support and scenario complexity) should be guided by Benner?s theory 
of student nurses? experience levels (Larew, Lessans, Spunt, Foster, & Covington, 2006). 
 
16 
 
Model Description 
 Patricia Benner (1984) describes five levels of competency in nursing: novice, advanced-
beginner, competent, proficient, and expert.  These levels of proficiency are distinguished by 
both the nurse?s experience and the theoretical knowledge of nursing science (Waldner & Olson, 
2007).  At the first level of skill acquisition, the novice?s actions are governed, due to lack of 
experience, by context-free rules based on principles and concepts learned in the classroom.  The 
novice?s attention is focused on tangible measurable data such as blood pressure readings or 
laboratory values.  At this stage, the novice?s connection to the situation and sense of 
responsibility to the patient is constrained by the single-minded attention to specific assessment 
data.  
 At the next level of skill, the advanced-beginner has obtained enough practice to 
recognize, for example, that variations in blood pressure and laboratory findings are potential 
manifestations of a more complex disease process.  Subsequent interventions are based on 
standard management guidelines and the student must prioritize patient-care tasks.  These crucial 
decisions require evolving clinical judgment skills.  Clinical judgment is defined as knowing 
what assessments should be made, what the assessment data mean, and what action should be 
taken first (Tanner, 2006).   The advanced-beginner becomes personally accountable for 
completing the necessary interventions. 
 At the competent level of practice, the concept of patient care becomes more 
comprehensive.  The competent practitioner possesses a deeper understanding of patient care 
issues particularly in relation to long-term health goals.  The nurse?s sense of responsibility for 
the patient at this stage is ?profound? (Benner, Tanner, &  Chesla, 1992, p. 22).  At the fourth 
 
17 
 
level, the proficient nurse?s actions are guided by experience rather than established assessment 
protocols.  Intuition is well-developed at this stage, as is the ability to anticipate events.   
 At the final stage of skill acquisition, the expert bases clinical decisions on extensive 
experience and relies on an instinctive grasp of the situation ?without wasteful considerations of 
a large range of unfruitful, alternative diagnoses and solutions? (Benner, 1984, p. 32).  The sense 
of responsibility at this stage is viewed within the context of the realities of the healthcare system 
e.g. the imbalance of decision-making power (Waldner & Olson, 2007).   
 The student nurse gradually progresses through the levels of proficiency during the 
educational experience and most will attain the level of advanced beginner before graduation 
(Benner et al., 1992).  For the purpose of this study, junior baccalaureate students are considered 
advanced beginners and CSEs should be designed with that in mind.           
Novice-to-Expert Theory and Simulation Design     
When designing simulation experiences in nursing education, the progression of skill 
attainment may be based on Benner?s first three proficiency levels (Waldner & Olson, 2007).  
These simulation experiences should progress from simple psychomotor skills practice to 
complex scenarios incorporating critical thinking and clinical judgment (Medley & Horne, 
2005).     
Learning situations for novices should include basic assessment skills associated with 
contextual situations and principles they have been exposed to in the classroom; for example, 
respiratory wheezing could be heard using a stethoscope on an asthmatic patient.  The use of low 
and medium-fidelity simulators is most appropriate at this level (Seropian, Brown, Gavilanes, & 
Driggers, 2004).  Simulation at the advanced beginner level should incorporate decision-making 
and protocol application.  For example, after assessment of the patient?s pain level, the student 
 
18 
 
determines the choice of pain medication along with the dosage and route of delivery.  High-
fidelity simulators are appropriate at this stage in order for the student to see the patient?s 
response to the pain relief measure (Seropian et al., 2004).  Students are able to not only 
demonstrate appropriate interventions, but also see the consequences of their actions.  Simulation 
exercises at the competent level should be designed with a degree of complexity that includes 
multiple patient problems, interaction with family members, and multidisciplinary collaboration 
(Larew, et al., 2006).     
Benner?s concepts regarding the skill acquisition of developing nurses can provide the 
blueprint for simulation design.  Applying Benner?s framework to simulation design may help 
ensure that learning opportunities are properly sequenced in the nursing education program for 
the most effective knowledge and competency development.    
Social Cognitive Theory 
Bandura?s Social Cognitive or Social Learning Theory (1977, 1986) is also applicable to 
this study.  Bandura?s conceptual framework addresses the role and importance of  self-efficacy 
in learning.  Bandura (1995) defines perceived self-efficacy as the individual?s belief that one 
can successfully complete a designated task.  Self-efficacy is thought to be positively correlated 
with the learner?s motivation, perseverance, and academic success (Bandura, 1977; Bong & 
Clark, 1999).  This attainment of self-efficacy is also considered necessary for successful nursing 
practice (Davidhizar, 1993; White, 2003).  The fundamental goal in clinical nursing education is 
to improve self-efficacy by involving students in learning experiences that result in the 
development of skill mastery.  Mastering new skills will further increase students? self-efficacy 
and provide new graduates with the necessary proficiency to enter the complex healthcare 
environment (Blum, Borglund, & Parcells, 2010).  As a result, current research in nursing 
 
19 
 
education is concerned with investigating non-traditional teaching strategies, such as simulation, 
that may increase student self-efficacy (Leigh, 2008a).      
 The terms self-efficacy and self-confidence are frequently used interchangeably.  
Bandura (1986) makes a distinction between the two terms.  Self-efficacy is one?s confidence in 
one?s ability to learn new skills, a general self-perception that is not associated with any specific 
task.  An individual?s self-efficacy is developed throughout life as new situations are experienced 
and new knowledge is acquired.  Someone who has low self-efficacy may believe that the 
learning process is filled with obstacles, a belief that negatively affects motivation and 
persistence, while someone with high self-efficacy approaches a task with a feeling of calm 
assurance (Pajares, 1996).  By contrast, Bandura states that self-confidence is ?a nondescript 
term that refers to strength of belief but does not necessarily specify what the certainty is about.  
I can be supremely confident that I will fail at an endeavor? (1997, p. 382).   
 Bandura (1986) describes methods through which self-efficacy can be achieved.  The 
first route to self-efficacy is through successful performance of a task.  The second method in 
building self-efficacy is the observation of others? successful performance of a task.  Thirdly, 
self-efficacy may be enhanced through positive verbal feedback during task performance.  And, 
lastly, minimizing the learner?s level of anxiety during a task can improve self-efficacy.  A 
simulation experience that incorporates a low-risk learning environment in which to deliver 
successful patient care, the opportunity to observe peer performance, and positive instructor 
feedback provides the methods Bandura believes are crucial to improved self-efficacy.  Of 
particular interest in this study is the additional student support provided through the mid-
scenario guided reflection.    
 
 
20 
 
Self-Efficacy and High-Fidelity Simulation 
 Because self-efficacy can affect student performance and learning, it is important to 
examine whether and in what ways HFS can promote self-efficacy.  Although HFS is used 
extensively in nursing education, there is a dearth of research supporting this teaching technique 
(Solnick & Weiss, 2007).  However, much of the available research examines the effect of HFS 
on learner self-efficacy (Kardong-Edgren, Adamson, & Fitzgerald, 2010; Prion, 2008).  Results 
of studies measuring student self-confidence with HFS have, with some consistency, shown a 
positive effect (Brown & Chronister, 2009).  Bandura?s described methods for achieving self-
efficacy (successful performance, observation of others, positive instructor feedback, and 
decreased anxiety) and their relationship to HFS outcomes will be examined.        
Successful Performance 
 Bandura?s (1977) theory proposes that students? self-confidence increases when they see 
their actions bring about desired outcomes.  One of the biggest benefits in the use of HFS in 
healthcare education is the opportunity for students to successfully provide care for a virtual 
patient in a risk-free environment (Seropian et al., 2004).  Marshall et al. (2001) tested the 
trauma management skills of medical interns using HFS.  The authors found a significant (p < 
0.002) improvement in participants? skills from pre- to post-simulation.  The participant?s self-
confidence scores also rose significantly (p < 0.01) after the CSE.  McCausland, Curran, and 
Cataldi (2004) designed a HFS scenario requiring 72 students in groups of four to provide care to 
a patient with heart failure.  Following the CSE, 85% of the students reported that they had the 
knowledge to make the necessary decisions regarding care of the patient.   
Ravert (2002) undertook a meta-analysis of HFS in healthcare education and found that 
75% of the studies showed a positive effect on skill acquisition.  Radhakrishnan, Roche, and 
 
21 
 
Cunningham (2007) conducted a pilot study evaluating the clinical performance of 12 senior 
baccalaureate students.  Students who practiced with the human patient simulator prior to an 
actual clinical experience had significantly higher skills scores than the control group consisting 
of students who had only standard clinical training.  
Observation of Others 
 Bandura (1986) proposes that self-efficacy can be improved when the learner observes 
others successfully accomplish a task.  Simulation experiences in nursing education are typically 
collaborative experiences with ample opportunity to observe the actions of others.  This 
observation can occur as the scenario progresses in addition to the common practice of viewing a 
recording of the simulation exercise during the post-simulation debriefing.  As simulation 
participants observe others, they are also processing information and internalizing the experience 
(Leflore, Anderson, Michael, Engle, & Anderson, 2007).   Participants in a study that examined 
student perceptions of a CSE (Schoening, Sittner, & Todd, 2006) reported that observing peers? 
decision-making and communication patterns was particularly instructive.  Leflore et al. (2007) 
found that instructor-modeled learning was more effective than self-directed learning among 
nurse practitioner students.   In a qualitative study conducted by Lasater (2007) involving the 
effect of HFS on clinical judgment and the value of collaborative learning in HFS, students 
reported that observation of peer simulation experiences was as informative as providing the care 
themselves. 
Positive Feedback 
 Bandura (1986) suggests that learners? self-efficacy is enhanced by positive verbal 
feedback from the teacher.  One advantage of simulation in education is the ability to supply the 
learner with immediate feedback (Haskovitz & Koop, 2004; Theroux & Pearce, 2006).  HFS is a 
 
22 
 
teaching strategy that provides frequent opportunity for positive feedback and the importance of 
verbal encouragement to the student regarding HFS has been demonstrated (Alinier, Hunt, 
Gordon, & Harwood, 2006).  Improvement in the patient?s condition as a result of successful 
student intervention by itself is a form of positive feedback.  While students should be allowed to 
make mistakes during a CSE, the CSE for novices should be designed to avoid a catastrophic 
outcome such as death (Horn & Carter, 2010; Kesten, Brown, Hurst, & Briggs, 2010).  
Furthermore, during the post-simulation debriefing, the facilitator should avoid focusing on the 
errors committed during the CSE but rather highlight the successful student actions (Cantrell, 
2008).  Public acknowledgment of performance improvement is not only pleasing to the learner, 
but also reinforces correct actions (Johnson-Russell & Bailey, 2010).          
Minimizing Anxiety 
 According to Bandura (1986), students who face a task with a feeling of dread generally 
lack confidence about their ability to accomplish that particular task.  A common experience for 
new nursing students is anxiety related to fear of harming a patient, feeling unprepared for a 
clinical situations, and concerns about the ability to communicate with a patient (Evans & Kelly, 
2004).  Gore, Hunt, Parker, and Raines (in press) sought to study the effects of HFS on student 
nurses? anxiety levels prior to first-time patient contact.  The study measured self-reported 
student anxiety levels among first-semester novice nursing students using the Spielberger State-
Trait Anxiety Inventory.  The control group had no CSE before their first contact with actual 
patients in a hospital setting while the experimental group participated in a pre-clinical 
simulation experience.  The experimental group?s anxiety scores were significantly lower (p = 
.01) than the control group?s (11.0 +/- 2.8 vs. 13 +/- 3.4).  Anecdotal evidence supplied by the 
 
23 
 
hospital clinical instructors supported the notion that the experimental group members were more 
confident in their abilities than the control group.       
 Bremner, Aduddell, Bennett, and VanGeest (2006) also documented the effect of HFS on 
nursing students? reported anxiety levels.  Forty-one junior-level baccalaureate students 
completed a questionnaire to determine whether a simulation experience relieved the stress 
associated with the first clinical day.  Forty-two percent reported that HFS decreased some of the 
stress associated with the first day of patient care.  Additionally, Schoening et al. (2006) studied 
the perceptions of 60 nursing students who participated in a preterm labor CSE.  The participants 
then reflected upon the CSE in journal form where they frequently reported feeling ?more 
comfortable? (p. 257) with a high-risk patient situation and further expected that the experience 
would be valuable to them in the future. 
Effect of HFS on Undergraduate Nursing Student Self-Efficacy 
Studies regarding the influence of HFS on the development of nursing student self-
confidence are numerous (Bearnson & Wiker, 2005; Jeffries & Rizzolo, 2006; Peteani, 2004; 
Smith & Roehrs, 2009).  One such study involved 56 novice nursing students using a human 
patient simulator to learn physical assessment skills.  Sixty-one percent of students reported 
increased confidence in assessment skills following the simulation exercise while 42% agreed 
that the simulation experience relieved some of the stress associated with the first day in clinical 
(Bremner, 2006).  In another study, researchers examined whether simulation participation 
increased the confidence of third-year students regarding their health teaching skills 
(Goldenberg, Andrusysyzn, & Iwasiw, 2005).  The students? self-efficacy scores for patient 
teaching were significantly higher following the simulation experience (p = 0.001).  
 
