Less May Be More! A Randomized Control Trial Investigating Virtual Clinical Simulations versus Face-to-face High Fidelity Simulations

Concurrent Session 1

Session Materials

Brief Abstract

Face-to-face clinical simulations, although costly, are commonly used in education. A RCT that investigated virtual and face-to-face clinical simulations regarding student learning outcomes will be highlighted. The virtual simulation platform will be demonstrated to engage attendees in the student experience of the experimental variable. Study results and recommendations will follow.


Dr. Cobbett has been a nursing professor for over 30 years and recently received the Canadian Association of Schools of Nursing Excellence in Nursing Education Award. Her research has focused predominantly in the area of nursing education with a specific focus related to best pedagogical practices in online nursing education,curriculum development, program evaluation and clinical simulations. Her methodological expertise is in quantitative approaches however the majority of her research also includes a qualitative aspect in addition to the quantitative methodology. Dr. Cobbett teaches face-to-face, hybrid and fully online courses.

Extended Abstract

Description and Goals: The goal of this research study presentation is to provide high school, college and university educators with new evidence suggesting that virtual clinical simulations (VCS) may be just as effective as high-cost, high fidelity, face-to-face (F2F) clinical simulations in regards to student learning outcomes. The virtual clinical simulation platform will be highlighted encouraging active engagement of participants. The presentation will include the research questions, methodology, results, and a discussion of the findings. Context The foundation for achieving competent, ethical, and safe nursing practice is considered to be clinical practices experiences (Diem et al., 2005). There are increasing challenges with planning quality, relevant clinical learning experiences for students, including increased student admissions, health care institution mergers creating fewer clinical placement areas, alternate models of care, and increased competition for health care placements (Foronda et al., 2013b; Hayden, 2010). To mitigate these challenges educators need to devise creative educational strategies to promote development of sound student clinical practice and clinical judgement. One such strategy described in the literature is the use of clinical simulation. Simulation is defined as learning that amplifies, mimics, or replaces real-life clinical situations (McAllister et al., 2013). Although there are many types of simulation, the focus of this RCT was on VCS and F2F high-fidelity clinical simulations. A combination of computer multimedia is utilized with VCS “with a central video or virtual world to produce interactive learning activities mediated by the learner” (Cant & Cooper, 2014, p. 1435). VCS may be a beneficial learning activity to more closely align theory with practice (Foronda et al., 2013a; Killion et al., 2011). Although the beneficial effects of medium and high fidelity simulation for students is cited in previous research (Hampson & Contrell, 2014; Ko & Kim, 2014; Kim-Godwin et al., 2013; Lewis & Ciak, 2011; Veltri et al., 2014), little information is available regarding the effects of VCS. Disadvantages of F2f clinical simulation cited in the literature include high financial, space, and human resource costs (Nagle et al., 2008). Recent literature of the use of VCS in nursing education is sparse. Examples include leadership styles (Foronda et al., 2014), disaster training (Farra et al., 2015; Ulrich et al., 2014), medication administration (Vottero, 2014), and transformative learning (Kleinheksel, 2014). However, research of effectiveness of VCS for undergraduate nursing education is limited, due in part to lack of comparative or control groups, and use of small samples. VCS may be more popular with 21st century students as they are known to positively interact with new technologies that are being used in teaching and learning (Montenery et al., 2013). Research Question Are there differences in the effectiveness of two methods of clinical simulation (virtual and face-to-face) in relation to student knowledge, self-confidence, and anxiety, for two maternal-newborn clinical scenarios (preeclampsia and Group B Streptococcus [GBS]) in third year undergraduate nursing students. Methods Research design: A randomized experimental pretest-post-test research design was used to evaluate the effectiveness of two simulations, VCS (vSim® for Nursing co-developed by Laedral and Wolters Kluwer Health from Lippincott) and a F2F high fidelity manikin clinical simulation. Setting: The research took place in a university in Eastern Canada. The setting for the VCS were two similar rooms, with a computer and a 42” projector screen and a research assistant in attendance. The Clinical Learning and Simulation Centre was the setting for all students completing the F2F high fidelity manikin simulation achieving constancy of environmental conditions. Participants: Third year undergraduate Bachelor of Science in Nursing students (N=56). Measures: Quantitative data collection instruments included pre/post-test knowledge, application and critical thinking tests, and the Nursing Anxiety and Self-Confidence with Clinical Decision Making Scale (NASC-CDM) (White, 2011). Qualitative data was collected using the Clinical Simulation Completion Questionnaire. Procedures: Following ethical approval (REB# 2014-3336), students were introduced to the study during a scheduled class, provided with an information sheet and consent form. Students were aware that their decision to participate would in no manner affect their course grade. Once consent was obtained, students were randomized to one of two groups, and then further randomized to one of 21 student dyads for completion of the clinical simulations. The experimental variable was the VCS and the control variable was F2F high fidelity simulation. The two simulation modalities were congruent in student learning objectives, complexity, cues and the debriefing pattern. Group 1 received the experimental variable for scenario one and the control variable for scenario two whereas Group 2 received the experimental variable for scenario two and the control variable for scenario one. Data was collected before and after each scenario, and at the completion of both scenario simulations. Results SPSS 22 for Windows was used to analyze the data. Baseline characteristics were assess by direct comparison and differences in student learning outcomes were assessed by independent sample t-tests. Qualitative data was analyzed using content analysis. Fifty-six of an eligible 84 students consented to participate in the study. The mean age of participants was 25 years (range: 20 to 44) with the majority being female (84%), and no previous university degree (81%). An independent samples t-test revealed no significant difference in scores for F2F (M = 4.80, SD = 1.19) and virtual (M = 4.12, SD = 1.54); t (48) = 1.75, p = .09, two-tailed) simulations for scenario one and F2F (M = 6.82, SD = 1.25) and VCS (M = 6.40, SD = 1.73); t (51) = 1.02, p = .31, two-tailed) for scenario two. There were no differences related to student self-confidence ((t = 1.93; p = .059) however student anxiety levels were significantly higher for the VCS group (M = 73.26) as compared to the F2F group (M= 57.75). Students reported that they preferred the F2F over the VCS and 61% of participants indicated that they were technically or highly technically competent. Discussion of Findings This study found no significant differences in student learning outcomes in VCS versus F2F high-fidelity clinical simulations. F2F high-fidelity simulations have been cited to be costly related to financial, faculty and equipment resources (Harder, 2010; Nagle et al., 2008) whereas VCS is less costly and can engage students repeatedly in a safe, reproducible and accessible environment. Contrary to the literature, we found that students reported a preference for the F2F simulation. When considering this incongruity, we noted that almost half of the students indicated their reason for not liking the VCS was related to technological issues, i.e., “online program was slow”, “didn’t know where to find things”. In hindsight, the design should have included a pre-study orientation to the VCS platform to ensure that students would not be focused on learning the software while trying to complete the simulation. Our finding of no statistically significant differences in student learning outcomes between the two types of simulations has implications for program planning, resource allocation and continued clinical simulation development. A thorough cost analysis of VCS versus F2F high-fidelity manikin simulation needs to be considered prior to planning and implementing clinical simulations, particularly important in this era of cost containment. In relation to student self-confidence, no self-reported differences indicates that both simulation modalities are effective in maintaining student self-confidence in clinical practice scenarios. Similar findings were reported by others’ in relation to clinical simulations (Fisher & King, 2013; Heinrichs et al., 2008; Leigh, 2008). Differences were found in students’ anxiety levels and were higher when completing the VCS as compared to the F2F simulation. We question whether the increased anxiety arose from the technology surrounding the VCS, and not the simulation itself? On the other hand, students may have been more comfortable in the F2F simulation as the majority of participants would have had prior exposure to the Simulation Centre earlier in their education. Several studies have investigated student anxiety during simulations (Beischel, 2013; Cheung & Au, 2011; Gore et al., 2011; Megel et al., 2012). Anxiety reducing strategies should be planned and implemented prior to any clinical simulation experience. Limitations and Recommendations for Future Research Limitations include the threat of testing, small sample size, and lack of an orientation session pre-study to the virtual clinical simulation platform. Future research includes repeating this RCT with larger sample sizes and conducting a thorough cost-benefit analysis of VSC verses F2F high-fidelity simulations. Conclusion With no differences in student learning outcomes, VCS have the potential to enhance clinical practicum preparation and is a promising educational learning activity. VCS incorporates learning principles of constructivism, enables self-directed learning, and ‘cybergogy’, in a realistic clinical practice setting, while facilitating student learning and self-confidence. 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