Simulations are a widespread method of learning in nursing professions, and they have attracted international interest in recent years (Gaba, 2004; White and Sherman-Justice, 2012). Simulations aim to resemble reality to achieve certain purposes. In specific reference to healthcare, simulations are attempts “to replicate some or nearly all of the essential aspects of a clinical situation so that the situation may be more readily understood and managed when it occurs for real in clinical practice. Simulation illustrates the process of healthcare, practicing skills to manage procedures or to support and develop know-how, teamwork, etc. to amplify or replace actual experience” (Gaba, 2011, pp 198-199). Nursing education has benefitted from the simulation methods in medical education, which adopted simulations from aviation (Gaba, 2011). The studies on simulations vary from effectiveness studies to confidential and satisfaction studies that compare teaching methods and strategies (Adamson, 2012). Studies have been performed on the perceptions of nursing simulations by nursing students, teachers and faculties (Baillie and Curzio, 2009), as well as a variety of comparative simulation studies, e.g., low-fidelity versus high-fidelity, online simulation versus simulation, students’ self-effectiveness, teaching strategies and other simulation technologies.

Previous simulation research has employed different theories as springboards to explain learning; in some studies, theoretical discussion is lacking or is mentioned only superficially. Studies have employed constructivism, (Kyrkjebø et al., 2006), experiential learning, expert learning (Adamson, 2012), problem-based learning (Walsh, 2011) and social practices (Elfrink et al., 2009), among others. Simulation learning has been integrated into nursing curricula with different teaching models and has introduced questions regarding the pedagogical roots and concepts of simulation teaching. In their systematic literature review, Kaakinen and Arwood (2009) concluded that most nursing simulation theory researchers address different aspects of teaching but not those of learning or the students.

This scoping review asks how learning is conceptualized in nursing simulations and what types of pedagogical models are used. First, we introduce our aim, review questions and review strategy; second, we present our results; and finally, we discuss our findings and review questions.

 

THE REVIEW

Aim

Learning through nursing simulations has been studied for years. However, carefully linked educational theories, empirical research and conceptual clarification are needed.  Otherwise, we will find ourselves in conceptual chaos regarding learning using nursing simulations. The aim of this scoping review was to examine the literature regarding the concepts of learning and pedagogical models in nursing simulations.  

We applied a review method known as a scoping review (Arksey and O’Malley 2005).  It is also called a scoping study by Arksey and O’Malley (2005), who outlined the first methodological framework. It can be described as “a process of mapping the existing literature or evidence base” (Armstrong et al., 2011). A scoping review can be used to explore the extent of the literature in a particular domain without describing the findings in detail (Armstrong et al., 2011), to determine  the  value  of  undertaking  a  full  systematic  review,  to summarize and disseminate research findings or to identify research gaps in the existing literature (Arksey and O’Malley 2005). Arksey and O’Malley developed a methodological framework for scoping studies upon which Levac et al. (2010) expanded. The original framework involves five stages: identifying the research question, identifying relevant studies, selecting the studies, charting the data and collating, summarizing and reporting the results. As an optional element, Arksey and O’Malley suggested a “consultation exercise” to inform and validate the findings from the main review, a stage that Levac et al. (2010) considered mandatory.

 

The first stage: identifying the review questions

We identified our research questions, considering the review’s purpose. Initially, the questions were broader, such as, “What is learning in simulations?” and “What kinds of learning do simulations produce?” However, during the review process, we formulated three more focused questions, as Levac et al. (2010) recommended. This iterative process of reflecting on and reforming research questions is typical for qualitative studies (Flick, 2014, 146-147).

The following questions were addressed:

1. How is learning using nursing simulations conceptualized?

2. What types of pedagogical models are used in nursing simulations?

3. Which educational concepts and theories are used in nursing simulations?

At this stage, we also defined a search strategy, as Levac et al. (2010) recommended. The strategy focused on how authors explicated educational concepts and theories in their studies and noted whether the authors addressed them in the discussion sections of their articles. We chose this strategy because the discussion sections of scientific articles often combine and evaluate literature and study results and state the practical and theoretical implications.