24 
 
Furthermore, students reported increased self-confidence in their skills regarding specific 
components of the teaching process - assessment, implementation and evaluation.   
Leigh (2008b) measured the confidence level of senior nursing students when responding 
to emergencies, a situation in which students are quite likely to find themselves soon after 
graduation.  Students (n = 65) participated in a simulated emergency using a one-group pre-test, 
post-test design.  Statistically significant increases in self-efficacy were found after the 
simulation experience indicating that simulation is an effective teaching tool in the transition 
from student to nurse. 
Students have reported greater levels of confidence in caring for patients in an actual 
clinical setting following an HFS experience.  One such study examined the gains in self-
confidence of junior nursing students (n = 60) caring for an insulin-managed patient (Dobbs, 
Sweitzer, & Jeffries, 2006).  Following the simulation, study participants expressed an overall 
confidence in their ability to care for an insulin-dependent patient in an actual clinical experience 
(mean ? 4.3; scale 1-5; 5 = strongly agree).  Similarly, McCausland, Curran, and Cataldi (2004) 
conducted a study with senior nursing students (n = 72) who participated in a heart failure 
scenario using HFS.  Results from the study revealed that 96% thought the simulation would 
help them in future actual patient care situations.   
 Despite the research indicating a positive correlation with self-efficacy and HFS, not all 
studies conclude that self-efficacy improves following HPS.  Feingold, Calaluce and Kallen 
(2004) investigated student perceptions regarding the value of HFS.  Baccalaureate students 
enrolled in an advanced acute care course completed a survey following a scenario involving a 
patient with worsening respiratory distress.  Less than half of the students (46.9%) believed that 
the CSE increased their self-confidence.       
 
25 
 
 Furthermore, research on HFS and its effects on self-efficacy is inconclusive regarding 
the superiority of HFS to other methods of instruction.  Swanson et al. (2010) explored the 
difference in self-confidence among students who used three different active learning methods:  
case study, student-led high-fidelity simulation, and an instructor-driven high-fidelity simulation.  
Analysis of the participants? self-reported self-confidence scores revealed no significant 
difference across the three groups (p = .878).  Scherer, Bruce and Runkawatt (2007) compared 
the perceived self-confidence of nurse practitioner students who participated in a cardiology HFS 
exercise with a control group of students who presented a case study about managing a cardiac 
event.  The students in the control group rated their confidence as significantly higher than did 
those in the simulation group (p = .040).   
Blum et al. (2010) reported similar results when comparing a group of junior-level 
baccalaureate students demonstrating newly acquired skills using low-fidelity mannequins or 
using HFS.  The investigators found a greater increase in student-perceived self-confidence for 
the control group compared to the simulation group.  Brown and Chronister (2009) compared 
measured self-confidence between two groups of senior nursing students enrolled in an 
electrocardiogram course.  The experimental group participated in a weekly HFS exercise while 
the control group received traditional classroom instruction only.  The reported self-confidence 
measures showed no significant difference between the two groups (p < .05).   Clearly, current 
research regarding HFS and self-efficacy contains conflicting findings and highlights the need 
for further research.    
Learner Satisfaction and High-Fidelity Simulation 
Learner satisfaction has been the focus of educational research (Jeffries, 2007).  More 
specifically, measuring learner satisfaction has been a focus of simulation research in nursing 
 
26 
 
education (Kardong-Edgren et al., 2010).   According to Chickering and Gamson (1987), 
students perform at a higher level if they are satisfied with their learning.  Chickering and 
Gamson further propose that learner satisfaction is highest when learning is relevant.  One of the 
advantages of a simulation exercise in healthcare education is the opportunity for students to 
integrate knowledge and skills learned in the classroom and apply them to a patient care scenario 
(Prion, 2008).  Students have described simulation as a safe and non-threatening method of 
practicing patient care skills (Abdo & Ravert, 2006; McCausland et al., 2004).    
Bremner et al. (2006) sought to determine the value of using human patient simulators 
from the perspective of novice nursing students.  The researchers were interested in investigating 
HPS teaching/learning utility, HPS realism, limitations of HPS as a teaching method, and the 
participants? confidence in using HPS to learn physical assessment skills.  In the study, 56 new 
nursing students in a baccalaureate program used HPS to perform a physical assessment.  Upon 
completion of this activity, students performed a second assessment.  Faculty changed the 
physical characteristics of the simulator between the first and second assessments.  Following the 
two assessments, 41 of the 56 students completed a two-part questionnaire regarding their 
experiences.     
Students were asked to: identify overall perceptions of their experience with the HPS, 
express an opinion on whether the simulation should be a required or voluntary assignment, note 
whether the simulation experience gave them confidence in assessment skills, and report whether 
the experience alleviated some stress from the first clinical day at the hospital.  A second survey 
requested written comments by the students after completing their entire clinical experience for 
the course.  Ninety-five percent of participants rated the CSE from good to excellent, 68% 
believed that simulation should be mandatory, 61% reported that the experience increased their 
 
27 
 
confidence with physical assessment skills, and 42% stated that practicing the skills relieved 
some stress associated with the first day of hospital clinical.  Student comments revealed that 
they believed HPS to be beneficial regarding clinical teaching, realism, and as preparation for 
working with actual patients.  The limitation reported most often by the students was lack of 
sufficient time with HPS.   
Feingold et al. (2004) also evaluated student and faculty perceptions regarding the use of 
a simulated clinical scenario.  Sixty-five senior nursing students participated in two scenario 
experiences at the beginning and end of an Acute Care of the Adult nursing course.  Students 
then completed a 20-item Likert style satisfaction survey that examined simulation realism, 
transfer of learned skills to a clinical setting, and value of the experience.  Faculty completed a 
17-item Likert style survey related to faculty support and the necessary training of faculty 
required to implement the simulation technology.  Students felt the experience provided 
appropriate realism (86.1%), tested clinical skills (83%), and decision-making (87.7%), was 
valuable to learning (76.5%), and provided adequate feedback (96.9%).  One unexpected finding 
was that less than half of the students felt that their confidence (46.9%) or competence (46.9%) 
increased.  Faculty all (100%) felt that the experience was realistic and effective.  Both faculty 
and students valued the experience.   
In a pilot study, Schoening et al. (2006) examined students? opinion of simulation as a 
method of instruction.  Sixty junior baccalaureate nursing students participated in the study 
during their high-risk obstetrical course.  Students participated in a high-fidelity patient 
simulation orientation with two weeks of scenario practice followed by a debriefing session.  A 
four-phase teaching method based on previous research was incorporated in the following 
manor:  Phase One: orientation, Phase two: participant training, Phase three: Simulation, Phase 
 
28 
 
four: Debriefing.  Students completed a ten-item evaluation instrument developed by the 
researchers that used a four-point Likert scale.  Some students supplied additional narrative 
comments. 
 Participants felt they were able to practice appropriate skills.  They also reported 
increased confidence as a result of the safe environment of the simulation setting.  Students also 
reported that they found value and satisfaction in the experience and they believed that the skills 
practiced were transferable to a clinical setting.  Students further stated that they enjoyed the 
teamwork experience. 
Similar to the research on HFS and its effects on self-efficacy, the evidence regarding 
learner satisfaction is inconclusive when comparing HFS to other instructional techniques.  
Swanson et al. (2010) investigated whether HFS is superior in terms of learner satisfaction by 
comparing HFS to the methods of: case study, student-led high-fidelity simulation, and an 
instructor-driven high-fidelity simulation.  The investigators found no significant difference 
across the groups in learner satisfaction scores (p = .892).   
Kardong-Edgren, Lungstrom, and Bendel (2009) studied possible differences in learner 
satisfaction between medium-fidelity and high-fidelity simulation exercises. Following the 
simulation experiences, student satisfaction was measured by a faculty-designed six-item tool.  
Results revealed that students were equally pleased with both the medium and high-fidelity 
simulation experiences.  No statistically significant difference in reported satisfaction was found 
between the two simulation technologies.    
The Role of Reflection in Learning 
 Simulation is an experiential learning activity (Gilley, 2004).  Simulation in health care 
education replicates the clinical experience and requires active involvement on the part of the 
 
29 
 
learner.  Adults learn best when they are actively engaged (Caine & Caine, 2006); however, this 
engagement requires that the learner experience ?reflection and action and feeling and thinking? 
(Kolb & Kolb, 2005, p. 194).  Fanning and Gaba (2007) state that ?the concept of reflection on 
an event or activity and subsequent analysis is the cornerstone of the experiential learning 
experience? (p. 116).   Reflection is defined as follows: 
Reflection involves taking the unprocessed, raw material of experience and engaging 
with it as a way to make sense of what has occurred.  It involves exploring often messy 
and confused events and focusing on the thoughts and emotions that accompany them.  
(Boud, 2001, p. 10) 
The gap between experiencing an episode and fully understanding it is bridged when the 
facilitator provides guided reflection within the learning experience.  In simulation, this guided 
reflection is customarily offered, after the scenario has ended, during the post-scenario 
debriefing.  The simulation design for this study will incorporate a guided reflection component 
in the middle of the CSE ? a phase this author refers to as mid-scenario reflection.  The 
philosophical foundation for this study and its focus on guided reflection is found in the works of 
Dewey (1933) and Sch?n (1983). 
 Reflective thought as a component of the learning process was first described by Dewey 
(1910, 1933).   Dewey explains the relationship between learning and experience and describes 
learning as ?not learning things, but the meanings of things? (1910, p. 176).  The inclusion of a 
reflective period is integral to learning the meaning of experiences.  With reflection, learning 
now becomes a dynamic process compared to a passive learning experience such as didactic 
instruction.  Dewey encourages educators to strategically place reflection within the learning 
experience.    
 
30 
 
According to Dewey, reflection begins with a ?perplexed, troubled, or confused 
situation? (1933, p. 12).  This leads to consideration of the problem, i.e. reflection ? the purpose 
of which is to ?transform a situation in which there is experienced obscurity, doubt, conflict, 
disturbance of some sort, into a situation that is clear, coherent, settled, harmonious? (p. 100).  
Student nurses confronted with a patient in acute, albeit simulated, distress almost certainly 
experience the situation as troubled, confused and filled with doubt.  Confrontation with the 
perplexing situation signals the beginning of Dewey?s five phases of reflective thinking:  
1) Suggestion: the mind grapples for possible solutions.  If the solution seems 
plausible in step one, the solution is applied, the process stops, and reflection does not occur.   
2) Intellectualization: the specific problem is placed into a relevant context for the 
purpose of further examination.   
3) Hypothesis development: this serves as a guide for further data collection 
regarding the problem.  
4) Hypothesis elaboration: reasoning about possible solutions occurs.  
5) Hypothesis testing: overt action is taken.    
Dewey explains that the five phases are not a lock-step process, they may occur in any 
order or not at all.  Furthermore, reflection may occur either during or after an experience.  
Dewey?s phases of reflective thinking are akin to the nursing process which is recognized 
internationally as describing the work of professional nurses (Wilkinson, 2007).  The nursing 
process consists of: assessment, problem identification, intervention planning, and 
implementation (American Nurses Association {ANA}, 2004).  This systematic approach to 
clinical reasoning also serves as the framework for the mid-scenario reflection in this study.     
 
