Virtual simulation in literature
There is evidence of the effectiveness of simulation-based interventions on im-proved patient outcomes. (Alinier & Platt 2014, 43). Simulation methodologies, and for example computerised patient simulators or virtual environments (Second Life®), have become more and more a part of nurse education. These methodologies are called as Full-scale simulation or the highest level of simulation. (Kilmon et al.
2010, 314–315.) Also Web- based simulation was found from the literature (Cant
& Cooper 2014, 1435).
Literature on virtual simulation in nurse education was reviewed by Pub Med (Medline) and Cinahl (Ebscohost). In addition, Medic (Nelliportaali) was used in order to gain an understanding of simulation in nurse education generally in Fin-land. A brief literature review shows that there is a growing body of evidence about virtual simulations in nurse education internationally but only little research about simulation (including virtual simulation) in Finland in spite of the fact that simu-lation has a growing role in the nursing curricula in Finland and also the role of technology in nurse education is becoming more and more important.
Table I shows the results of a non-systematic literature search in January 2016. In Finland there is a tradition of simulation in the context of emergency situations and surgical (medical) simulation but, nevertheless, virtual (reality) simulation is new in the field of nurse education. The majority of the 175 papers introduced an avatar or a virtual patient but none of them discussed other ways of Virtual Learn-ing Simulation (VLE) based simulation.
TABLE 1.
Literature search: Database, search and results (with or without filters).
Database Search Result Chosen
Pub med (virtual simulation in nursing), last 5 years 92 4
Cinahl virtual simulation in nursing 21 6
Pub med (((simulation) AND nurse education))
AND Finland, no filters 16
-Cinahl (((simulation) AND nurse education))
AND Finland, no filters 3
-Medic simulaatio AND hoitotyö* koulutu*, no filters 17
-Total 175 10
At universities, simulation has been used in one way or another, depending on the nurse educator’s skills in simulation and the number of hours the educator is able to use for the simulation. In the future, virtual simulation could become a part of
other simulation strategies or be used independently, but the development of im-mersive virtual simulations is time and labour intensive (Kilmon et al. 2010, 316).
Virtual simulation is an online educational approach where the trainees may use avatars (Foronda et al. 2014, 57; Kidd et al. 2012, 31; Tilton et al. 2015, 394) or virtual patients (Guise et al. 2012, 683; Liaw et al. 2015, e5) to practice various nursing skills. In a pilot test the nurse trainees expressed less anxiety and knew bet-ter what to expect when they were using avatars to practice communicative skills (Foronda et al. 2014, 56). Although the results of avatar based online simulations have been encouraging, there is evidence that the scores of the test and control groups do not differ significantly in the virtual and face-to-face simulations (Men-zel et al. 2014, 4; Quail et al. 2016, 1). Virtual simulation required more time com-pared to face-to-face simulation (Menzel et al. 2014, 6), moreover, it has also been seen as quite difficult technically but, on the other hand, moderately effective and a fun way of learning (Kidd et al. 2012, 35).
According to the nurse trainees’ reports, the fact that in a virtual environment mistakes were not definitive (Kidd et al. 2012, 36) and a possibility to practice making difficult decisions (Hudson et al. 2015, 802) as well as to be able to train one’s nursing skills at home were positive aspects of virtual simulation. New teach-ing strategies like virtual simulation increases nurse trainees’ active involvement, responsiveness and challenges the students to come to the class prepared, and, in addition, the use of technology in the classroom meets the needs of the newest gen-eration. (Montenery et al. 2013, 406.)
It has been suggested that virtual simulation could be integrated within online or blend-ed and/or cross-cultural learning environments (Guise et al. 2012, 688; Liaw et al. 2015, e5). Repeatability was seen as a big benefit of virtual simulation because of the availabil-ity of the resources (Cant & Cooper 2014, 1440). Negative aspects of virtual simulation were manoeuvring the avatar and the lack of realism (Kidd et al. 2012, 35). In addition, the virtual patient was more challenging than a real one (Quail et al. 2016, 10).
It is a fact that it is not possible to practice all the special skills a nurse trainee needs at clinical placement by virtual simulation scenarios (Cant & Cooper 2014, 1441).
