International Journal of Nursing Education Scholarship

Volume 7, Issue 1 2010 Article 11

Theory-Based Research of High Fidelity Simulation Use in Nursing Education: A Review of the Literature
Liam Rourke Megan Schmidt Neera Garga

University of Calgary, lrourke@ucalgary.ca University of Calgary, mmschmid@ucalgary.ca SSB-Foothills Medical Centre, ngarga@hotmail.com

Copyright c 2010 The Berkeley Electronic Press. All rights reserved.

Theory-Based Research of High Fidelity Simulation Use in Nursing Education: A Review of the Literature
Liam Rourke, Megan Schmidt, and Neera Garga

Abstract
In this article, we explore the extent to which theory-based research is informing our understanding of high-delity simulation use in nursing education. We reviewed the primary literature archived in the Cumulative Index of Nursing and Applied Health Literature (CINAHL) and Proquest Dissertation and Theses for empirical reports using the key terms high-delity simulation and nursing from the years 1989 to 2009. Of the articles that matched our inclusion criteria: 45% made no use of theory; 45% made minimal use; and 10% made adequate use. We argue that theory-based research could bring coherence and external validity to this domain. KEYWORDS: high-delity simulation, nursing education, nursing research


Rourke et al.: Theory-Based Research of HFS Use in Nursing

High-fidelity simulations (HFS) are used extensively in nursing education, yet stakeholders continue to criticize the amount, quality, and character of the research that might justify their use (Aliner, Hunt, & Gordon, 2004; Fountain & Alfred, 2009; Hyland & Hawkins, 2009; Lasater, 2007; Leigh, 2008; Nehring, 2008; Overly, Sudikoff, & Shapiro, 2007; Ravert, 2002; Schoening, Sittner, & Todd, 2006; Seropian, Brown, Gavilanes, & Driggers, 2004; Shapiro et al., 2004; Steadman et al., 2006). A common criticism is that the collection of studies is overloaded with evaluative descriptions of cases conducted by stakeholders that, unfortunately, do not epitomize the principles of evaluation, descriptive research, or case study. In such a research program, two problems are inevitable: the results are piecemeal and they lack external validity. The source of these problems, we argue, is the nominal role that theorybased research plays in this domain. When theoretical frameworks are used to guide the formulation of hypotheses, collection of data, and interpretation of results; a collection of studies can become a coherent body of literature that is unified, generalizable, and progressive. The purpose of this study is to investigate our claim that theory-based research plays an inadequate role in the study of HFS use in nursing education. To do so, we review the primary literature, and we classify the articles using Silvas (1986) taxonomy of theory-use in nursing research. Though others have contributed general reviews of the HFS literature in the health sciences (Issenberg, McGaghie, Petrusa, Lee, & Scalese, 2005; Ravert, 2002), and in nursing education (Hyland & Hawkins, 2009), only Leigh (2008) and Kaakinen and Arwood (2009) have provided focused reviews. Our study builds on these efforts. The paper begins with a description of both key termsHFS and theory and a review of the literature on these topics. HFS in Nursing Education Gredler (2003) offers the following description of simulations in educational contexts: A simulation is an evolving case study of a particular social or physical reality in which participants take on bona fide roles with well-defined constraints and responsibilities. The goal for participants is to take a particular role; address the issues, threats, or

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International Journal of Nursing Education Scholarship, Vol. 7 [2010], Iss. 1, Art. 11

