Fundamentals of Anatomy and Physiology For Nursing and Healthcare Students An Essential Guide for Nursing and Healthcare Students 2nd Edition Ian Peate (Editor)
Series Editors: Adam I. Levine · Samuel DeMaria Jr.
Jared M. Kutzin
KT Waxman
Connie M. Lopez
Debra Kiegaldie, Editors
Comprehensive Healthcare Simulation: Nursing
Comprehensive Healthcare Simulation
Series Editors
Adam I. Levine, Department of Anesthesiology
Mount Sinai Medical Center
New York, USA
Samuel DeMaria Jr., Department of Anesthesiology
Mount Sinai Medical Center
New York, USA
Tis series focuses on the use of simulation in healthcare education, one of the most exciting and signifcant innovations in healthcare teaching since Halsted put forth the paradigm of "see one, do one, teach one." Each volume focuses either on the use of simulation in teaching in a specifc specialty or on a cross-cutting topic of broad interest, such as the development of a simulation center. Te volumes stand alone and are also designed to complement Levine, DeMaria, Schwartz, and Sim, eds., THE COMPREHENSIVE TEXTBOOK OF HEALTHCARE SIMULATION by providing detailed and practical guidance beyond the scope of the larger book and presenting the most up-to-date information available. Series Editors Drs. Adam I. Levine and Samuel DeMaria Jr. are afliated with the Icahn School of Medicine at Mount Sinai, New York, New York, USA, home to one of the foremost simulation centers in healthcare education. Dr. Levine is widely regarded as a pioneer in the use of simulation in healthcare education. Editors of individual series volumes and their contributors are all recognized leaders in simulation-based healthcare education.
Jared M. Kutzin • KT Waxman
Connie M. Lopez • Debra Kiegaldie
Editors
Comprehensive Healthcare Simulation: Nursing
Editors
Jared M. Kutzin
Emergency Medicine
Icahn School of Medicine at Mount Sinai
Director of Emergency Medicine Simulation
Mount Sinai Hospital
New York, NY, USA
Connie M. Lopez
Perinatal Patient Safety
Kaiser Permanente
Pleasanton, CA, USA
KT Waxman
School of Nursing
University of California San Francisco San Francisco, CA, USA
Debra Kiegaldie
Eastern Health Clinical School, Faculty of Medicine, Nursing & Health Sciences
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This book is dedicated to my family, friends, and mentors without whom it would not have been possible. Thank you to Jenny Rudolph for indulging a graduate student’s question and shedding light on “how the way we talk, changes the way we work.” Thank you to Chuck Pozner for opening the doors of STRATUS many years ago. To my loving and supportive wife, Melissa, without whom the late nights would not have been possible. And to my children, Sylvie and Eli, who provide me with endless hours of practice in advocacy, inquiry, and debriefng.
Jared M. Kutzin
I would like to dedicate this book to all of those educators who believe in simulation, advocate for it, and are passionate about the outcomes. For those of us who have seen the “lightbulb come on” in debriefng, it makes what we do worth it. I would like to thank my family for supporting me all of these years as I traveled the world to spread the word about simulation! Thank you Steve, Ashley, Sam, Brian, Tom, and the grands: Olive, Meyer, and Bette.
KT Waxman
Simulation is a wonderful teaching strategy that has transformed the way we deliver education in the nursing profession. I dedicate this book to the simulation champions in nursing. I would like to thank my family for their unwavering support throughout my academic and simulation journey—this is for you Farnel, Aaron, Ashleigh, and Brittany.
Debra Kiegaldie
I extend my heartfelt gratitude to my fellow editors, whose unwavering support and dedication have been invaluable throughout the creation of this textbook. I deeply appreciate my family and friends’ endless encouragement and understanding, which have been instrumental in navigating this professional endeavor. Thank you for your support, and I hope you enjoy this read!
Connie M. Lopez
A special thank you to the inspiring authors and dedicated healthcare simulation teams around the world. Your commitment to patient safety and innovation through simulation has reshaped the learning, training, and patient care landscape.
To the authors who weaved expertise and insight onto pages, your words serve as bridges connecting theory to practice, fostering a deeper understanding of simulation, and drive the evolution of healthcare education.
To the healthcare simulation teams who bring scenarios to life, your creativity and efforts in crafting realistic simulations empower healthcare professionals to hone their skills, refne their approaches, and ultimately deliver safer, more effective patient care.
Thank you for your passion and collaborative spirit, which continues to elevate the standards of healthcare education and practice. Your contributions resonate profoundly, shaping the future of healthcare for generations to come.
Foreword
One cold Nebraska January day, our college president stopped in my offce and asked if I would go to a conference in Florida. Of course, I said yes. Later, I asked her what she wanted me to do there, and she said, “check out this patient simulator and let me know if I should buy it.” She already had the money due to years of fundraising. My response: “What’s a patient simulator?” This was in 2003 and thus began my career in simulation. Upon my return with an enthusiastic “Yes!” she placed me in charge of simulation because I was now the expert— being as I was the only one that knew what a simulator was. Her gift to me was allowing me to replace my clinical responsibilities with simulation and giving me the time and freedom to fgure it out on my own. Of course, in those days there were no books, journals, courses, or organizations. On weekends, I played with the technology until I learned the nuances of the programming, but then also purposefully did things incorrectly so I could fgure out how the machines worked. After a year, I moved to industry, designing curriculum for nursing schools to use with simulation. I returned to academia after 2 years and have since worked with nursing, medicine, and allied health both in academia and clinical environments.
Nurse simulationists were supported by the early work of the National League for Nursing (NLN) which began studying simulation in the early 2000s. The NLN partnered with Medical Education Technologies, Inc. (METI, now known as CAE Healthcare) to provide research grants to support nurses to learn how to best teach with the Human Patient Simulator. A partnership with Laerdal to develop and test simulation models to promote learning, led by Dr. Pamela Jeffries, continues to provide support for nursing educators through the development of a theoretical framework to guide decisions related to all aspects of simulation education (Forneris et al. 2017). These early collaborations between academia and vendors were crucial to the progress of nursing’s use of simulation, helping to elevate simulation to a viable pedagogy, and providing resources to support nurse educators to learn a new teaching role. In 2011, the International Nursing Association of Clinical Simulation and Learning (INACSL) published the frst standards of best practice for simulation educators (Leighton 2011). These efforts helped to support early adopters when promoting simulation to their leadership.
The use of simulation has grown signifcantly over the years; however, cost has always been a factor. Nursing education is expensive due to the need for small clinical groups with low student-to-faculty ratios. We had been teaching this way for decades; however, the cost of simulation was a major barrier. The vendors realized that nursing education could not bear the expense of the simulators (our frst one cost $216,000!) and worked hard over the ensuing years to lower the price point. In addition, grant funding and major donations helped many schools to overcome the cost of the equipment. However, money continues to be scarce for faculty development. Numerous programs have been developed over the years from 1-day courses to doctoral programs; however, the cost of these opportunities often falls to the simulationist rather than the employer. Anecdotally, annual conferences are heavily attended by novices, indicating that the feld is still new enough that people are hired into their positions without adequate knowledge or experience. This is supported by social media posts from people asking for help in learning their new job role. There is work to do in order to help employers understand that simulation is a unique pedagogy with evidence-based standards of best practice that can lead to excellent
learning outcomes when facilitated by qualifed educators. Support for education and training of the facilitators, as well as the operations personnel continues to be substandard.
We are at a point in time where we need to carefully consider the role of simulation in nursing education and training. During the pandemic, many faculty converted in-person training to online platforms but often without support and training for how to teach online. Some State Boards of Nursing agreed for online simulation to replace traditional clinical hours; however, without the rigor of a multi-site study such as the one that compared outcomes of traditional clinical and in-person simulation (Hayden et al. 2014). Early research indicates that learning needs are met differently in the traditional clinical, in-person simulation, and screen-based simulation environments (Leighton et al. 2021), and it is imperative that outcomes are thoroughly evaluated before online simulation becomes a viable substitution.
I have believed for a while that manikin-based simulation will be replaced to a great extent by virtual reality due to the ability to create immersive, realistic, and less costly learning experiences. However, as a result of the pandemic, I suspect that the timeline will shorten as we had to learn (although under duress and stress) how to drastically change how we teach with simulation. There is a lot to learn yet, but we do know that some of the ways we accomplished simulation virtually worked very well and should be continued. Others didn’t work and need to be refned. It is exciting to see the volume of research being produced that shows favorable learning outcomes that will inform future best practices in this area. We have an opportunity to take what has been learned while researching various aspects of simulation and use these results to better inform traditional clinical practice.
We have made tremendous progress with simulation pedagogy in the past two decades and I’m excited to see what comes next. The early efforts in nursing education were fueled by the excitement of intuitively knowing that simulation was an important modality to add to our teaching arsenal. We learned a lot by trial and error, but isn’t that the same thing we are asking of our learners? I am forever grateful to be on this exciting, innovative, challenging, and rewarding career path and look forward to seeing where the future takes us.
References
• Forneris SG, Tagliareni ME, Jeffries PR, Rizzolo MA. National league for nursing and simulation innovation resource center. In: Foisy-Doll C, Leighton K, editors. Simulation champions: courage, caring and connections. Wolters Kluwer; 2017. p. 61 69.
• Hayden JK, Smiley RA, Alexander M, Kardong-Edgren S, Jeffries PR. The NCSBN national simulation study: a longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. J Nurs Regul. 2014;5(2):S3 40. https://doi.org/10.1016/S2155-8256(15)30062-4
• Leighton K. President’s message. Clin Simul Nurs. 2011;7(Suppl):S2. https://doi. org/10.1016/j.ecns.2011.05.004.
Executive Director, Itqan Clinical Simulation and Innovation Center, Hamad Medical Corporation
My earliest days in manikin-based sim were with Mindi Anderson at UT Arlington around 2004–2006. I was one of the faculty assigned to help in her physical assessment class. She started using a METI Man that the graduate school had purchased with a grant but decided that they did not have time to learn how to use. She dug him out of the crate and fred him up. We used him to help our students listen and learn lung and bowel sounds and some heart sounds. We also wrote little vignettes for practicing the assessment of various body systems, for example, skin–hair–nails. Hours were spent fnding images of skin cancer on Google and transfer-
ring them to clear overheads, then cutting and pasting them down to stick on the manikin for a 15-min experience each week in our physical assessment class. There were few scenarios available then, so we made things up as we went along and invented our own ways to use this $250,000 resource. Our course was the frst one to start using simulation, if I recall correctly. Our nursing school leadership came to see this manikin in action, and they all “got it” at frst glance. So much so that they wrote for and received a large grant for the building of a Smart Hospital that was designed for 20 Laerdal manikins. And it happened quickly, towards the end of a spring semester. The manikins arrived and were stacked like cordwood in the school hallways, on racks. It looked like a morgue. The “adoption” of simulation was eased by the vision of the leadership.
Many (and I use the word many deliberately) faculty were threatened by the “rise of the machines.” Many said the words “you are trying to take my job” with little understanding or desire to learn what might be possible. When we say it takes 17 years on average for a new practice to become accepted, it has been about 17 years since manikins like SimMan 3G and the CAE manikins came on the nursing scene. To have the pandemic hit and have to move to screen-based simulation and widespread adoption of vendor or individually developed screenbased scenarios or virtual reality simulation is ironic. The same things may now be said by those who became skilled at running a manikin, “you’re trying to take my job.” Manikins were going to be one stop on the way to Star Trek Holodeck. If you paid attention, you could see this. Manikins were too big, too expensive, and too fnicky, for the average nursing program to deal with. The great thing we learned was that it was not about the manikin. It was about how to teach more effectively. So as the manikins begin to disappear to a certain extent and are replaced with screen-based simulation and VR, we are better educators overall. We have fgured out that the skills we developed in simulation apply to traditional clinical situations, i.e., pre-briefng, debriefng, and Socratic questioning.
