The use of high-fidelity simulation (HFS) in health care education has emerged as a possible solution to address limited clinical experiences related to patient, preceptor, situational, or site availabilities (Birkhoff & Donner, 2010; Jeffries & Rizzolo, 2006; National League for Nursing, 2013). HFS also provides students with a safe environment to learn and make mistakes without compromising patient safety. Research studies have shown HFS to be beneficial in acquiring new knowledge in many clinical areas, including medical-surgical, advanced cardiac life support, and acute myocardial infarction treatment (Brannan, White, & Bezanson, 2008; Elfrink, Kirkpatrick, Nininger, & Schubert, 2010; Hoadley, 2009).

Research has also shown that knowledge decreases over time, with a drop in test scores of 9 percent after three months (Sisson, Swartz, & Wolf, 1992). Several factors influence knowledge retention, including that it is improved with repeat testing/retrieval (Barber, Rajaram, & Marsh, 2008; Larsen, Butler, & Roediger, 2009), improved if memory is tied to an emotion (Buchanan & Lovallo, 2001; DeMaria et al., 2010; Reisberg & Hertel, 2005), improved with simultaneous learning (Burns & Ladd, 2006), and improved if given in small portions over time (Raman et al., 2010).

The purpose of this research was to examine the effects of HFS on knowledge retention. Does HFS influence the knowledge nursing students retain as they enter professional practice?

METHOD

This was a quasiexperimental study with a repeat measures design, which included a pretest, immediate posttest, and a four-month retention test. Forty-four junior-level nursing students participated in either a lecture-only (control) or lecture with simulation (intervention) experience. The control group consisted of 19 students (3 male, 16 female); the intervention group contained 25 students (3 male, 22 female).

Procedure

Participants in both groups completed a knowledge test following the pediatric neurology lecture (pretest), immediately following the simulation (posttest), and four months following completion of the course (retention test). Students were randomized into the control or intervention group based on their selection of simulation day.

The simulation scenario took place in the simulation laboratory with course faculty serving as facilitators of the scenario. The students gathered for a presimulation conference where objectives were clarified and roles were assigned. The simulation experience took 7 to 10 minutes and was videotaped. Immediately following the simulation scenario, the students participated in the debriefing process and had an opportunity to watch the video; they had time to reflect during the debriefing.

Instruments

Knowledge gain and retention were measured with an 11-item multiple-choice knowledge test, developed by the researchers, on the emergent care of an infant with a subdural hematoma. Reliability and validity for this test were established through psychometric testing (mean discrimination score of 30) and review by five nurse experts.

The Nursing Education Simulation Theoretical Framework and simulation design tools developed through the National League for Nursing/Laerdal Simulation study were used to guide this research. The theoretical framework is grounded in theories of learner-centered practices, constructivism, and collaboration (Jeffries, 2007).

The simulation design tools included Educational Practices Questionnaire, Simulation Design Scale, and the Student Satisfaction and Self-Confidence in Learning Scale. Cronbach's alpha coefficients verifying the reliability of the simulation design tools revealed the following: Educational Practices Questionnaire (0.80), Simulation Design Scale (0.87), and Student Satisfaction and Self-Confidence in Learning Scale (0.73). The independent variables included the instructional method and time. The dependent variables included satisfaction rates, knowledge, and simulation design quality.

Analysis

Independent and paired t-tests were completed on each of the knowledge tests. The pretest was analyzed to see if there was a statistically significant baseline difference in scores between the intervention and control groups. The pretest was compared to the posttest to see if there was a significant difference in knowledge gain between the two groups. The posttest was compared to the retention test to assess for knowledge retention. Finally, the pretest was compared to the retention test to assess if learning levels had returned to presimulation levels.

RESULTS

Analysis revealed no between-group differences in knowledge content at baseline (t = -1.15, df = 42, p = .257). There was a statistically significant difference in learning between the intervention and control group (t = -3.39, df = 29, p = .002); however, there was no statistically significant impact on four-month knowledge retention (t = -.30, df = 42, p = .766). The intervention group's knowledge returned to preintervention levels at four months (t = .122, df = 24, p = .904), whereas the control group's knowledge remained constant (t = -.825, df = 18, p = .420). Students perceived that the simulation was designed well (91 percent) and educational practices were utilized (92 percent); students were satisfied with the experience (92 percent).

DISCUSSION

Knowledge gain and retention are important outcomes of HFS experiences. Students should have significant learning to account for their time, the time spent by faculty, and the cost of equipment. Although this study had a small sample size and limited randomization, the results can help to better inform faculty on important outcomes of the simulation experience. The results indicate that there is a statistically significant difference in knowledge gain between lecture-only and lecture with simulation experiences, which is consistent with the results of past studies (Brannan et al., 2008; Elfrink, Nininger, Rohig, & Lee, 2009; Hoadley, 2009).

The lack of statistically significant findings related to knowledge retention was a surprising result. The simulation experience did incorporate many proven methods for improving knowledge retention such as repeat testing, components of experiential and cognitive learning, and emotions; yet, no statistically significant difference was found.

Levett-Jones, Lapkin, Hoffman, Arthur, and Roche (2011) had similar results with two-week knowledge retention being equal between medium and HFS experiences. The researchers found no statistically significant difference between groups. Further research is needed to optimize the HFS experience to promote knowledge retention.

CONSIDERATIONS FOR PRACTICE

Although the use of lecture and discussion will continue to be foundational in nursing education, the addition of HFS scenarios may help to supplement the material. The benefits of HFS experiences must balance out the faculty hours and additional technical and monetary obligations. Utilization of multiple simulation attempts, with focused objectives and standardized debriefing, may help improve long-term memory of the content.

Faculty should also account for the effects of cognitive fatigue. If the content is too complex or stressful for the students, knowledge retention may suffer. Results of this study show that HFS may be an effective method for helping students learn. However, more research is needed to determine best practices to achieve optimum learning outcomes.

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