problems that arise in the situation; and experience the effects of their decisions ( 9). In nursing education, simulation has broad connotations that may include static mannequins, part-task trainers, computer games, standardized patients, and high-fidelity simulators. The topic of this review is high-fidelity simulation (HFS), which involves the recreation of life-like situations with maximal feedback and responsiveness exemplified by products such as Laerdal SimMan3D. Nurse educators and their students are fervent about the efficacy of these technologies; yet, nursing researchers struggle to substantiate their opinions (e.g. Aliner et al., 2004; Hoadley, 2009; LeFlore & Anderson, 2008). They have been unable to: document a consistent advantage for HFS over traditional methods of instruction (Leigh, 2008; Wenke et al., 2008); pinpoint a set of educational objectives for which HFS is uniquely suited; or offer a cognitive, social, or biological explanation that would justify a hypothesis of enhanced learning in HFS. We hypothesize that this is due to a lack of theory-based research in this domain. Theory-Based Research in Nursing In the context of nursing research Polit and Beck (2007) define a theory as an abstract generalization that presents a systematic explanation about the relationships among phenomena (p. 734). They explain that theoretical frameworks have two critical roles in nursing research. First, frameworks are efficient mechanisms for knitting disparate observations and accumulated facts into an orderly scheme. Second, theory-based work enables researchers to move beyond the superficial description of phenomena to, first, the identification of mechanisms underlying phenomena, and second, the prediction and control of phenomena. Gioiella (1996) argues that theory-based research, possessing the qualities Polit and Beck (2007) enumerate, is essential to decision-making in health care. For the same reasons it is essential to decision-making in health care education. Decision-makers consider many grounds; however, an important one should be evidence of differential effectiveness. Evidence obtained through atheoretical, data gathering (which Gioiella characterizes as reporting, not science [p. 47]), does not satisfy this role because it is not generalizable to significant parts of the population. Gioiella concludes, Only if data are linked to a theoretical framework can the activity be considered research and good science (p. 37).

http://www.bepress.com/ijnes/vol7/iss1/art11 DOI: 10.2202/1548-923X.1965


Rourke et al.: Theory-Based Research of HFS Use in Nursing

Despite the conviction that theory-based research is important in nursing, Silva (1986) questions the extent to which it transpires. In her examination of 62 articles indexed by Medline and CINAHL, she found only 9 that made adequate use of theory. Articles that achieved this designation met six criteria, including the following four: 1) a theory is explicitly stated as the framework for the research, 2) the theory is described in sufficient depth so that its relationship to the hypotheses is clear, 3) the hypotheses are deduced clearly from the theories propositions, and 4) the results are discussed in terms of how they support, refute, or explain relevant aspects of the theory. Silva (1986) found that a more common use of theory in nursing research involves identifying a particular theory but doing little with it. Typically the theory is named and briefly summarized but minimally integrated into the rest of the study (p. 3). In addition to contributing little to practice or theory, Silva criticized such studies as creating the illusion of theory-based research when it was not the case. She classified 24 of the 62 studies in this category, and the remaining 29 in the category insufficient use of theory. Theory-based Research in Nursing Education Theory-based research plays an equally productive role in studies of teaching, learning, and instructional technologies in nursing education. Gall, Gall, and Borg (2007) identify three advantages of this type of research. First, they point out that the constituents of theoriesthe constructs or variables and their interrelationshipscan highlight commonalities among phenomena that otherwise would remain invisible. For instance, researchers have measured the effect of HFS on self-confidence and alternately its effect on self-efficacy; or they have studied the effect of HFS on critical thinking, clinical judgment, and higherlevel educational objectives. The conduct of both sets of studies suggests that the researchers conceptions of their dependent variables are isomorphic, yet the different labels obscure the possibility of synthesizing findings. Second, Gall et al. (2007) argue that theory-based studies are less likely to field trivial questions. In HFS research, inconsequential findings arise frequently from studies that are essentially descriptions and, to some extent, evaluations of the researcher-slash-instructors use of HFS in their course. The findings are valuable to the instructor but not to the wider community studying educational uses of simulations if they are not constructed around constructs and variables nested in larger theories.

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International Journal of Nursing Education Scholarship, Vol. 7 [2010], Iss. 1, Art. 11

