Increasing Confidence and Improving Clinical Competence: using

high-fidelity simulation to bridge the gap between nursing education

and clinical practice.
Kristi Burns, RN, BSN

Master of Science in Nursing Student

The University of Texas at Tyler - College of Nursing and Health Sciences

INTRODUCTION
Simulation as a learning strategy in the education
of undergraduate nursing students is a dynamic
process involving the creation of a hypothetical
opportunity that incorporates an authentic
representation of reality, facilitates active
student engagement, and integrates the
complexities of practical and theoretical
learning with an opportunity for
repetition, feedback, evaluation, and
reflection (Sook Roh, 2014).
Students level of self-confidence
and clinical judgment is a key determination
of students satisfaction in clinical experience. In
the ever changing field of nursing, the health care
environment can present unique challenges to
nursing students entering into clinical experiences.
Worrying they could harm a patient, dreading being
unprepared for the particulars of clinical situations,
and feeling uncertain of how to communicate with
patients and families, new students experience
initial jitters, compromising their self-confidence
and calling into question their competence (Blum,
Borglund, & Parcells, 2010). Therefore, fostering
confidence and competence in Bachelor prepared
nursing students through the use of high-fidelity
simulation is priority in developing the next
generation of healthcare providers.

RESEARCH QUESTION
In bachelor prepared nursing students in the US, does
the use of high fidelity simulation as 50% of clinical
experiences, as compared to no use of simulation in
clinical experiences, increase students competence
and self-confidence in the workplace as evidence by
successful completion of annual competency reviews
and self-report of increased confidence?

REVIEW OF LITERATURE
High-fidelity simulation has been used to augment
clinical learning, providing critical thinking and
psychomotor learning opportunities in
lowand high-risk clinical environments
and
populations (Richardson & Claman,
2014).
Simulation makes for an ideal
learning
environment for nursing students: it mirrors the
clinical setting and mimics patients responses in a
controlled setting, without the risk of students
harming patients. Unpredictable patient conditions
can be included, as can the patients responses to
students interventions (Weaver, 2014). The literature
shows nursing students want their learning to be
interactive and reflective of a real world context
(Mills, West, Langtree, Usher, Henry, ChamberlainSalaun, & Mason, 2013). Simulated situations provide
students with an opportunity to practice nursing based
on knowledge, skills and attitudes in a safe learning
context (Tosterud, Hedelin, & Hall-Lord, 2013).
Current studies show that students perceive enhanced
performance following immersive simulation
involving clinical emergency scenarios (Gordon &
Buckley, 2009; Swenty & Eggleston, 2010; Mould,
White & Gallagher, 2011). According to research by
Yuan, Williams & Fang (2011) further research needs
to be conducted to examine the transferability of the
simulation experience into real clinical situations.
There is a need to assess the effects of simulationbased training on learners actual performance with
objective measures and to assess
whether the improvements in selfefficacy brought about by simulationbased training translate into improvements in patient-focused outcomes
(Sook Roh, 2014).

DECISION & RATIONALE

Based upon the review of the literature, there is little
evidence concerning the effect of high-fidelity
simulation on nursing students self-confidence and
competence as it translates to real world clinical practice.
Although students reported increased confidence across
a range of technical and nontechnical skills
following immersive simulation, this may
not necessarily translate to changed or
enhanced behavior and psychomotor skills
during clinical emergencies in their workplaces. Transference to the clinical setting
of skills learned and practiced during simulation remains
the elusive goal of simulation in nursing education
(Gordon & Buckley, 2009). Therefore, it is purposed to
conduct a study to examine the effects of simulation use
in clinical experience on confidence and competence in
the workplace.

IMPLEMENTATION
An observational, longitudinal study design with a
control group consisting of senior level BSN students
chosen by convenience sampling will be used. The
study will take place over 2 years, through the final
year of a nursing program and into the first year of
nursing practice. Participants will be randomly
assigned to one of two groups: (1) a traditional
clinical group with no simulation use, or (2) a clinical
group using simulation scenarios as 50% of their
clinical experience. An OSCE will be administered
prior to the study and aubsequently after the
completion of each year. Self-assessment and peer
review will take
place at the conclusion of each
year. SPSS will be used for data analysis to perform a
paired t- test to assess the differences in competence
and confidence before and after the study.

CONCEPTUAL FRAMEWORK
Patricia Benners From Novice to Expert Theory,
as well as Albert Banduras Self-Efficacy Theory
will help drive this study.
Study Variable
Independent Variable:
Use of simulation throughout
the nursing education program

Dependent Variable:
Student level of competence

Study Variable
Independent Variable:
Use of simulation throughout
the nursing education program

Dependent Variable:
Student reported level of selfconfidence

Benners Theory

Operational Definition

Each step builds on the

previous one as abstract
principles are refined and
expanded by experience and
the learner gains clinical
expertise.

Thorough description of the

simulation process through
well thought out case study
scenarios.
Description of relationship
between instructor and student
during simulation process.

Gains perspective from

planning own actions based on
conscious, abstract, and
analytical thinking and helps to
achieve greater efficiency and
organization.

Describe the process of annual

workplace competency/skills
tests.
Description of student
performance on
competence/skills tests.

Banduras Theory

Operational Definition

Self-efficacy developing from

mastery experiences in which
goals are achieved through
perseverance and overcoming
obstacles and from observing
others succeed through
sustained effort.

Descriptions of behaviors,
environment, and
personal/cognitive factors that
influence self-efficacy.

Self-efficacy relates to a
persons perception of their
ability to reach a goal.

Description of students self

reported confidence levels as it
relates to behaviors,
environment, and
personal/cognitive factors.

IMPLICATIONS FOR EBP

Nursing knowledge and clinical performance are the
basis for undergraduate education and determine the
level of competence with which the new graduate
enters the workforce (Hicks, Coke, & Li, 2009).
Simulation makes for an ideal environment for
nursing students: it mirrors the clinical setting and
mimics patients responses in a controlled setting,
without the risk of students harming patients
(Weaver, 2014). Transference to the clinical setting
of skills learned and practiced during simulation
remains the elusive goal of simulation in nursing
education (Gordon & Buckley, 2009). The proposed
research study may illustrate that the use of highfidelity simulation in the senior year of nursing
education can improve competence and confidence
in the workplace.

References

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