 

The second stage: identifying relevant studies

 We identified relevant studies. This stage balances the breadth and comprehensiveness of the scoping study with the feasibility of resources, and it can be challenging, as Levac et al. (2010) observed. We formulated clear inclusion and exclusion criteria (databases covering both educational and healthcare journals, only peer-reviewed articles, time frames, nursing journals in PubMed, access at our universities and full papers). In a scoping review, these criteria can also be developed during the process, as Armstrong et al. (2011) noted. For example, we included the last criteria (access at our universities and full papers) initially, but we did not need to utilize them in the final phases; we had access to all of the studies that were included in the review. We employed both qualitative and quantitative methods, which can be performed in scoping reviews (Arksey and O’Malley 2005). We used five databases: Science Direct (Elsevier), Web of Science (ISI), Academic Search Elite (EBSCO), PubMed (Medline) and ERIC (ProQuest). These databases encompass both nursing and educational literature databases. Our review of nursing and education journals included the dates from January 2000 to December 2013; only peer-reviewed articles in English were included. The primary search terms were: “nursing”, “simulation”, “learning” and “pedagogy” (excluding book chapters and conference papers). We also conducted searches by hand (Jeffries, 2005; Waxman, Telles; 2009; Keskitalo et al., 2010; Lafond, Vincet, 2013) because these articles illuminated the aim of the review and encouraged  debate   on   the  simulation  models.  We used these articles to underpin this study.

 

The third stage: Study selection

We selected relevant studies using two researchers who worked independently and together. The process was iterative in nature and involved different phases, such as searching for articles, reading the literature and refining the search strategy and search words (Levac et al., 2010). The study selection comprised four phases. First, we obtained all articles that contained the four search words, and all four words were required to appear in the article. At first glance, we found that most of the words were only mentioned or were present only in the references. In the second phase, the primary search words were required to appear in the title, abstract, keywords and/or introduction. Additionally, we omitted duplicates and included only full papers. Seven review articles (Table 2) were included at this stage of our review.

The first phase produced 384 articles in Science Direct, 15 articles in EBSCO, 31 articles in ERIC, and 21 articles in Web of Science; in PubMed, we restricted the search to only nursing journals, which produced 375 articles. A total of 826 articles were included (see Table 1 for the search outcomes and data sources). The second phase resulted in 326 articles. These articles were then divided in half for each of the two researchers to read. In the third phase, we further investigated the discussion sections with respect to the concepts, learning and pedagogy implemented in the nursing simulations. We accepted only empirical research and review articles (66 articles). In the fourth phase, we accepted those empirical studies that elaborated on theorists, theories, learning and/or curricula in their conclusion or discussion sections (32 articles, see Annex 1 and Figure 1). Below are the step-by-step phases of our analysis. 

 

 

 

The fourth stage: Charting the data

We compiled two tables. The first table presented the technical data we collated, including the author(s), year, country of origin, journal name, article title, curriculum implemented and result(s), to provide an overview of the articles. The second table contained the following information: the first author and publication year, study design, focus on teacher and/or student, educational term(s) used, educational concepts and theories with referenced names, and whether the educational concepts and theories were mentioned or elaborated on in the article’s discussion or conclusion sections. This table helped us to answer our research questions, and Arksey and O’Malley (2005) called this type  an “analytical-descriptive” method that is employed in narrative traditions.

 

The fifth stage: Collating, summarizing and reporting the results

Levac et al. (2010) recommended that researchers break the fifth stage into three distinctive steps. First, the analysis can include both a numerical summary analysis and qualitative thematic analysis. The second step reports the results and produces the outcomes that refer to the overall purpose or research questions. The third step considers the meaning of the findings as they relate to the overall study purpose and discusses the implications for future research, practice and policy. We perform this step in the discussion section of this article. Next, we summarize the findings of review articles (Table 2), present an overview of the review and elaborate on each review question.

 

 

Seven review articles discussed the concept of simulation as a learning strategy, compared high-fidelity simulation with other learning strategies, discussed how to use simulation in health professions and discussed how simulation learning currently appears in the literature as a combination of different teaching strategies. Two articles explored the National League for Nursing (NLN)/Jeffries Simulation Framework, one as a framework for development work and the other regarding its scientific state. We briefly summarize the results of the review articles to provide an overview (Table 2).

fifteen in the USA, four each in Australia and the UK, three in Canada, two in Norway, and one each in Hong Kong, Ireland and Singapore. One study was international, performed in both Finland and the USA, which indicates that learning and simulations are of international interest, although it is centered in the USA.

The studies covered a rich variety of simulations: standardized patients, human patient simulations, high-fidelity and low-fidelity patients and diverse simulation scenarios. The simulations were used to teach a variety of nursing skills: acute nursing, clinical skills, observation of patients’ conditions, airway management, childbirth and end-of-life encounters, among other examples. Learning in simulation was often described as active, dynamic, interactive, experiential, safe, student-centered, integrative, authentic and meaningful compared with “traditional” and teacher-centered learning methods, which were typically lectures. The debriefing phases of the simulations were highlighted, particularly as forums for learning. The studies used both qualitative and quantitative methods, different types of questionnaires, and participants who were mostly students.