31 
 
Assessment frames the patient care situation and is based on the subjective and objective 
data received both from the patient?s medical record and the patient?s responses to questions.  
Assessment gives meaning to the clinical judgments being made.  Problem identification 
involves choosing the focus of care and setting priorities based on the analysis of the assessment.  
At this point, the student must consider the relationships between and among competing nursing 
diagnoses, i.e. determining the relationship between pain and heart rate.  Once the focus of care 
is determined, the student plans research-based interventions based on the desired outcome i.e. 
administering antibiotics in order to reduce fever.  Implementation of the planned care occurs 
after the mid-scenario reflection.   
According to Pesut (2004), ?framing? is defined as attributing meaning to a set of facts.  
Although providing students with a structure for reflection to achieve framing is important, 
integration of the simulation experience into a conceptual framework can be challenging 
(Dreifuerst, 2009).  The instructor must build on a framework that the learner is familiar with and 
can use in the future ? hence the choice of the nursing process for this study.  The mid-scenario 
reflection incorporated into this study?s simulation design is intended to guide the clinical 
reasoning process in a structured manner using the existing cognitive framework of the nursing 
process.  Using the nursing process for the integration of new knowledge is common and usually 
occurs during post-scenario debriefing (Kuiper, Heinrich, Matthias, Graham, & Bell-Kotwell, 
2008).  
Influenced by Dewey?s model, Sch?n (1983) studied reflective practices among medical 
professionals whose learning, he believes, can be greatly enhanced by reflection.  Sch?n makes 
the distinction between ?reflection-in-action? and ?reflection-on-action.?  Reflection-in-action 
takes place while the individual is engaged in an experience and is fundamental to the ?art of 
 
32 
 
practice? (p. 50).  At this stage, knowledge gained from past experiences are woven into the new, 
unfamiliar situation.  Sch?n believes that the level of response is affected by the competence of 
the practitioner.  Finding time for reflection-in-action during an actual busy clinical experience is 
often not possible (Pierson, 1998); however, lack of time is not problematic in simulated patient 
care.  The scenario design for this study incorporates a distinct, dedicated, and guided reflection-
in-action ?time out? period more suitable to the inexperienced practitioner. 
 Sch?n?s concept of reflection-on-action is described as the review of an event following 
its completion.  The goal of this post-mortem analysis is to establish new discoveries in the mind 
of the practitioner in order to apply the new knowledge to future situations.  This reflection-on-
action occurs in the post-scenario debriefing process.  During debriefing, reflection-on-action 
involves a conscious return to the experience for the purpose of re-evaluation and to determine 
what should be done differently.  Furthermore, Sch?n encourages learning by doing, a ?reflective 
practicum? (p. 18).  Patient care simulation contains elements of such a reflective learning 
environment proposed by Sch?n.   
The Role of Reflection 
 The literature regarding the role of reflection in nursing practice shows support for the 
idea that focused reflection promotes the development of clinical reasoning (Davies, 1995; 
Mezirow, 1998; Shields, 1995)).  Murphy (2004) defines clinical reasoning as ?the practitioner?s 
ability to assess patient problems or needs and analyze the data to accurately identify and frame 
problems within the context of the patient?s environment? (p. 227).  Babenko-Mould, 
Andrusyszyn, and Goldenberg (2004) believe that both reflection and feedback are essential to 
the professional development of the nurse.   
 
33 
 
 Studies have identified positive outcomes of  reflective professional nursing practice such 
as: increased learning from a clinical experience (Atkins & Murphy, 1993), acceptance of 
professional responsibility (Johns, 1995),  improved patient care related to enhanced critical 
thinking in complex care situations (Brookfield, 2000), enhanced professional identity (Taylor, 
2001), and increased professional competence (Rudolf, Simon, Rivard, Dufresne, & Raemer, 
2007).   
Although there is little research regarding the reflective practice of nurses and patient 
outcomes, Paget (2001) examined whether reflection had a direct influence on clinical practice.  
Study participants (n = 70) received formal instruction regarding reflective practices in the form 
of classroom teaching and self-study using modules.  Seventy-eight percent of the sample group 
reported positive changes to their practices ? increased self-awareness and assertiveness ? as a 
result of the reflection training.  What is not clear is whether these changes would persist over 
the long-term.   
In a related study, Conway (1998) explored ways in which the reflective ability of the 
nurse affects patient care.   Among the participants who were identified as ?experts? (n = 35), 
Conway found variations in the reflective abilities of the group.  The study results indicate that 
nurses with minimal reflective abilities gave illness-oriented care while the more reflective 
nurses gave care based on the needs of the individual.    
 A link has been made in nursing education between competent clinical judgment and 
teaching strategies that provide guided reflection (Decker et al. 2010; Glaze, 2001; Paget, 2001).  
Such structured reflection is best provided by a mentor who is available throughout learning to 
help the learner infuse meaning into the experience, and anchor theory to practice (Johns, 2004).   
In this way, the use of reflection narrows the gap between theory and practice (Ruth-Sahd, 2003).  
 
34 
 
Kuiper and Pesut (2004) proposed that guided, structured reflection is especially beneficial to the 
novice practitioner because the necessary skills to analyze nursing practice are not yet in place.    
 Kolb?s experiential learning theory (1984) hypothesizes that the learner makes the 
experience meaningful by reflecting upon it.  The meaning attained through reflection is then 
categorized and incorporated into an existing cognitive framework.  Bandura (1977) also 
recognizes the role of reflection in learning and defines the learner as someone who is self-
directed, proactive, and reflective.  Benner (1984), too, recognizes how reflection assists in the 
metamorphosis from novice to nurse expert.   
Sewchuck (2005) describes how experiential learning accommodates four different styles 
of learning: accommodating learners, diverging learners, converging learners, and assimilating 
learners.  Diverging learners learn best from experience but then internalize the experience by 
reflecting upon it.  Kolb (1984) classifies nursing as a profession that attracts diverging learners.      
 However, engaging in reflection does not guarantee learning; there must be active 
involvement on the part of the learner (Teekman, 2000).  Nor do all learners reflect in a 
consistent manner (Dreifuerst, 2009).  Furthermore, the development of reflective thinking can 
be impeded by students? fear of harsh judgment and evaluation by instructors (Richardson & 
Maltby, 1995).  A non-judgmental supportive climate is necessary for the reflective process 
(Davies, 1995).  Johns (2004) warns that because reflection can lead to negative thinking, faculty 
must be willing to serve as guides to support the learner throughout the process.  These concepts, 
the role of guided reflection in learning, active involvement in the learning process, and student 
support to achieve reflection, form the basis of this study?s simulation design.       
 Guided reflection should be an integral part of the simulation experience (Jeffries, 2007).  
Jeffries proposes the following: simulation is an experiential learning strategy, guided reflection 
 
35 
 
promotes insight, insight is important in developing clinical judgment, and improved clinical 
judgment promotes effective patient care.  These assumptions are sound and Jeffries encourages 
researchers in the systematic study of these concepts.   
 Research regarding guided reflection and its role in simulation supports the notion that 
students consider guided reflection in the form of faculty feedback an important feature of 
simulation design (Issenberg, McGaghie, Petrusa, Gordon, & Scales, 2005).  Chickering and 
Gamson (1987) contend that the interaction between faculty and students is one of the 
cornerstones of best educational practices.  Students wish to be supported and share interactive 
time with faculty whose purpose it is to help develop their understanding of quality patient care 
(Jeffries & McNelis, 2010).  Additionally, a qualitative synthesis of simulation-based medical 
training covering a 40 year period found that feedback is the most important variable in 
simulation for promoting effective learning (McGaghie, Issenberg, Petrusa, & Ross, 2010).   
 Lasater (2007) explored the experiences of nursing students (n = 48) enrolled in a nursing 
program that implemented a high-fidelity simulation of an adult in respiratory distress.  One of 
the themes that emerged in the focus group data analysis was a strong desire for more direct 
feedback from the simulation facilitator.  The students reported that faculty feedback consisted of 
supportive verbal comments such as ?good job? (p. 274), but what they most desired was more 
definitive clinical feedback about the patient?s condition.   
 Cantrell, Meakim, and Cash (2008) published similar findings regarding student 
perceptions of a pediatric-based clinical simulation.  Students identified a need for support and 
guidance from faculty during the simulations.  When the expected guidance from faculty was not 
forthcoming, the students reported an increase in anxiety and stress levels.  In addition, students 
perceived that the nature of the feedback was important as well.  Students identified several 
 
36 
 
effective feedback techniques including humor and a ?supportive and coaching demeanor? (p. 
26).  In contrast, faculty who did not assist students in making patient care decisions during the 
scenario actually had a negative effect on learning.  The authors recommend that students should 
be aware regarding what support and guidance they can (or cannot) expect from faculty.  These 
findings bolster an earlier study by Cantrell (2008) wherein students rated support and feedback 
as the most important features of simulation.    
Childs and Sepples (2006) examined the perceptions of students (n = 55) who 
participated in a series of scenarios that increased in complexity after which students evaluated 
the simulation design characteristics.  The participants identified faculty feedback as the most 
important educational practice of the simulation.  Clearly, nurse educators need to be aware that 
learning outcomes and learner satisfaction are dependent upon faculty support and feedback 
during the simulation.   
Levels of Facilitation 
A number of reflective/debriefing models are described in the literature.  Dismukes and 
Smith (2000) examined debriefing strategies in the aviation industry and identified three levels 
of facilitation, high, intermediate, and low, by which instructors can facilitate guided reflection 
with simulation participants.  McDonnell, Jobe, and Dismukes (1997) contend that facilitation 
?is conducted on a broad continuum from high (most desirable) to low (least desirable)? (p. 8).  
The authors recommend that group discussion should be facilitated at the highest levels possible. 
The high level of facilitation actually denotes a low level of facilitator involvement.  At 
this level, the facilitator may outline steps in the debriefing but participants are essentially 
responsible for debriefing themselves.  The facilitator encourages discussion through the strategy 
 
37 
 
of open-ended question and the liberal use of silence in order to stimulate group responses.  At 
this level, participants are capable of discussing salient issues with little instructor guidance. 
The intermediate level of instructor involvement is useful when participants need 
assistance in analyzing the experience at a deep level yet are capable of some independent 
discussion.  Techniques that are appropriate at this level include asking questions in various 
ways to illicit responses from the group.  The primary role of the facilitator is to help the 
participants in the self-discovery of important concepts related to the simulation. 
Low-level facilitation may be necessary when the participants show little initiative and 
when superficial responses are elicited during the reflective period.  The facilitator may need to 
lead a step-by-step discussion of the issues.  Self-discovery is restricted at this stage and the 
group may need a detailed identification and summary of the problems along with explicit 
directions regarding the proper steps in addressing the problems. 
For the purpose of this study, the intermediate level of instruction was chosen for the 
mid-scenario reflection.  Junior nursing students lack the experience to participate at the high 
level of facilitation yet are eager to make meaning of the simulation and appear highly motivated 
to do so.  These advanced beginner students should best respond to an intermediate level of 
facilitation in which the facilitator attempts to evoke substantive analysis, discussion, and 
evaluation of the patient-care scenario.   
Literature Support for Mid-Scenario Reflection 
A basic premise for this study is the inclusion of a guided reflection period during a 
simulation time-out.  While a reflection period is traditionally incorporated into the post-scenario 
debriefing, this may be too late.  Boud, Keogh, and Walker (1985) warn that the reflective 
process ?can become diffuse and disparate so that conclusions or outcomes may not emerge? 
 