Barriers to simulation and whether or not they have been broken down-Through death and retirement, the last simulation naysayers will fnally disappear. In reality, simulation and the knowledge of simulation pedagogy saved the spring class of 2020 nursing students by providing a way (for many, the only way) to complete requirements for graduation, to get them out into the working population, to help with the pandemic. What would we have done without this highly developed understanding of how to teach using this pedagogy? The real barriers to simulation adoption continue to be: the costs, the need to understand technology on a level that most of us do not, and the continued lack of education on how to use simulation in so many nursing graduate educator programs. It is astonishing to me that after 17–20 years of simulation use by all health professions education, multiple journals devoted to healthcare simulation, multiple societies and associations, and conferences worldwide on this topic, there are still nursing MS educator programs with cursory mention of simulation.
Suzie Kardong-Edgren Associate Professor at the MGH Institute of Health Professions in Boston
I was fortunate to be appointed the NLN program director in the early 2003 work with program coordinators across ten different schools including associate degree, diploma, and baccalaureate programs. Using simulation pedagogy was just beginning and my charge from the NLN was to conduct simulation research—does it work? Working with the program coordinators, we embarked on a literature review/systematic analysis just like we would start any new research program of study. We found very little in the literature regarding simulations. Many of the studies conducted talked about how the participants liked being immersed in simulations, but there were gaps in the fndings on what a simulation looked like, how to implement a high-quality simulation and how to evaluate the outcomes of this new emerging pedagogy. As a group, we conducted our frst study in simulation research but realized that we had more to offer to nurse educators and that was creating a “cookbook” on how to develop, implement, and evaluate simulations. This conclusion led me to the frst NLN book called Simulation in
Nursing Education: From Conceptualization to Evaluation published in 2007. Since then, we have two other editions (2012, 2021). This book was written for nurse educators who were beginning to embrace simulation pedagogy; the content provided direction and strategies on getting started with simulations, setting up early simulation centers, and overall, provided the NLN Jeffries framework which served as a model to guide the development, implementation, and evaluation of simulations. In 2015, working with many nurse researchers in INACSL and the NLN and nursing theorist, Dr. Beth Rodgers and nurse scientist Dr. Katie Haerling, the NLN Jeffries Simulation Framework was deemed to be a mid-range theory now called The NLN Jeffries Simulation Theory. A monograph was published in 2016 highlighting this theory, the components, and utilization of the important work.
In the early 2000s, the use of clinical simulation in nursing education was embryonic; many were just beginning to explore with few embracing the technology. Within 5 years, the notion of clinical simulations exploded, more schools of nursing were adopting the use of simulations although at times, faculty were not developed in knowing how to use simulations in their teaching, however, many of the schools’ leaders were purchasing manikins for the educators, but not providing faculty development in this area. There was a great need at this time for more faculty development. Continuing to work with the NLN, a new project was created and this was to develop the Simulation Innovation Resource Center (SIRC) that served as a one-stopshop for simulation information and provided a mechanism to build an online community with other educators who were asking questions and embarking on clinical simulations. In addition, I worked with several different authors to create online courses in faculty development in simulation so we had a convenient, accessible, cost-effective mechanism to develop faculty in using this pedagogy. The SIRC site still exists today and more courses have been added throughout the years.
In addition to providing faculty development opportunities to those educators who wanted to embrace the simulation pedagogy, the rise of simulations became more prevalent as more evidence was obtained and disseminated across the health professions. In 2014, I had the privilege along with Dr. Suzie Kardong-Edgren, to serve as a consultant on the national, landmark National Council of State Boards of Nursing (NCSBN) study. This study recruited leaders from ten, pre-licensure schools of nursing to invest if simulations worked—there were three arms of the study that included a control group, substitution of simulations at 25 and 50% across the curriculum. This landmark study provided strong evidence and robust results that substituting simulations for clinical hours did not affect the learner’s knowledge, skills, or transition to practice therefore recommendations stated that simulations could be used up to 50% to substitute for clinical education in schools of nursing if best practices used in the study were implemented. The national study had policy implications across the 50 states and internationally; state boards of nursing heeded the evidence and began to make policy changes based on the evidence. In addition, a blue-ribbon panel of researchers, educators, and leaders from prominent nursing organizations met and wrote a paper on providing guiding principles when using the simulation pedagogy based on the study fndings.
I always saw the use of clinical simulations as a “clinical redesign” in helping to improve nursing and other health professions education. The way we have been doing clinical education (the gold standard of sending students to clinical with one instructor taking care of one patient during the day) leaves many gaps when graduates transition to practice. I believed in “experiential learning” which the use of simulation pedagogy provides. Using simulations, the students actually get to “practice” his/her role they are preparing for, for example, the RN and the NP. Faculty members observing simulations provide direct feedback during debriefng when using this pedagogy. The student learns what he/she did right or wrong. A good faculty facilitator in debriefng will help the student to “connect the dots” from theory to practice. The value of simulations can’t be underestimated! The evolution and quick adoption of simulations, I believe, is because of the value in our educational arena’s faculty see when incorporating clinical simulations into the curriculum. Students want more simulations; they defnitely learn from clinical simulations when done in a high-quality manner. We now have more evi-
dence from the health professions providing “best practices” in using clinical simulation pedagogy and outcome data that demonstrate using simulations can make a difference in the knowledge and understanding of clinical practice. Of course, I am a believer of clinical simulations, an early pioneer, an early adopter, and will continue to support and disseminate the value of clinical simulations across health professions education.
The biggest barrier of using and incorporating clinical simulations into a nursing program/curriculum is the lack of faculty development. The simulation pedagogy requires training education on how to use this pedagogy, how to create simulations, implement, and debrief. During the past year in the pandemic, many nursing faculty/educators had to pivot quickly; even if they were not using simulations, one ended up using simulation, specifcally virtual or screen-based simulations in order to provide instructional continuity at the school level so students could progress and graduate. Faculty development even became more important during this time since clinical simulations were the “go to” to provide the needed, required clinical education.
Were barriers broken down? I am not sure about that, but I do know faculty were immersed in using different teaching pedagogies they were not used to using whether it was online teaching or providing clinical education via virtual simulations. Other barriers pre-COVID and still existing today include the need for evidence and best practices. The evidence has emerged in these areas but more is still needed. There are many gaps in the use of simulations not only for pre-licensure students, but also for NPs and graduate clinical education. We have much more work to do to develop nursing and other health professions’ faculty members to teach using simulation pedagogy, but we have grown tremendously in this area and looking ahead, the future looks very promising.
Pam Jeffries Dean, Vanderbilt School of Nursing Valere Potter Distinguished Professor of Nursing
Preface
I have been in simulation since 2004. I was fortunate to receive grant funding from the Gordon and Betty Moore Foundation to create the Bay Area Simulation Collaborative which eventually evolved into the California Simulation Alliance. The impact that simulation has had on nursing education and practice in California has been signifcant. We were well prepared for the pandemic in terms of moving to online learning using simulation. We are at a point now that we are advocating for regulatory changes at the Board of Nursing level.
Simulation has grown into a profession evidenced by the Society for Simulation in Healthcare’s certifcation process, new jobs opening up, and employers taking notice of how important educated and experienced simulationists are to the growth of their programs and their return on investment. In the late 2000s, it was all about the technology, the manikin. Now, simulation encompasses a wide range of methodologies such as task trainers, role-play, standardized patients, computer-based, min/mid/high-fdelity simulators, and virtual reality. The evolution of simulation has been exciting to watch. With schools being the early adopters, hospitals followed suit and now, the next step is to build academic/service relationships to maximize the utilization of the equipment and space to train both students and staff together. I envision orientation times in hospitals to go down if students are able to learn in a simulated environment in the hospital before touching patients on the units. I envision more VR being used in both hospitals and schools.
There are many barriers to simulation, and I believe these are because administrators, staff, and faculty naysayers do not understand the value proposition for simulation. As simulationists, we need to continue to advocate for simulation at all levels in our organizations. We need to be able to articulate the value of simulation as it relates to patient safety. Simulation is here to stay; we cannot go back to old mental models of education!
KT Waxman San Francisco, CA, USA
Nursing is a complex and specialized feld of study with many nuances between specialties, areas of practice, and environments of care. Similarly, education, especially adult education, is equally complex. Creating rich learning opportunities that engage multigenerational learners with complex learning styles is a challenge that must be met every day by nurse educators in academia and clinical practice. Simulation-based education has emerged as a tool to bridge the gap between theory and practice often cited as a cause for poor outcomes, ineffcient/unsafe care, high turnover of nursing staff, and an underprepared nursing workforce. The need for expertise and continuing professional development to correctly utilize simulation has never been greater. Simulation has taken a prolifc role in replacing clinical sites as part of undergraduate nursing education programs, has flled gaps in the graduate nursing programs, and is utilized by nurse educators with clinical staff daily in hospitals across the globe. From resourcelimited environments to top academic medical centers, simulation has a place to improve education, clinical practice, and the care provided to patients.
We have tried to take a practical approach in this textbook with many examples for specifc educational environments and specialties. We want to provide a resource for nurse educators on how part-task trainers, high-technology full-body simulators, standardized patients, virtual reality, and distance simulation techniques can be used to help prepare the current and future generations of nurses.
This textbook opens with an introduction and foundational simulation concepts. It then branches into three core sections, focused on specifc learner groups (undergraduate, graduate, and continuing professional development). It concludes with a section on operations and administration of simulation programs and a look into the future of simulation with examples of unique and forward-thinking simulation programs from other specialties.
We hope that you fnd this book flled with exemplars that you can use to broaden your understanding and use of simulation. We recognize that many nurse educators have spent years developing their specialized clinical (and educational) practice. Simulation is still novel to many in nursing education, and it is a wonderful tool to help break down silos, build comradery, and expand your mindset. We see this text as a nurse educators’ handy reference when developing or collaborating on a program that may fall slightly out of their comfort zone.
Thank you to all our authors for sharing their expertise, their tireless effort in putting their knowledge onto paper, their patience, and their dedication to enhancing simulation education for nurses across the globe!
New York, NY, USA
Jared M. Kutzin San Francisco, CA, USA
K.T. Waxman Pleasanton, CA, USA
Debra Kiegaldie
Connie M. Lopez Moorabbin, VIC, Australia
Jaclyn Conelius,
Leland Rockstraw
Kati Maxkenzie and Joilah
Kiralee Ciampa
and Debra Kiegaldie
Michelle A. Kelly, Diane Dennis, Sissel Eikeland Husebø, Yun Kang, and Gary Francis
14 Assessment and Evaluation in Nursing Education: A Simulation Perspective
Loretta Garvey and Debra Kiegaldie Part III Graduate Nursing Education
15 Simulation Modalities for Graduate Nursing Programs
Bernadette Henrichs and John M. O’Donnell
16 Writing Clinical Simulations for Advanced Practice Registered Nurse Education
Sabrina Beroz
17 Simulation in Family Nurse Practitioner Education
Jo Loomis
18 Acute Care Nurse Practitioner
Mary K. Donnelly
19 Psychiatric Mental Health Nurse Practitioner
Joan Fraino
20 Primary Care Pediatric Nurse Practitioner Simulation Techniques
Ruth K. Rosenblum and Julianne Doucette
21 Simulation for Certified Nurse-Midwifery and Women’s and Gender-Related Health Care Nurse Practitioner Students
Nancy Selix and Justin Waryold
22 Simulation in Nurse Anesthesia Education
John M. O’Donnell and Bernadette Henrichs
23 Using Simulation with Master’s Entry to the Profession of Nursing Students (MEPN)
Amy Nichols and Laura L. Van Auker
24 Leading a Multidisciplinary Team to Develop and Implement Interprofessional Education (IPE) Simulation
Dayna L. Herrera and Sarah E. Pearce
25 Assessing Learning in Graduate Education Simulation 251 Garrett K. Chan
26 Simulation for Nursing Leadership Development 255 K. T. Waxman and Christine Delucas
Part IV Simulation for Continuing Professional Development
27 Simulation Modalities for Nursing Professional Development 261 Susan Doolittle and Virginia Riggall
28 Writing Clinical Simulations for Continued Professional Development
Virginia Riggall and Susan Doolittle
29 Simulation for New Hire/Pre-Hire Orientation
Karen Josey and Carrie Brandon
30 Simulation for Nursing Competencies
Cynthia Shum
31
32
33
34 Simulations for
Kimberly Bilskey and Tara J. Lemoine
35
Tara J. Lemoine, Kimberly Bilskey, and Rebecca
37 Interprofessional
Lygia L. Arcaro and Richard L. Fidler
38
Kirsty J. Freeman, Robert Amm, and Melanie Goode
39 Perioperative
Jennifer C. Mendenhall, Anjanette Y. Pong, Marc Parent, and Cindy M. Blenis
Jill Sanko
42
43
Penni I. Watts, Tedra Smith, Beth Hallmark, and Becky Damazo
KT Waxman and Marie Gilbert Part VI The Future
Ann Russell, Jordan Holmes, Nancy McNaughton, Kerry Knickle, and Juanita Richardson
Part I
Fundamentals of Simulation in Nursing
History of Simulation in Nursing: An Overview
Elizabeth Horsley and Judy Bornais
Nurse educators have historically been extremely creative in their teaching methods. In fact, nurses of a certain age will remember injecting oranges to practice psychomotor skills. Others may remember practicing bed baths and positioning on classmates, and although we did not have the terminology at the time, those were forms of simulation. These creative approaches to teaching have given rise to simulation-based education. However, modern-day simulation education has evolved into a specialized discipline with its own established theories, frameworks, and best practices [1]. Nurse educators in academic and clinical practice have embraced the pedagogy, and as such, there has been an astounding trajectory of the integration of simulation-based education (SBE) into nursing curricula. Not only has simulation pedagogy evolved, but simulation technologies have also developed over the years. Ranging from full-body patient simulators to highly realistic task trainers to virtual reality experiences being integrated into curriculums. Simulation has grown to encompass professional designations, advanced education, and a robust body of scholarship.