We identified thirteen conceptualizations of simulation-based learning (the first question). Five comprehensive pedagogical models of nursing simulations were pre-sented in the studies (the second question), and diverse educational theories were employed as well (the third question). The findings are summarized in a narrative-descriptive manner. In the discussion section, we elaborate on the results.

 

Conceptualizations of learning in simulations

Our first review question asked  how  learning  in  nursing simulations was conceptualized. Learning  in nursing simulation has been conceptualized in many ways (Table 3); in most studies, learning  was conceptualized as simulation-based learning (Dieckmann, 2009; Sekiguchi et al., 2013; Fadale et al., 2014; Poore et al., 2014; Yeun et al., 2014). However, the studies lacked deeper conceptual-historical analysis and the concepts were given and taken for granted.  Roots of the concepts were not explained in detail. Furthermore, simulation- and problem-based learning was merged differently (Murphy et al., 2011; Liaw et al., 2010; Adamson, 2012). Authors also used multiple conceptualizations of learning in their articles, and a number of authors employed conceptua-lizations that were produced by expert councils, such as the National League for Nursing (USA, Arthur et al., 2013) and the Nursing and Midwifery Council (UK, Hope and Prescott 2011).

 

 

 

Educational concepts and theories in nursing simulations

Our third review question asked which educational concepts and theories are used in nursing simulations. The articles were divided into three categories: those that focused on and used basic education theories, such as narrative pedagogy (Cangelosi, 2008) or situated learning theory (Rush et al., 2010); those that employed simulation learning concepts and frameworks, such as the NESF (Swanson et al., 2011) or the simulation learning pyramid (Kopp and Hanson, 2012); and those that employed theories from other disciplines, such as socialization theory (Walton et al., 2011) or critical feminist sociology (Limoges, 2010). The articles were further divided into two categories: those in which learning was mentioned but not discussed further and those in which education concepts and theories were also addressed in the discussion section. A number of education-related insights were revealed in the studies. Table 4 shows a typology of the results; the table is divided into three types of insights: a) practical tools and methods, b) conceptual tools, such as models and frameworks and c) research methods.

 

 

 

The sixth stage: Consultation

This stage involved consultation with different stake-holders. First, we established the purpose for consulting the stakeholders, which was to obtain feedback on the results from different perspectives. We sent our stakeholders the preliminary abstract, introduction, aim and purpose of the review and preliminary findings via e-mail. We requested consultation from eight experts who represented four areas: education (nursing teachers), research (university researchers), practice (hospital nurses) and policy (national authority); two persons from each area answered the questions. The five consultation questions were:  “What are the strengths of the findings?” “What are the weaknesses of the findings?” “Are the findings applicable to your work?” “Are the findings transferable to your work?” and “What kind of simulation research is needed in the future?” All experts replied individually to the questions by e-mail, except for the hospital nurses, who responded together. We classified the results into four categories: strengths, weaknesses, applicability and future research. We report here on the first two categories, and in the discussion section, we report on the remaining findings. The stakeholders perceived the review findings’ strengths to be: comprehensiveness; internationality; the inclusion of multiple methods, concepts and models; and the heterogeneity and complexity of learning. Furthermore, the review highlighted the connection between pedagogy and simulations. As weaknesses, the experts identified that multiple concepts were not adequately defined and the pedagogical models and theories had been only referred to. These consultation findings highlight that multiplicity and heterogeneity can be both strengths and weaknesses. This conclusion reveals that the phenomenon of learning using simulations is complex and challenging. We have attempted to describe the concepts and models that were used in the review articles, but in most cases, the authors did not explain their justifications regarding learning using simulations the theories had been only referred to.

In our review, we focused on how learning was conceptualized in nursing simulations. The most widely used concept was simulation-based learning, and the most referenced education theory was experiential learning. In contrast to Kaakinen and Arwood’s (2009) review results, most of our studies focused on students and their learning.

At present, conceptual chaos appears to encompass learning using nursing simulations; we identified 13 different conceptualizations. This variety suggests that learning using nursing simulations in the context of striving to become a nursing professional is complex and multi-layered and that simulation itself is a multifaceted and intricate phenomenon. Studies have attempted to comprehend these phenomena by introducing new concepts that clarify them. Future research that focuses on the history of the concept as well as on conceptual analysis is needed. From a practical point of view, it would be beneficial to achieve, at least to some extent, conceptual and terminological stability as our stakeholders also suggested. One promising attempt to standardize the terminology was made by Meakim et al. (2013).

