Best Practices Issue - May 2023

As clinical placement challenges in nursing education continue, nursing programs report increasing use of high-fidelity simulation (HFS) to augment student learning. Identified benefits of HFS include reduced risk of harm to live patients, opportunities to immediately identify and correct mistakes in a safe environment, and exposure to scenarios that may not arise during participation in face-to-face clinical experiences. Conversely, recent research results suggest that students experience high levels of anxiety during HFS – especially when assigned the role of the primary nurse. This anxiety poses a threat to learning, performance, and student safety (Al-Ghareeb et al., 2019; Cantrell et al., 2017; Cheung & Au, 2011; Cordeau, 2010; Nielsen & Harder, 2013). Students report feelings of anxiety in simulation stemming from a variety of sources, including not knowing what to expect in an HFS, being watched, and fear of doing something wrong (Cantrell et al., 2017). Elevated levels of anxiety have repeatedly been shown to reduce the performance of nursing students during simulations (Al-Ghareeb et al., 2019; Shearer, 2016). Once primarily a formative educational activity, simulation has evolved to become an evaluative activity (Gantt, 2013). Its potential value in high-stakes testing, such as for licensure examination, increases the need for students’ preparation in coping with HFS-related anxiety (Kardong-Edgren et al., 2011).

Often, the anxiety surrounding simulation decreases students’ ability to perform well and retain the information they have learned (Al-Ghareeb et al., 2019). As the use of HFS increases in nursing education, student anxiety must be managed to support student performance and accurate assessment of skills. Although the level of simulation-related anxiety and its contributors appear frequently in nursing education literature, a paucity of research exists that addresses effective management strategies for HFS-related anxiety (Cantrell et al., 2017., Janzen et al., 2016; Nielsen & Harder, 2013; Shearer, 2016).

Nursing students demonstrate and report anxiety during HFS regardless of how well-prepared they feel for the simulation (Gantt, 2013; Shearer, 2016). Assignment to the role of the primary nurse is a particularly stressful aspect of HFS for nursing students. In HFS, the primary nurse is typically assigned the responsibility of patient care, performing assessments, calling providers, and delegating tasks to the students assigned to other roles (Zulkosky et al., 2016). Students report that the primary nurse role is a significant cause of anxiety (Lasater, 2007; Yockey & Henry, 2019), and effective decision-making in this role decreases when compared to performing in other roles, such as an observer role (Zulkosky et al., 2016).

A recent qualitative research project at a large university in the western United States provides valuable insight into the coping strategies employed by students assigned to the primary nurse role (Clements, 2020). Participants were asked how they managed their feelings and emotions during simulation, and how effective they felt these coping strategies were. Three different themes emerged: individual coping skills, peer-aided coping skills, and instructor-aided coping skills.

The individual coping skills reported include positive self-talk and a review of knowledge and skills associated with the scenario. One student reported needing time to “mentally prepare herself and be calm” and found that positive self-talk such as “It’s totally fine if I mess up; it’s really not that big of a deal” helped with anxiety reduction. Another student explained the need to review requisite knowledge and skills thoroughly because “sometimes I was just really nervous, and it was ok, and sometimes I was super nervous, and my brain would just turn off.”

Students reported anxiety reduction by using peer-aided coping strategies including group planning, skill review discussions, and an expectation of peer support after the simulation. Collaborating to make a plan during the pre-brief simulation session made one student “feel more confident.” Another participant stated, “I like that we get time to like, talk it through together and you’re not by yourself in the preparation goal.” Study participants also reported aiding peers by saying, “We could tell someone was really stressed about something or didn’t know how to do something we’re all there to like, remind them of the steps and talk them through it.” Participants who mentioned peer-aided coping skills articulated the advantages of peer support. They reported feeling “relief” when the simulation ended and they returned to the debriefing room with their peers. One participant said, “I like going back in the room and you get a lot of positive feedback from everyone so you’re like ok like actually I did better than I thought I did.” Another participant echoed the expectation of peer support during and after the simulation and stated, “When you’re in the middle of it, a lot of times you’re like, ‘Oh my gosh I’m doing horrible’ …, but then everyone tells you that you’re doing good, so you do feel good about yourself.”

Regarding instructor-aided coping skills, participants discussed interventions by simulation instructors that helped alleviate some of their anxiety. Facilitating an opportunity for peer-aided coping by giving students time to prepare for the simulation as a group received positive feedback from students. Additionally, providing students with a list of possible nursing skills to be included in the scenario was also applauded. Finally, one student mentioned that an instructor who encouraged a supportive environment helped to “calm your nerves,” and “having a supportive professor also makes a difference, one who’s like just go in and make sure that you try…we’re all just here to help you.”

Overall, nursing students are currently using limited coping strategies to manage simulation anxiety and are especially lacking in individual coping skills. Nursing students are also experiencing a varying ability to learn in the primary nurse role. Participants who did report using coping skills also shared that they were able to learn in the primary nurse role, suggesting an increased focus on teaching nursing students coping skills may help them manage their anxiety and enhance their learning. Further research into discovering effective coping mechanisms for simulation anxiety would help identify how to best support learning in the primary nurse role during high-fidelity simulation.

Because heightened anxiety undoubtedly affects student HFS performance, the use of HFS as a high-stakes summative evaluation should be considered as only a portion of the student’s overall preparation to function independently in the nursing role. Furthermore, nursing simulation instructors should incorporate coping skills within the curriculum to reduce the negative impact of simulation-related anxiety on student learning, especially in the primary nurse role. Instructors should encourage peer-aided and instructor-aided coping skills, promote peer and instructor encouragement, allow time for group planning and discussion, and provide advance-preparation resources.

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