Health professionals education has undergone radical changes in recent decades. Historically, medical education traditionally relied on an apprenticeship-type model where skills were learned from a combination of textbooks and observation and then practiced on patients [2]. The training was deemed satisfactory if the learner had “seen one, done one, and taught one” [3], or it was declared that a learner had accumulated enough time or exposure to a particular skill or specifc type of case. This traditional approach to training and teaching was fairly well entrenched across health profes-
E. Horsley (*)
The Brooklyn Hospital Centre, New York, NY, USA
J. Bornais
Offce of Experiential Learning, Faculty of Nursing, University of Windsor, Windsor, ON, Canada
Adjunct Faculty, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
sions for decades and remained unchallenged. The rise of educational research into how learning happens and the most effective types of teaching strategies has debunked these traditional models. For example, teams at Northwestern University in Chicago researched medical residents’ level of competence with a number of procedural skills and concluded that simply having accumulated hours of clinical experience did not correlate with technical competence in performing the skills [4]. A similar observation could be made about traditional nursing clinical practicums, in that total hours spent on a clinical unit -which has been lauded as the gold standard of practicum education—does not translate to competence [5]. These factors have made it necessary to explore innovative and alternative ways of teaching and training and have helped simulation-based education to emerge as an effective teaching strategy for both student learners and practicing health professionals.
Simulation is an experiential learning approach that can “… replace or amplify real experience along with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner” ([6]: i2). Wellconstructed simulation activities allow a learner or teams of learners to participate in realistic situations, then refect on the experience, whether at intermittent points during the scenario or at the end, through a guided debriefng. Simulation provides learners with the opportunity to experience the complexity of a clinical environment without the risk to patients or the possible hazards of an actual adverse patient event. A simulation activity that has been planned, developed, and implemented according to established best practice standards can facilitate the simultaneous evaluation of knowledge, clinical reasoning, and teamwork [7]. Simulationbased education is not restricted to undergraduate education or novice practitioners but can provide seasoned staff and clinicians with an opportunity to learn in a safe environment without the risk of harming patients or fear of judgment or punishment if they make mistakes [8].
J. M. Kutzin et al. (eds.), Comprehensive Healthcare Simulation: Nursing, Comprehensive Healthcare Simulation, https://doi.org/10.1007/978-3-031-31090-4_1
3
This chapter begins with the evolution of simulation and the societal factors that made it possible for simulation to become an accepted teaching strategy within nursing and healthcare. We then outline the background and development of simulation equipment and technology as well as contextualize the development of simulation as a teaching strategy within nursing education and practice.
Establishing Simulation as a Teaching Strategy
It is important to explore the roots of simulation in order to fully understand and appreciate its trajectory in nursing education. Simulation in nursing education has drawn upon the experiences of the military, aviation, and other health professions, such as medicine and, more specifcally, anesthesia, who were early adopters of simulation within healthcare. The earliest evidence of simulation models is the documented remains from antiquity which appears to be models of patients made from clay and stone [9]. It is presumed that these were used to illustrate features of the disease. These simulators would have been used by male physicians to diagnose women during a time when modesty rules precluded full exposure of the body [9]. An obstetrical trainer, “the phantom,” was made from a human pelvis and a deceased baby in eighteenth-century Paris and used to teach delivery techniques to obstetricians [10].
Some of the earliest recorded immersive simulations come in the form of war games [11, 12]. The game of chess, developed in the tenth century, represents a form of simulation whereby the game was played with the objective of testing out potential battle strategies [13]. In 1664, jousting, a recreational activity of medieval knights, allowed for the development of battlefeld skills [12]. Simulation, as we know it, in the nursing feld has more closely modeled itself on the initiatives of the aviation industry [14]. The aviation industry is arguably one of the most substantial adopters of simulation and an industry that sets the standards for both technical and team training. The earliest fight simulator can be attributed to Edwin Link, who built and patented the “Link Trainer” in 1929 [15]. The Link Trainer allowed for the simulation of poor weather conditions, and pilots were able to hone their skills in instrument fying. This trainer was slow to gain traction; however, in 1934, after numerous postal carriers were involved in fatal crashes in bad weather, the potential for Link Box training was realized [14]. All pilots were expected to engage in this simulated training as the value of simulation to prevent catastrophic events was realized [10]. Flight simulators gained popularity for many of the same reasons simulation in healthcare education gained popularity—it provided a safe, standardized environment for learners at various levels of expertise. Aviation,
much like healthcare, is an arena where waiting to test and train in real situations would be too dangerous and cost prohibitive [12]. Much like aviation, early nursing simulation focused on the technical skills nurses need to learn, especially those which occurred infrequently but which were critical to patient outcomes.
While aviation training was initially focused on the technical skills of the pilot, World War II created a need for team training within the newer and larger aircraft. Simulation now had to include the pilot, the navigator, and the bomber. While each had tasks and responsibilities which required rolespecifc training, the crew also needed team training so they would have the best chance of being successful on their mission [11]. The shift now was for entire fight crews to become to be educated in team training. As such, aviation not only set the standard for the technical training of pilots but is often credited as the originator of Crew Resource Management (CRM), a team-based training program that was introduced in the 1980s in an effort to fatten the hierarchy among fight crews and enhance communication amongst members of the fight team. In an examination of airline disasters in the 1970s, it appeared that failures in communication were causal factors. It was hypothesized and hoped that training such as CRM could potentially alleviate the hesitation junior crew members felt in speaking to superiors [11].
The importance of simulation in communication and team training expanded beyond just aviation to health care education. A team from Stanford began to incorporate the aviation industry’s principles of crew resource management into anesthesia crisis resource management [13]. This type of training adapted CRM principles of teamwork and communication and was renamed Crisis Resource Management to focus on situations faced by anesthesia professionals, whether they happened in the operating room, intensive care unit, or emergency department. CRM has grown beyond just anesthesia to a method of team training focusing on communication patterns, crisis management, and giving all team members the confdence to assert themselves and speak up. CRM can be woven into a plethora of healthcare simulation activities ranging from cardiac arrest to trauma team training. Along this line, in 2005, the Agency for Healthcare Research and Quality collaborated with the U.S. Department of Defense (in the United States) to develop “Team Strategies and Tools to Enhance Performance and Patient Safety, more commonly known as TeamSTEPPS®. TeamSTEPPS® consists of a number of evidence-based teamwork tools geared towards optimizing patient outcomes through effective communication and teamwork skills among the healthcare team. Simulation has proven to be an ideal platform for team training to develop and solidify CRM and/or TeamSTEPPS® skills. Interestingly, the TeamSTEPPS® curriculum now has a designated section on how to incorporate simulation into this training.
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The idea of using simulation, whether it be an orange or a link box, has a long history, but it was arguably the patient safety movement that brought simulation to the forefront. One of the pivotal moments which shifted so much of how healthcare professionals practice, and subsequently health professions education, was the release of the Institute of Medicine Report “To Err is Human” in 1999, which concluded that up to 98,000 deaths each year could be the result of a preventable error. These fndings shocked and reverberated through healthcare and the health professions education communities. The landmark report by the Institute of Medicine around safety and quality in healthcare is still often referred to in the simulation literature as one of the drivers towards the proliferation of the use of simulation [16].
Simulators and Simulated Patients
While there is a lengthy history of using replications of anatomical structures for education, what we commonly think of as simulation started evolving in the early twentieth century [12]. Most notably, and arguably the most often referred to, early instance of using simulation in nursing education was recorded in 1911 with the life-sized doll known as “Mrs. Chase.” Mrs. Chase was developed when the principal of the Harford Hospital (CT) Training School, Ms. Lauder Sutherland (a nursing graduate of the Toronto General Hospital), hypothesized that if students could practice skills on some type of doll, patients could be spared some discomfort [17]. In 1910, Ms. Sutherland contacted a doll maker, the M. J. Chase Company (named for real-life dollmaker Martha Jenkins Chase) of Pawtucket, Rhode Island, USA. The real “Mrs. Chase” and her husband Julian designed and crafted the frst prototype [18]. By 1911, the frst Mrs. Chase was ready to be put into service as the frst patient for generations of nursing students to come as a means to teach and refne psychomotor skills, such as dressing and transferring. The prototype doll was tested at Memorial Hospital in Pawtucket. She had injection sites and was able to have numerous genito-urinary skills completed on her. Much like today, not every school could afford to acquire its own Mrs. Chase, so by 1914, do-it-yourself patterns were available from Columbia University. Over time, Mrs. Chase’s appearance was refned, and her body functions upgraded. She remained a constant in many nursing programs until the early ’80s [17, 19]. The incredibly and increasingly diverse range of realistic patient simulators we see today can trace their lineage back to the venerable Mrs. Chase.
Next to Mrs. Chase, one of the most well-recognized names in simulation is “Resusci Anne.” Anne evolved from the imagination and skill of Asmund Laerdal, a Norwegian toy maker who was encouraged by a Norwegian anesthetist to develop a “doll” that could be used for teaching and prac-
ticing mouth-to-mouth resuscitation skills [20]. His creation was Resusci Anne, whose face was modeled after a young unidentifed French girl who had drowned and was found foating in the River Seine in the 1890s. Anne was more than simply a doll, as she had a degree of physical fdelity in her neck that allowed for hyperextension in order for there to be adequate ventilation. Laerdal, acting on the recommendations from the medical community, also built a spring mechanism into the chest wall so that cardiac compressions could be simulated, and Anne became one of the frst massproduced manikins [20]. This unit gave rise to the subsequent iterations of full-body simulators that followed, and the Laerdal Company evolved into a major manufacturer of simulators and task trainers. Resusci-Anne continues to be used to teach basic cardiopulmonary resuscitation skills, albeit in a much more modernized and technologically enhanced form [21].
By the end of the 1960s more computer-driven, mechanical patient simulators, like we are familiar with today, were in the early design and development phases. Sim One was developed by Dr. Stephen Abrahamson, an engineer, and Dr. Judson Denson, a physician from the University of Southern California. The model, which began as a teaching tool for anesthesia, evolved into a simulated human form that had a full panel of vital signs and was able to respond physiologically to the treatments administered. The inventors saw the potential for a much safer way of training novice clinicians in skills, such as intubation, as opposed to the then-common method of allowing novices to practice on real patients. Although this looked like a potential breakthrough for medical education, it did not garner enough traction to gain widespread popularity. The unit was costly to produce and maintain, the apprenticeship model of medical education was still prevailing, and no one was actively looking for any radical changes in medical education [12].
