Nurse Education Today 36 (2016) 3743

Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/nedt

Beginning and advanced students perceptions of the use of low- and

high-delity mannequins in nursing simulation
Tulay Basak a,, Vesile Unver a,1, Jacqueline Moss b,2, Penni Watts b,3, Vanessa Gaioso b,4
a
b

Gulhane Military Medical Academy, School of Nursing, Ankara, Turkey

UAB School of Nursing, 1720 2nd Avenue South, NB 506A, Birmingham, AL, USA

a r t i c l e

i n f o

Article history:
Accepted 14 July 2015
Keywords:
Low-delity
High-delity
Nursing
Simulation
Perception

s u m m a r y
Background: There is little research evidence that demonstrates the difference between the use of low- and highdelity mannequins in assisting students to acquire their skills when students are at different points in their
nursing education experience.
Objectives: Our study examined differences between the use of low- and high-delity mannequins on student
outcomes with both beginner and advanced students.
Design: A quasi-experimental investigation.
Settings: Participants performed two simulations, one simulation using a low-delity mannequin and the other
simulation using a high-delity mannequin.
Participants: First and fourth semester pre-licensure students from a Bachelor of Science in Nursing program and
an accelerated nursing entry program participated in this study.
Methods: A Students Satisfaction and Self-condence Scale and Simulation Design Scale were used to obtain data.
Statistical analysis was performed using the Statistical Package for the Social Sciences for Windows version 17.0.
The results obtained from scales were compared using Wilcoxon sign test and MannWhitney U test. A p value of
b 0.05 was considered statistically signicant.
Results: The student satisfaction score of the students in the low-delity mannequin group was 3.62 1.01, while
that of the students in the high-delity mannequin group was 4.67 0.44dir (p = 0.01). The total score of the
simulation design scale in the low-delity mannequin group was 4.15 0.63, while it was 4.73 0.33 in the
high-delity mannequin group (p = 0.01).
Conclusions: Students perceptions of simulation experiences using high-delity mannequins were found to be
higher in contrast to their perceptions of experiences using low-delity mannequins.
2015 Published by Elsevier Ltd.

Introduction
Advances in technology have had a signicant effect on the development of teaching and learning methods used in educational settings. In
nursing education, simulation training involves extensive use of such
technologies to prepare students for clinical practice in a risk-free
environment. The World Health Organization (WHO, 2011) recommends the use of simulation-based education to improve the security
of patients. Students who are prepared for clinical practice using
simulation decrease the risk to patients associated with a novices lack
of experience.

Corresponding author. Tel.: +90 312 304 3956.

E-mail addresses: tbasak@gata.edu.tr (T. Basak), vunver@gata.edu.tr (V. Unver),
mossja@uab.edu (J. Moss), piwatts@uab.edu (P. Watts), vgaioso@uab.edu (V. Gaioso).
1
Tel.: +90 312 304 3956.
2
Tel.: +1 205 934 0657.
3
Tel.: +1 205 934 6560.
4
Tel.: +1 205 996 9608.

http://dx.doi.org/10.1016/j.nedt.2015.07.020
0260-6917/ 2015 Published by Elsevier Ltd.

As a result of the need for nurses internationally, the number of

nursing students has been increasing, increasing the need for clinical
practice sites and experiences. Since real experience in practice is limited, students cannot always be provided with sufcient opportunities to
practice the number and variety of skills necessary for competent entry
into professional nursing practice. Nursing faculty must employ innovative techniques to improve students clinical skills and support their
practice experience. Simulation-based training can provide students
with rich learning experiences (Parr and Sweeney, 2006). Nursing
students often report that they experience anxiety when they try to
transfer their theoretical knowledge to practice (Sinclair and Ferguson,
2009). Simulation training is used as a signicant teaching-learning
strategy to improve nursing students clinical skills, to integrate
theory and practice and to overcome students negative experiences
(Cannon-Diebl, 2009). Simulation can be employed to create experiential student-centered training environments (Jeffries, 2012).
Simulation-related technologies have been expanding from lowdelity technologies to high-delity technologies. In low-delity
simulation training, task-trainers and mannequins are usually static

