Nurse educators perceptions of simulation teaching in Chinese context: benefits and barriers

Introduction

As an alternative educational pedagogy, simulation replicates a particular set of conditions to resemble authentic clinical (Khalaila, 2014). Simulation-based teaching has become more and more popular in health education. It provides an effective way for students to prepare for complicated clinical situations, especially for the low incidence high-risk events (Almeida et al., 2018), and it allows interdisciplinary teamwork, enables students and medical staff to cultivate communication skills, enhances their clinical practice in a nonthreatening setting (Norman, 2012). In nursing education, there are a plethora of studies support that both nurse faculty and students found simulation is valuable and beneficial to develop metacognitive thinking, improve students’ self-confidence and satisfaction of learning (Gaba, 2004; Jeffries, 2012; Yeun et al., 2014; Zhang et al., 2014; Lee et al., 2020). Furthermore, a longitudinal study conducted by the National Council of State Boards of Nursing (NCSBN) suggested that qualified simulated experience can efficiently replace up to 50% of clinical placements (Hayden et al., 2014). Simulation-based teaching becomes a vital teaching strategy in nursing education.

Simulation-based education was introduced into Chinese nursing education at the beginning of the 1990s (Wang, Fitzpatrick & Petrini, 2013b). Under the Chinese national nurse agenda for promoting a higher quality nursing education (Gao et al., 2017), many institutions and schools have integrated innovative simulation activities into their education programs and nursing curricula, moving from traditional teaching into student-centered education to better prepare graduates for the increasing complexities of health care environments (Xie, Jiang & Yin, 2015; Li, Wang & Liu, 2017). Moreover, the growing attention of the public to their health care rights restricts nursing students’ clinical practice opportunities (Park & Kim, 2000). As a result, an increasing number of nursing schools have considered applying more simulation in their curricula (Wang, Fitzpatrick & Petrini, 2013a; Wang, Sun & Wu, 2014a). Although nearly three decades have passed, many nurse educators continue to struggle to maximize the usage of simulation, facilitate students’ simulation preparation, conduct simulation and evaluate the outcomes of simulation experiences (Bogossian et al., 2018). Nursing faculty shortages, high workload demand, and insufficient funds delay the usage of simulation throughout nursing curricula. Moreover, there is a lack of qualified simulation facilitators in China (Li, Petrini & Stone, 2018).

The International Nursing Association for Clinical Simulation and Learning (INACSL) created standards of simulation facilitation with best practice, which indicates that a facilitator with well-developed simulation facilitation skills manages the complexity of simulation activities (Boese et al., 2013). In 2018, the National League for Nursing (NLN) implemented a China Faculty Development Program for Simulation to leverage the resources of Chinese nursing schools to lead Chinese nurse educators in the transformation of nursing education. This transformation would provide for the development of a safe and effective nursing workforce in China through leadership training and faculty development in the use of simulation in teaching and learning (Forneris, 2019). Considering that simulation education is the key to guiding students’ learning (Boese et al., 2013), determining how Chinese nurse educators feel about using simulation in their institutions is very important for faculty training and can influence simulation adoption. This study aimed to identify the nurse educators’ experiences of using simulation-based education from various regions of China, explore their perceptions and identify factors that influence the implementation of simulation in the current context of China.

Research questions. Research questions for this study were: (1) What is the current status of simulation teaching adoption by Chinese nursing educators? (2) What are the perceived barriers and benefits of simulation implementation from nursing instructors?

Theoretical Framework

Built on the foundation of initial National League of Nursing (NLN)/Jeffries’ simulation framework (Jeffries, 2005), the NLN-Jeffries Simulation Theory is a theoretical framework comprising seven conceptual components: context, background, design, simulation experience, facilitator and educational strategies, participant and outcomes (Hallmark, Thomas & Gantt, 2014). The NLN recommends using the theory framework to guide simulation activities (Adamson, 2015). Facilitator characteristics, such as the educators’ experiences, teaching ability, nursing competence, and technological skills, are aspects that influence the educator’s ability to facilitate and evaluate simulation (Boese et al., 2013; Jeffries, 2016). In this study, the National League for Nursing-Jeffries Simulation Theory provided the framework for gathering faculty’s opinions in this survey.