In 1968 “Harvey,” the cardiac assessment simulator developed by Dr. Michael Gordon at the University of Miami, was unveiled. Clinicians could assess Harvey (named for Dr. Gordon’s mentor at Georgetown University, Dr. W. Proctor Harvey) by auscultation and palpation of some pulse points, and he was able to replicate a wide variety of cardiac conditions. Harvey underwent rigorous testing and vetting for educational effcacy [20]. He continues to thrive and have an enduring presence and popularity in the simulation community because of his ability to help learners develop their cardiac assessment skills and knowledge of cardiac abnormalities.
The concept of full-body simulators came to the forefront again in the 1980s. Two separate groups, one at the University of Florida led by Dr. Michael Good, Dr. J. S. Gravenstein, and Dr. Samsun Lampotang, and the other at Stanford University led by Dr. David Gaba, experimented and produced prototypes of the full body simulators we are familiar
with today. Medical Education Technologies Inc. (METI, now CAE) and MedSim, respectively [20]. From these developments emerged the movement in the 2000s of units that solely represented the airway and/or allowed for cardiac arrest practice to life-like humans replicating pediatrics, geriatric, maternal, and other conditions. This allowed for a broad application among healthcare professions. Manufacturers also expanded their offerings to support simulation-based education beyond simply producing manikins and task trainers. METI produced ready-made curricula to be used alongside their patient simulators. Similarly, Laerdal developed its own scenario packages, ready for full integration with their manikins.
Simulation as a Teaching Strategy Within Nursing Education and Practice
Describing the full history of nursing practice and education is beyond the scope of this chapter, but we will provide a brief overview to contextualize how simulations use was developed. Early nursing practice in North America has its roots in religious orders. Of note, the frst hospital in North America, the Hotel Dieu in Montreal, was opened by Sister Jeanne Mance in 1645 [22]. Prior to the evolution of formal institutions to care for the ill or infrm, families assumed responsibility for their own. Following the Civil War in the United States (1861–1865) and the rise of industrialization in the US, public institutions began to open and provide care. Hospitals thus evolved, but they fell prey to the societal problems of the times and were often unsanitary, overcrowded, and a source of outbreaks [23].
Florence Nightingale, who is by and large most credited with the origination of what we know as nursing today, heralded a new age of nursing care in a secular age. She established the frst nursing school, St. Thomas, in London in 1860. The three overarching objectives of the school were: to train matrons who could organize and train future nurses; train nurses who could supervise and educate in indigent care in the community. The school’s objectives were to train matrons in both the theoretical and practical (hands-on) content of nursing; train them to organize and train future nurses and educate them in indigent care in the community. Nightingale’s apprenticeship training model solidifed nursing as a respectable occupation for women. Before this model was implemented, hospital care was carried out by a range of available ward attendants—“male and female, religious and lay, paid and unpaid, skilled and unskilled” caregivers ([22]: 74). Following the Nightingale Model, the frst nursing school in the US, the Bellevue Hospital School of Nursing in New York City, and the frst nursing school in Canada, the Mack School of Nursing in St. Catharines, Ontario, were opened in 1873 and 1874, respectively.
As hospital and scientifc medicine advanced in the late 1800s, hospital care became focused on treatment and ther-
apy ([22]: 74). Over this time, the practice of nursing and the requisite education began to take shape. Apprenticeship training became popular as a way to elevate the status of nursing and attract middle-class paying patients as trained nurses boosted the status of a hospital. This model provided the necessary knowledge, skills, and attitudes to care for the ill, indigent, and infrmed with a central focus on mastering technical skills and became the primary method of training nurses for nearly a century. Over time, this evolved into a more concerted effort to integrate theoretical and clinical knowledge, incorporating the scientifc and humanistic basis for practice as nursing education was incorporated into universities and community colleges. As the twentieth century progressed, there was a gradual incorporation of sciences with defned competencies in the cognitive, psychomotor, and affective domains.
In order to help nurses develop their psychomotor skills, nursing labs started to emerge with the frst iterations of a simulation lab in a school of nursing in the 1930s. The Indiana University Training School for Nurses was described as having manikins for the purpose of teaching students to give injections [8]. By the 1960s, like other forms of professional education, nursing was demanding higher standards of preparation in order to practice. Nurses need to be prepared for more complex and diverse roles. There was a proliferation of specialized intensive care units, while at the same time, the intensity of care required on a general duty unit increased. Nursing roles were expanding into the community, and advanced practice roles for nurses, such as Certifed Registered Nurse Anesthetists (CRNAs), Nurse Practitioners (NPs), and Clinical Nurse Specialists (CNS), were expanding. In order to provide the necessary skills training for their learners, nursing programs across the continent began the process of designing and outftting their own versions of a skills practice lab or learning resource centers.
In the earliest days of the adoption of simulation in nursing programs, the commonly referred to reasons for its implementation was the lack of clinical placement sites and the changing demographics of patients in hospitals. Hospital stays were becoming increasingly shorter and the patients were more acute and complex. These factors made it imperative to explore innovative and alternative ways of teaching and training. “With increasing numbers of nursing students and decreasing numbers of available clinical sites and nursing faculty, the use of simulation has become an integral part of nursing education” ([24]: 528). The traditional ideas around clinical practicums were that with suffcient hours in a clinical placement, regardless of whether a student was actively engaged or was merely observing, it was reasonable to assume the student somehow gained the knowledge and skill necessary to progress. The reality, however, is that students are often at the mercy of patient census and random happenstance. There really is no way for any clinical instructor to standardize the experiences of a clinical group. Literature began to explore the student clinical experience,
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and a thorough examination of the clinical day revealed students had signifcant amounts of downtime and were often “looking for something to do” [24].
As simulation was becoming more and more commonplace in nursing education, nursing leaders in the United States, in 2008, began to entertain the idea of simulation being a reasonable replacement for clinical time. To contextualize the societal changes that were infuencing this decision, it is important to note that in 1995 the frst National Conference on Nursing Skills Labs occurred to help educators share ideas and research fndings on how best to engage and teach nursing skills. By 1999–2000 a group of nursing educators “identifed the need for a professional organization to meet the growing needs of nurse educators using simulation” [25]. In 2002 the INACSL (International Association for Clinical Simulation and Learning) organization was founded, which examined simulation research and advocating of simulation evidence and best practice. In 2011 INACSL published the frst edition of the Standards of Best Practice in simulation. The most recent iteration of these standards renamed the Healthcare Simulation Standards of Best Practice™, was published in 2021. This rebranding refects an effort to broader the applicability of these standards beyond just nursing.
In 2014 simulation in undergraduate nursing education was advanced with the landmark 2014 NCSBN (National Council of State Boards of Nursing) multi-site study, which concluded that up to 50% of the clinical time could be substituted with high-quality simulation activities [26]. With a robust simulation program in place, a clinical educator could make deliberate and meaningful choices for educational experiences for students, as opposed to the uncertainty and lack of standardization of the clinical placement. By 2015, using the data gathered from the NCSBN study as well as previous simulation research studies, an expert panel convened by NCSBN used the simulation data along with the International Nursing Association for Clinical and Simulation and Learning (INACSL) Standards of Best Practice: SimulationSM to develop simulation guidelines for nursing programs [27]. Today, many state boards of nursing and state legislatures in the United States have started to explore adopting specifc standards and requirements to allow nursing schools to replace clinical hours with simulation. The early work by INACSL and the Society for Simulation in Healthcare (SSH) has provided the foundation for this evolution in nursing education.
Simulation Modalities
Well into the third decade of the 2000s, simulation for nursing education came in a variety of formats. For many nurse educators in the early 2000s, training was provided by the manufacturers, and many believed that higher levels of technology made for a better learning experience. While many of the cur-
rent simulation tools have become sophisticated and incorporate technology, it is important to recognize that technology is not needed for a simulation to be effective. As simulation has developed, so too has our understanding of what makes for a quality simulation-based educational experience. A study by Levett-Jones et al. [28] suggests that students highly value simulation regardless of the level of sophistication and fdelity, suggesting that expensive simulation equipment is not required to achieve the learning benefts that occur from the immersive education design.
In light of that, it is still important to discuss the various iterations of patient simulators. Mrs. Chase, the life-sized model discussed earlier, is an example of a low-fdelity basic simulator. In addition to life-sized static manikins, simulators include part(ial) task trainers—plastic or gelatinous models of body parts or manikins which allow learners to focus on developing specifc psychomotor skills such as urinary catheterization or central line care. Other examples of low-technology simulators include simulated wound sites and homemade trainers. Low-technology simulators, which tend to be less complex than their mid- and high-technology counterparts, are ideal for use when the objective is to learn and develop competency in a specifc psychomotor skill. But, this category of simulation tool can be used for much more than just repetitive practice and skill development; it all depends on how they are utilized. As an example, when detailed patient information and different participant roles are integrated along with low-technology simulators into a simulated learning scenario, the development of critical thinking and integration of theory with practice can occur.
Medium-Fidelity Simulators
Medium-fdelity simulators offer a higher level of interactivity with the learner and are more realistic than their lowtechnology counterparts. Often these simulators have some programming capabilities and can respond to learners’ actions but are limited in their physiological responses and verbal noises [29]. Examples of medium-fdelity simulators include CAE JUNO Nursing Skills Manikin and Laerdal’s Megacode Kelly™ with VitalSim capability. MediumFidelity manikins, like their high-fdelity counterparts, are often integrated into full-scale simulations with props, makeup, and replicated environments to create a level of realism that allows learners to integrate their assessment, psychomotor, and critical thinking skills to make clinical judgments and see the outcome of their decisions.
High-Fidelity Simulators
High-fdelity human simulators were introduced in the 1980s. The two early models were the CASE (Comprehensive
Anesthesia Simulation Environment) 1.2 model and the Gainesville Anesthesia Simulator (GAS), which were developed primarily for anesthesia training [20]. These early models have since evolved into sophisticated full-body computerized high-fdelity simulators that “have the ability to mimic, at a very high level, human body functions” ([30]: 14). With embedded software, current models may be programmed to allow the learner to experience different clinical presentations, and simulationists can control the manikin’s response to the learners’ actions and their clinical decisions. These full-body computerized simulators typically come equipped with a functioning mouth and airway that allow for intubation and ventilation. They contain a chest wall that expands and relaxes with respirations and which can be programmed with various lung sounds. In addition, these sophisticated mannikins also contain programmable heart and bowel sounds that can be auscultated using a stethoscope just as they would on a real patient. Included with these mannikins is the ability to project real-time displays of an electrocardiogram, arterial pressures, pulse oximetry, temperature, and the respiratory cycle. Designed with physiological modeling, these manikins are capable of realistic verbal and physiological responses. Typical features also include the ability for endotracheal tube insertion, bilateral chest tube insertion, intravenous lines which allow for running IV and “blood” fashback, and urinary catheters which, when inserted, can drain yellow fuid, simulating “urine”. As a result of their realistic features, these manikins are often most useful in full-scale, also referred to as full-mission, simulations. Full mission simulation requires a realistic environment and the use of actual medical supplies and equipment [31]. When the focus is on obtaining a health history, incorporating psychomotor skills and clinical judgment and decision-making, along with providing effective communication, the human-patient simulator is a great option.
Simulated Patients and Simulated Participants
An SP, also known as a simulated or standardized patient, the two terms are used interchangeably, is an individual who is “trained to portray a patient in realistic and repeatable ways” ([32]: 2). The use of SPs dates back to 1963 when neurologist and medical educator Howard Burrows created the frst documented simulated patient who provided the same symptoms to allow clerkship students to practice and receive feedback. Despite the widespread use of SPs in medical education [33], it took until the early 2000s for SPs to be noted in the nursing literature [34]. The majority of the literature reporting the use of SPs is with graduate or post-degree nursing programs such as NP programs [35] though more recent studies have incorporated SPs to facilitate effective commu-
E. Horsley and J. Bornais
nication skills by nursing students [36] and have shown that SPs can improve health assessment skills among frst-year nursing students [34]. SPs have not only been used to portray a patient, but they have also been used as family members in hybrid simulations. Because of this increased role of SPs, the terminology has also evolved, and the term “simulated participant” is now more commonly used. The more inclusive term, simulated participant, refers to all human role players involved in any simulation context [32]. An ideal time to incorporate simulated participants into a simulation is when the learning objective is focused on communication, developing health history-taking skills, or health teaching. Using simulated participants as the simulation modality allows for face-to-face human interactions with both verbal and nonverbal cues, facial expressions, and emotions.