Finally, Gall et al. (2007) note that a theory can provide a rational basis for explaining or interpreting results. This becomes particularly relevant across HFS studies that yield contradictory results. Waldner and Olson (2007) review studies in which HFS learning activities were compared with alternatives on various outcomes. The results are irreconcilable: HFS is associated with greater, similar, and lesser improvements in clinical skills (Aliner et al., 2004; Bauer & Huynh, 2001; Ravert, 2002) self-efficacy (Madorin & Iwasiw, 1999; Ravert, 2002; Wenke et al., 2008); and knowledge acquisition (Ravert, 2002; Griggs, 2002; Wenke et al.). Without recourse to a higher-level system of interrelated constructs, it is difficult to present a coherent and persuasive story about such discrepant results. In this introduction, we have proposed one explanation for the prevalence, in the HFS nursing education literature, of subjective descriptions of cases; namely, the lack of theory-based research. In the following section we explain our methodology for investigating this claim. Method To explore this hypothesis, we conducted a literature review. Our review focused on articles catalogued by the Cumulative Index of Nursing and Applied Health Literature (CINAHL), to keep the focus squarely on nursing research, and Proquest Dissertations and Theses because doctoral investigations and reports place an extraordinary emphasis on theoretical frameworks for research. For this preliminary investigation, we examined studies published between 1989 and 2009. We searched the database using the key terms high-fidelity simulations and nursing, and this returned 87 results. From these, we selected only the reports of empirical researchstudies in which data had been systematically collected and analyzed to answer a research question. We classified these articles into three categories of theory-use, which we derived from Silvas (1986) germinal work. Below we describe the categories, and we provide examples for the first two to clarify the process: 1. Adequate use of theory: A theory is discussed in depth, and its constituent constructs and their interrelationships provide the foundation for a studys purpose, research questions, data collection, interpretation of findings, and discussion. Mandorin and Iwasiws (1999) study exemplifies this category. The framework for their study was self-efficacy theory (Bandura, 1977), which for current purposes we provide the following gloss: a) self-efficacy is task specific self-confidence, b) it influences all

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Rourke et al.: Theory-Based Research of HFS Use in Nursing

aspects of behavior, notably, persistence in the face of obstacles; and c) its primary antecedent is the opportunity to engage in and gain mastery over a task. From these premises, the authors deduced the following research question: Does participation in a simulation enhance self-efficacy? Data collection included a measure of self-efficacy administered at key times surrounding the simulation, and the authors interpretation of their findings is derivative of the constructs and premises that constitute selfefficacy theory. 2. Minimal use of theory: A theory is identified and explicated satisfactorily, but its integration into the rest of the study is minimal, intermittent, or noncommittal. Jankouskas et al.s (2007) study exemplifies this category. In their introduction they identify self-efficacy theory as the framework for their program and provide a concise description. They employ some of the theorys constructs to interpret and discuss their results; however, a) no data is collected about the participants self-efficacy, and b) the tenets of self-efficacy theory are peripheral to the general problem that the study addresses and to its research questions (i.e., Can HFS support the acquisition of nontechnical skills in multidisciplinary settings?). 3. No use of theory: The study is not conceptualized around a theory. Two researchers, working independently, read and categorized each of the articles. Once the initial categorization was complete, interrater agreement was calculated to determine the reliability of the process. Cohens kappa was used as a chance-corrected measure of agreement. Findings Our search of CINAHL database over the last decade returned 47 articles that satisfied our main inclusion criteria. Of these, the distribution of articles by type (as described by the American Psychological Association (APA) (2009), is presented in table 1.

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International Journal of Nursing Education Scholarship, Vol. 7 [2010], Iss. 1, Art. 11

Table 1. Distribution of articles by APA article type Article type

Empirical report Case study1 Literature review Theoretical article Methodological article
1

F
20 20 3 1 0

Percentage
45 45 7 2 0

Note that the APAs description of case study as an article type is distinct from the conventional understanding of case study as a research design. In this category we have classified the numerous narrative descriptions of authors programs, their reflections on their programs, HFS in general, and advice to colleagues.

Our analysis of the frequency of theory-based research considered only the empirical reports. Our classification of these into the three categories of theorybased research resulted in the frequencies and percentages presented in Table 2. Table 2. Distribution of articles by theory-use
Theory-use No use Minimal use Adequate use f 9 9 2 Percentage 45 45 10

The interrater reliability for our categorization decisions was k = .88, which Landis and Koch (1977) characterize as almost perfect agreement. Disagreements were resolved through discussion, and the analysis proceeded with the reconciled data. Tables three through five identify the articles that embody the three uses of theory. Table 3. Empirical reports making adequate use of theory
Authors Hanberg (2007) Larew, Lessans, Spunt, Foster & Covinton, (2006) Steadman et al. (2006) Article Title The diffusion of high fidelity simulation in nursing education: barriers and recommendations for best practice Application of Benners theory in an interactive patient care simulation Simulation based training is superior to problem based learning for the acquisition of critical assessment and management skills Theory Diffusion of innovations Novice to expert Problem based learning