38

T. Basak et al. / Nurse Education Today 36 (2016) 3743

with minimal replication of physiological responses, whereas in

high-delity simulation training, full-scale, computer-integrated and
physiologically responsive mannequins are used to replicate a full
range of clinical experiences (Jeffries, 2005; Ballangrud et al., 2014;
Kathleen and Kuznar, 2007). High-delity simulation has been
promoted as an innovative teaching strategy that can be used in transferring students self-condence and competence into clinical settings
(Bambini et al., 2009).
Some research suggests that simulations which involve high-delity
mannequins improve students clinical skills, communication, decisionmaking, critical-thinking, and has a positive effect on their selfcondence and teamwork (Brannan et al., 2008; Kameg et al., 2010;
Ackerman, 2009; Shared et al., 2013; Kardong-Edgren et al., 2007).
However, high-delity mannequins are costly and require extensive
training to program and maintain. Furthermore, developing and executing simulations using high-delity mannequins can require much more
faculty time and expertise (Kardong-Edgren et al., 2007). In addition,
two previous studies have shown that there is no statistically signicant
difference between low-delity, moderate and high-delity simulation
on student performance (Chang et al., 2002; Kardong-Edgren et al.,
2007). Therefore, it is not clear that the signicant investment in time,
money, and expertise developing high-delity simulation experiences
pays off in improved student outcomes.
Background
The National League for Nursing/Jeffries Simulation Framework was
developed through the NLN/Laerdal simulation study to guide clinical
simulation in nursing. It has ve componentsfacilitator, participant,
educational practices, simulation design characteristics and expected
student outcomes. The aim of the framework is to prepare faculty for
their role in developing, implementing and evaluating the use of clinical
simulation in nursing curriculum (Jeffries, 2012). This framework
guided the design of this study and study simulation design.
When planning simulation-based educational experiences, it is
important to make sure that the method and simulation equipment
to be used is congruent with the learning goals of the simulation
(McGovern et al., 2013). There is evidence to support the assertion
that simulation experiences using high-delity mannequins allows
students to make connections between theory and practice (Kidd and
Kendall, 2006; Shepherd et al., 2007; Butler and Veltre, 2009). In addition, such simulations are argued to be an effective educational strategy
to teach nursing process and can enhance critical thinking (Burns et al.,
2010).
Educational experiences using high-delity mannequins employ the
principles of active learning and provide valuable opportunities for
students to improve both psychomotor skills and critical thinking
(Childs and Sepples, 2006). There are many advantages offered by
high-delity mannequins in teaching clinical skills. Such advantages
include the planned and gradual improvement in problem solving,
opportunities for unlimited repeating of skills, provision of immediate
feedback and allowing students to learn at their own pace. In addition,
research suggests that nursing students became less anxious in clinical
settings following the use of clinical scenarios with high-delity mannequins (OBrien et al., 2001; Childs and Sepples, 2006). Also, it potentially
offers nursing students varied clinical experiences with high-risk events
and events rarely seen thus reducing their discomfort and unfamiliarity
with these important care situations. Simulations with high-delity
mannequins play a signicant role in improving nursing students' selfcondence and ability to cope with such difcult patient care situations.
(Prentice and ORourke, 2013).
There has been an increase in the use of high-delity mannequins in
nursing education in recent years. More than 40% of nursing education
programs reported the use of high-delity mannequins in the training
of novice students (Hayden, 2010). The National Council of State Boards
of Nursing recently performed a study to examine whether time and

activities in a simulation laboratory could effectively substitute for traditional clinical hours in the nursing curriculum. They found no difference
in nursing knowledge, clinical competency and perception of learning
needs being met among undergraduate students when traditional
clinical hours are substituted with 25% and 50% of simulation hours.
They came to the conclusion that simulation expeiences, when well
structured, with adequately prepared faculty and appropriate resources,
dedication, foresight and vision can produce excellent student outcomes in pre-licensure nursing programs (Hayden et al., 2014).
Beginner students can increase their expertise in technical skills
when they participate in scenarios with high-delity mannequins,
while more advanced students may improve their evaluative and
critical thinking skills in the same educational setting (Maas and
Flood, 2011). However, research on the use of high-delity mannequins
in early periods of nursing education is very rare. The difference
between the use of high- and low-delity mannequins in simulationbased education have been compared in only a few studies (Wang
et al., 2013.)
There is little research evidence that demonstrates the difference
between the use of low- and high-delity mannequins in assisting students to acquire their skills when students are at different points in their
nursing education experience. Our study examined differences between
the use of low- and high-delity mannequins on student perceptions of
satisfaction, condence and evaluation of simulation experience with
both beginner and advanced students. The investigators wanted to see
if student perceptions of satisfaction, condence and evaluation of
simulation experience varied when using different levels of delity,
and if there was also a difference by level of nursing student.
Research Questions
The research questions used to guide this study were:
1. Is there a difference in student satisfaction, condence and evaluation of simulation design when experiencing simulation using low
or high-delity mannequins?
2. Is there a difference in student condence, satisfaction and evaluation of simulation design between beginner and advanced students
in simulations using low- and high-delity mannequins?
Methodology
Study Design
The study was designed and carried out as a quasi-experimental
investigation. The study was conducted in a large school of nursing in
the southeastern United States. Approval to conduct the study was
obtained from the organizations Institutional Review Board (IRB) and
each student provided informed consent prior to participation.
Participants
First and fourth semester pre-licensure students from a Bachelor of
Science in Nursing (BSN) program and an accelerated nursing entry
program participated in this study. The beginner group consisted of
rst semester BSN students, the advanced group consisted of fourth
semester BSN and third semester accelerated nursing students. After
all students were informed about the study, 66 volunteer students (34
beginner; 32 advanced) agreed to participate in the study.
Data Collection
The participants were asked for a convenient time that would not
conict with the participants school schedule to complete the study
simulations. The students were divided into subgroups consisting of 3
students. Each subgroup performed two simulations, one simulation