First there is a need to practice the special skills like resuscitation or measuring blood pressure at a university setting. However, the problem is that if the nurse trainee does it only once during the three-year education, how does s/he remember the procedure
when facing the real situation in real life? A trainee should have an opportunity to refresh his/her memory. But how? This article provides an idea of a relatively new ap-proach to virtual simulation in nurse education at Satakunta University of Applied Sciences: an electronic web based simulation handbook, eSimulation Handbook (eSH). It aims at providing learning that align with other models of simulation.
The idea of the eSimulation Handbook
To make it easier to refresh nursing skills, two nurse educators started to produce videos in March 2015 by using a smartphone. At first, they focussed on small issues like a delirium patient to prepare the nurse trainees for unexpected situations they most likely are going to face. In addition, they focussed on basic skills like measur-ing blood pressure and blood sugar. Soon they noticed that there is a bigger need to collect all videos in the same place to support simulation in nurse education at Satakunta University of Applied Sciences.
eSimulation Handbook was created to provide resources and strategies that best assist students in simulation training by offering a virtual, 24/7 open learning plat-form for nurse trainees. The importance of refreshing nursing procedures was the core idea of eSH. It is not possible to remember everything after the simulation scenarios if it is practiced only once. Some nurse trainees have to face the fact that they may not have a chance to train the skills gained at the simulation scenarios during the clinical placement at all. The clinical placements vary at lot within the Satakunta University of Applied Sciences area and it is not possible to guarantee similar placements to all nurse trainees.
eSH is a Moodle (Modular Object-Oriented Dynamic Learning Environment) based virtual learning platform for nurse trainees that is used in Satakunta Univer-sity of Applied Sciences. The privacy settings make Moodle private; access is not al-lowed for outsiders. To enter eSH the nurse trainees need a password and they have to have an access to the Moodle of Satakunta University of Applied Sciences. After graduating the user rights to Moodle expire and when they have finished their stud-ies it is not possible to use eSH anymore.
The eSimulation Handbook consists of 9 modules. A nurse trainee follows the course division of the curricula to find the right videos from eSH. There is one mod-ule of simulation basics: an introduction to simulation, videos of a simulation room for nurse trainees who have never before participated in simulation training. The
introduction videos of a computerised patient simulator familiarise students with how to nurse a computerised simulation patient and a simulation evaluation form, which the nurse trainees print out before the training session, helps them to observe the scenarios. The other modules consist of one module of basic nurse studies, seven modules of professional nurse studies and one module of multicultural nurse studies which are meant to be watched at the different stages of the studies. The module of the basic nurse studies consists of videos like how a nurse undresses and prepares a patient after death or how to measure blood sugar/blood pressure.
The professional modules follow the curricula of nurse studies 2013: medical, sur-gical, acute and perioperative, child and adolescents’, mental health (including dis-abilities) and gerontological and rehabilitation nursing. From the beginning to the very end of the studies a nurse trainee is able to check from the eSH for example how to take an ECG by watching videos. By pausing the video it is possible to practice ECG monitoring, preparing the liquids, antibiotics, safe blood transfusion etc. on their own time. The multicultural module includes material about immigrants that is at the moment needed all over Europe.
There is a growing need for methodological studies as well and maybe in the future there are videos about literature search from databases or research methods. You-Tube® has many possibilities but the problem is that most of the videos are in English or in other foreign languages and nurse trainees in Finland prefer Finnish to gain the best learning of the topic.
About videos in eSH
Nurse educators uploaded their videos in Moodle or on YouTube® after editing them with the Adobe ProConnector® programme or Windows Movie Maker®. Some of the videos linked in eSH are originally from YouTube® and the internet address is linked in eSH. The nurse educators participated in a two day editing course to learn how to edit the materials.
Creating a video took more time than assumed: one 8 minutes long video took approxi-mately from 8 to 16 hours to be completed. It was challenging to write a manuscript, shoot several videos and edit them alongside working. Some videos were filmed in clini-cal settings with informed consent of the patient. The nurse educators made sure that it was impossible to recognise the patients from the video. The name of the nurse trainee
who appeared in the video was at the end of the video and it was possible to recognise the trainee. Nurse trainees participated in the videos only if they gave their oral permission.
In future, nurse trainees could create their own videos as bachelor theses or as a part of simulation scenarios. A few videos are now in the manuscript phase and will be linked in eSH in autumn 2016. There are also plans to create internet based games for nursing as a part of eSH in the future to support the simulation pedagogy at Sa-takunta University of Applied Sciences.