Materials & Methods

Results

In total, 136 participants completed the questionnaire, and 131 (96.3%) were female. Sixty-nine (50.7%) had a master’s degree, sixty-one (44.9%) held a bachelor’s degree, three (2.2%) had a diploma, and three (2.2%) were doctoral degrees /doctoral candidates. The age of participants ranged from 25 to 58 years old (36.67 ± 7.76), and the average work experiences ranged from 0 to 33 years (9.75 ± 7.90).

Implementation of simulation in the nursing program

The self-reported implementation of simulation shows that 108 (79.4%) of participants have used simulation in their work, while other participants reported they have never used it. The frequency of use of simulation in the previous 12 months ranged from 0 to 200 times. Figure 1 details the frequency of the use of simulation.

Seventy-five participants responded to the question that focused on what hinders them from adopting simulation in their working setting: 34 (45.33%) stated that they did not know how to run a scenario; 24 (15.4%) think that their courses were not appropriate for simulation, seven (9.33%) considered that simulation was too complex to implement, and the others (13.3%) reported reasons such as “students do not adapt [sic]” and “I do not like design scenario [sic].” Compared with the reasons why they plan to use simulation in the future, 131 participants responded as follows: 63 (48.09%) stated that there is a need for simulation in their course, 39 (29.77%) showed interest in using simulation-based teaching, 17 (12.98%) reported that they followed their institution’s requirements, and the remaining (9.2%) reported implementing simulation in teaching research and course reform activities.

Discussion

Nursing educators are constantly striving to advance nursing education through innovative technology to prepare future nurses for the complexities of the health- care environments (Jansen et al., 2009). Through the integration of simulation into nursing education programs, the goal of providing quality education that enhances students’ learning outcomes could be partially achieved (Hayden, 2010; Warren et al., 2016). This study reports the survey findings relating to Chinese nurse educators’ perceptions in the adoption of simulation, with a focus on the factors that influence the use of simulation.

Participants of the survey mentioned that faculty show growing interests in the adoption of simulation in teaching, and an increasing number of nursing schools have purchased or are planning to use this innovative approach (Wang, Sun & Wu, 2014a; Zhang, 2017). The majority of respondents positively indicate that simulation served to increase students learning satisfaction, better motivate students’ active learning, and promote learning outcomes. Simulation spans the gap between theories and practice by creating a safe clinical learning context (O’Donnell et al., 2014). This literature supports the consensus of the advantages of simulation pedagogy. Simulation pedagogy contributes to the acquisition of students’ knowledge and skills and strengthens their metacognitive abilities (Hayden et al., 2014; Lam’e & Dixon-Woods, 2020; O’Donnell et al., 2014).

Although faculty show a generally supportive attitude towards simulation, their frequency of using simulation is not high (Nehring & Lashley, 2004). Simulation has not been fully used by nursing educators in China (Anderson et al., 2012). Our study results show that less than 92(67.6%) of the respondents had used this teaching method frequently, which means use simulation in their teaching less than ten times in the last year. Compared with existing studies that reported inadequate financial support, time and technology as the major obstacles to the usage of simulation in nursing education (Al-Ghareeb & Cooper, 2016; Cuchna, Walker & Van Lunen, 2019), the survey data reflects that more faculty struggle in helping students adapt to simulation learning, enhancing student engagement, and integrating simulation into the nursing course and curriculum. In the process of using simulation, they experienced a lack of team support. Instructor development was a chief obstacle to the full adoption of simulation in nursing education (Taibi & Kardong-Edgren, 2014). Educator preparedness in simulation teaching can influence the learners’ readiness for learning and the learning outcomes (Cockerham, 2015). Educator development in simulation should include a solid understanding of the principles of constructivism and learner-centered instruction as a foundation for simulation pedagogy (Taibi & Kardong-Edgren, 2014; Boese et al., 2013). Periodic faculty development programs for continuous simulation quality improvement are also needed to acknowledge ongoing faculty skills (Taibi & Kardong-Edgren, 2014).