Computer-Based and Virtual Reality Simulation
Screen-based simulations have evolved signifcantly over the last 10 years. From programs in the early 2000s that allowed participants to observe blood fow and listen to heart sounds based on where the computer-based stethoscope was placed to highly interactive immersive simulation environments whereby learners use avatars to make clinical decisions and see the outcomes of their decisions, the use of computerbased simulation continues to evolve in nursing education [37]. Computer simulation games, as well as threedimensional projections, whereby learners can manipulate images that appear suspended before them, are helping to provide safe environments for learners. Virtual reality (VR) simulations have also progressed in the last two decades, with social network platforms providing opportunities for students and nursing faculty to interface to create safe learning experiences [38]. In addition, technology has advanced to allow for haptic feedback whereby the learner receives feedback not only on the clinical decisions they made but on the technique they used. The virtual reality IV simulator is an example commonly used for nursing students to develop their phlebotomy skills, whereby the student can palpate and “feel” for a vein prior to inserting the IV cannula into a touchpad. The virtual reality program incorporates input from the touchpad and registers the depth of the needle as well as the angle and insertion technique. Haptic systems are ideal for use when the learning goal is to develop a specifc skill where feedback is helpful or to evaluate specifc skills with real-time tracking of the learner’s performance [31].
Augmented reality (AR) or mixed reality (MR), on the other hand, involves a blending of interactive digital-based elements, sometimes through specialized viewing headgear or digital apps, with aspects of the real world. In simulations where the learning objective is to help students understand the interconnectedness of the human body, use of a
Hololens, a headworn AR device, allows students to display, enlarge, rotate, and manipulate anatomy within a manikin. This is far more effective in meeting the desired outcome than plastic models. VR/AR/MR, collectively known as Extended Reality (XR) is only beginning to see its place in nursing education, and its use will increase in the future as clinical placements continue to become more limited. Simulation has a long and storied history, even though many may not be familiar with how it has been translated from the military and aviation into healthcare and from straw-stuffed dolls to highly complex computer and virtual reality simulators. The advent of simulation in nursing education (both academic and clinical) has led to an enhanced ability to educate and assess learners and improve the systems of care provided to patients by nurses globally. The future of simulation in nursing education is endless.
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2 Simulation Modalities
Jaclyn Conelius, Nancy Spear Owen, and Susan Reynolds
Introduction
This chapter will discuss defnitions and types of modalities for simulations. It will also give some helpful tips regarding each of the modalities as well as examples for use in a nursing undergraduate or graduate curriculum. However, the learning objectives and resources will always drive the choice of simulation modality.
Modality: Manikin-Based Simulation
Defnition: Manikins are full-body simulators used to educate students and healthcare professionals by simulating the structure and function of the human body (ssh.org). They can be found in sizes and simulated ages that extend across the lifespan.
Scope: There is a wide range of complexity to manikins with varying levels of fdelity and physiologic function. General guidelines are described below, but please read the manufacturer’s instructions for details of available functions on specifc manikins.
Low-fdelity manikins have the basic structure of a human body without internal electronics to mimic sounds such as voice or lung, heart, and bowel sounds. They are relatively inexpensive, tolerant of water, and can be good choices for learning and practicing nursing procedural skills such as enema administration, nasogastric tube insertion, and tracheal suctioning. A low-fdelity manikin gives students the ability to integrate patient safety skills like patient identifcation using a wristband with the procedural skill they are practicing.
Mid-fdelity manikins have internal electronics. They typically have assorted heart, lung, and bowel sounds which
J. Conelius · S. Reynolds
Fairfeld University, Fairfeld, CT, USA
N. S. Owen (*)
Columbia University School of Nursing, New York, NY, USA e-mail: nso2108@cumc.columbia.edu
can be programmed for students to practice identifcation and treatment. Further options across this modality often include static pupil variation, chest rise, and voice options. Scenario programming is also usually available.
High-fdelity human patient simulators can simulate more complex scenarios. These manikins typically have the abilities of a well-equipped mid-fdelity manikin with chest rise, voice, and body sound, plus additional functions such as adjustable pulse strength, airway compliance, and seizures. More dynamic changes intra-scenario are often possible such as pupillary changes and the use of radio frequency identifcation (RFID) technology to elicit physiologic responses to medications. Due to internal electronics, the installation of fuids may be more limited. Some high-fdelity models ft a certain professional specialty, such as trauma or midwifery, which give the opportunity for even more specialized functions.
Tips: When designing simulation experiences, developing objectives early in the process is key to ensuring a proper educational program and selecting the right simulation modality. The facilities and resources that are available will also dictate the simulation modality that can be used. Most nursing programs have a need for variety in their feet of manikins. When using mid and high-fdelity manikins, users have the choice of running scenarios on the fy or pre-programming them to run in automatic mode. Examples of manikin-based simulations for undergraduate and graduate nursing students are presented in Table 2.1
Modality-Task Trainer/Partial Task Trainer
Defnition: Task trainers or partial task trainers are the choice when the goal of the simulation is to focus on a psychomotor skill in isolation. They allow learners to repetitively practice one specifc task, which develops muscle memory and ultimately competency. Part-task trainers do not usually incorporate patient feedback. Instead, they offers
Table 2.1 Examples of use of manikin-based simulations in undergraduate and graduate nursing
Undergraduate nursing students Graduate nursing students
Human patient simulators
Use when simulation objectives entail high-risk procedures or when accurate assessment fndings are critical to meeting them
Low fdelity Practice labs to learn how to change the linens of an occupied bed
A scenario in a nursing skills lab entails placing an indwelling urinary catheter or nasogastric tube
Practice CPR skills
Mid fdelity
High fdelity
A scenario that requires a student to identify adventitious breath sounds and provide appropriate interventions
A scenario that involves a student identifying that their patient is having a seizure and intervening appropriately
A scenario that involves a primary care or neonatal nurse practitioner student identifying a murmur in a neonate
A scenario that involves a midwifery student attending the birth of an infant complicated by shoulder dystocia
A scenario that involves a CRNA student managing an airway during surgery
A scenario that involves an acute care practitioner caring for a critical care patient with ARDS
faculty a way to provide immediate directive feedback and to verify skill competency prior to performing on a real person.
Scope: Some examples of skills in which partial task trainers can be used are venipuncture of the arms, ultrasoundcompatible central line trainers, pelvic exam trainers, and prostate exam trainers.
Tips: Task trainers allow for focused, repetitive skills practice and consistency in experiences among learners. Some aspects of task trainers that may be a barrier are the time required to train faculty to use the trainers, the cost of the trainers themselves, space for implementing them into a simulation program, and upkeep and storage of equipment.
Modality: Role Play
Defnition: Role Play is a simulation modality that capitalizes on the importance of the social context of learning. It is the interaction of two or more players to simulate communication [1].
Table 2.2 Examples of use of role play simulations in undergraduate and graduate nursing
Undergraduate students Graduate students
Role play These examples can be adjusted for all types of students
During a health assessment lab, give student partners symptoms to verbalize during the exam
Practice confict management skills
Practice SBAR communication
During an advanced health assessment lab, give student partners symptoms to verbalize during the exam
In a leadership class, practice interviewing skills
With a scripted role-play, demonstrate good and inadequate practices around the use of interpreters
Scope: Role play can be used in a variety of scenarios. Students can role-play a patient, the nurse, or another scenario role. The level of the script can vary from fully scripted, partially scripted, and unscripted [1]. In an unscripted patient/ nurse role play, the nurse can be provided a task that they need to accomplish while the patient is provided a character and emotional context to the situation at hand.
Tips: Students who play the role of a patient can often gain invaluable empathy for the vulnerable position that their patients occupy. When the objective of the exercise is to build effective communication techniques, role-play simulation experiences are experiential activities that can have a positive starting point for student learning. Examples of roleplay simulations for undergraduate and graduate nursing students are presented in Table 2.2.
Modality: Unfolding Case
Defnition: An unfolding case is a patient experience that evolves over time. The experiences involve one patient or a family unit. Changes in the patient’s condition develop with each encounter (NLN.org).
Scope: Unfolding cases are useful for all levels of students. The timing of the unfolding case can vary from one class period to an entire semester to an entire program. They can simulate a patient across one admission, one life event, a lifetime, or anything in between. Unfolding cases span two or more encounters with the patient but have no other limiting conditions.
Tips: Unfolding cases can help students build relationships with their patients over time and offer students the opportunity to practice transfers of care across providers. Examples of unfolding case simulations for undergraduate and graduate nursing students are presented in Table 2.3.
J. Conelius
Table 2.3 Examples of use of unfolding case simulations in undergraduate and graduate nursing
Unfolding case
Undergraduate students Graduate students
Students care for a patient across admission, surgical procedure, post-op management, and discharge
Students care for elderly patients at home with complications that arise in each visit, such as wounds, memory loss, and depression
Primary care FNP students care for a patient through healthy yearly visits, diagnosis of chronic illness, and end-of-life situations
Midwifery students care for patients through well-woman visits, 9 months of prenatal visits, labor and birth, and postpartum care
CRNA students care for patients during preoperative consent, operative anesthesia, and post-op complications or pain control
Modality: Standardized or Simulated Patients (SPs)
Defnition: The terminology involved with standardized or simulated patients can be confusing. Both terms are referred to as SPs and refer to a person specially trained to play the role of a patient in a simulation. If a person is in the role of someone other than a patient, such as a family member or healthcare worker, they are referred to as a standardized or simulated participant. The Healthcare Simulation Dictionary, Ed 2.1, defnes a standardized patient as “an individual who is trained to portray a real patient to simulate a set of symptoms or problems used for healthcare education, evaluation, and research ([2]: 49). Other terms used to refer to SPs are actor, simulated person, or role player, but should be avoided as they fail to capture important components of the role. SPs in any role interact with learners to facilitate learning objectives. They are coached by a standardized patient educator (SPE) to perform in the same way for each new learner, which is the reason for the term standardized. SPs may provide learners with feedback on their interactions which is a unique feature of this modality.
Standardized refers to the ability to bring conformity with a standard and repeat in a consistent way. The term standardized patient is used when every learner needs to experience the same patient interaction, such as with competency testing or objective structured clinical exams/ encounters (OSCE). Simulated refers to making something
appear genuine or real. The term simulated patient can have more variability in the portrayal of the patient and is a term used for formative assessments. Although standardized and simulated are often used interchangeably, it is crucial to distinguish the purpose of the SP role to match learner assessments during the design phase of a scenario. The Human Simulation Continuum Model developed by GlivaMcConvey et al. describes how the degree of SP standardization ranges from low to high in six different applications. The six applications of SPs from low standardization to high standardization are role player, structured role player, embedded participant, simulated patient, standardized patient, and standardized patient for high stakes assessment (HSA) ([3]: 32).
Scope: Standardized patient programs have been developed around the world. SPs are used across a continuum of less structured simulations, such as role play to strict standardization for high-stakes exams [3]. SPs have historically been used for teaching and learning the following: health assessment and physical examinations; communication skills; emergency preparedness and disaster drills; and culture and diversity. Most recently, the standardized patient methodology has expanded use to distance learning with telepresence web conferencing software. Ballman and colleagues reported that using standardized patients in distance learning in graduate nurse practitioner programs facilitates confdence, clinical reasoning, and problemsolving skills.
Preparing students with SP simulation before attending mental health clinical helps to ease anxiety and build confdence. Standardized patients have also been brought into the classroom to work through an unfolding case study with larger groups of students. Therapeutic communication between patient and nurse, as well as professional communication between a nurse and other healthcare providers, are effective uses of standardized patients.
