Systematic review of the literature on simulation in nursing education


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Twenty five of the 40 studies Half of the studies compared education using high-fidelity simulators with a control group. Learners at various levels of training were represented.

The overall effect size for the random effects model was 0. The possibility of a publication bias was minimal because the funnel plot appeared symmetrical. Studies using HFSs 0.

For cognitive outcome, which is a sub-domain of learning, the effect size was the highest for HFS 0. Regarding affective outcome, HFS 0. MFS 1. The present study provided meta-analytical data for evidence-based education through a comprehensive analysis of simulation-based nursing education with diverse backgrounds and characteristics. Through this process, 20 Korean papers were included additionally and half of papers were Korean. This could cause different result compared to previous one. In addition to including a reaction outcome according to fidelity levels, effect sizes based on outcomes and fidelity level were identified.

A systematic search of the literature resulted in 40 published studies that were eligible for inclusion in this meta-analysis. These primary studies provided evidence of the effects of simulation-based nursing education in various evaluation and learning environments.


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Random assignment studies accounted for The medium-to-large effect size 0. This is consistent with the findings of a study on health professional education [ 16 ], which reported that technology-enhanced simulation training produced moderate to large effects. Regarding simulator fidelity level, HFS 0. This result supports the findings of a previous meta-analysis of simulation in health professions, showing that HSF offers benefits over LFS [ 17 ]. However, these findings should be interpreted with caution. Recent studies suggest that the degree of realism required of a simulation is a function of the learning task and context, and can therefore vary widely for different areas of educational outcomes [ 17 ].

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Satisfaction levels are high among students participating in simulation learning that utilizes human simulators or SP [ 18 ]. Considering that problem-based learning PBL lessons were found to enhance student attitudes more than traditional lectures [ 19 ], student participation and actual activity appear to have positive effects on satisfaction and learning attitudes. In the sub-group analysis for learning outcome according to fidelity level, the effect size was the largest for psychomotor outcome, followed by affective and cognitive outcomes.

This result differs somewhat from the meta-analysis on the effects of PBL [ 19 ], in which effect sizes were the largest for psychomotor outcomes, followed by the cognitive and affective domains. Specifically, the effect size of cognitive outcome was the largest for HFS 0. In the psychomotor domain, the order was MFS 1.

These results demonstrate that HFS and SP are effective in producing cognitive and affective outcomes; however, to achieve psychomotor learning outcomes, technical training using MFS would be more helpful, which concurs with the lack of positive association between fidelity and process skills [ 17 ]. However, the present study has the limitation of not considering learning-related factors in the analyses based on the fidelity level of simulators. Even though debriefing has become more crucial in simulation-based learning and the methods have diversified over the years, a few selected studies do not indicate the methods of debriefing they had used, making it difficult to categorize and discuss the effects of each debriefing method.

This may be because it is customary to omit debriefing while learning from low fidelity simulations, especially for training simple nursing skills. In addition, we did not include studies published in languages other than English or Korean.

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Despite such limitations, this study demonstrated that simulation-based nursing education has an educational effect, with particularly strong effects in the psychomotor domain. Since the effects are not proportional to fidelity level, educational interventions should be broad enough to satisfy educational goals, all of which are supported by the results presented above. In addition, a recent study reported that debriefing was the most important factor in simulation, with positive effects from self-debriefing and video-facilitated instructor debriefing [ 20 ].

Based on these findings, the clinical reflection process needs to be improved to increase the learning effects in the cognitive domain. Our results indicated that simulation-based nursing educational interventions were effective with particularly large effects in the psychomotor domain.

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In addition, the effect of simulation-based nursing education was not proportional to fidelity level. Therefore, it is important to use an appropriate level of simulation to meet all of the educational goals and outcomes. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. Hovancsek MT. Using simulations in nursing education. In: Jeffries PR, editor. Simulation in nursing education: from conceptualization to evaluation. New York: National League for Nursing; Dieckmann P. Simulation settings for learning in acute medical care.

In: Dieckmann P, editor. Using simulations for education, training and research. Lengerich: Pabst; Nurse Educ Prac. Int J Evid Based Healthc. Ann Intern Med. Case control study checklist. Deepening the theoretical foundations of patient simulation as social practice. Simul Healthc.

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Simulation and new learning technologies. Simulation: not just a manikin. J Nurs Educ. A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nurs Educ Perspect ; 26 : 96 — Effectiveness of simulation-based nursing education depending on fidelity: a meta-analysis.

BMC Med Educ ; 16 : Higgins JP , Green S. PLoS Med ; 6 : e Hunt DP.

The concept of knowledge and how to measure it. Journal of Intellectual Capital ; 4 : — Sehwail L , DeYong C. Six Sigma in health care. Leadersh Health Serv ; 16 : 1 — 5. Zulkosky K. Nurs Forum ; 44 : 93 — Using computer assisted learning for clinical skills education in nursing: integrative review. J Adv Nurs ; 63 : — Krippendorff K. The GATE frame: critical appraisal with pictures.

Fixed- and random-effects models in meta-analysis. Psychol Methods ; 3 : — Chapter 7: Converting Among Effect Sizes.

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In : Introduction to Meta-Analysis. Cohen J. Statistical power analysis for the behavioral sciences. NJ : Lawrence Earlbaum Associates , ; 2. Cumming G. Understanding the new statistics: Effect sizes, confidence intervals, and meta-analysis : Routledge , Statistical methods for dealing with publication bias in meta-analysis. Stat Med ; 34 : — References : Wiley Online Library , Higgins JPT.

Commentary: Heterogeneity in meta-analysis should be expected and appropriately quantified. Int J Epidemiol ; 37 : — Comparison of knowledge, confidence in skill performance CSP and satisfaction in problem-based learning PBL and simulation with PBL educational modalities in caring for children with bronchiolitis. Nurse Educ Today ; 35 : — Evaluating high-fidelity human simulators and standardized patients in an undergraduate nursing health assessment course.

systematic review of the literature on simulation in nursing education Systematic review of the literature on simulation in nursing education
systematic review of the literature on simulation in nursing education Systematic review of the literature on simulation in nursing education
systematic review of the literature on simulation in nursing education Systematic review of the literature on simulation in nursing education
systematic review of the literature on simulation in nursing education Systematic review of the literature on simulation in nursing education
systematic review of the literature on simulation in nursing education Systematic review of the literature on simulation in nursing education
systematic review of the literature on simulation in nursing education Systematic review of the literature on simulation in nursing education
systematic review of the literature on simulation in nursing education Systematic review of the literature on simulation in nursing education
systematic review of the literature on simulation in nursing education Systematic review of the literature on simulation in nursing education
Systematic review of the literature on simulation in nursing education

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