T. Basak et al. / Nurse Education Today 36 (2016) 3743

using a low-delity mannequin and the other simulation using a

high-delity mannequin. Both case scenarios were related to a patient/mannequin with respiratory distress. The study simulation
experiences for each of the two scenarios (low delity and high delity) included the same elements related to the needs of a patient in
respiratory distress. The same simulation scenarios were used for
both the advanced and beginner groups of students.
Participants were expected to perform appropriate nursing care for
this patient/mannequin that took approximately 10 min for each of
the two simulations. The determination of which scenario was presented rst, high or low delity, was decided by casting lots. Afterwards, the
students participated in a debrieng session, lasting approximately
20 min, where they had the opportunity to discuss the case scenario
and clarify any questions about their performance in the simulation.
The debrieng session is a routine procedure conducted after all
sessions in the simulation lab, so the students already expect these
self-reective discussions.
After the debrieng sessions, the participants were asked to
complete two questionnaires: (1) students satisfaction and selfcondence scale (13 questions related to student self-condence
and satisfaction with the learning experience) and the (2) simulation
design scale (20 questions regarding participants perceptions of the
simulation objectives, student support, problem solving and guided
reection). The maximum amount of time used to answer these questionnaires was 15 min. All the participants completed the same simulation scenarios and debrieng sessions as well as completing the same
questionnaires. The questionnaires did not have any identiers and
the participants also placed the questionnaires in a closed box to guarantee the condentiality of the surveys.

Instruments
Students Satisfaction and Self-condence Scale
This instrument is a 13-item scale to measure student satisfaction
with the simulation activity (5 items) and self-condence in learning
(8 items). Cronbachs alpha for satisfaction in previous studies has
been at .94, and for self-condence at .87 (Jeffries, 2012). In a
previous study with Chinese students, the Cronbachs alpha for
satisfaction was .94, and for self-condence it was .72 (Wang et al.,
2013).

Simulation Design Scale

The SDS is a 20-item tool developed to measure constructs from
the Jeffries (2005) simulation model. The design features rated by
the students include objectives and information (5 items), student
support (4 items), problem solving (5 items), guided reection or
feedback (4 items) and delity (2 items). The Cronbachs alpha for
the instrument in a previous study was .92 (Jeffries, 2012). In a
previous study with Chinese students, the Cronbachs alpha was .88
(Wang et al., 2013).

Data Analysis
Statistical analysis was performed using the Statistical Package for
the Social Sciences (SPSS, Inc., Chicago, IL, USA) for Windows version
17.0. The normality of data was tested using KolmogorovSmirnov
test. Descriptive statistics were presented using the arithmetic mean
and standard deviation, minimummaximum, frequency and percentage. Data were not normally distributed; therefore, non-parametric
statistical tests were used to analyze study data. The results obtained
from scales were compared using Wilcoxon sign test, MannWhitney
U test and analysis of covariance (ANCOVA). A p value of b 0.05 was considered statistically signicant.

39

Results
Socio-demographic Characteristics
The average age of beginner students was 23.27 6.56, advanced
students were 24.75 6.12. Of the beginner students, 91.2% were
female and 87.5% of advanced students were females. Although BSN
and accelerated entry students were recruited for the advanced student
group, there was no signicance difference between the two groups in
age (t = 0.01, p N 0.05). Table 1 shows the socio-demographic features
of the students.
Students Satisfaction, Self-condence and Simulation Design for Low- and
High-delity Mannequins
Cronbachs alpha was completed to test for reliability of the instruments indicated. In this study, the overall Cronbach's alpha for the
student satisfaction scale was .91, and for the self-condence in learning
scale was .80, and for the simulation design scale was .93.
The comparison of students scores on the student satisfaction scale,
self-condence in learning scale and simulation design scale between
their evaluation of simulations using low- and high-delity mannequins
were found to be statistically signicantly different. More specically,
the student satisfaction score of the students in the low-delity mannequin group was 3.62 1.01, while that of the students in the highdelity mannequin group was 4.67 0.44dir (Z = 6.35; p = 0.01).
The total score of the simulation design scale in the low-delity mannequin group was 4.15 0.63, while it was 4.73 0.33 in the high-delity
mannequin group (Z = 6.30 p = 0.01). Table 2 shows the comparison
of students satisfaction and self-condence scale scores and simulation
design scale scores based on the experiment groups, namely, the low-delity mannequin group and high-delity mannequin group.
Students Satisfaction, Self-condence and Simulation Design for Beginner
and Advanced Nursing
The intergroup comparison of the scores of the beginner and
advanced groups in the scales of student satisfaction, self-condence
in learning and simulation design in student evaluations of using lowand high-delity mannequins showed that there was a statistically
signicant difference (p b 0.05). Overall, beginning students were less
satised with the low-delity simulations than advanced students.
However, the scores of the advanced students in two subscales of the
simulation design scale were found to not be signicantly different. Of
these subscales, the score of these students in the support subscale in
regard to the simulation with low-delity mannequin was 4.74
0.45, while it was 4.87 0.27 in their evaluations of the simulation
with high-delity mannequins (Z = 1.53; p = .13). The score in
the other subscales, namely, feedback/guided reection, in regard to
low-delity mannequins was found to be 4.86 0.28, that in the
high-delity mannequin was 4.94 0.20 (Z = 1.98; p = .05).
Table 3 shows intragroup and intergroup comparisons of beginner and
advanced students scores in the self-satisfaction, self-condence and
simulation design scales.
According to the intragroup comparison of beginning and advanced
students, the scores of student satisfaction, self-condence in learning