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Rourke et al.: Theory-Based Research of HFS Use in Nursing

Table 4. Empirical reports making minimal use of theory

Authors Anderson (2007) Foster, Sheriff, & Cheney, (2008). Fountain & Alfred, (2009). Gee (2006) Hoadley (2009) Kuiper, Heinrich, Matthias, & Graham, BellKotwall, (2008). Lasater (2007) Article Title Effect of integrated high-fidelity simulation in knowledge, perceived self-efficacy and satisfaction of nurse practitioner students in newborn assessment. Using nonfaculty registered nurses to facilitate high-fidelity human patient simulation activities Student satisfaction with high-fidelity simulation: does it correlate with learning styles? The effects of simulation on nurse anesthesia students' perceived self-efficacy. Learning advanced cardiac life support: a comparison study of the effects of low and high fidelity simulation Debriefing with the OPT Model of Clinical Reasoning during high fidelity patient simulation Theory Andragogy, Multiple intelligences, Social learning Nursing education simulation Multiple intelligences Self-efficacy Experiential learning Situated cognition

High-fidelity simulation and the development of clinical judgment: students' experiences Effectiveness of two methods to teach and evaluate new content to neonatal transport personnel using HFS Using clinical simulations in geriatric nursing continuing education

LeFlore & Anderson (2008). Palmer et al., 2008

Experiential Learning, Active learning Self-efficacy Constructivism

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Table 5. Empirical reports making no use of theory

First Author Aliner, Hunt, & Gordon (2004). Dillon (2009) Hotchkiss & Mendoza (2001). Jones (2005) Kuduvalli, Parker, Christopher, Leuwer, & Guha (2009). Leighton (2007) Nehring (2008) Reilly &, Spratt (2007). Schoening Sittner & Todd (2006) Todd, Manz, Hawkins, Parsons & Hercinge, (2008). Article Title Effectiveness of intermediate-fidelity simulation training technology in undergraduate nursing education Simulation as a means to foster collaborative interdisciplinary education AANA Journal Course: update for nurse anesthetists. Full-body patient simulation technology: gaining experience using a malignant hyperthermia model Faculty members' comfort levels in utilizing high-fidelity simulation in a Bachelor of Science nursing program Retention and transferability of team resource management skills in anesthetic emergencies: the long-term impact of a high-fidelity simulation based course. Learning needs in the traditional clinical environment and the simulated clinical environment: a survey of undergraduate nursing students U.S. Boards of Nursing and the use of high-fidelity patient simulators in nursing education The perceptions of undergraduate student nurses of high-fidelity simulationbased learning: a case report from the University of Tasmania Simulated clinical experience: nursing students' perceptions and the educators' role The development of a quantitative evaluation tool for simulations in nursing education

Discussion The purpose of this review was to gauge the extent to which theory-based research is contributing to our understanding of HFS use in nursing education. Our findings indicate its contribution is negligible. Only ten percent of the studies made adequate use a theory of learning, instruction, or technology to guide the formulation of research questions, the collection of data, interpretation of results, and, importantly, prescriptions for practice and subsequent research. Our results are consistent with Silvas (1986), whose taxonomy of theoryuse in nursing research provided the basis for data analysis. The purpose of Silvas study was to advocate for a wider application of theory-based research in nursing, thus our findings, appearing two decades later, are disheartening. Many of the articles we reviewed opened with criticisms of the body of research on HFS use in nursing education, often portraying the set of results as