In our review, the most widely used conceptualization was simulation-based learning, which suggests that the process and phenomenon of learning are rooted and grounded in simulation. However, Teräs et al. (2013) argued that anchoring learning in simulation methods can narrow the concept of learning and instead proposed simulation-mediated learning. The concept of “simulation- and problem-based learning” refers to a combination of two learning methods.  Our stakeholders also pointed out that conceptualizations seem to be method- driven.  “Scenario-based simulation training” emphasizes the scenarios used in simulations, and “high-fidelity simulated learning environments” highlight the technological levels of patient simulators. We argue that conceptualizations of learning in simulations need to be based on educational theories rather than methods and instruments. 

If learning in simulation is understood as mimicking or imitating real-world work situations, as was the case in a number of studies, then we propose the question, “Is learning reduced to a demonstration?” We argue that learning using simulations is far more complex and has greater potential. If nursing educators attempt to mimic real-world work experiences, there is a danger that vital information will be lost and that we will not fully utilize simulations as learning forums. However, learning using simulations could embrace the variety of different work practices through repetition and reflection. We need to carefully elaborate on and analyze who is learning and what, where and when they are learning, as Alexander et al. (2009) proposed.

The field has begun to develop models for learning in nursing simulations, and the basis for many studies has been models of simulation settings (Dieckmann, 2009). According to Dieckmann, these models are based on many theories without being differentiated. Our review introduced five different nursing simulation models. The most popular and widely used models in different situations are conceptual (Jeffries, 2005) and theoretical (Jeffries and Rogers, 2007) framework models. These models have served as frameworks for research and have tested practical skills using framework features (Dobbs et al., 2006). Lafond and Vincet (2013) conducted a profound theoretical analysis from the NLN/JSF model using Fawcett’s analysis criteria and proposed further investigation. Keskitalo et al. (2010) designed a facilitat-ing, training and learning model (FTL) and described how it supports meaningful characteristics of learning; this model combines the processes and characteristics of learning. Clinical practices and problem-based learning were also sources of inspiration for pedagogical models.

Typically, we produce new models in science when we know little about a phenomenon, as Knuuttila (2005) proposed for evaluating models in science. In her footsteps, we perceive models as researchers’ epistemological tools that are used to produce new knowledge and understanding (Knuuttila, 2005). However, models are dynamic, and special interest must be focused on how they are used in nursing education. Morgan and Morrison (1999) approached models as mediating instruments of scientific work, writing that although models and simulations are closely associated, it is important to isolate “what it is about a model that enables it to ‘represent’ by producing simulations” (p. 29). Thus, simulations can be used to explore the extensions and limitations of the pedagogical model itself.

A number of education concepts and theories were mentioned, ranging from constructivism to situated learning. Most studies introduced the names of learning theories with little justification for the meanings behind the theories. It appears that an education theorist must be mentioned to give the article education credibility. Learning in simulations appeared to be assumed as self-evident, meaning that learning was mentioned and assumed in many studies but was discussed in detail in only a few studies (Keskitalo et al., 2010; Rush et al., 2010; Keskitalo et al., 2013).

As Alexander et al. (2009) noted, learning can be resisted or even be disadvantageous. Furthermore, students can learn issues in simulations that teachers do not want them to learn; Langemeyer (2012) noted that students learned stereotypical professional and gender roles in simulations. As our stakeholders noted, the review results focused mostly on education practice, research and policy, and more knowledge and models are needed for real-world work situations. Furthermore, our stakeholders suggested more research from evaluation and simulation methods and extend to the other domain.

 

Review limitations

There are a number of limitations in our review. First, we did not assess the original education concepts and theories to evaluate how the authors had adapted them. Second, we did not include “theory” as a search word, which may have limited the number of review articles. Third, we included only nursing journals; other areas of healthcare education may also have been beneficial. The fourth limitation was that we reviewed studies that were published in English, which limited any international scope. 

This review suggests multiple implications for nursing simulation researchers and teachers. First, simulation researchers and nursing teachers need to be aware of and more careful in using multiple conceptualizations of learning, and they need to develop teaching and instruction so that decisions are made based on education theories. Real-world work simulations need practical learning models that are developed in their own contexts. Future research is needed on conceptual analysis, strong empirical studies linked to education theories, and how to use simulations as evaluation methods. A suggestion for further research is to determine whether these review results are relevant to other healthcare fields and other professional domains.

The author has not declared any conflict of interests.