Table 1
Socio-demographic characteristics of the students.
Age
Min

Beginner (n = 34)
Advanced (n = 32)

19
20

Gender
Max

54
38

M SD

23.27 6.56
24.75 6.12

Female

Men

31
28

91.2
87.5

3
4

8.8
12.5

40

T. Basak et al. / Nurse Education Today 36 (2016) 3743

Table 2
Comparisons of students satisfaction and self-condence and simulation design scale scores according to low- and high-delity mannequins.
Low-delity Mannequin

High-delity Mannequin

Statistical tests

M SD

M SD

Student satisfaction
Self-condence in learning

3.62 1.01
3.91 0.80

4.67 0.44
4.51 0.38

Z = 6.35; p = 0.01
Z = 5.20; p = 0.01

Simulation design scale

Objectives and information
Support
Problem solving
Feedback/guided reection
Fidelity
Total score

3.89 0.94
4.63 0.60
4.00 0.93
4.75 0.48
2.99 1.41
4.15 0.63

4.66 0.52
4.85 0.30
4.51 0.58
4.93 0.21
4.77 0.41
4.73 0.33

Z = 0.62; p = 0.01
Z = 3.00; p = 0.03
Z = 4.38; p = 0.01
Z = 3.49; p = 0.01
Z = 6.09; p = 0.01
Z = 6.30; p = 0.01

Wilcoxon sign test.

and total simulation design using the low-delity mannequin showed

that there was a statistically signicant difference between the beginner
and advanced groups (Z = 2.01; Z = 2.29; Z = 2.39; p b 0.05).
Again, advanced students rated the low-delity simulation experience
higher than the beginning students (Table 3). There was no statistically
signicant difference between the beginner and advanced groups on
the simulation design score except for the problem solving subscore

for the simulation with the low-delity mannequin (p N 0.05)

(Table 3). After adjusting for beginneradvanced groups, the estimated
means found statistically signicant differences for student satisfaction
(F = 34.20, p b 0.05), self-condence in learning (F = 17.31, p b 0.05)
and total (F = 25.20, p b 0.05) and subscale of simulation design:
problem solving (F = 11.51, p b 0.05), objective (F = 17.18, p b 0.05),
support (F = 4.80, p b 0.05) and delity (F = 5.86, p b 0.05) across all

Table 3
Intragroup and intergroup comparisons of beginner and advances students satisfaction, and self-condence and simulation design scale scores according to low- and high-delity
mannequins.
Statistical tests

Low-delity Mannequin

High-delity Mannequin

M SD

M SD

Student satisfaction
Beginner
Advanced
Statistical test

3.55 1.05
3.91 0.90
Z = 2.01; p = 0.04

4.64 0.50
4.72 0.39
Z = 0.39; p = 0.69

Z = 4.78; p = 0.001
Z = 4.21; p = 0.001

Self-condence in learning
Beginner
Advanced
Statistical test

3.73 0.75
4.09 0.82
Z = 2.29; p = 0.02

4.48 0.42
4.54 0.33
Z = 0.43; p = 0.66

Z = 4.26; p = 0.001
Z = 2.90; p = 0.004

Simulation design scale

Objectives and information
Beginner
Advanced
Statistical test

3.72 0.93
4.08 0.92
Z = 1.67; p = 0.10

4.70 0.46
4.62 0.59
Z = 0.68; p = 0.05

Z = 4.34; p = 0.001
Z = 3.53; p = 0.001

Support
Beginner
Advanced
Statistical test

4.52 0.71
4.74 0.45
Z = 0.71; p = 0.05

4.84 0.33
4.87 0.27
Z = 0.20; p = 0.83

Z = 2.60; p = 0.009
Z = 1.53; p = 0.13

Problem solving
Beginner
Advanced
Statistical test

3.74 0.96
4.28 0.85
Z = 2.45; p = 0.01

4.41 0.66
4.62 0.46
Z = 1.37; p = 0.16

Z = 3.80; p = 0.001
Z = 2.35; p = 0.019

Feedback/guided reection
Beginner
Advanced
Statistical test

4.64 0.59
4.86 0.28
Z = 1.44; p = 0.14

4.92 0.22
4.94 0.20
Z = 0.54; p = 0.58

Z = 2.94; p = 0.003
Z = 1.98; p = 0.05

Fidelity
Beginner
Advanced
Statistical test

2.68 1.46
3.33 1.30
Z = 1.95; p = 0.05

4.72 0.48
4.81 0.33
Z = 0.65 p = 0.51

Z = 4.48; p = 0.001
Z = 4.21; p = 0.001

Total score
Beginner
Advanced
Statistical test

3.97 0.69
4.34 0.52
Z = 2.39; p = 0.01

4.70 0.35
4.75 0.32
Z = 0.57; p = 0.57

Z = 4.73; p = 0.001
Z = 4.06; p = 0.001

Wilcoxon sign test.

MannWhitney U test.