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Rourke et al.: Theory-Based Research of HFS Use in Nursing

piecemeal. None of the critics ventured a reason for this, however. We contend that the stamp-collecting nature of this enterprise (to paraphrase Ernest Rutherfords famous quip) is a reflection of its indifference to theories, models, or conceptual frameworks. Polit and Becks (2007) explanation of theories as efficient mechanisms for knitting disparate observations into orderly facts foreshadows our findings. We can illustrate this point with a close reading of any of the sets of studies that employed, in a minimal way, the same theory. Kaakinen and Arwoods (2009) review and ours indicate that experiential learning theory (Kolb, 1983) has the broadest currency among HFS researchers and practitioners, so we will examine that set of studies. The next paragraph prefaces that analysis with a terse explication of ELT. In ELT, learning is defined as the process whereby knowledge is created through the transformation of experience (Kolb, 1983, p. 38). This process is constructed as involving four stages. It begins with an event that contradicts expectationsa concrete experience in the ELT terminology. This precipitates a search for similar events that are compared and contrasted, reflective observation. In the third stage, learners organize the puzzling phenomena through the logical process of induction, and in the fourth stageactive experimentationthey deploy the resulting schema in new instances to evaluate its usefulness. ELT offers a specific understanding of learning, its constituent processes, and a distinctive use of words such as experience, reflection, and learning. The studies we classified as making minimal use of ELT are Howard (2007), Hoadley (2009), Lasater (2005), and Linden (2008), the latter three of which are dissertations. The first difficulty with these studies is that, though purportedly beginning with the same system of constructs through which learning is viewed, each examines different instructional outcomes and processes. Respectively, Linden, Howard, Lasater, and Hoadley examined the impact of HFS on lower level educational objectives, higher level educational objectives, satisfaction, and self-confidence. Thus, potential advantages of theory-based research, including the ability to synthesize observations from multiple studies and to contribute to a non-trivial collection of results, do not materialize. A second difficulty with these studies is that they are not investigating the types of learning processes and outcomes that Kolb (1983) was attempting to account for with ELT. Such superficial uses of theory comprised the most frequent categorization in Silvas (1986) study which she criticized because they could make no contribution to the testing and refinement of the theory. The two

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recurrent complaints about HFS researchthat the results are piecemeal and lack external validityare related to the inadequate use of theory demonstrated by these studies. Our study should not be read as a criticism of inductive or wholly descriptive researchmuch of our own work is in this vein (e.g. Rourke, 2005). Our recommendation is that this body of research is tipped too heavily toward the descriptive: even the literature reviews in this domain yield little beyond lists of findings (e.g., Issenberg et al., 2005; Hyland & Hawkins, 2009). A final suggestion for subsequent research is to evaluate the theories of learning, instruction, and technology that are used to construct HFS in nursing education. Self-efficacy theory, which appeared frequently in our review, provides a sound framework of constructs that resonate with participants experiences of HFS and with nursing programs educational objectives for HFS. Other common theories may be less insightful. ELT, for instance, especially its derivation from Kolb (Kolb, 1983) has come under mounting criticism in the last two decades as other theorists, congenial to themes of learning from experience but more sensitive to contemporary cognitive and cultural sciences, have proposed more productive theories (e.g., Lave and Wenger, 1991; Brown, Collins, & Duguid, 1989). References Aliner, G., Hunt, W., & Gordon, R. (2004). Determining the value of simulation in nurse education: Study design and initial results. Nurse Education in Practice, 4(3), 200-207. American Psychological Association (2009). Publication manual of the American Psychological Association (6th ed.). Washington: Author. Anderson, M. (2007). Effect of integrated high-fidelity simulation in knowledge, perceived self-efficacy and satisfaction of nurse practitioner students in newborn assessment. (Unpublished doctoral dissertation). Available from Proquest Dissertation and Theses database. (UMI no. 3271408). Bandura A. (1977). Self-efficacy: Toward a unifying theory of behavioral change, Psychological Review, 84(2),191-215. Bauer, N., & Hunyh, M. (2001). Teaching blood pressure management: CDROM versus conventional classroom instruction. Journal of Nursing Education, 40(3), 138-141. Brown, J., Collins, A., & Duguid, P. (1989). Situated cognition and the culture of learning. Educational Researcher, 18, 32-42.

