Locating "gold standard" evidence for simulation as a substitute for clinical practice in prelicensure health professional education: A systematic review.

AIMS AND OBJECTIVES: To extract, examine and report the highest available levels of evidence from healthcare disciplines in the use of simulation-based education as substitution for clinical placement in prelicensure programmes. BACKGROUND: Simulation is widely employed across prelicensure health professional education to create safe, realistic clinical learning experiences for students. Whether simulation can be employed to substitute for actual clinical placement, and if so, in what proportion, replacement ratio and duration, is unclear. METHODS: A systematic review and quality appraisal of primary studies related to prelicensure students in all health disciplines, guided by the PRISMA checklist. RESULTS: Ten primary studies were included, representing 2,370 students from three health disciplines in four countries. Nine studies were experimental and quasi-experimental and methodological quality was assessed as moderate to high with good to very good inter-rater agreement. Direct substitution of simulation for clinical practice ranged from 5% to 50%. With one exception, replacement ratios were 1:1 and duration of replacement ranged from 21 hr-2 years. Levels of evaluation included measures of reaction, knowledge and behaviour transfer; no negative outcomes were reported. We appraised practicalities for design of substitution, design limitations and knowledge transfer to accreditation standards for prelicensure programmes. CONCLUSIONS: This review synthesised highest levels and quality of available evidence for substitution of simulation for clinical placement in health professional education. Included studies were heterogenous in simulation interventions (proportion, ratio and duration) and in the evaluation of outcomes. Future studies should incorporate standardised simulation curricula, widen the health professions represented and strengthen experimental designs. RELEVANCE TO CLINICAL PRACTICE: Current evidence for clinical educational preparation does not appear to be translated into programme accreditation standards governing clinical practice experience for prelicensure programmes in relevant jurisdictions. Overall, a stronger evidence base is necessary to inform future curricula and policy development, to strengthen clinical practice in health.

A cross-national study to objectively evaluate the quality of diverse simulation approaches for undergraduate nursing students.

The aim of this paper is to report the results of a cross-national study that evaluated a range of simulation sessions using an observation schedule developed from evidence-based quality indicators. Observational data were collected from 17 simulation sessions conducted for undergraduate nursing students at three universities in Australia and the United Kingdom. The observation schedule contained 27 questions that rated simulation quality. Data were collected by direct observation and from video recordings of the simulation sessions. Results indicated that the highest quality scores were for provision of learning objectives prior to the simulation session (90%) and debriefing (72%). Student preparatiosn and orientation (67%) and perceived realism and fidelity (67%) were scored lower than other components of the simulation sessions. This observational study proved to be an effective strategy to identify areas of strength and those needing further development to improve simulation sessions.

Continuing education for nurses: a necessity or a nicety?

The changing health care climate has resulted in escalating financial constraints. One department that is often scrutinized for its cost-benefit relation to the hospital is the nursing education department. These departments are increasingly being reduced in size and investment in the continuing education of nurses is being rationalized. However, reducing financial support of education may be counterproductive in both the short- and long-term. This article does not propose a "recipe" for effectively facilitating continuing education. However, it does provide sound justification for investing in the continuing education of nurses and demonstrates not only that quality education results in enhanced knowledge and skills, but that there is also a positive correlation between professional development and factors such as staff satisfaction, staff retention, and quality patient care.

Self-directed learning: implications and limitations for undergraduate nursing education.

Self-directed learning (SDL) is an educational concept that has received increasing attention in recent years, particularly in the context of higher education. Whilst the benefits of SDL have been espoused by a number of adult education theorists (Brookfield, S., 1986. Understanding and Facilitating Adult Learning. Jossey-Bass, San Francisco; Houle, C., 1984. Patterns of Learning: New Perspectives on Life-Span Education. Jossey-Bass, San Francisco; Knowles, M., 1998. The Adult Leaner: A Neglected Species, fifth ed., Gulf, Houston; Tough, A., 1979. The Adults Learning Project: A Fresh Approach to Theory and Practice in Adult Learning. Ontario Institute for Studies in Education, Toronto), its introduction into curricula has not always been successful (Nolan, J., Nolan, M., 1997a. Self-directed and student-centred learning in nurse education: 1. British Journal of Nursing 6 (1), 51-55; Nolan, J., Nolan, M., 1997b. Self-directed and student-centred learning in nurse education: 2. British Journal of Nursing 6 (2), 103-107; Slevin, O., Lavery, M., 1991. Self-directed learning and student supervision. Nurse Education Today 11, 368-377). The indiscriminate application of SDL principles and poorly prepared teachers and/or students has at times meant that the introduction of SDL has been resented rather than welcomed (Iwasiw, C., 1987. The role of the teacher in self-directed learning. Nurse Education Today 7, 222-227; Turunen, H., Taskinen, H., Voutilainen, U., Tossavainen, K., Sinkkonen, S., 1997. Nursing and social work students' initial orientation towards their studies. Nurse Education Today 17, 67-71). This paper clarifies and explores these issues by: (a) examining the origins of SDL; (b) discussing the relevance of self-directed learning to Knowles' theory of adult learning and contemporary educational practices such as enquiry based learning and problem based learning; and (c) highlighting the implications and limitations of SDL with regard to adult education in general, and undergraduate nursing education in particular.