Our study indicates that the respondents’ prior simulation training experiences haven’t changed their real application of simulation. Survey findings support the research of Arthur, Levett-Jones & Kable (2013) and King et al. (2008), which indicated that faculty had positive intentions to use simulation, but negative beliefs regarding the real application. An additional study pointed out that there were no significant differences in using the simulation technology pre and post attending the training program (Jones, Fahrenwald & Ficek, 2013). One of the possible reasons is that lots of Chinese educators have not been trained adequately. Several participants reflect that they have attended some seminars or workshops. Most of these training are one-time offerings, and some are sporadic. The information provided can help them gain a quick understanding of simulation teaching, but this knowledge has a different focus, not systematic enough to support their actual implementation (Cheng et al., 2015). A few educators reported that they have only received the training from manikin companies.

In the survey, some educators reported that they dare not try simulation because they had no hands-on learning activities in simulation training. These findings are consistent with the literature (Katz, Peifer & Armstrong, 2010; Jones, Fahrenwald & Ficek, 2013). In China, most of the simulation training programs focused primarily on the technical aspects of the simulation operation with little regard for the qualification of the simulation instructors (Cheng et al., 2015; Issenberg, 2006). Appropriate content selection to meet the pressing needs of faculty development can make the simulation instructor training more effective and promote the use of simulation (Topping et al., 2015). Taibi & Kardong-Edgren (2014) conducted an online survey to explore the training needs of simulation. They reported that the training priorities for simulation instructors include facilitating interprofessional communication, followed by guiding a debriefing session and integrating the simulation pedagogy into nursing curricula. They also indicated that the lowest need was mechanically operating a simulator. In their study, the faculty expressed that they would try simulation teaching with more support.

Recently, many Chinese faculty members realized that the use of simulation in nursing education requires additional knowledge and preparation (Shen et al., 2019). They have started to improve their simulation competencies in various ways (Forneris, 2019). But our survey results indicated that when using the simulation with students, a lot of faculty members had a lack of confidence regarding their own level of proficiency with simulation facilitation. By comparison, educators who used simulation teaching more frequently in the past 12 months showed stronger self-confidence. The faculty would gain confidence with the increased use of simulation (Katz, Peifer & Armstrong, 2010). The literature proposes that the persistent deliberate practice is an efficient way to develop necessary simulation teaching skills (Topping et al., 2015). Some researchers suggested that preferred strategies to develop simulation competencies were: (1) observing skilled instructors’ simulation teaching and understanding simulation through trial and error (Bentley & Seaback, 2011; Anderson et al., 2012); or (2) practicing simulation teaching in a safe and simulated educational environment with feedback from experienced simulation facilitators (Waxman & Telles, 2009). Some researchers emphasize that an overall training program of simulation-based education may promote competences of nursing educators (Roh, Kim & Issenberg, 2019; Topping et al., 2015).

Conclusions

Although simulated teaching was introduced to China in the late 90s, it remains underused in nursing education (Zhu & Zhu, 2019). Many Chinese nursing schools have begun to realize the necessity of simulation-based education and are now scrambling to build simulation center/laboratories. In contrast, the training of simulation instructors is still in its early stages (Wang, Sun & Wu, 2014b). The quality of nursing simulation varies due to the lack of qualified instructors, and insufficiency of simulation teaching standards and the qualification of certification for simulation instructors exacerbates the situation. Given that many nursing faculty hope to master simulation teaching ability and improve their teaching quality to realize the students learning outcomes by participating in simulation training (Taibi & Kardong-Edgren, 2014), our study suggests that formal faculty training programs should be based on the educators’ training needs, systematically design the training topics, and provide hands-on learning simulation activities with expert feedback to help nursing educators enhance competencies required for simulation teaching progressively.

Supplemental Information