SPs are often used for an objective structured clinical exam/encounter (OSCE) which is “a station or series of stations designed to assess performance competency in individual clinical or other professional skills”. Learners are evaluated via direct observation, checklists, learner presentations, or written follow-up exercises. The examinations may be formative and offer feedback or summative and be used for making high-stakes educational decisions ([2]: 34).
A specialized group of standardized patients used for NP programs are male urogenital teaching associates (MUTA) and gynecological or genitourinary teaching associates (GTA). A MUTA is a male and a GTA is a female, “specifcally trained to teach, assess, and provide feedback to learn-
ers about accurate urogenital and rectal examination techniques” ([2]: 20). MUTA’s and GTA’s also “address the communication skills needed to provide a comfortable exam in a standardized manner, while using their bodies as teaching tools in a supportive, non-threatening environment (ASPE)” ([2]: 20).
Tips: The Association of Standardized Patient Educators (ASPE) is a global interprofessional organization that provides ASPE Standards of Best Practice, resources, mentoring, a case development template, and professional development [2]. If a simulation program is new to the use of SPs, it may help to start small with only one or two simulations and to find a mentor through ASPE. The expansion of remote simulations offers an opportunity to build diversity in SP programs. Many programs hire SPs through a staffing agency, and this may help eliminate onboarding and staff costs, especially as the cost of SPs varies considerably, based on experience and location. When developing a new SP program, the Comprehensive Healthcare Simulation: Implementing Best Practices in Standardized Patient Methodology , 2019, book would provide additional valuable resources. Examples of standardized patient simulations for undergraduate and graduate nursing students are presented in Table 2.4 .
Modality: Virtual Reality
Defnition: Virtual reality simulation “use a variety of immersive, highly visual, 3D characteristics to replicate reallife situations and /or health care procedures; virtual reality is distinguished from computer-based simulation in that it generally incorporates physical or other interfaces such as a computer keyboard, mouse, speech and voice recognition, motion sensors, or haptic devices” ([2]: 41).
Additional terms to include when choosing immersive technologies and virtual reality are headgear and haptics. Headgear can also be referred to as a head-mounted device, HMD, or headset. Haptics refers to “devices that provide tactile feedback to the user. Haptics can simulate touching, palpating an organ, or body part, and the cutting, tearing, or traction on a tissue” ([2]: 15).
Standardized patients
Undergraduate students Graduate students
Students care for homebound patients following hospital discharge to address safety during transitions in care
Competency checkout for medication administration, including patient education
Mental health issues include hearing voices, substance use disorders
De-escalation
Students practice communication techniques for handoffs and situationbackground-assessmentrecommendation (SBAR) reports
SP plays the role of a family member in pediatric simulation
Objective structured clinical exams (OSCE)
Primary care FNP students in telehealth conduct remote patient monitoring to assess EKG, vital signs, and cardiac output for management of cardiovascular disease
Acute care NP assessment of chest pain in ER setting
Oncology sub-specialty practices diffcult conversation of starting a chemotherapy regime
Psych mental health NP suicidal ideation screening and plan of care
CRNA students conduct a pre-operative physical assessment with a health history for co-morbidities
Scope: The newer simulation modality that is expanding in use for both undergraduate and graduate nursing students is immersive VR. Immersive virtual reality modality follows a continuum of low to high immersion and includes a growing number of different types of VR. Immersion “describes the level to which the learner becomes involved in the simulation; a high degree of immersion indicates that the learner is treating the simulation as if it was a real-life (or close to real-life) event” ([2]: 17). A form of virtual reality that is less immersive but highly interactive is computer-generated environments involving a screen-based, three-dimensional program, a computer mouse, keyboard, or joystick. There is less sensory involvement than in other forms of VR, but it can be highly interactive as students play in the frst person. In these virtual reality games, students can participate in clinical situations as an avatar to assess clinical situations, make clinical decisions, and practice skills. Some VR games offer learners a single patient or a multi-patient scenario to develop prioritization skills and clinical judgement. Other technologies are live muti player VR games which allow development of teamwork, interdisciplinary collaboration, communication skills, and real-time instructor feedback.
Tips: Virtual reality is an area that is rapidly changing as the technology develops. This modality is being used in healthcare to improve patient outcomes, such as decreasing pain and improving relaxation. VR in nursing education has been found to improve learners in cognitive, psychomotor, and affective domains but additional research is needed to determine best practices [4]. Head-mounted device or display (HMD) is used for viewing images for viewing and comes in many styles with different qualities and price ranges. HMDs can be as simple as a Google cardboard or a low-cost plastic device to a highly sophisticated and more expensive one. Examples of virtual reality simulations for undergraduate and graduate nursing students are presented in Table 2.5
Table 2.4 Examples for use of standardized patient simulations in undergraduate and graduate nursing
J. Conelius
Table 2.5 Examples for use of virtual reality simulations in undergraduate and graduate nursing
Virtual reality
Undergraduate students
Donning and doffng PPE
Urinary catheterization
Decontamination
Mass casualty event
BLS & Resuscitation
Cultural empathy development
Graduate students
IV insertion
Advanced health assessment
Ultrasound skills
Neonatal resuscitation
Emergency responses
Advanced cardiac life support
Interprofessional training
Modality: Screen Based or Computer Simulations
Defnition: A simulation is presented on a computer screen using graphical images and text, like popular gaming formats, where the operator interacts with the interface using a keyboard, mouse, joystick, or other input device.
Scope: These computer-based products are expanding and offer options for frst-semester pre-licensure through graduate nursing programs. Computer software can measure clinical judgment, clinical reasoning, and learning outcomes [5, 4]. Computer-based simulation programs often align with textbooks which makes the scenarios easy to connect clinical with didactic content. High-quality computer simulation programs are mapped to nursing accreditation standards. A computerized simulation offers standardized content and can be repeated as many times as needed, which benefts students who learn best with repetition. Since the computer simulations can be done for remote learning, there is fexibility with students completing them on their own time. This modality helps to limit scheduling conficts and can be useful for clinical make-ups. The American Heart Association (AHA) and other publishers offer several computer-based options for learning about resuscitation, cardiac care, and frst aid.
Tips: Internet connections are often needed. It is helpful to have a designated simulation educator or faculty member be the person to implement a new software program to help students, simulation team members, faculty, or administration with understanding how to implement, sustain the product use, assess student learning, and evaluate the effectiveness of the program. Some programs provide feedback directly to the student, but it is still best practice to ensure students are given a chance to debrief the scenario and ask questions. Examples of computer-based simulations for undergraduate and graduate nursing students are presented in Table 2.6.
Table 2.6 Examples of use of computer-based simulations in undergraduate and graduate nursing
Undergraduate students
Computer simulation
Communication skills
Head-to-toe assessments
Pharmacology
Med-Surg
Community
Pediatrics
Maternal child health
Graduate students
Clinical case studies
Differential diagnosis
Prescribing medications
Health assessment
Modality: Augmented Reality/Mixed Reality
Defnition: Augmented reality (AR) is when “stimuli are superimposed on real-world objects (overlays digital computer-generated information on objects or places in the real world)” for enhancing the user experience. “A technology that overlays digital computer-generated information on objects or places in the real world for the purpose of enhancing the user experience” ([2]: 9). Mixed reality simulation combines both physically real and computer generated content to create a learning environment ([2]: 30).
Scope: AR in nursing is a newer concept. Only certain simulation centers have investing in the technology and space for AR. There is not much of a demand for this type of simulation in undergraduate or graduate nursing curriculums to date and there is limited literature regarding the evaluation of this type of simulation [6]. Mixed reality use in nursing is growing as computer and technology engineering improves. One example of the use of mixed reality would be immersion spaces where 360 video images are projected on walls to create a computer generated hospital unit, community setting, or global view, combined with a real manikin that is brought into the space for a scenario. In mixed reality, sound, odor, or other interactive components can be added to improve the immersive experience.
Tips: There are multiple pros to using AR in nursing, such as time-saving by not needing all the expensive equipment during a simulation, easy information retrieval from the program, and the facilitator and the students being able to see different perspectives during a simulation. Some ways to utilize AR in the undergraduate nursing curriculum would be simulating the birth of a patient and showing the cardinal movements in the AR headset as the baby descends in the manikins abdomen. Another way would be augmenting the simulation environment so it feels more like an ICU or operating room environment through an AR device. Furthermore, in an advanced graduate practice curriculum, AR may be
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This adjustment and award were accepted and observed, until the election in November, 1876, when a controversy arose as to the result, the Republicans claiming the election of Stephen B. Packard as Governor by about 3,500 majority, and a Republican Legislature; and the Democrats claiming the election of Francis T. Nicholls as Governor, by about 8,000 majority, and a Democratic Legislature. Committees of gentlemen visited New Orleans, by request of President Grant and of various political organizations, to witness the count of the votes by the Returning Board. And in December, 1876, on the meeting of Congress, committees of investigation were appointed by the Senate and by the House of Representatives. Exciting events were now daily transpiring. On the 1st of January, 1877, the Legislature organized in the State House without exhibitions of violence. The Democrats did not unite in the proceedings, but met in a separate building, and organized a separate Legislature. Telegraphic communication was had between the State House and the Custom House, where was the office of Marshal Pitkin, who with the aid of the United States troops, was ready for any emergency. About noon the Democratic members, accompanied by about 500 persons, called at the State House and demanded admission. The officer on duty replied that the members could enter, but the crowd could not. A formal demand was then made upon General Badger and other officials, by the spokesman, for the removal of the obstructions, barricades, police, etc., which prevented the ingress of members, which being denied, Col. Bush, in behalf of the crowd, read a formal protest, and the Democrats retired. Gov. Kellogg was presented by a committee with a copy of the protest, and he replied, that as chief magistrate and conservator of the peace of the State, believing that there was danger of the organization of the General Assembly being violently interfered with, he had caused a police force to be stationed in the lower portion of the building; that he had no motive but to preserve the peace; that no member or attache of either house will be interfered with in any way, and that no United States troops are stationed in the capitol building. Clerk Trezevant declined to call the House to order unless the policemen were removed. Upon the refusal to do so, he withdrew, when Louis Sauer, a member, called the roll, and 68 members—a full House being 120—answered to their names. Ex-Gov. Hahn was
elected Speaker, receiving 53 votes as against 15 for Ex-Gov. Warmoth.
The Senate was organized by Lieutenant-Governor Antoine with 19 present—a full Senate being 30—eight of whom held over, and 11 were returned by the Board. Gov. Kellogg’s message was presented to each House.
The Democrats organized their Legislature in St. Patrick’s hall. The Senators were called to order by Senator Ogden. Nineteen Senators, including nine holding over, and four, who were counted out by the board, were present.
The Democratic members of the House were called to order by Clerk Trezevant, and 61 answered to their names. Louis Bush was elected Speaker.
January 3d—Republican Legislature passed a resolution asking for military protection against apprehended Democratic violence, and it was telegraphed to the President.
On Sunday, January 8th, Gov. Kellogg telegraphed to President Grant to the same effect.
January 8th—Stephen B. Packard took the oath of office as Governor, and C. C. Antoine as Lieutenant-Governor, at the State House at 1:30, in the presence of the Legislature.
January 8—Francis T. Nicholls and L. A. Wiltz to-day took the oath of office of Governor and Lieutenant-Governor, respectively, on the balcony of St. Patrick’s hall.
By the 11th of January both parties were waiting for the action of the authorities at Washington. Gov. Packard to-day commissioned A. S. Badger Major-General of the State National Guard, and directed him to organize the first division at once. Two members of the Packard Legislature, Mr. Barrett, of Rapides, and Mr. Kennedy, of St. Charles, had withdrawn from that body and gone over to the Nicholls Legislature.
Messrs. Breux, Barrett, Kennedy, Estopival, Wheeler, and Hamlet, elected as Republicans, under the advice of Pinchback—a defeated Republican candidate for U. S. Senator, left the Packard or Republican, and joined the Nicholls Legislature.
On the 15th, Governor Packard, after receiving a copy of the telegram of the President to General Augur, issued a proclamation
aimed at the “organized and armed combination and conspiracy of men now offering unlawful and violent resistance to the lawful authority of the State government.”