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Dillon, P. (2009). Simulation as a means to foster collaborative interdisciplinary education. Nursing Education Perspectives, 30(2), 87-90. Foster, J., Sheriff, S., & Cheney, S. (2008). Using non-faculty registered nurses to facilitate high-fidelity human patient simulation activities. Nurse Educator, 33(3), 137-141. Fountain, R., & Alfred, D. (2009). Student satisfaction with high-fidelity simulation: Does it correlate with learning styles? Nursing Education Perspectives, 30(2), 96-98. Gall, M., Gall, J. & Borg, W. (2007). Educational research: An introduction (8th ed.). New Jersey: Allyn & Bacon. Gee, R. (2006). The effects of simulation on nurse anesthesia students' perceived self-efficacy. (Unpublished doctoral dissertation). Available from Proquest Dissertation and Theses database. (UMI no. 3240513). Gioiella, E. (1996). The importance of theory-guided research and practice in the changing health care scene. Nursing Science Quarterly, 9(2), 46-47. Gredler, M. E. (2003). Games and simulations and their relationship to learning. In D. H. Jonassen (Ed.), Handbook of research on educational communications and technology (2nd ed.), (pp. 571-582). Mahwah, NJ: Lawrence Erlbaum Associates. Griggs, R. (2002). The effects of the use of a human patient simulator on the acquisition of nursing knowledge in undergraduate nursing students at a university in Illinois. (Unpublished doctoral dissertation). Available from Proquest Dissertation and Theses database (UMI no. 3100754). Hanberg, A. (2007). The diffusion of high fidelity simulation in nursing education: Barriers and recommendations for best practice. (Unpublished doctoral dissertation). Available from Proquest Dissertation and Theses database. (UMI no. 3318406). Hoadley, T. (2009). Learning advanced cardiac life support: A comparison study of the effects of low and high fidelity simulation. Nursing Education Research, 30(2), 91-95. Hotchkiss, M., & Mendoza, S. (2001). Update for nurse anesthetists: Full-body patient simulation technology: Gaining experience using a malignant hyperthermia model. AANA Journal, 69(1), 59-65. Howard, V. (2007). A comparison of educational strategies for the acquisition of medical-surgical nursing knowledge and critical thinking skills: Human patient simulator vs. the interactive case study approach. (Unpublished doctoral dissertation). Proquest Dissertation and Theses database (UMI no. 3270096) Hyland, J., & Hawkins, M. (2009). High-fidelity human simulation in nursing education: A review of literature and guide for implementation. Teaching and Learning in Nursing, 4(1), 14-21.

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Issenberg, S, McGaghie, W., Petrusa, W., Lee, G., & Scalese, R. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Medicine Teacher, 27(1), 10-28. Jankouskas, T., Bush, M., Rudy, S., Henry, J. Dyer, A., Liu, W., & Sinz, E. (2007). Crisis resource managements: Evaluating outcomes of a multidisciplinary team. Simulation in Health Care, 2(2), 96-101. Jones, A. (2005). Faculty members' comfort levels in utilizing high-fidelity simulation in a Bachelor of Science nursing program. (Unpublished doctoral dissertation). Available from Proquest Dissertation and Theses. (UMI no. 3206229). Kaakinen, J., & Arwood, E. (2009). Systematic review of nursing simulation literature for use of learning theory. International Journal of Nursing Education Scholarship. 6(1). doi: 10.2202/1548-923X.1688 Kuduvalli, P., Parker, M., Christopher, J., Leuwer, M., & Guha, A. (2009). Retention and transferability of team resource management skills in anesthetic emergencies: The long-term impact of a high-fidelity simulation based course. European Journal of Anaesthesiology, 26(1), 17-22. Kolb, D. (1983). Experiential learning:Experience as the source of learning and development. New Jersey: PrenticeHall. Kuiper, R., Heinrich, C., Matthias, A., Graham, M., & Bell-Kotwall, L. (2008). Debriefing with the OPT Model of Clinical Reasoning during high fidelity patient simulation. International Journal of Nursing Education Scholarship, 5(1). doi: 10.2202/1548-923X.1466 Landis, J., & Koch, G. (1977). The measurement of observer agreement for categorical data. Biometrics,33, 159-174. Larew, C., Lessans, S., Spunt, D., Foster, D., & Covinton, B. (2006). Application of Benner's theory in an interactive patient care simulation. Nursing Education Perspectives, 27(1), 16-21. Lasater, K. (2007). High fidelity simulation and the development of clinical judgment: Students experiences. Journal of Nursing Education, 46(6), 269276. Lave, J., & Wenger, E. (1991). Situated learning:Legitimate peripheral participation. Cambridge: Cambridge University Press. Leflore, J., & Anderson, M. (2008). Effectiveness of two methods to teach and evaluate new content to neonatal transport personnel using high fidelity simulations. Journal of Perinatal and Neonatal Nursing, 22(4), 319-328. Leigh, (2008). High fidelity patient simulation and nursing students' self-efficacy: A review of the literature. International Journal of Nursing Education Scholarship, 5(1). doi: 10.2202/1548-923X.1613