T. Basak et al. / Nurse Education Today 36 (2016) 3743

groups. This nding shows that high-delity mannequins had more of

an effect on student satisfaction, self-condence in learning and perceptions of simulation design than low-delity mannequins.
Comparison of the scores between the beginner and advanced
groups in the scales of student satisfaction, self-condence in learning
and simulation design when participating in the simulation using the
high-delity mannequin showed that there was no statistically signicant difference (p b 0.05) (Table 3). This nding was important as it
indicated no intragroup difference in the simulations with the highdelity mannequin. Both the beginning and advanced students rated
the experience using high-delity mannequins higher than simulation
experiences using the low-delity mannequins.

41

clinical situations before handling the real patients. Researchers

have found that when clinical simulations are developed to be
realistic as possible, students feel more like they are learning in a
real-world setting (Finan et al., 2012; Swenty and Eggleston, 2011;
Jeffries, 2005).
Another nding of the current study is that both beginner and
advanced students had higher scores in delity, which is a subscale of
the high-delity mannequin on simulation design in contrast to the
low-delity mannequin group (Table 3). This nding indicates
that the student views about delity did not vary in the groups of
beginner and advanced students. Simulation scenarios in which the
high-delity mannequins are used are seen much more frequently as
reecting real-life situations.

Discussion
Students Satisfaction, Self-condence and Simulation Design: Difference
between Low- and High-delity Mannequins
This section discusses the ndings obtained from the comparison of
the low- and high-delity mannequins in the nursing simulations. The
ndings indicate that the scores of the students in the scales of student
satisfaction, self-condence in learning and simulation design are statistically higher in the simulations using high-delity mannequins in
contrast to those in the simulations with low-delity mannequins
(Table 2). Although there are few studies dealing with the comparison
of simulation using low- and high-delity mannequins, the results of
these studies analyzing the effects of the delity level on learning outcomes and student satisfaction are inconsistent (Kardong-Edgren
et al., 2009; Lapkin and Levett-Jones, 2011; Rodgers et al., 2009). Several
studies concluded that simulation education with low- or high-delity
mannequins does not have a signicant effect on learning outcomes
(Groom et al., 2014; De Giovanni et al., 2009; Friedman et al., 2009;
Kardong-Edgren et al., 2007, 2009; Kinney and Henderson, 2008; Lee
et al., 2008; Gore et al., 2014). Similarly Kardong-Edgren et al. (2007)
found in their pilot study that the use of low- and high-delity mannequins does not lead to any signicant score differences in pre- and posttests (Kardong-Edgren et al., 2007). Hoadley (2009) compared the
effectiveness of the simulations with the low- and high-delity
mannequins in education for cardiac life support. They found that simulations with the high-delity group had higher scores in terms of
knowledge, skills performance, satisfaction and self-condence, but
that there was no statistically signicant difference in the scores of
two groups (Hoadley, 2009). However, there are some other studies
which concluded that the simulation education with high-delity
mannequins increased the self-condence and satisfaction scores of
nursing students, which is also the nding of our study (Burns et al.,
2010; Brown and Chronister, 2009; Smith and Roehrs, 2009). It is
argued that the high-delity mannequins provide the students with
the opportunity to control the feelings of fear and panic and that
this self-control has positive effects on the students self-condence
(Leigh, 2008).
Simulation design characteristics were used as fundamental
guiding principles in the development, implementation and evaluation of the simulation scenarios (Groom et al., 2014). In our study,
student perceptions of the simulation design were higher in the
group in which the high-delity mannequin was used. Butler and
Veltre (2009) compared simulations using low- and high-delity
mannequins and Wang et al (2013) made this comparison between
high- and mid-delity mannequins. They reached similar results
(Butler and Veltre, 2009; Wang et al., 2013). Smith and Roehrs
(2009) found that in high-delity mannequins, the characteristics
of the simulation design were also correlated with self-condence
and self-satisfaction. In this study, high-delity mannequins elicited
high perceptions of the simulation implementation design characteristics. The most signicant benet of the use of the high-delity
mannequins was the opportunity to offer the students more realistic