38 
 
(p. 3).  It is the author?s experience that students will often reach incorrect or non-contextual 
conclusions early in the CSE and this erroneous thinking continues unchecked throughout the 
scenario.  The ?messy and confused events? that Boud (2001, p. 10) describes may best be tidied 
up and clarified during the scenario as opposed to after the scenario. 
As the scenario unfolds, there is little time for reflection and little opportunity for the 
learner to gather one?s thoughts and enhance one?s existing cognitive framework (Waldner & 
Olson, 2007).  The scenario minutes tick by quickly and students often feel buffeted by so much 
relentless sensory and data input.  There is little time to make sense of it all.  The purpose of 
mid-scenario reflection is to pause and attempt to corral these untamed thoughts and give them 
order.   
Yet, little information is found in the literature regarding the practice of mid-scenario 
reflection in high-fidelity simulation.  However, a teaching strategy defined as ?partial-
instructor-driven simulation?, described by Dubose, Sellinger-Karmel, and Scoloveno (2010), 
affords a pause during the scenario at which time the instructor provides guidance and direction 
as needed. The authors liken the scenario to a play and the ?states? (p. 199) are analogous to 
scenes in the play.  The partial-instructor-driven strategy is described as follows: 
 When state 1 begins, the students enter the room (with a plan) and carry out their plan 
without interruption.  This approach gives students time to carry out their intended plan and 
offers them the opportunity for self-corrections.  Group decisions and discussions are employed 
to assist in the recognition of problems presented.  If the students venture off track, as often 
happens, the simulated experience is taken in that new direction.  Otherwise, redirection will not 
occur until the students themselves change the direction of the experience or until the students 
 
39 
 
reach a time when they need to leave the bedside to either obtain labs or call the healthcare 
provider.  That ends the state and begins a debriefing session with the facilitator.   
 During the debriefing period, the faculty member can ask prompting questions, tie 
together students? assessment findings, and discuss how the students perceive they addressed 
their plan.  This period of reflection gives students time away from the stress of hands-on care to 
regroup and assess their decisions.  They may choose to alter their plan or recognize that they 
drifted from their intended plan.  Being away from the bedside also offers students a chance to 
reorganize their thoughts without the simulation progressing so that further responses are 
required [emphasis added].  (Dubose et al., 2010, pp. 199?200). 
 Once questions are answered, points clarified, and a plan of care is agreed upon, the 
scenario resumes and is now in ?state 2? (p. 200).  The authors describe the advantages of the 
partial-instructor-driven design: 
The benefits of this style is that it allows students to reorganize their thoughts without 
further simulated conditions altering their decisions.  It promotes an opportunity for the 
student to self-correct or to correct one another as opposed to receiving instruction from a 
faculty member.  This simulation approach also allows a new plan to be formulated 
before the next state is presented. (Dubose et al., 2010, p. 200). 
 This method is associated with Dewey?s belief that allowing learners to discover and self-
correct gives them a chance to take responsibility for their learning.  Offering mid-scenario 
reflection also correlates with Benner?s (1984) idea that for learners at the novice or advanced-
beginner stage, the facilitator should be present to guide the students? decisions and actions at 
pre-determined intervals.  However, research regarding this teaching strategy has not been found 
in the simulation literature. 
 
40 
 
 Furthermore, the literature contains few examples, definitions, or discussions of mid-
scenario reflection as a simulation teaching strategy.  Waldner and Olson (2007), describe the 
application of Benner?s (1984) theory to simulation design and suggest that, as advanced 
beginners focus on the patient?s condition, the simulation ?can either be interrupted to discuss  
assessments and decisions on the spot or this debriefing can occur afterwards? (p. 9).  The 
authors contrast this strategy with that of a more complex simulation with learners at the 
competent level when interrupting the scenario to discuss decisions would be distracting and 
intrusive.     
 Clapper (2009) recommends ?ongoing reflection? (p. 6) during the simulation experience.  
The advantage with ongoing reflection is that immediate corrections can be made if necessary.  
Clapper believes that such ongoing reflection benefits the learner by allowing the learner to 
change course as needed in addition to correctly perform tasks.   
 Fanning and Gaba (2007) briefly describe a situation when ?in-scenario debriefing? (p. 6) 
could occur.  The authors recommend this pause in the proceedings in instances of team 
dysfunction or for the purpose of teaching a specific psychomotor skill.  The debriefing should 
take place in a room that is separate from the virtual bedside in order to diffuse tension and 
provide a ?comfortable, private, and a relatively intimate environment? (p. 6).     
 One study regarding selected teaching strategies for simulation (Swanson et al., 2010) 
describes a simulation design in which the instructor designated ?time-out? periods in the midst 
of the scenario.  During the time-out, the instructor guided students in thinking about their 
assessments and interventions before resumption of the scenario.  Though the reflection period 
was not the focus of the study, the authors report that this pause allowed students to think about 
their performance and subsequent decision-making during a myocardial infarction scenario.   
 
41 
 
 Ishoy, Epps, and Packard (2010) conducted a pilot study exploring a similar simulation 
strategy that incorporated what the researchers termed ?do-overs? (p. 117).  The researchers 
examined first-year nursing students? responses to a simulation design that included a chance for 
a ?do-over? i.e. to perform the scenario once again following an instructor-led debriefing.  The 
participants (n = 68) were divided into two groups.  The experimental group reported 
experiencing less anxiety than the group that did not repeat the scenario.  The control group 
reported the need for greater insight regarding the simulation experience compared to the 
experimental group.  Furthermore, the students that were allowed a ?do-over? had increased 
satisfaction and self-confidence scores following the simulation.    
 In conclusion, it has been proposed that reflective thinking is necessary for the 
development of clinical judgment (Kuiper & Pesut, 2004; Pesut & Herman, 1999).  Yet there is 
little evidence regarding the integration of guided reflection during a simulated learning 
experience.  The integration of reflection into simulated experiences may provide a way to 
ultimately improve clinical judgment.  However, research is needed to find the most effective 
educational practices to achieve this goal.          
Chapter Summary 
The use of HFS is relatively new in nursing education and, as a result, there is a current 
lack of research regarding best educational practices for this new teaching strategy.  The NESF is 
one theory-based framework developed to address unanswered questions about the design, 
implementation, and evaluation of simulation exercises in nursing education.  Benner?s Novice-
to-Expert Theory provides an additional conceptual framework with which to design HFS 
scenarios based on the student?s level of skill acquisition.   
 
42 
 
The measurements of student self-efficacy and learner satisfaction have been a focus of 
simulation research in nursing education.  Bandura?s Social Cognitive Theory (1986) explores 
the development of self-efficacy in education.  Bandura?s theory is congruent with a principle 
goal of nursing education: to improve student self-efficacy by involving students in learning 
experiences that result in skill mastery.  Chickering and Gamson (1987) propose that students 
experience greater levels of learning satisfaction and perform more effectively when they 
perceive the lessons are relevant.  Indeed, one of the foremost advantages of simulation as a 
teaching strategy is that it allows nursing students to integrate didactic knowledge by applying it 
to a patient care scenario.   
Simulation is an experiential learning activity that requires active involvement on the part 
of the learner.  However, such engagement requires reflection by the learner in order to bridge 
the gap between simply experiencing the scenario and fully understanding it.  The works of 
Dewey (1910, 1933) and Sch?n (1983) regarding the role of guided reflection in learning provide 
additional philosophical foundations for this study.   
Finally, Jeffries (2005) proposes that guided reflection should be an integral part of any 
simulation experience.  However, little information is found in the literature regarding a 
simulation design that incorporates mid-scenario guided reflection.   The information in this 
chapter was used to design a study in order to examine the effects of mid-scenario reflection on 
learning outcomes.     
  
 
43 
 
  
  
  
  
 
CHAPTER 3.  METHODS 
 
Introduction 
The purpose of this study was to evaluate the effect of a simulation design incorporating 
mid-scenario reflection on learning outcomes.  Learning outcomes were measured by post-
simulation reports of student self-confidence and student satisfaction with the simulation 
experience.  The relationship of mid-scenario reflection and learning outcomes was also 
explored.  In addition, the perceived characteristics of a simulation design incorporating mid-
scenario reflection were examined.  This chapter includes information about the design, setting, 
sample, sampling procedures, instruments, data collection, and data analysis.     
Research Questions 
The following research questions were used in this study: 
1. What are the perceived characteristics of a simulation design incorporating mid-
scenario reflection?   
2.  What is the effect of a simulation design incorporating mid-scenario reflection on 
student self-confidence? 
3. What is the effect of a simulation design incorporating mid-scenario reflection on 
learner satisfaction? 
4. What is the relationship between perceived simulation design characteristics and 
learning outcomes? 
 
44 
 
Research Design 
A descriptive correlational design was used for this study.  This type of design examines 
the relationship between two or more variables.  The researcher ?is not testing whether one 
variable causes another variable ? but is interested in quantifying the streng th of the relationship 
between variables or in testing ? a specific relationship? (LoBiondo -Wood & Haber, 2010a, p. 
200).  This research design was chosen in order to examine the relationship of the components in 
the Nursing Education Simulation Framework (NESF) (Jeffries, 2007).  The NESF is used to 
implement and evaluate simulation in nursing education.  A correlational study may provide ?a 
potential foundation for future, experimental research studies? (LoBiando-Wood & Haber, 
2010a, p. 201).   
 In this study, students participated in a required obstetrical high-fidelity simulation (HFS) 
scenario.  Upon completion of the scenario, students were asked to complete two instruments ? 
the Simulation Design Scale and Student Satisfaction and the Self-Confidence in Learning 
instruments.  Results were analyzed to determine the relationships, if any, between the five 
simulation design characteristics and the learning outcomes of student satisfaction and student 
self-confidence.  The independent variable in this study was the incorporation of a mid-scenario 
guided reflection period.  The dependent variables in this study were the students? self-reported 
satisfaction and self-confidence scores.     
Setting 
This study was conducted at a School of Nursing located in a public university in the 
southeastern United States.  This school offers a traditional baccalaureate nursing curriculum in 
addition to a graduate program at the master?s level.  The program has been approved by the 
state Board of Nursing and has received accreditation from the American Association of 
 
45 
 
Colleges of Nursing.  Approximately 104 students comprised of both juniors and seniors are 
enrolled at any one time.   
As students progress through the program, they are enrolled in courses that include 
fundamentals, professional theory, medical-surgical, pediatric, women?s health, community 
health, critical care, research, and leadership.  In the junior year, students are enrolled in the 
women?s health course that offers didactic and clinical instruction in obstetrical and 
gynecological nursing.  Part of the 90 hour clinical component includes a four-hour clinical 
simulation exercise (CSE) with a manikin, Noelle?.  Noelle? is manufactured by Gaumard 
Scientific? and is a high-fidelity reproduction of an average-sized adult equipped with an 
interactive software package that allows the operator to reproduce normal and abnormal 
physiologic conditions encountered in practice.  The manikin?s features include the ability to 
simulate labor and birth.  
The School of Nursing contains a simulation laboratory consisting of two large rooms 
both of which replicate a clinical setting.  One room contains the low-fidelity manikins and task 
trainers.  The room that houses Noelle? also contains two additional high-fidelity manikins.  
Noelle? is situated on an electronically-controlled hospital bed in a realistic representation of a 
private hospital room.  Noelle? is connected to monitors that display vital signs ? temperature, 
pulse, respiration, and oxygen saturation ? in addition to a fetal monitor that displays real-time 
contractions and fetal heart rate. 
The hospital room also features a bedside table with simulated oxygen and suction 
equipment situated on a wall panel.  The room is also equipped with a telephone, clock, and 
bedside computer that displays Noelle?s? medical record.  There are microphones and cameras 
at the bedside of each high-fidelity manikin.  A control booth installed behind a one-way glass 
 
46 
 
window contains the computer controls for the manikins and an audio system that allows 
communication between simulation participants and operators/faculty inside the booth.  The 
control booth, with seating for three, also features audiovisual recording equipment and a large-
screen monitor. 
Sample 
A convenience sample of 47 junior baccalaureate nursing students enrolled in a required 
women?s health clinical course was used in this study.  Students who did not wish to provide 
informed consent to complete the instruments were excluded from the study.  Random 
assignment was used to schedule the students in groups of three for the CSE.    
Ethical Considerations 
 For the purpose of human rights protection, a request for expedited approval from the 
university?s Institutional Review Board was submitted and granted (Appendix B).  Informed 
consent from the study participants was obtained (Appendix C).  Although the simulation 
experience was a requirement for the course, participation in the study was not mandatory.  
Students were notified that participation was voluntary and that lack of participation would not 
affect their course grade.  This information was reinforced on the informed consent form.   
 Participants were instructed to use a numerical identifier rather than names on the study 
instruments in order to minimize the risk that survey responses would be disclosed to others.  
After the data was entered in a software program, the completed instruments were placed in a 
locked cabinet that could be opened solely by the principal researcher.   
Data Collection 
Students enrolled in the women?s health course are expected to complete a High-Fidelity 
Simulation (HFS) experience as part of the clinical requirement.  Students were scheduled for a 
 
47 
 
60-minute HFS session offered on eight different days over a four-week period with two groups 
scheduled per day.   Each group, consisting of three randomly assigned students, was given 35 
minutes in which to complete the obstetrical scenario.      
Prior to the HFS, all students received classroom content on the pathophysiology and 
nursing care of a full-term pregnant patient with chorioamnionitis.  Students prepared further for 
the experience by reading the assigned material in the course textbook and reviewing the written 
HFS objectives prior to the simulation (see Table 1). 
 