The Nicholls court issued an order to Sheriff Handy to provide the means for protecting the court from any violence or intrusion on the part of the adherents of “S. B. Packard, a wicked and shameless impostor.”
Governor Packard on the 16th, in a letter to Gen. Augur, acknowledges the receipt of a communication from his aide-de-camp asking for assurances from him that the President’s wishes concerning the preservation of the present status be respected, and says that the request would have been more appropriate if made immediately after his installation as Governor and before many of the main branches of the Government had been forcibly taken possession of by the opposition. He says: “I had scarcely taken the oath of office when the White League were called to arms; the Court room and the records of the Supreme Court of the State were forcibly taken possession of, and various precinct police-stations were captured in like manner by overwhelming forces. Orders had been issued by the Secretary of War early on that day that all unauthorized armed bodies should desist. A dispatch from yourself of the same date to the Secretary of War, conveyed the assurances that Nicholls had promised the disbandment of his armed forces. * * * It was my understanding, that neither side should be permitted to interfere with the status of the other side. Yet the day after this order was received and the pledge given by Nicholls, a force of several hundred armed White Leaguers repaired to the State Arsenal and took therefrom into their own keeping five pieces of artillery, and a garrison of armed men was placed in and around the Supreme Court building. That on the following day, January 11, an armed company of the White League broke into and took possession of the office of the Recorder of Mortgages. * * * In view of all these facts it seemed to me that to give the pledge verbally asked of me this morning would be to sanction revolution, and by acquiescence give it the force of accomplished fact, and I therefore declined.”
Many telegrams followed between the Secretary of War, J. Don. Cameron, Gen’l Augur and Mr. Packard, the latter daily complaining of new “outrages by the White League,” while the Nicholls
government professed to accord rights to all classes, and to obey the instructions from Washington, to faithfully maintain the status of affairs until decisive action should be taken by the National government. None was taken, President Grant being unwilling to outline a Southern policy for his successor in office.
Election of Hayes and Wheeler.
The troubles in the South, and the almost general overthrow of the “carpet-bag government,” impressed all with the fact that the Presidential election of 1876 would be exceedingly close and exciting, and the result confirmed this belief. The Greenbackers were the first to meet in National Convention, at Indianapolis, May 17th. Peter Cooper of New York was nominated for President, and Samuel F. Cary of Ohio, for Vice-President.
The Republican National Convention met at Cincinnati, June 14th, with James G. Blaine recognized as the leading candidate. Grant had been named for a third term, and there was a belief that his name would be presented. Such was the feeling on this question that the House of Congress and a Republican State Convention in Pennsylvania, had passed resolutions declaring that a third term for President would be a violation of the “unwritten law” handed down through the examples of Washington, and Jackson. His name, however, was not then presented. The “unit rule” at this Convention was for the first time resisted, and by the friends of Blaine, with a view to release from instructions of State Conventions some of his friends. New York had instructed for Conkling, and Pennsylvania for Hartranft. In both of these states some delegates had been chosen by their respective Congressional districts, in advance of any State action, and these elections were as a rule confirmed by the State bodies. Where they were not, there were contests, and the right of district representation was jeopardized if not destroyed by the reinforcement of the unit rule. It was therefore thought to be a question of much importance by the warring interests. Hon. Edw. McPherson was the temporary Chairman of the Convention, and he took the earliest opportunity presented to decide against the binding force of the unit rule, and to assert the liberty of each delegate to vote as he pleased. The Convention sustained the decision on an appeal.
Ballots of the Cincinnati Republican Convention, 1876:
Gen. Rutherford B. Hayes, of Ohio, was nominated for President, and Hon. Wm. A. Wheeler, of New York, for Vice-President.
The Democratic National Convention met at St. Louis, June 28th. Great interest was excited by the attitude of John Kelly, the Tammany leader of New York, who was present and opposed with great bitterness the nomination of Tilden. He afterwards bowed to the will of the majority and supported him. Both the unit and the two-thirds rule were observed in this body, as they have long been by the Democratic party. On the second ballot, Hon. Samuel J. Tilden, of New York, had 535 votes to 203 for all others. His leading competitor was Hon. Thomas A. Hendricks, of Indiana, who was nominated for Vice-President.
The Electoral Count.
The election followed Nov. 7th, 1876, Hayes and Wheeler carrying all of the Northern States except Connecticut, New York, New Jersey and Indiana; Tilden and Hendricks carried all of the Southern States except South Carolina, Florida and Louisiana. The three last named States were claimed by the Democrats, but their members of the Congressional Investigating Committee quieted rival claims as to South Carolina by agreeing that it had fairly chosen the Republican electors. So close was the result that success or failure hinged upon the returns of Florida and Louisiana, and for days and weeks conflicting stories and claims came from these States. The Democrats claimed that they had won on the face of the returns from Louisiana, and that there was no authority to go behind these. The Republicans publicly alleged frauds in nearly all of the Southern States; that the colored vote had been violently suppressed in the Gulf States, but they did not formally dispute the face of the returns in any State save where the returning boards gave them the victory. This doubtful state of affairs induced a number of prominent politicians of both the great parties to visit the State capitals of South Carolina, Florida and Louisiana to witness the count. Some of these were appointed by President Grant; others by the Democratic National Committee, and both sets were at the time called the “visiting statesmen,” a phrase on which the political changes were rung for months and years thereafter.
The electoral votes of Florida were decided by the returning board to be Republican by a majority of 926,—this after throwing out the votes of several districts where fraudulent returns were alleged to be apparent or shown by testimony. The Board was cited before the State Supreme Court, which ordered a count of the face of the returns; a second meeting only led to a second Republican return, and the Republican electors were then declared to have been chosen by a majority of 206, though before this was done, the Electoral
College of the State had met and cast their four votes for Hayes and Wheeler. Both parties agreed very closely in their counts, except as to Baker county, from which the Republicans claimed 41 majority, the Democrats 95 majority—the returning board accepting the Republican claim.
In Louisiana the Packard returning board was headed by J. Madison Wells, and this body refused to permit the Democrats to be represented therein. It was in session three weeks, the excitement all the time being at fever heat, and finally made the following average returns: Republican electors, 74,436; Democratic, 70,505; Republican majority, 3,931. McEnery, who claimed to be Governor, gave the Democratic electors a certificate based on an average vote of 83,635 against 75,759, a Democratic majority of 7,876.
In Oregon, the three Republican electors had an admitted majority of the popular vote, but on a claim that one of the number was a Federal office-holder and therefore ineligible, the Democratic Governor gave a certificate to two of the Republican electors, and a Mr. Cronin, Democrat. The three Republican electors were certified by the Secretary of State, who was the canvassing officer by law. This Oregon business led to grave suspicions against Mr. Tilden, who was thereafter freely charged by the Republicans with the use of his immense private fortune to control the result, and thereafter, the New York Tribune, with unexampled enterprise, exposed and reprinted the “cipher dispatches” from Gramercy, which Mr. Pelton, the nephew and private secretary of Mr. Tilden, had sent to Democratic “visiting statesmen” in the four disputed sections. In 1878, the Potter Investigating Committee subsequently confirmed the “cipher dispatches” but Mr. Tilden denied any knowledge of them.
The second session of the 44th Congress met on Dec. 5th, 1876, and while by that time all knew the dangers of the approaching electoral count, yet neither House would consent to the revision of the joint rule regulating the count. The Republicans claimed that the President of the Senate had the sole authority to open and announce the returns in the presence of the two Houses; the Democrats plainly disputed this right, and claimed that the joint body could control the count under the law. Some Democrats went so far as to say that the House (which was Democratic, with Samuel J. Randall in the
Speaker’s chair) could for itself decide when the emergency had arrived in which it was to elect a President.
There was grave danger, and it was asserted that the Democrats, fearing the President of the Senate would exercise the power of declaring the result, were preparing first to forcibly and at least with secrecy swear in and inaugurate Tilden. Mr. Watterson, member of the House from Kentucky, boasted that he had completed arrangements to have 100,000 men at Washington on inauguration day, to see that Tilden was installed. President Grant and Secretary of War Cameron, thought the condition of affairs critical, and both made active though secret preparations to secure the safe if not the peaceful inauguration of Hayes. Grant, in one of his sententious utterances, said he “would have peace if he had to fight for it.” To this end he sent for Gov. Hartranft of Pennsylvania, to know if he could stop any attempted movement of New York troops to Washington, as he had information that the purpose was to forcibly install Tilden. Gov. Hartranft replied that he could do it with the National Guard and the Grand Army of the Republic. He was told to return to Harrisburg and prepare for such an emergency. This he did, and as the Legislature was then in session, a Republican caucus was called, and it resolved, without knowing exactly why, to sustain any action of the Governor with the resources of the State. Secretary Cameron also sent for Gen’l Sherman, and for a time went on with comprehensive preparations, which if there had been need for completion, would certainly have put a speedy check upon the madness of any mob. There is a most interesting unwritten history of events then transpiring which no one now living can fully relate without unjustifiable violations of political and personal confidences. But the danger was avoided by the patriotism of prominent members of Congress representing both of the great political parties. These gentlemen held several important and private conferences, and substantially agreed upon a result several days before the exciting struggle which followed the introduction of the Electoral Commission Act. The leaders on the part of the Republicans in these conferences were Conkling, Edmunds, Frelinghuysen; on the part of the Democrats Bayard, Gordon, Randall and Hewitt, the latter a member of the House and Chairman of the National Democratic Committee.
The Electoral Commission Act, the basis of agreement, was supported by Conkling in a speech of great power, and of all men engaged in this great work he was at the time most suspected by the Republicans, who feared that his admitted dislike to Hayes would cause him to favor a bill which would secure the return of Tilden, and as both of the gentlemen were New Yorkers, there was for several days grave fears of a combination between the two. The result showed the injustice done, and convinced theretofore doubting Republicans that Conkling, even as a partisan, was faithful and farseeing. The Electoral Commission measure was a Democratic one, if we are to judge from the character of the votes cast for and against it. In the Senate the vote stood 47 for to 17 against. There were 21 Republicans for it and 16 against, while there were also 26 Democrats for it to only 1 (Eaton) against. In the House much the same proportion was maintained, the bill passing that body by 191 to 86. The following is the text of the
ELECTORAL COMMISSION ACT.
An act to provide for and regulate the counting of votes for President and Vice-President, and the decision of questions arising thereon, for the term commencing March fourth, Anno Domini eighteen hundred and seventy-seven.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, That the Senate and House of Representatives shall meet in the hall of the House of Representatives, at the hour of one o’clock post meridian, on the first Thursday in February, Anno Domini eighteen hundred and seventyseven; the President of the Senate shall be their presiding officer. Two tellers shall be previously appointed on the part of the Senate, and two on the part of the House of Representatives, to whom shall be handed, as they are opened by the President of the Senate, all the certificates, and papers purporting to be certificates, of the electoral votes, which certificates and papers shall be opened, presented and acted upon in the alphabetical order of the States, beginning with the letter A; and said tellers having then read the same in presence and hearing of the two Houses, shall make a list of the votes as they shall appear from the said certificates; and the votes having been
ascertained and counted as in this act provided, the result of the same shall be delivered to the President of the Senate, who shall thereupon announce the state of the vote, and the names of the persons, if any elected, which announcement shall be deemed a sufficient declaration of the persons elected President and VicePresident of the United States, and, together with a list of the votes, be entered on the journals of the Houses. Upon such reading of any such certificate or paper when there shall only be one return from a State, the President of the Senate shall call for objections, if any. Every objection shall be made in writing, and shall state clearly and concisely, and without argument, the ground thereof, and shall be signed by at least one Senator and one Member of the House of Representatives before the same shall be received. When all objections so made to any vote or paper from a State shall have been received and read, the Senate shall thereupon withdraw, and such objections shall be submitted to the Senate for its decision; and the Speaker of the House of Representatives shall, in like manner, submit such objections to the House of Representatives for its decision; and no electoral vote or votes from any State from which but one return has been received shall be rejected, except by the affirmative vote of the two Houses. When the two Houses have votes, they shall immediately again meet, and the presiding officer shall then announce the decision of the question submitted.