Students Satisfaction, Self-condence and Simulation Design for Beginner

and Advanced Nursing
In this study, student scores on the scales of student satisfaction, selfcondence in learning and simulation design were compared in
intragroup and intergroup. In the intragroup comparison, both beginner
and advanced students had signicantly higher scores in the scales of
student satisfaction, self-condence in learning and simulation design
when evaluating the high-delity mannequin simulations in contrast
to those evaluating the low-delity mannequin simulations (Table 3).
The use of the high-delity mannequin has been rarely analyzed in
the rst year of the nursing education or in beginner nursing students
(Burns et al., 2010; Bearnson and Wiker, 2005; Hayden, 2010;
Kardong-Edgren et al., 2009; Moule et al., 2008). The simulation experience of the beginner students generally is more focused on skills
education and not simulation (Blum et al., 2010; Grady et al., 2008;
Alfes, 2011).
Research suggests that beginner students experience fear of
communicating with patients and are anxious of being harmful to
them in their early clinical practice (Blum et al., 2010). However, there
is some evidence that the use of high-delity simulations reduces stress
levels of the beginner students in real clinical settings (Khalaila, 2014).
Blum et al. (2010) concluded that the high-delity simulation provides
low-risk learning opportunities and increased the rst semester undergraduate nursing students self-condence and competence. However,
the difference was not statistically signicant (Blum et al., 2010). Physically and psychologically safe learning environments should be
simulated in order to reduce incorrect implementation, to offer a safe
environment to patients and to reduce the students fear of clinical practice. Using simulation earlier in nursing educational programs and
teaching skill in context could lead to greater condence and competency in these beginning students.
In the current study, it was found that the total scores of advanced
students on the scales measuring student satisfaction, self-condence
in learning and simulation design with regards to the use of low-delity
mannequins are higher than those of the beginner students (Table 3).
This difference may be a result of the prior experiences of the advanced
group. Lamond et al. (1996) argued that the prior experiences of
students have very strong effects on their self-condence. Tiffen et al
(2009) analyzed the effects of the low-delity mannequin experience
on self-condence. They found that this experience is much more
inuential on the students self-condence in contrast to the usual
course lecture and education with laboratory materials. In the current
study, the use of high-delity mannequins was found not to lead to
any signicant differences between the beginner group and the
advanced group. In addition, both groups were found to have similar
views about the simulation with the high-delity mannequin.
The inconsistency in study ndings comparing the use of low- and
high-delity mannequins in simulation could be due to the differences
between measuring student perception and measuring knowledge
gained from the experience. In our studies and in other studies where
high-delity simulation was rated higher, students perceptions of

42

T. Basak et al. / Nurse Education Today 36 (2016) 3743

their experience was measured. Perhaps students perceive the experience as being better because the technology is more advanced. This
could also be why, as in our study, advanced students were more forgiving of the low-technology experience than beginning students. They
had more experience with simulation experiences including those
using low- and high-delity mannequins. More research is needed in
this area to sort out how perceptions of technology and not the actual
experience may be impacting the students responses.
Limitations
The study had a relatively small sample size that it might have
prevented the researchers from accurately identifying differences.
This study was conducted only at a single site, which limits the generalization of these ndings. It is suggested that similar studies should be
conducted at multiple sites and with larger sample sizes.
The advanced group is comprised of BSN and accelerated students.
The accelerated students life experiences may differ greatly from than
the BSN students. It may have a potential impact on the results related
to intragroup comparisons.
Conclusion
Students perceptions of simulation experiences using high-delity
mannequins were found to be higher in contrast to their perceptions
of experiences using low-delity mannequins. More specically, their
ratings on the scales of student satisfaction, self-condence in learning
and simulation design scale were higher when the simulations with
the high-delity mannequins are used. Both beginning and advanced
students perceived simulations using high-delity mannequins as
being more benecial; however, advanced students rated simulation
using low-delity mannequins as more benecial than beginning
students. Additional research is needed to determine how students
perceptions of the technology itself and not the simulation might
be impacting how they are evaluating the value of the simulation
experience.
Authors Contribution to the Paper
All of the authors have contributed to the study on conception and
design, drafting the article, revising it critically for important intellectual
content and nal approval of the version to be published. All authors are
in agreement with the content of the manuscript.
Funding
This study was founded by 2219-Postdoctoral Research Scholarship
Program of The Scientic and Technological Research Council of Turkey.
Conict of interest
No conict of interest has been declared by the authors.
Acknowledgement
We would like to thank The Scientic and Technological Research
Council of Turkey, and all the simulation laboratory staff and students
who gave their time making this study possible.
References
Ackerman, A.D., 2009. Investigation of learning outcomes for the acquisition and
retention of CPR knowledge and skills learned with the use of high-delity simulation. Clin. Simul. Nurs. 5, 213222.
Alfes, C.M., 2011. Evaluating the use of simulation with beginning nursing students.
J. Nurs. Educ. 50 (2), 8993. http://dx.doi.org/10.3928/01484834-20101230-03.