Table 1 
Simulation Objectives of the Obstetrical Scenario 
At the conclusion of the scenario, the student will be able to 
1. Perform basic nursing skills necessary in giving care to the laboring patient 
2. Assess uterine contractions including intensity, duration, and frequency 
3. Assess fetal well-being during labor   
4. Analyze the laboring patient?s reaction to drugs received during the labor process 
5. Develop a plan of care for the laboring patient experiencing complications using the 
nursing process 
6. Communicate effectively with the health care team 
 
A term pregnancy chorioamnionitis scenario was developed by faculty for use in this 
study.   The chorioamniotis condition was chosen because students are seldom able to care for 
such patients due to the high-risk nature of the complication. Skills necessary for the scenario 
had been taught previously in the curriculum.  
 
48 
 
The physiological events involved in chorioamnionitis were programmed into the HPS by 
faculty.  Communication by the patient included such statements as ?I feel terrible?, ?I?ve never 
hurt so bad in my life?, and ?I?m burning up?.  The fetal heart rate was programmed at the 
elevated rate of 158?168 beats per minute with moderate variability.  Noelle?sTM vital sign 
monitor displayed a temperature of 101.4 degrees with an elevated heart rate of 102 and elevated 
respiratory rate of 22.  Once the appropriate interventions were accomplished, the fetal heart rate, 
maternal heart rate, respiratory rate, and temperature returned to normal levels.  Table 2 
illustrates the outline for the scenario. 
 
Table 2 
Scenario Outline 
Time Frame Patient Responses Expected Student 
Performance 
Patient Cues 
Assessment 
 
5 ? 10 Minutes 
T - 101.4 
P ? 102 
R ? 22 
FHR ? 166 
 
Lung sounds ? clear 
 
 
Cervix ? 5/80%/0 station 
 
 
Contractions 3 ? 5 minutes 
for 60 seconds with 
moderate intensity  
Introduce self 
 
 
Perform hand hygiene 
 
Conduct initial 
assessment 
 
Recognize abnormal 
findings 
 
Discuss patient?s status 
and the need to call the 
CNM 
?I?ve never hurt so bad 
in my life.? 
 
?I?m burning up.? 
 
?Please get me 
something for this pain.? 
 
?Is my baby OK?? 
(table continues) 
 
49 
 
Table 2 (continued) 
Time Frame Patient Responses Expected Student 
Performance 
Patient Cues 
Reflection/Planning 
 
5 Minutes 
 Discuss patient 
assessment, plan, 
interventions, and 
expected outcomes 
 
Intervention 
 
10 Minutes 
T ? 101.5 
P ? 104 
R ? 22 
FHR ? 142 
 
Contractions 3-5 minutes 
for 60 seconds with 
moderate intensity 
Call CNM 
Explain rationales for 
medications 
 
Verify allergies 
 
Administer IV antibiotic, 
pain medication, 
acetaminophen 
 
Instruct patient regarding 
relaxation techniques 
?I?m not allergic to 
anything.? 
 
?How long will this pain 
medicine take to work?? 
Re-evaluation 
 
10 Minutes 
T ? 99.5 
P ? 84 
R ? 16 
FHR ? 142 
 
Contractions 3-5 minutes 
for 60 seconds with 
moderate intensity  
Continue to monitor 
patient, fetal status, and 
labor progression 
 
Document care 
?I?m starting to feel 
better.? 
 
Immediately before the HFS, students were informed about the schedule of events for the 
simulation after which the written objectives for the exercise were reviewed.  Students next 
received a brief orientation to the Human Patient Simulator (HPS) and the simulation laboratory.  
 
50 
 
Participants were randomly assigned to a role for the simulation ? roles included that of primary 
nurse, secondary nurse, and nurse-recorder.  The primary nurse was responsible for leading the 
team in patient care although all students were expected to be involved directly in the patient?s 
care.  The role of the two faculty was to provide support, facilitate student activities as needed, 
and to monitor and evaluate the appropriateness of care.   
The obstetrical scenario design included the partial instructor-driven teaching strategy 
described by Dubose, Sellinger-Karmel, and Scoloveno (2010).  Two instructors were placed in 
the laboratory control booth ? one operated the HPS, spoke for both the patient and the Certified 
Nurse Midwife (CNM) while the other observed the students.  In accordance with the partial-
instructor driven technique, there was no instructor at the bedside.  Table 3 illustrates how the 
five design features that are part of the NESF (objectives, support, problem solving, guided 
reflection, and fidelity) were included in the scenario. 
 
Table 3 
Design Characteristics of the Obstetrical Scenario 
Design Characteristics  Simulation Scenario 
Objectives Students reviewed the written simulation objectives and the 
patient?s medical record prior to the scheduled simulation.  Upon 
arrival, students received a verbal report from the nurse.  
Students were allowed to ask questions and review the medical 
record located at the bedside.   
(table continues) 
 
 
51 
 
Table 3 (continued) 
Design Characteristics  Simulation Scenario 
Support All necessary medical supplies were placed close to the patient?s 
bed.  A telephone was in the room.  Students also had hand-held 
electronic devices containing resources for medications and 
laboratory values. 
Problem Solving The patient complained of intense pain and feeling ?hot?.  The 
patient provided the pain cues every three minutes during 
contractions.  Students assessed the patient?s pain level, vital 
signs, contraction status, fetal heart rate, and character of the 
amniotic fluid.   
Guided Reflection A 5?10 minute mid-scenario reflection was held before students 
called the CNM, i.e. between 7?10 minutes after the scenario 
commenced.  Assessment data, diagnoses, and treatment plans 
were discussed during a facilitator-led group session in an 
adjacent classroom.  The discussion points were written on a 
blackboard. 
 A 15?20 minute post-scenario faculty-led debriefing was held.  
Students shared their feelings about the simulation, reviewed the 
patient?s condition, and discussed their actions.  The debriefing 
also included a discussion about transferability to future clinical 
situations.  
(table continues) 
 
52 
 
 
 To begin the scenario, students were informed that it was 2:30 p.m. Sunday on a labor 
and delivery unit.  Students then received a verbal report by the nurse who had been caring for 
the patient since admission.  The researcher played the role of the nurse.  The verbal report was 
given as follows: 
          ?Noelle Miller is a 23 year-old female gravida 2 para 1 at 39 weeks gestation who 
is a patient of the midwife, Doris Hall.  She was admitted last night at 9 o?clock after 
coming to the unit complaining of vaginal leaking of clear fluid for three hours.  A 
nitrazine test was done that was positive for ruptured membranes.  At that time, she was 2 
centimeters dilated, contracting about every 10 minutes and they were mild by palpation.  
She?s been contracting all night and now they are occurring every 3?5 minutes.  The fetal 
heart rate has been stable in the 130s.  I checked her an hour ago at 1:30 and she?s 5 
centimeters, 80% effaced, and at 0 station.  She says she doesn?t want an epidural right 
now.  I gave her 2 milligrams of butorphanol IV for pain at 10:45 this morning.  She?s 
coping well with the contractions but says she doesn?t feel good.  She?s got an 18 gauge 
catheter in her right forearm with D5LR running at 125 ccs. per hour.  Her husband 
Table 3 (continued) 
Design Characteristics  Simulation Scenario 
Fidelity The room resembled an actual hospital labor room.  An 
intravenous line was connected to a bedside pump and inserted 
into the patient?s right forearm.  The simulator supplied lung 
sounds and palpable uterine contractions, and talked to the 
students.  
 
53 
 
stayed all night but didn?t sleep so he just went home to eat and get a shower.  This is her 
second baby ? her son is a year-and-a-half old.  She has no significant medical history 
and hasn?t had any problems with this pregnancy.  Her lab work on admission was 
normal.  Do you have any questions before I leave??       
When all questions were answered, students were instructed to enter the patient?s room as 
they would in an actual clinical setting. The researcher then entered the control room.  The 
students interacted with the patient, obtained initial physical assessment data, and discussed the 
findings as a group.  The primary nurse usually delegated the data collection to others such as 
frequency and duration of contractions, fetal heart rate, vital signs, lung sounds, the relevant 
information regarding the patient?s prenatal course, confirmation of medical record data, and 
character of the patient?s pain.  Students collaborated regarding the patient?s abnormal 
assessment findings and invariably reached a decision to call the CNM.   
Once the students reached the point when it became necessary to telephone the CNM and 
update her regarding the patient?s status and receive new medication and treatment orders, the 
facilitator stopped the simulation.  The group then adjourned to an adjacent classroom for a five 
to ten minute facilitator-led guided reflection period that included a discussion regarding 
assessment findings and the diagnoses based on the findings.  At that time, the group mutually 
developed a plan of care and returned to the simulation lab in order to resume the scenario and 
begin interventions.  The nursing process was used as a framework for the mid-scenario 
discussion.   
The nursing process consists of: assessment, problem identification, intervention, 
planning, and implementation (American Nurses Association [ANA], 2004). Use of the nursing 
process was an attempt on the part of the researcher to guide clinical reasoning in a structured 
 
54 
 
manner using an existing cognitive framework with which the students were already familiar.  
Figure 2 illustrates how the nursing process was incorporated into the mid-scenario reflection.     
 
   Patient Data Diagnosis Interventions 
 
Figure 2.  Nursing Process for the Mid-Scenario Debriefing 
  
Objective                         
 
T  = 101.4 
 
P = 102 
 
RR = 22 
 
BP = 128/84 
 
FHR = 166 
 
UCs = q 3-5 
minutes x 60 
seconds  
with moderate 
intensity 
 
Dilation = 5 
cm/80%/0 station 
 
 
Subjective 
 
?My pain is 10 
out of 10? 
 
?I don?t feel 
good? 
 
?I?m burning 
up?   
 
 
 
Pain related to 
labor  
Anxiety related to 
pain 
Infection related 
to prolonged 
rupture of 
membranes 
 
Call CNM 
 
Update CNM on 
patient?s 
condition 
 
Administer  
ampicillin 2 
grams IV 
 
Administer 
butorphanol 2 
grams IV 
 
Administer  650 
milligrams 
acetaminophen 
PO 
 
Continue to 
monitor 
 
Teach patient 
relaxation 
techniques 
 
 
              Desired Outcomes 
 
Patient will experience pain relief 
 
Patient?s temperature will return to 
normal 
 
FHR will return to normal 
 
 
 
55 
 
The scenario concluded when students administered IV pain medication, an IV antibiotic, 
and an oral dose of acetaminophen or 35 minutes had elapsed, whichever came first.  All groups 
successfully completed the scenario during the allotted time.  The total time for the scenario was 
35 minutes, including the mid-scenario guided reflection period.  Following the conclusion of the 
scenario, the students participated in a 15?20 minute post-simulation debriefing.  Student 
feelings, opinions, and responses during the scenario were discussed.  After debriefing, each 
participant completed the two instruments and a demographic questionnaire (Appendix D) after 
signing the informed consent.  The researcher reminded the students that participation in the 
study was voluntary.  After the instruments were completed, the researcher thanked the students.  
Completion time for the instruments was about 10 minutes.   
Instrumentation 
Two instruments developed by the National League of Nursing (NLN) were used in this 
study: 1) the Simulation Design Scale and 2) the Student Satisfaction and Self-Confidence in 
Learning Scale.  Permission was received (Appendix D) for the use of both tools by the NLN.   
Sample items from both instruments can be found in Appendix E.  
Simulation Design Scale (SDS) 
The SDS is a 20-item tool with a five point Likert-type scale with subscales measuring 
the five simulation design features ? objectives, support, problem solving, feedback, and fidelity.  
The instrument is composed of two parts.  The first section examines students? reported 
perceptions of the presence of each of the design characteristics and the second asks students 
about the importance of the design features.  Possible responses range from ?strongly agree? to 
?strongly disagree.?  An ?undecided? option is also available.  Content validity was determined 
by a panel of nine nurse experts and the SDS has a reported Cronbach?s alpha of 0.92 for the 
 
56 
 
presence of the design features (Jeffries & Rizzolo, 2006).  Alpha scores above .70 indicate 
sufficient evidence for internal consistency of an instrument (LoBiondo-Wood & Haber, 2010b).   
In an effort to determine the students? perceptions of the mid-scenario reflection, the SDS 
instrument was modified for the purposes of this study.  After analysis by six nurse experts, the 
following new questions were added.  New additions to the problem-solving domain are as 
follows: 
The mid-scenario discussion provided insight about my patient's condition 
The mid-scenario discussion provided me the opportunity to prioritize nursing assessment 
and care 
The mid-scenario discussion provided me the opportunity to set goals for my patient 
Items added to the feedback/guided reflection domain: 
 The mid-scenario discussion provided constructive feedback 
The mid-scenario discussion allowed me to analyze my own behavior and actions 
The mid-scenario discussion helped link classroom theory to practice 
The original SDS instrument includes a series of questions regarding how important each item is 
to the subject.  This information was beyond the scope of this study and was therefore excluded.   
Student Satisfaction and Self-Confidence in Learning 
This 13-item instrument is scored on a five-point Likert-type scale and asks participants 
to rate their satisfaction with the simulation experience and their perceived levels of self-
confidence gained through simulation participation.  Possible responses range from ?strongly 
agree? to ?strongly disagree.?  An ?undecided? option is also available.  The instrument is based 
on Kirkpatrick?s (1995) evaluation framework.  The Student Satisfaction and Self-Confidence in 
Learning Scale has a reported Cronbach?s alpha of 0.94 for the five-item satisfaction subscale 
 