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Leighton, K. (2007). Learning needs in the traditional clinical environment and the simulated clinical environment: A survey of undergraduate nursing students. Paper presented at the SimTech Health Simulation Conference. Retrieved July 13, 2009 from http://digitalcommons.unl.edu/dissertations/AAI3271929 Linden, L. (2008). The effect of clinical simulation and traditional teaching versus traditional teaching alone on critical thinking of nursing students. (Unpublished doctoral dissertation). Available from Proquest Dissertations and Theses database. (UMI no. 3310890). Madorin, S., & Iwasiw, C. (1999). The effects of computer-assisted instruction on the self-efficacy of baccalaureate nursing students. Journal of Nursing Education, 38(6), 282-285. Nehring, W. (2008). U.S. boards of nursing and the use of high-fidelity patient simulators in nursing education. Journal of Professional Nursing, 24(2), 109-117. Overly, F., Sudikoff, S., & Shapiro, M. (2007). High-fidelity medical simulation as an assessment tool for pediatric residents' airway management skills. Pediatric Emergency Care, 23(1), 582-587. Palmer, M, Kowlowitz, V., Campbell, J., Carr, C., Dillon, R., Durham, C., & Rasin, J. (2008). Using clinical simulations in geriatric nursing continuing education. Nursing Outlook, 56(4), 159-166. Polit, D., & Beck, C. (2007). Nursing research: Generating and assessing evidence for nursing practice (8th ed.). New Jersey: Lippincott Williams And Wilkins. Ravert, P. (2002). An integrative review of computer-based simulation in the education process. Computers, Infomatics, Nursing, 20(5), 203-208. Reilly A, &, Spratt, C. (2007). The perceptions of undergraduate student nurses of high-fidelity simulation-based learning: A case report from the University of Tasmania. Nurse Educator Today, 27(6), 542-550. Rourke, L. (2005). Learning through online discussion. (Unpublished doctoral dissertation). Available from Proquest Dissertations and Theses database. (AAT no. NR08724). Schoening, A., Sittner, B., & Todd, M. (2006). Simulated clinical experience: Nursing students' perceptions and the educators' role. Nurse Educator, 31(6). Seropian, M., Brown, K. Gavilanes, J., & Driggers, B. (2004). Simulation: Not just a manikin. Journal of Nursing Education 43(4), 164-169.

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Shapiro, M., Morey, J., Small, L, Langford, V., Kaylor, C., Jagminas, L., & Jay, D. (2004). Simulation based teamwork training for emergency department staff: Does it improve clinical team performance when added to an existing didactic teamwork curriculum? Quality & Safety in Health Care, 13(6), 417-421. Silva, M. (1986). Research testing nursing theory: State of the art. Advances in Nursing Science, 16(9), 1-11. Steadman, R. Coates, W., Huang, Y., Matevosian, R., Larmon, D., McCullough, L., & Ariel, D. (2006). Simulation based training is superior to problem based learning for the acquisition of critical assessment and management skills. Critical Care Medicine, 34(8), 252-253. Todd, M. Manz, J., Hawkins, K., Parsons, M., & Hercinge, M. (2008). The development of a quantitative evaluation tool for simulations in nursing education. International Journal of Nursing Education Scholarship, 5(1). doi: 10.2202/1548-923X.1705 Waldner, M.H., & Olson, J.K. (2007). Taking the patient to the classroom: Applying theoretical frameworks to simulation in nursing education. International Journal of Nursing Education Scholarship, 4(1), 1-14. doi: 10.2202/1548-923X.1317 Wenke, M., Waurick, R., Schotes, D., Wenk, M., Gerdes, C., Van Aken, H., & Popping, D. (2008). Simulation based education is no better than problembased discussions and induces misjudgment in self-assessment. Advances in Health Science Education, 14, 159-171.

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