Ballangrud, R., Hall-Lord, M.L., Hedelin, B., Persenius, M., 2014. Intensive care unit nurses
evaluation of simulation used for team training. Nurs. Crit. Care 19 (4), 175184.
http://dx.doi.org/10.1111/nicc.12031.
Bambini, D., Washburn, J., Perkins, R., 2009. Outcomes of clinical simulation for novice
nursing students: Communication, condence, clinical judgment. Nurs. Educ.
Perspect. 30 (2), 7982.
Bearnson, C.S., Wiker, K.M., 2005. Human patient simulators: A new face in baccalaureate
nursing education at Brigham Young University. J. Nurs. Educ. 44 (9), 421425.
Blum, C.A., Borglund, S., Parcells, D., 2010. High-delity nursing simulation: Impact on
student self-condence and clinical competence. Int. J. Nurs. Educ. Scholarsh. 7
(18), 2035. http://dx.doi.org/10.2202/1548-923X.
Brannan, J.D., White, A., Bezanson, J.L., 2008. Simulator effects on cognitive skills and
condence levels. J. Nurs. Educ. 47 (11), 495500.
Brown, D., Chronister, C., 2009. The effects of simulation learning on critical thinking and
self-condence when incorporated into an electrocardiogram nursing course. Clin.
Simul. Nurs. 5 (1), e45e52. http://dx.doi.org/10.1016/j.ecns.2008.11.001.
Burns, H.K., ODonnell, J., Artman, J., 2010. High-delity simulation in teaching problem
solving to 1st-year nursing students a novel use of the nursing process. Clin. Simul.
Nurs. 6, e87e95. http://dx.doi.org/10.1016/j.ecns.2009.07.005.
Butler, K.W., Veltre, D.E., 2009. Implementation of active learning pedagogy comparing low-delity simulation versus high-delity simulation in pediatric nursing
education. Clin. Simul. Nurs. 5 (4), e129e136. http://dx.doi.org/10.1016/j.ecns.
2009.03.118.
Cannon-Diebl, M.R., 2009. Simulation in healthcare and nursing state of the science. Nurs.
Crit. Care 32 (2), 128136.
Chang, K.K., Chung, J.W., Wong, T.K., 2002. Learning intravenous cannulation: A
comparison of the conventional method and the cathsim intravenous training
system. J. Clin. Nurs. 11 (1), 7378.
Childs, J.C., Sepples, S., 2006. Clinical teaching by simulation lessons learned from a
complex patient care scenario. Nurs. Educ. Perspect. 27 (3), 154158.
De Giovanni, D., Roberts, T., Norman, G., 2009. Relative effectiveness of high- versus lowdelity simulation in learning heart sounds. Med. Educ. 43 (7), 661668. http://dx.
doi.org/10.1111/j.1365-2923.2009.03398.x.
Finan, E., Bismilla, Z., Whyte, H.E., LeBlanc, V., McNamara, P.J., 2012. High-delity simulator technology may not be superior to traditional low-delity equipment for neonatal
resuscitation training. J. Perinatol. 32 (4), 287292. http://dx.doi.org/10.1038/jp.
2011.96.
Friedman, Z., Siddiqui, N., Katznelson, R., Devito, I., Bould, M.D., Naik, V., 2009. Clinical
impact of epidural anesthesia simulation on short and long-term learning curve:
High- versus low-delity model training. Reg. Anesth. Pain Med. 34 (3), 229232.
http://dx.doi.org/10.1097/AAP.0b013e3181a34345.
Gore, T., Leighton, K., Sanderson, B., Wang, C., 2014. Fidelitys effect on student perceived
preparedness for patient care. Clin. Simul. Nurs. 10 (6), e309e315. http://dx.doi.org/
10.1016/j.ecns.2014.01.003.
Grady, J.L., Kehrer, R.G., Trusty, C.E., Entin, E.B., Entin, E.E., Brunye, T.T., 2008. Learning
nursing procedures: The inuence of simulator delity and student gender on teaching effectiveness. J. Nurs. Educ. 47 (9), 403408. http://dx.doi.org/10.3928/
01484834-20080901-09.
Groom, J.A., Henderson, D., Sittner, B.J., 2014. National League for Nursing Jeffries Simulation Framework State of the Science Project: Simulation Design Characteristics. Clin.
Simul. Nurs. 10 (7), 337344. http://dx.doi.org/10.1016/j.ecns.2013.02.004.
Hayden, J.K., 2010. Use of simulation in nursing education: National survey results. J. Nurs.
Regul. 1 (3), 5257.
Hayden, J.K., Smiley, R.A., Alexander, M., Kardong-Edgren, S., Jeffries, P.R., 2014. The
NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. J. Nurs.
Regul. 5 (2), S3S64.
Hoadley, T., 2009. Learning advanced cardiac life support: A comparison study of the
effects of low- and high-delity simulation. Nurs. Educ. Perspect. 30 (2), 9195.
http://dx.doi.org/10.1043/1536-5026-030.002.0091.
Jeffries, P.R., 2005. A framework for designing, implementing and evaluating simulations
used as teaching strategies in nursing. Nurs. Educ. Perspect. 26 (2), 96110.
Jeffries, P.R., 2012. Simulation in Nursing Education: from Conceptualization to
Evaluation. 2nd ed. National League for Nursing, New York.
Kameg, K., Howard, V., Clochesy, J., Mitchell, A.M., Suresky, J., 2010. Impact of high delity
human simulation on self-efcacy of communication skills. Issues Ment. Health Nurs.
31 (5), 315323.
Kardong-Edgren, S., Anderson, M., Michaels, J., 2007. Does simulation delity improve
student test scores? Clin. Simul. Nurs. 3 (1), e21e24. http://dx.doi.org/10.1016/j.
ecns.2009.05.035.
Kardong-Edgren, S., Lungstrom, N., Bendel, B., 2009. VitalSim versus SimMan: A comparison of BSN student test scores, knowledge retention and satisfaction. Clin. Simul.
Nurs. 5, e105e111. http://dx.doi.org/10.1016/j.ecns.2009.01.007.
Kathleen, A., Kuznar, E., 2007. Associate degree nursing students perceptions of learning
using a high-delity human patient simulator. Teach. Learn. Nurs. 2 (2), 4652.
http://dx.doi.org/10.1016/j.teln.2007.01.009.
Khalaila, R., 2014. Simulation in nursing education: An evaluation of students outcomes
at their rst clinical practice combined with simulations. Nurse Educ. Today 34 (2),
252258.
Kidd, T., Kendall, S., 2006. Review of effective advanced cardiac life support training using
experiential learning. J. Clin. Nurs. 16 (1), 5866.
Kinney, S., Henderson, D., 2008. Comparison of low delity simulation learning strategy
with traditional lecture. Clin. Simul. Nurs. 4 (2), e15e18.
Lamond, D., Crow, R., Chase, J., Doggen, K., Swinkels, M., 1996. Information sources used in
decision making: Considerations for simulation development. Int. J. Nurs. Stud. 33
(1), 4757.