57 
 
and 0.87 for the eight-item self-confidence subscale.  These scores indicate strong reliability for 
internal consistency (LoBionco-Wood & Haber, 2010b).  Content validity was established by a 
review panel of 10 expert nurses (Jeffries & Rizzolo, 2006).    
Data Analysis 
 Descriptive statistics were used for data analysis using simple means and standard 
deviations to describe characteristics of the data.  Responses to the SDS and the Student 
Satisfaction and Self-Confidence in Learning scales were entered into a Microsoft ExcelTM 
spreadsheet.  The participants? responses were labeled with their identification numbers.  The 
data from the spreadsheet were imported to the PASWTM 18.0 statistical software. 
Descriptive statistics were used to answer research question one: 
1. What are the perceived characteristics of a simulation design incorporating mid-
scenario reflection?   
Data from the SDS were used to answer this question including the mean and standard 
deviation scores for each of the instrument?s five subscales.  Furthermore, the mean and standard 
deviation scores for each of the 20 items of the SDS were analyzed.   
 Descriptive statistics and correlational analysis were used to answer research question 
two: 
2. What is the effect of a simulation design incorporating mid-scenario reflection on 
student self-confidence? 
Using the data from the Student Satisfaction and Self-Confidence in Learning Scale 
satisfaction subscale, a mean score and standard deviation were calculated for each of the eight 
items of the subscale.  The Pearson Product-Moment Correlation was used to examine the 
relationship between the five simulation design characteristics and self-confidence.   
 
58 
 
A bivariate correlational analysis is used to determine the relationship, or degree of 
association, between two or more variables (Sullivan-Bolyai & Bova, 2010).  The mean score of 
each of the five design characteristics of the SDS is compared to the mean score of the 
Satisfaction and Self-Confidence subscales.   
Descriptive statistics and correlational analysis were used to answer research question 
three:   
3. What is the effect of a simulation design incorporating mid-scenario reflection on 
learner satisfaction? 
Using the data from the Student Satisfaction and Self-Confidence in Learning Scale 
satisfaction subscale, a mean score and standard deviation were calculated for each of the five 
items of the subscale.  The Pearson Product-Moment Correlation was used to examine the 
relationship between the five simulation design characteristics and learner satisfaction.   
A multiple regression analysis was used to answer research question four: 
4. What is the relationship between perceived simulation design characteristics and 
learning outcomes? 
             Multiple regression is used to determine which variables contribute to the dependent 
variable and to what degree (Sullivan-Bolyai & Bova, 2010).  
Chapter Summary 
 This chapter described the methods for this descriptive correlational study. The study 
design examined the relationships between simulation design characteristics and students? 
reported satisfaction and self-efficacy.  The setting for this study, the participants, and the data 
collection procedures were described.  The instruments for the collection of data along with their 
 
59 
 
attendant reliability and validity were discussed.   The methods for descriptive data analysis were 
also described.   
 
  
 
60 
 
  
  
  
  
 
CHAPTER 4.  RESULTS 
 
Introduction 
While high-fidelity simulation (HFS) is used increasingly in nursing education, there is a dearth 
of quantitative evidence regarding the most effective role of the instructor in simulation.  The 
purpose of this descriptive correlational study was to examine the effect of a simulation design 
incorporating an instructor-led mid-scenario reflection on learning outcomes.  This chapter 
examines the results obtained by employing descriptive statistical analysis (mean and standard 
deviation), correlational statistical analysis, and multiple linear regression.  A description of the 
demographics of the sample is included.    
Participants 
 The population for this study consisted of baccalaureate nursing students in their junior 
year enrolled in a Women?s Health clinical course at a research university in the southeast during 
the summer term of 2011.  The course is placed at mid-point in the nursing curriculum in the 
third semester of a five-semester program.  This was the third high-fidelity simulation exercise 
that the students participated in since beginning their studies.  Although the course enrollment 
was 49, one student did not provide consent and one returned survey included a response that did 
not correlate with any numerical identifiers listed at the time consent was given.  Therefore, the 
final sample number was 47.  The majority of the participants were female (n = 45).  All 
participants were present during the class when the chorioamnionitis content was presented and 
each had spent at least one day providing actual patient care on an obstetrical unit.    
 
61 
 
Data Analysis 
All data were examined before the analysis for data entry errors and outliers.  The analysis of the 
data was accomplished using the PASWTM 18.0 statistical software program.  An alpha of 0.05 
was used for all statistical tests.  A p value less than 0.05 was considered statistically significant 
and not a result of sampling error.   
A Cronbach?s alpha reliability coefficient was used to measure internal reliability for both NLN 
instruments used in the research.  For an instrument to be considered reliable, a level of r = 0.70 
or higher is needed (LoBiondo-Wood & Haber, 2010b).   The reliability analysis using 
Cronbach?s alpha in this sample was 0.89 for the 20-item Simulation Design Scale.  This result 
indicated a strong internal consistency though the value was slightly lower than the reported 0.92 
found by Jeffries and Rizzolo (2006).  The result of the reliability analysis for this sample for the 
five-item satisfaction scale was 0.86 compared to the 0.94 results obtained by Jeffries and 
Rizzolo (2006).  A Cronbach?s alpha of 0.83 was obtained by this study for the self-confidence 
scale. Jeffries and Rizzolo (2006) had a reported value of 0.87. 
The sample size (n = 47) was not large enough to conduct a factor analysis.  A minimum of 10 
participants per item is considered an appropriate number for a factor analysis.  This would 
require 130 participants for the learner satisfaction and self-confidence instrument and 200 
participants for the Simulation Design Scale items (Sullivan-Bolyai & Bova, 2010).   
Analysis of the data was conducted to examine each research question.  Analysis for each 
research question follows. 
Research Question 1 
 Research question 1 was: What are the perceived characteristics of a simulation design 
incorporating mid-scenario reflection?  Descriptive statistics from the Simulation Design Scale 
 
62 
 
were used to measure the overall mean score and standard deviation for each of the five 
subscales.  The mean and standard deviation were also calculated for each of the 20 items in the 
subscale.  Using the Simulation Design Scale, students rated each design characteristic using a 
five-point Likert scale.  A response of ?1? indicated ?strongly disagree? and a response of ?5? 
indicated ?strongly agree?.    
The results indicated that students perceived that each design feature was incorporated into the 
HFS.  The highest mean score belonged to the subscales of Feedback (4.9, SD = 0.17) and 
Problem Solving (4.9, SD = 0.22) both of which elements included the mid-scenario reflection.  
However, the lowest mean score was only slightly lower for Objectives (4.7, SD = 0.41).  One 
participant response of ?not applicable? resulted in the 0 value for item number seven.  
Descriptive statistics for all five design characteristics are provided in Table 4.  
 
Table 4 
Descriptive Information for the Simulation Design Scale (n = 47) 
Item Number Minimum Maximum Mean Standard Deviation 
Objectives 3.0 5.0 4.7 0.41 
1 2.0 5.0 4.6 0.64 
2 3.0 5.0 4.8 0.46 
3 3.0 5.0 4.6 0.57 
4 3.0 5.0 4.8 0.48 
5 3.0 5.0 4.7 0.49 
(table continues) 
 
 
63 
 
Table 4 (continued) 
Item Number Minimum Maximum Mean Standard Deviation 
Support 3.0 5.0 4.8 0.38 
6 4.0 5.0 4.9 0.36 
7 .00 5.0 4.7 0.83 
8 4.0 5.0 4.9 0.28 
9 4.0 5.0 4.9 0.34 
Problem Solving 4.0 5.0 4.9 0.22 
10 4.0 5.0 4.7 0.46 
11 4.0 5.0 4.9 0.25 
12 4.0 5.0 4.9 0.34 
13 4.0 5.0 4.9 0.20 
14 4.0 5.0 4.9 0.25 
Feedback 4.0 5.0 4.9 0.17 
15 4.0 5.0 4.9 0.20 
16 4.0 5.0 4.9 0.24 
17 4.0 5.0 4.9 0.20 
18 4.0 5.0 4.9 0.15 
Fidelity 4.0 5.0 4.8 0.40 
19 4.0 5.0 4.8 0.43 
20 4.0 5.0 4.8 0.40 
 
 
 
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Research Questions Two and Three 
 Research question two was, ?What is the effect of a simulation design incorporating mid-
scenario reflection on student self-confidence??  Research question three was, ?What is the effect 
of a simulation design incorporating mid-scenario reflection on learner satisfaction??  
Descriptive statistics were also used to analyze the items in the Student Satisfaction and Self-
Confidence in Learning instrument.  Students rated each item using a five-point Likert scale with 
1 indicating ?strongly agree? and a response of ?5? indicated ?strongly agree?.  The results 
indicated that students felt positively about the HFS.  The overall Satisfaction score was 4.8 (SD 
= .35) and the overall Self-Confidence score was 4.6 (SD = .40).  The individual satisfaction 
items with the highest scores were items three (X = 4.9; SD = .35) and five (X = 4.9; SD = .40).  
Items three and five were respectively ?I enjoyed how my instructor taught simulation? and ?The 
way my instructor taught simulation was suitable to the way I learn?.  The response with the 
highest score in the Self-Confidence domain was item nine (X = 4.8; SD = .46).  Item nine was 
?My instructor used helpful resources to teach the simulation?.  Descriptive statistics for the 
overall scores for Self-Confidence and Satisfaction in addition to scores for all thirteen items are 
provided in Table 5.   
 
  
 
65 
 
Table 5 
Descriptive Information for the Student Satisfaction and Self-Confidence in Learning 
Item Number Minimum Maximum Mean SD 
Satisfaction Overall 3.2 5.0 4.8 .35 
1 4.0 5.0 4.8 .38 
2 3.0 5.0 4.7 .52 
3 3.0 5.0 4.9 .35 
4 3.0 5.0 4.8 .46 
5 3.0 5.0 4.9 .40 
Self-Confidence Overall 3.5 5.0 4.6 .40 
6 3.0 5.0 4.5 .62 
7 3.0 5.0 4.6 .56 
8 3.0 5.0 4.7 .49 
9 3.0 5.0 4.8 .46 
10 4.0 5.0 4.7 .47 
11 3.0 5.0 4.7 .50 
12 4.0 5.0 4.7 .47 
13 1.0 5.0 4.3 .94 
 
 The Pearson Product-Moment Correlation was used to answer questions two and three.  
An analysis was conducted to examine the correlation between the five simulation design 
characteristics and the learning outcomes of satisfaction and self-confidence.  The sample size (n 
= 47) was appropriate for the Pearson Product-Moment Correlation to examine correlational 
statistics.  The statistics provide information about the strength and degree of the relationship 
 
66 
 
between two variables with a recommended correlation of 0.7 or greater in order to establish that 
a relationship exists (Sullivan-Bolyai & Bova, 2010).   
 Correlation between design characteristics and student self-confidence.  All five 
design characteristics showed statistically significant correlations (p < .05) with self-confidence.  
The design element with the highest correlation to self-confidence was Objectives (rs = .660) 
indicating a moderate correlation.  The design element with the lowest correlation to self-
confidence was Fidelity (rs = .429) which indicated a weak/moderately weak correlation.   
 Correlation between design characteristics and learner satisfaction.  All five design 
characteristics showed statistically significant correlations (p < .05) with learner satisfaction.  
The design characteristic with the highest correlation to learner satisfaction was Objectives (rs = 
.779).  The characteristic of Support was moderately correlated with learner satisfaction (rs = 
.605).  The design characteristic with the lowest correlation to satisfaction was Feedback (rs = 
.380) which indicated a weak correlation between the two variables (see Table 6 for details).   
 
Table 6 
Correlation (r2) between Design Characteristics and Self-Confidence/Satisfaction (n = 47) 
Design Characteristics Self-Confidence Satisfaction 
Objectives .660** .779** 
Support .547** .605** 
Problem Solving .587** .540** 
Feedback .441** .380** 
Fidelity .429** .408** 
**Indicates significance at 0.01 
 
67 
 
Research Question Four 
 Research question four was, ?What is the relationship between perceived simulation 
design characteristics and learning outcomes??  A multiple regression was conducted to 
determine if the design characteristics can predict the learning outcomes of self-confidence or 
satisfaction on the part of the HFS participant.  The study was particularly interested in 
identifying whether the mid-scenario reflection contained in the Support and Feedback domains 
was a predictor for either learner self-confidence or learner satisfaction.   
 Self-confidence.  A multiple regression was conducted to investigate whether the 
simulation design characteristics can predict self-confidence.  The model summary demonstrated 
that the five design characteristics combined had an impact on self-confidence.  Results indicated 
that the simulation design elements statistically significantly predict self-confidence (R = .759, p 
= .000).  The R2 indicated that approximately 58% of the variance in self-confidence can be 
accounted for by its relationship with the five design elements (see Table 7).  The ANOVA 
analysis showed the model is appropriate to interpret the relationship between the design 
characteristics and learner self-confidence (F (5,41) = 11.133, p = .000) (see Table 8). 
 
Table 7 
Model Summary of Design Characteristics as Predictors of Self-Confidence 
Model R R Square Adjusted R Square Std. Error of the Estimate 
1 .759a .576 .524 .27268 
a. Predictors: (Constant) Objectives, Support, Problem Solving, Feedback, Fidelity 
  
 
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Table 8 
Multiple Regression Analysis of Design Characteristics as Predictors of Self-Confidence 
Model Sum of Squares df Mean Square F Sig. 
Regression 4.139 5 .828 11.133 .000a 
Residual 3.049 41 .074   
Total 7.188 46    
a.  Predictors: (Constant) Objectives, Support, Problem Solving, Feedback, Fidelity 
 
 The coefficient table showed that the design characteristic of Objectives (t = 2.953, p = 
.005) statistically significantly predicts self-confidence.  The coefficient table demonstrated that 
the design characteristics of Support (t = .916, p = .365), Problem Solving (t = 1.258, p = .215), 
Feedback (t = 1.958, p = .057), and Fidelity (t = .600, p = .552) do not significantly predict self-
confidence.  The element of Feedback is very close to an alpha level of .05.  However, power 
may be low due to the small number of participants.  It is possible the relationship between 
Feedback and self-confidence might prove to be significant with a larger sample size (see Table 
9). 
 
  
 
69 
 
Table 9 
Coefficientsa 
Model Unstandardized Coefficients Standardized 
Coefficients 
  
 B Std. Error Beta t Sig. 
(Constant)  -2.447  1.398   -1.750   .088 
Objectives     .376    .127    .392   2.953   .005 
Support     .144    .158    .139     .916   .365 
Problem Solving     .364    .289    .198   1.258   .215 
Feedback     .502    .256    .213   1.958   .057 
Fidelity     .071    .119    .072     .600   .552 
a.  Dependent Variable: Self-Confidence 
 
 Learner satisfaction.  A multiple regression was conducted to investigate whether the 
simulation design characteristics can predict learner satisfaction.  The model summary 
demonstrated that the five design characteristics combined had an impact on satisfaction.  
Results indicated that the simulation design elements statistically significantly predict learner 
satisfaction (R = .834, p = .000).  The R2 indicated that approximately 70% of the variance in 
satisfaction can be accounted for by its relationship with the five design elements (see Table 10).  
The ANOVA table showed the model is appropriate to interpret the relationship between the 
design characteristics and learner satisfaction (F (5,41) = 18.677, p = .000) (see Table 11). 
 
  
 
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Table 10 
Model Summary of Design Characteristics as Predictors of Satisfaction 
Model R R Square Adjusted R Square Std. Error of the Estimate 
1 .834a .695 .658 .20472 
a. Predictors: (Constant) Objectives, Support, Problem Solving, Feedback, Fidelity 
 
Table 11 
Multiple Regression Analysis of Design Characteristics as Predictors of Satisfaction 
Model Sum of Squares df Mean Square F Sig. 
Regression 3.914 5 .783 18.677 .000a 
Residual 1.718 41 .042   
Total 5.632 46    
a.  Predictors: (Constant) Objectives, Support, Problem Solving, Feedback, Fidelity 
 
 The coefficient table (see Table 12) showed the design characteristic Objectives (t = 
5.555, p = .000) was found to significantly contribute to the level of learner satisfaction.  The 
design characteristic of Support (t =  2.452, p = .019) was also found to significantly contribute 
to learner satisfaction.  The remaining three design characteristics of Problem Solving (t = -.281, 
p =.780), Feedback (t = 1.203, p = .236), and Fidelity (t = -.122, p = .903) did not significantly 
contribute in predicting the level of learner satisfaction.  
 
  
 
71 
 
Table 12 
Coefficientsa 
Model Unstandardized Coefficients Standardized 
Coefficients 
  
 B Std. Error Beta t Sig. 
(Constant)  .113 1.050  .108 .915 
Objectives .531 .096 .625 5.555 .000 
Support .290 .118 .315 2.452 .019 
Problem Solving .061 .217 -.038 -.281 .780 
Feedback .232 .193 .111 1.203 .236 
Fidelity -.011 .089 -.012 -.122 .903 
a.  Dependent Variable: Learner Satisfaction 
 
Additional Findings 
 The debriefing sessions following the simulation exercise garnered additional 
information regarding learners? perceptions about the HFS.  Several students commented that ?it 
was nice to know exactly what we were going to be doing.?  Many students expressed the belief 
that the virtual clinical experience was actually ?more stressful? than the actual clinical 
experience because they weren?t always certain that they would be fully supported by faculty 
during the HFS.  However, students had favorable comments regarding the HFS such as ?I wish 
we could do more of these? and ?This was the best simulation we?ve ever done?.  Several 
students indicated that they felt confident about caring for an actual patient with 
chorioamnionitis as a result of the simulation experience. 
 
72 
 
 Students made many anecdotal comments regarding the mid-scenario reflection.  Several 
noted that ?I had felt more confident about talking to the nurse-midwife because I knew what I 
needed and wanted to communicate to her?.  Several students also offered unsolicited comments 
such as ?taking the time-out gave me a chance to think about what I needed to do for the 
patient?.  Another frequent comment was ?this experience gives me more confidence to go into a 
real clinical situation?.    
In addition, faculty participants and faculty observers noted that every student group successfully 
cared for the patient and always appeared to ?feel good about their performance? at the 
scenario?s conclusion. 
Summary 
 A description of study participants (n = 47) was presented.  This chapter also provided 
information regarding the reliability analysis of both NLN instruments used in this study.  
Descriptive statistics were presented for the five simulation design characteristics and how well 
participants perceived that these five elements were incorporated into the simulation exercise.   
 Correlational analyses were also presented.  All five design characteristics were 
significantly correlated with the learning outcomes of self-confidence and satisfaction with the 
simulation experience.  These correlations ranged from moderately weak to strong.  Additional 
analysis using multiple regression found that the five combined design characteristics accounted 
for over half the variance in learning outcomes. 
 
  
 
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CHAPTER 5.  CONCLUSIONS, IMPLICATIONS, AND RECOMMENDATIONS 
 
Introduction 
This study was based on the need to explore best practices for high-fidelity simulation 
(HFS) instruction in nursing education.  The purpose of this study was to examine the perceived 
characteristics of a simulation design incorporating an instructor-guided mid-scenario reflection 
period and explore how and whether this design affected learning outcomes.  Study participants 
included 47 junior nursing students enrolled in a Women?s Health clinical course.  Data for the 
study was obtained with the use of two instruments developed by the NLN ? the Simulation 
Design Scale and the Student Satisfaction and Self-Confidence in Learning Scale.  This chapter 
will provide a summary of the findings, implications for nursing education, and 
recommendations for further research related to HFS.       
Summary of Findings 
 A descriptive correlational design was used for this study.  Forty-seven baccalaureate 
junior nursing students in a southeastern university participated in the study.  The students were 
enrolled in a Women?s Health clinical course in which the HFS was part of the course 
requirement.  The students participated in a HFS that focused on care for a full-term laboring 
patient with chorioamnionitis ? an acute infection of the chorionic and amniotic membranes.   
Each group, composed of three randomly-assigned students, was given 35 minutes in 
which to complete the simulation exercise.  Prior to the HFS, students received the 
chorioamnionitis content in the form of a lecture, read the relevant assigned material in the 
 
74 
 
course textbook, and reviewed the written HFS objectives prior to the simulation.  Once the 
students assessed the condition of the patient and determined it was time to speak with the 
Certified Nurse-Midwife (CNM), the facilitator stopped the simulation.  The group then 
adjourned to a nearby classroom for a 10 minute facilitator-led guided reflection period.  At this 
time, the group discussed the patient?s condition, made a diagnosis, and developed a plan of care.  
The scenario resumed, interventions were accomplished, and a debriefing period followed after 
the nursing care was delivered.      
Participants completed the two instruments ? the Simulation Design Scale and the 
Student Satisfaction and Self-Confidence in Learning Scale.  The surveys were compared to a 
list of identifying numbers participants provided at the time consent was given.  One survey did 
not contain an identifying number and one participant declined to give consent to participate in 
the study.  Data from the instruments were entered into the PASWTM 18.0 statistical software 
program. 
The results indicated that study participants perceived that all five design characteristics 
measured in the Simulation Design Scale (objectives, support, problem solving, guided 
reflection, and fidelity) were present in the scenario.  The elements of Feedback and Problem 
Solving had the highest mean scores.  These two elements included the items regarding the mid-
scenario reflection; however, each design characteristic was highly rated by the participants.   
A Pearson Product-Moment Correlation revealed that all five design characteristics had 
statistically significant correlations with learner satisfaction and self-confidence.  The design 
characteristic with the strongest correlation to both student self-confidence and learner 
satisfaction was Objectives.  The weakest correlation for self-confidence was Fidelity while the 
weakest correlation for learner satisfaction was Feedback.   
 
75 
 
A multiple regression analysis was conducted to examine which design elements can best 
predict learning outcomes.  These results revealed that the five design characteristics combined 
had an impact on both self-confidence and satisfaction.  The t-tests indicated that Objectives was 
the single best predictor for both learner self-confidence and satisfaction.  The design 
characteristic of Support also contributed to predicting learner satisfaction.   
Conclusions 
 In spite of the growing use of HFS in nursing education, there is a dearth of research-
based evidence regarding best simulation practices.  More specifically, little is known about the 
role of the instructor in HFS.  This study explored the relationship of simulation design 
characteristics, including the role of the instructor on learning outcomes.  
 The results of the students? perceptions of the presence of the five design characteristics 
based on the Jeffries (2005) Simulation Model revealed that all design features were present.  
The subscales of Feedback and Problem Solving had the highest means.  The mean score for 
Feedback was 4.9 (SD = 0.17) and the Problem Solving mean was also 4.9 (SD = 0.22).  Both of 
these elements contained items regarding the presence of the mid-scenario reflection.  This 
finding indicates that participants may have found the inclusion of the mid-scenario reflection 
period valuable enough that these two domains scored higher than the other design elements.  
These results appear to support the use of mid-scenario reflection in HFS.  The literature contains 
few examples of a reflective period incorporated in an HFS though some researchers have 
advocated that reflection be included in the scenario (Clapper, 2010; Fanning & Gabba, 2007; 
Waldner & Olson, 2007).   No quantitative studies were found that examined mid-scenario 
reflection. 
 
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 Responses to the Student Satisfaction and Self-Confidence in Learning instrument 
indicate that student were satisfied overall with the obstetrical HFS.  These results are supported 
by other studies that have found that nursing students generally feel positive about the HFS 
experience (Bearnson & Wilker, 2005; Bremner et al., 2006; McCausland et al., 2004).  
Responses to the items measuring Self-Confidence indicate that students felt confident about 
their skills and knowledge regarding the simulation content.  Additionally, many students 
commented that they enjoyed the HFS and several requested more obstetrical simulations. These 
findings are also supported by other studies (Goldenberg et al., 2005; Leigh, 2008b).   
 The analysis of the correlation of the five simulation design characteristics and the 
learning outcomes revealed that all five were significantly correlated with self-confidence and 
learner satisfaction.  The domain of Objectives was the most strongly correlated design element.  
This finding supports the notion that specific, detailed, and clear Objectives are an essential 
component of HFS.  Furthermore, the simulation objectives should also match the knowledge 
and experience level of the HFS participant (Jeffries, 2005, 2007).  The strong positive 
correlation between Objectives and desired learning outcomes is consistent with findings from 
other studies regarding this relationship (Childs & Sepples, 2006; Smith & Roehrs, 2009).   
 Although still statistically significant, the design elements that included the mid-scenario 
reflection (Problem Solving and Feedback) were moderately to weakly correlated with learning 
outcomes. These findings are consistent with other studies that have examined the effect of 
design characteristics on learning outcomes (Dobbs et al., 2005; Ishtoy et al., 2010).  However, 
these studies did not involve a structured instructor-led guided reflection period.  There is little 
evidence in the literature regarding the role of instructor feedback in HFS; specifics regarding 
how and when feedback was given is inconsistent and often not defined at all (Jeffries, 2005).          
 