T. Basak et al. / Nurse Education Today 36 (2016) 3743

Lapkin, S., Levett-Jones, T., 2011. A cost-utility analysis of medium vs. high-delity human
patient simulation mannequins in nursing education. J. Clin. Nurs. 20 (23-24),
35433552. http://dx.doi.org/10.1111/j.1365-2702.2011.03843.x (Epub 2011 Sep 15).
Lee, K.H., Grantham, H., Boyd, R., 2008. Comparison of high- and low-delity mannequins
for clinical performance assessment. Emerg. Med. Australas. 20, 508514. http://dx.
doi.org/10.1111/j.1742-6723.2008.01137.x.
Leigh, G.T., 2008. High-delity patient simulation and nursing students self-efcacy: A
review of the literature. Int. J. Nurs. Educ. Scholarsh. 5 (1), 117. http://dx.doi.org/
10.2202/1548-923X.1613.
Maas, N.A., Flood, L.S., 2011. Implementing high-delity simulation in practical nursing education. Clin. Simul. Nurs. 7, e229e235. http://dx.doi.org/10.1016/j.ecns.2010.04.001.
McGovern, B., Lapum, J., Clune, L., Martin, S.L., 2013. Theoretical framing of high-delity
simulation with Carpers fundamental patterns of knowing in nursing. J. Nurs. Educ.
52 (1), 4649.
Moule, P., Wilford, A., Sales, R., Lockyer, L., 2008. Student experiences and mentor views of
the use of simulation for learning. Nurse Educ. Today 28 (7), 790797. http://dx.doi.
org/10.1016/j.nedt.2008.03.00.
OBrien, G., Haughton, A., Flanagan, B., 2001. Interns perceptions of performance and
condence in participating in and managing simulated and real cardiac arrest situations. Med. Teach. 23 (4), 389395.
Parr, M.B., Sweeney, N.M., 2006. Use of human patient simulation in an undergraduate
critical care courses. Crit. Care Nurs. Q. 29 (3), 188198.
Prentice, D., ORourke, T., 2013. Using high-delity simulation to teach blood transfusion reaction. J. Infus. Nurs. 36 (3), 207210. http://dx.doi.org/10.1097/NAN.
0b013e318288a3d9.

43

Rodgers, D.L., Securro, S., Pauley, R.D., 2009. The effect of high-delity simulation on
educational outcomes in an advanced cardiovascular life support course. Simul.
Healthc. 4 (4), 200206. http://dx.doi.org/10.1097/SIH.0b013e3181b1b877.
Shared, S., Kern, D., Zoller, J., Blue, A., 2013. Interprofessional teamwork skills as predictors
of clinical outcomes in simulated healthcare setting. J. Allied Health 42 (1), e1e6.
Shepherd, I.A., Kelly, C.M., Skene, F.M., White, K.T., 2007. Enhancing graduate nurses
health assessment knowledge and skills using low-delity adult human simulation.
Simul. Healthc. 2 (1), 1624.
Sinclair, B., Ferguson, K., 2009. Integrating simulated teaching/learning strategies in
undergraduate nursing education education. Int. J. Nurs. Educ. Scholarsh. 6, 7.
http://dx.doi.org/10.2202/1548-923X.1676 (Epub 2009 Mar 16).
Smith, S.J., Roehrs, C.J., 2009. High-delity simulation: Factors correlated with nursing student satisfaction and self-condence. Nurs. Educ. Perspect. 30 (2), 7478.
Swenty, C.F., Eggleston, B.M., 2011. The evaluation of simulation in a baccalaureate
nursing program. Clin. Simul. Nurs. 7 (5), e181e187. http://dx.doi.org/10.1016/j.
ecns.2010.02.006.
Tiffen, J., Graf, N., Corbridge, S., 2009. Effectiveness of a low-delity simulation experience
in building condence among advanced practice nursing graduate students. Clin.
Simul. Nurs. 5, e113e117. http://dx.doi.org/10.1016/j.ecns.2009.01.009.
Wang, A.L., Fitzpatrick, J., Petrini, M.A., 2013. Comparison of two simulation methods on
Chinese BSN students learning. Clin. Simul. Nurs. 9 (6), e207e212. http://dx.doi.
org/10.1016/j.ecns.2012.01.007.
WHO, 2011. Patient Safety Curriculum Guide. Multi-professional Edition, World Health
Organization. http://whqlibdoc.who.int/publications/2011/9789241501958_eng.pdf
(accessed 25/01/13).