77 
 
These results of the effects of the mid-scenario reflection were surprising in light of the 
many favorable anecdotal remarks made by participants regarding the scenario ?time out?.  The 
students appeared to value the opportunity to experience a pause in the action in order to reflect.  
Perhaps measuring the level of learner anxiety would provide more information about the 
influence of a structured reflection period.    
The multiple regression findings indicated that the five design characteristics combined 
had an impact on both learning outcomes.  However, the findings revealed that Objectives was 
the best single predictor for self-confidence.   
Two design elements ? Objectives and Support ? were predictors for learner 
satisfaction.  Interestingly, the design characteristic of Objectives was not rated as highly on the 
Simulation Design Scale as Problem Solving or Feedback.  However, Objectives was the most 
strongly correlated element for learning outcomes while Support was moderately correlated.    
Implications 
 Because HFS is used increasingly in nursing education to teach the principles of safe and 
effective patient care, it is necessary to determine best simulation practices.  Providing, planning, 
and implementing HFS is time-consuming and requires a great deal of organization commitment.  
The cost of the expensive HFS technology for schools and, ultimately, the student, makes the 
development of effective teaching strategies critical.   
For nurse educators, the findings regarding the significance of the design characteristics 
illustrate the importance of a carefully considered simulation design on learning outcomes.  It is 
not an overstatement to declare that desirable learning outcomes begin with the simulation 
design.          
 
78 
 
This study found that the design characteristics of the Nursing Education Simulation 
Framework (NESF) (Jeffries, 2005) were statistically significantly correlated with both learner 
satisfaction and self-confidence.  The NESF is used extensively in simulation research and this 
study supports the relationships defined in that model.  However, no information was found in 
the literature about how commonly the NESF is used by faculty for simulation design unrelated 
to research.  The results of this study and others support the notion that the design characteristics 
suggested by the model are sound.  Therefore, perhaps the formal adoption of the NESF should 
be considered by schools of nursing for use as a framework for curriculum-wide simulation 
design.    
In this study, Objectives emerged as the most significant design characteristic in 
predicting learning outcomes.  Clear objectives that are based on the learner?s skill level lay the 
foundation for a solid simulation design.  Nurse educators contemplating a simulation design 
should begin with written objectives.  Collaboration with other faculty and the simulation center 
staff should be encouraged in order to determine and clarify the purpose of the simulation 
exercise.  Too often, the focus may be on the ?high-tech? simulation equipment while the? low-
tech? list of written objectives is neglected.   In addition, a clear set of learning objectives should 
serve as foundational principles that guide the operations of the simulation laboratory.       
Information regarding the Objectives should include the timeframe, the purpose of the 
simulation, and what the learner is expected to learn.  This information should be provided prior 
to the simulation in written form and reinforced by the instructor before the scenario commences.  
Pre-simulation objectives should also include an orientation to the simulation environment 
including the, mannequin, equipment, and supplies.  Written objectives can also be used during 
 
79 
 
the debriefing as a template for students to discuss how they met the objectives and to help 
solidify the concepts of the patient care provided. 
Reflection is essential to learning and guided reflection is a critical component of the 
simulation experience.  This opportunity for the learner to reflect upon the learning experience 
usually occurs during the debriefing following the scenario. However, providing reflection 
during the scenario may provide additional insight into the patient?s condition and aid in setting 
goals for the patient?s care.  Too often, students can reach an erroneous conclusion or get ?lost? 
in the rapid current of events.  In such a case, the mistakes made are not evident until the 
exercise is over.     
The mid-scenario reflection in combination with the other design characteristics had an 
impact on learning outcomes.  Though mid-scenario reflection was not the design element most 
predictive of self-confidence or learner satisfaction, it was positively correlated with learning 
outcomes.  The anecdotal comments from the students indicated that the opportunity to reflect on 
the simulation was helpful.  Perhaps a larger sample size might yield different results than those 
found in this study.      
Recommendations  
This study examined the relationship between simulation design characteristics and 
learning outcomes.  However, only a small group of homogeneous baccalaureate nursing 
students from one public university in the southeastern United States was studied.  Some bias 
may have resulted from the fact that the researcher and the instructor were one and the same 
person.  In addition, the results relied on self-reported data. Furthermore, there was some 
variability in communication during each mid-scenario reflection due to differing student 
responses and questions.  Further research is needed to determine which simulation teaching 
 
80 
 
strategies are most effective for which types of learners and in what stages of development.  
Future research should involve larger sample sizes representative of demographically and 
geographically-varied students to determine if similar results are found.   
Although there were limitations to this study, it is the first to describe and study the 
concept of mid-scenario reflection.  One limitation of this study was the lack of a control group.  
Further studies regarding the effectiveness of a mid-scenario reflection should compare data 
from students in both experimental and control groups.  Experimental design in simulation 
research is the exception rather than the norm (Kardong-Edgren, et al., 2010).  Furthermore, 
additional correlational research might also help define other teaching strategies that positively 
affect learning outcomes.  The measurement of learner anxiety might yield interesting results in 
future studies examining the influence of mid-scenario reflection.    
Little is known about the lasting effect of student self-confidence.  While this study found 
that students reported high levels of self-confidence after the HFS, it is not known whether the 
confidence gained will help students during the transition to actual practice.  Further research is 
needed to determine whether increasing the frequency of HFS opportunities will result in 
increasing levels of self-confidence.  Furthermore, there is a dearth of knowledge regarding 
whether HFS is superior in producing high levels of self-confidence and learner satisfaction 
compared to more traditional educational strategies (Alinier, Hunt, & Gordon, 2006; Cioffi, 
2001; Leigh, 2008; McConville & Lane, 2006; Scherer, Bruce, & Runkawatt, 2007).  Some 
nurse educators consider HFS to be a superior teaching method but there is no current data to 
validate this belief (Medley & Horne, 2005).   
This study measured two outcomes suggested by the Jeffries (2005) Simulation Model.  
Other learning outcomes proposed by the model such as knowledge, critical thinking, and 
 
81 
 
performance should be studied.  Another important area of study would be the transferability of 
skills to the clinical setting.  Simulation research in nursing education has focused primarily on 
learners? perceptions of the HFS rather than patient outcomes (Solnick, 2005).  Rigorous studies 
exploring the relationship between HFS and actual patient outcomes would be beneficial.     
Results of this study indicate that learning objectives significantly contributed to the 
levels of learner satisfaction and self-confidence.  More research is needed to determine how 
HFS learning objectives can be developed and provided to simulation participants to improve 
learning outcomes.  Different approaches to developing learning objectives may be needed 
depending upon the participant?s level of skill.   
Summary 
 Simulation allows nurse educators to create patient care situations in order to meet 
program learning objectives in a controlled environment without risk to the patient.  Although 
the use of HFS in nursing education is increasing, there is a paucity of evidence regarding best 
teaching strategies for optimizing learning outcomes (Jeffries, 2005; Kardong-Edgren, Adamson, 
& Fitzgerald, 2010; Prion, 2008).  More research is needed as nurse educators are beginning to 
use the body of simulation literature to determine the best practices for its use in nursing 
education programs (Harder, 2009).  This study appears to add to the evidence that HFS is an 
effective teaching strategy.       
 This quantitative study also adds to the body of knowledge regarding the presence of 
design characteristics and the learning outcomes of self-confidence and satisfaction.  The results 
of this study indicate that the design element of Objectives accounts for a significant amount of 
variation in both learning outcomes.     
 
82 
 
Simulation laboratories used in nursing programs provide the setting for both education 
and research.  HFS is a powerful teaching tool allowing the direct application of theory.  In the 
years ahead, HFS should continue to be an innovative and effective method for realizing the 
program objectives of nursing education.   
 
 
  
 
83 
 
  
  
  
  
 
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Appendix A 
Permission to Use the Nursing Education Simulation Framework 
 
  
 
100 
 
 
 
  
 
101 
 
  
  
  
  
 
Appendix B 
Institutional Review Board Approval 
 
  
 
102 
 
3/4/2011 
 
 
Dear Dr. Raines, 
 
Your protocol entitled "Simulation Design in Nursing Education:  The Impact?" has been 
reviewed.  Your protocol has now received final approval as "Expedited" under 45 CFR 
46.110(#7). 
 
This e-mail serves as official notice that your protocol has been approved.  A formal 
approval letter will not be sent unless you notify us that you need one.  By accepting 
this approval, you also accept your responsibilities associated with this approval.  Details of your 
responsibilities are attached.  Please print and retain. 
 
If you need your consent document quickly, please let us know.   You may not begin 
your research that involves human subjects until you receive your informed consent with an IRB 
approval stamp applied.  Please make two copies of the document for each participant.  You will 
keep a signed copy and give the other to him/her. 
 
Your protocol will expire on February 22, 2012.  Put that date on your calendar now. About 
three weeks before that time you will need to submit a final report or renewal request.  (You 
might send yourself a delayed e-mail reminder for next January.)   
  
If you have any questions, please let us know. 
 
Best wishes for success with your research! 
 
Office of Research Compliance 
307 Samford Hall 
Auburn University, AL  36849 
(334) 844-5966 
hsubjec@auburn.edu 
 
 
  
 
103 
 
  
  
  
  
 
Appendix C 
Informed Consent 
 
  
 
104 
 
 
 
 
105 
 
 
  
 
106 
 
  
  
  
  
 
Appendix D 
Permission for Use of NLN Instruments 
 
  
 
107 
 
From: Alyss Doyle  | Coordinator of Educational Programming | National League 
for Nursing | 
To: Kimberly Raines 
Regarding: Request for NLN Survey Instruments 
 
It is my pleasure to grant you permission to use the ?Educational 
Practices Questionnaire,? and ?Simulation Design Scale?. 
NLN/Laerdal Research Tools. In granting permission to use the 
instruments, it is understood that the following assumptions 
operate and "caveats" will be respected:  
  
 
1. It is the sole responsibility of (you) the researcher to 
determine whether the NLN questionnaire is appropriate to her or his 
particular study.  
2. Modifications to a survey may affect the reliability and/or 
validity of results. Any modifications made to a survey are the sole 
responsibility of the researcher.  
3. When published or printed, any research findings produced using 
an NLN survey must be properly cited as specified in the Instrument 
Request Form. If the content of the NLN survey was modified in any way, 
this must also be clearly indicated in the text, footnotes and endnotes 
of all materials where findings are published or printed.  
 
I am pleased that material developed by the National League for Nursing 
is seen as valuable as you evaluate ways to enhance learning, and I am 
pleased that we are able to grant permission for use of the ?Educational 
Practices Questionnaire (student version),? and  ?Simulation Design 
Scale? instruments.  
 
  
 
Alyss Doyle  | Coordinator of Educational Programming | National League 
for Nursing | www.nln.org <http://www.nln.org/>  
adoyle@nln.org | Phone: 800-669-1656 x145 | Fax: 212-812-0391 | 61 
Broadway | New York, NY 10006 
 
 <http://www.nln.org/art/emailsigwithsummit.gif>  
 
 
  
 
108 
 
  
  
  
  
 
Appendix E 
Simulation Design Scale and Student Satisfaction and Self-Confidence in Learning Instruments 
 
 
Sample Items from the Simulation Design Scale (SDS) 
2.    I clearly understood the purpose and objectives of the simulation 
7.    My need for help was recognized 
9.    I was supported in the learning process 
 
Sample Items from the Student Satisfaction and Self-Confidence in Learning Instrument 
1.    The teaching methods used in this simulation were helpful and effective 
3.    I enjoyed how my instructor taught the simulation 
6.    I am confident that I am mastering the content of the simulation activity that my instructors    
       presented to me