S . 2. That if more than one return, or paper purporting to be a return from a State, shall have been received by the President of the Senate, purporting to be the certificate of electoral votes given at the last preceding election for President and Vice-President in such State (unless they shall be duplicates of the same return), all such returns and papers shall be opened by him in the presence of the two Houses when met as aforesaid, and read by the tellers, and all such returns and papers shall thereupon be submitted to the judgment and decision as to which is the true and lawful electoral vote of such State, of a commission constituted as follows, namely: During the session of each House, on the Tuesday next preceding the first Thursday in February, eighteen hundred and seventy-seven, each House shall, by viva voce vote, appoint five of its members, with the five associate justices of the Supreme Court of the United States to be ascertained as hereinafter provided, shall constitute a commission for the decision of all questions upon or in respect of such double
returns named in this section. On the Tuesday next preceding the first Thursday in February, Anno Domini, eighteen hundred and seventy-seven, or as soon thereafter as may be, the associate justices of the Supreme Court of the United States now assigned to the first, third, eighth, and ninth circuits shall select, in such manner as a majority of them shall deem fit, another of the associate justices of said court, which five persons shall be members of said commission; and the person longest in commission of said five justices shall be the president of said commission. The members of said commission shall respectively take and subscribe the following oath: “I do solemnly swear (or affirm, as the case maybe,) that I will impartially examine and consider all questions submitted to the commission of which I am a member, and a true judgment give thereon, agreeably to the Constitution and the laws: so help me God;” which oath shall be filed with the Secretary of the Senate. When the commission shall have been thus organized, it shall not be in the power of either House to dissolve the same, or to withdraw any of its members; but if any such Senator or member shall die or become physically unable to perform the duties required by this act, the fact of such death or physical inability shall be by said commission, before it shall proceed further, communicated to the Senate or House of Representatives, as the case may be, which body shall immediately and without debate proceed by viva voce vote to fill the place so vacated, and the person so appointed shall take and subscribe the oath hereinbefore prescribed, and become a member of said commission; and in like manner, if any of said justices of the Supreme Court shall die or become physically incapable of performing the duties required by this act, the other of said justices, members of the said commission, shall immediately appoint another justice of said court a member of said commission, and in like manner, if any of said justices of the Supreme Court shall die or become physically incapable of performing the duties required by this act, the other of said justices, members of the said commission, shall immediately appoint another justice of said court a member of said commission, and, in such appointment, regard shall be had to the impartiality and freedom from bias sought by the original appointments to said commission, who shall thereupon immediately take and subscribe the oath hereinbefore prescribed, and become a member of said commission to fill the vacancy so occasioned. All the certificates and papers
purporting to be certificates of the electoral votes of each State shall be opened, in the alphabetical order of the States, as provided in section one of this act; and when there shall be more than one such certificate or paper, as the certificates and papers from such State shall so be opened (excepting duplicates of the same return), they shall be read by the tellers, and thereupon the President of the Senate shall call for objections, if any. Every objection shall be made in writing, and shall state clearly and concisely, and without argument, the ground thereof, and shall be signed by at least one Senator and one member of the House of Representatives before the same shall be received. When all such objections so made to any certificate, vote, or paper from a State shall have been received and read, all such certificates, votes and papers so objected to, and all papers accompanying the same, together with such objections, shall be forthwith submitted to said commission, which shall proceed to consider the same, with the same powers, if any, now possessed for that purpose by the two Houses acting separately or together, and, by a majority of votes, decide whether any and what votes from such State are the votes provided for by the Constitution of the United States, and how many and what persons were duly appointed electors in such State, and may therein take into view such petitions, depositions, and other papers, if any, as shall, by the Constitution and now existing law, be competent and pertinent in such consideration; which decision shall be made in writing, stating briefly the ground thereof, and signed by the members of said commission agreeing therein; whereupon the two Houses shall again meet, and such decision shall be read and entered in the journal of each house, and the counting of the vote shall proceed in conformity therewith, unless, upon objection made thereto in writing by at least five Senators and five members of the House of Representatives, the two Houses shall separately concur in ordering otherwise, in which case such concurrent order shall govern. No votes or papers from any other State shall be acted upon until the objections previously made to the votes or papers from any State shall have been finally disposed of.
S . 3. That, while the two Houses shall be in meeting, as provided in this act, no debate shall be allowed and no question shall be put by the presiding officer, except to either House on a motion to withdraw, and he shall have power to preserve order.
S . 4. That when the two Houses separate to decide upon an objection that may have been made to the counting of any electoral vote or votes from any State, or upon objection to a report of said commission, or other question arising under this act, each Senator and Representative may speak to such objection or question ten minutes, and not oftener than once; but after such debate shall have lasted two hours, it shall be the duty of each House to put the main question without further debate.
S . 5. That at such joint meeting of the two Houses, seats shall be provided as follows: For the President of the Senate, the Speaker’s chair; for the Speaker, immediately upon his left; the Senators in the body of the hall upon the right of the presiding officer; for the Representatives, in the body of the hall not provided for the Senators; for the tellers, Secretary of the Senate, and Clerk of the House of Representatives, at the Clerk’s desk; for the other officers of the two Houses, in front of the Clerk’s desk and upon each side of the Speaker’s platform. Such joint meeting shall not be dissolved until the count of electoral votes shall be completed and the result declared; and no recess shall be taken unless a question shall have arisen in regard to counting any such votes, or otherwise under this act, in which case it shall be competent for either House, acting separately, in the manner hereinbefore provided, to direct a recess of such House not beyond the next day, Sunday excepted, at the hour of ten o’clock in the forenoon. And while any question is being considered by said commission, either House may proceed with its legislative or other business.
S . 6. That nothing in this act shall be held to impair or affect any right now existing under the Constitution and laws to question, by proceeding in the judicial courts of the United States, the right or title of the person who shall be declared elected, or who shall claim to be President or Vice-President of the United States, if any such right exists.
S . 7. That said commission shall make its own rules, keep a record of its proceedings, and shall have power to employ such persons as may be necessary for the transaction of its business and the execution of its powers.
Approved, January 29, 1877.
Members of the Commission.
Hon. N C , Associate Justice Supreme Court, First Circuit.
Hon. W S , Associate Justice Supreme Court, Third Circuit.
Hon. S F. M , Associate Justice Supreme Court, Eighth Circuit.
Hon. S J. F , Associate Justice Supreme Court, Ninth Circuit.
Hon. J P. B , Associate Justice Supreme Court, Fifth Circuit.
Hon. G F. E , United States Senator.
Hon. O P. M , United States Senator.
Hon. F T. F , United States Senator.
Hon. A G. T , United States Senator.
Hon. T F. B , United States Senator.
Hon. H B. P , United States Representative.
Hon. E H , United States Representative.
Hon. J G. A , United States Representative.
Hon. J A. G , United States Representative.
Hon. G F. H , United States Representative.
The Electoral Commission met February 1st, and by uniform votes of 8 to 7, decided all objections to the Electoral votes of Florida, Louisiana, South Carolina, and Oregon, in favor of the Republicans, and while the two Houses disagreed on nearly all of these points by strict party votes, the electoral votes were, under the provisions of the law, given to Hayes and Wheeler, and the final result declared to be 185 electors for Hayes and Wheeler, to 184 for Tilden and
Hendricks. Questions of eligibility had been raised against individual electors from Michigan, Nevada, Pennsylvania, Rhode Island, Vermont and Wisconsin, but the Commission did not sustain any of them, and as a rule they were unsupported by evidence. Thus closed the gravest crisis which ever attended an electoral count in this country, so far as the Nation was concerned; and while for some weeks the better desire to peacefully settle all differences prevailed, in a few weeks partisan bitterness was manifested on the part of a great majority of Northern Democrats, who believed their party had been deprived by a partisan spirit of its rightful President.
The Title of President Hayes.
The uniform vote of 8 to 7 on all important propositions considered by the Electoral Commission, to their minds showed a partisan spirit, the existence of which it was difficult to deny. The action of the Republican “visiting statesmen” in Louisiana, in practically overthrowing the Packard or Republican government there, caused distrust and dissatisfaction in the minds of the more radical Republicans, who contended with every show of reason that if Hayes carried Louisiana, Packard must also have done so. The only sensible excuse for seating Hayes on the one side and throwing out Governor Packard on the other, was a patriotic desire for peace in the settlement of both Presidential and Southern State issues. This desire was plainly manifested by President Hayes on the day of his inauguration and for two years thereafter. He took early occasion to visit Atlanta, Ga., and while at that point and en route there made the most conciliatory speeches, in which he called those who had engaged in the Rebellion, “brothers,” “gallant soldiers,” etc. These speeches excited much attention. They had little if any effect upon the South, while the more radical Republicans accused the President of “slopping over.” They did not allay the hostility of the Democratic party, and did not restore the feeling in the South to a condition better than that which it had shown during the exciting days of the Electoral count. The South then, under the lead of men like Stephens, Hill and Gordon, in the main showed every desire for a peaceful settlement. As a rule only the Border States and Northern Democrats manifested extreme distrust and bitterness, and these were plainly told by some of the leaders from the Gulf States, that so far as they were concerned, they had had enough of civil war.
As late as April 22, 1877, the Maryland Legislature passed the following:
Resolved by the General Assembly of Maryland, That the Attorney-General of the State be, and he is hereby, instructed, in case Congress shall provide for expediting the action, to exhibit a bill in the Supreme Court of the United States, on behalf of the State of Maryland, with proper parties thereto, setting forth the fact that due effect has not been given to the electoral vote cast by this State on the 6th day of December, 1876, by reason of fraudulent returns made from other States and allowed to be counted provisionally by the Electoral Commission, and subject to judicial revision, and praying said court to make the revision contemplated by the act establishing said commission; and upon such revision to declare the returns from the States of Louisiana and Florida, which were counted for Rutherford B. Hayes and William A. Wheeler, fraudulent and void, and that the legal electoral votes of said States were cast for Samuel J. Tilden as President, and Thomas A. Hendricks as Vice-President, and that by virtue thereof and of 184 votes cast by other States, of which 8 were cast by the State of Maryland, the said Tilden and Hendricks were duly elected, and praying said Court to decree accordingly.
It was this resolution which induced the Clarkson N. Potter resolution of investigation, a resolution the passage of which was resisted by the Republicans through filibustering for many days, but was finally passed by 146 Democratic votes to 2 Democratic votes (Mills and Morse) against, the Republicans not voting.
The Cipher Despatches.
An amendment offered to the Potter resolution but not accepted, and defeated by the Democratic majority, cited some fair specimens of the cipher dispatches exposed by the New York Tribune. These are matters of historical interest, and convey information as to the methods which politicians will resort to in desperate emergencies. We therefore quote the more pertinent portions.
Resolved, That the select committee to whom this House has committed the investigation of certain matters affecting, as is alleged, the legal title of the President of the United States to the high office which he now holds, be and is hereby instructed in the course of its investigations to fully inquire into all the facts connected with the election in the State of Florida in November, 1876, and especially into the circumstances attending the transmission and receiving of certain telegraphic dispatches sent in said year between Tallahassee in said State and New York City, viz.:
“T , November 9, 1876.
“A. S. H , New York:
“Comply if possible with my telegram.
“Geo. P. R .”
Also the following:
“T , December 1, 1876.
“W. T. P , New York:
“Answer Mac’s dispatch immediately, or we will be embarrassed at a critical time.
And also the facts connected with all telegraphic dispatches between one John F. Coyle and said Pelton, under the latters real or fictitious name, and with any and all demands for money on or about December 1, 1876, from said Tallahassee, on said Pelton, or said Hewitt, or with any attempt to corrupt or bribe any official of the said State of Florida by any person acting for said Pelton, or in the interest of Samuel J. Tilden as a presidential candidate.
Also to investigate the charges of intimidation at Lake City, in Columbia county, where Joel Niblack and other white men put ropes around the necks of colored men and proposed to hang them, but released them on their promise to join a Democratic club and vote for Samuel J. Tilden.
Also the facts of the election in Jackson county, where the ballotboxes were kept out of the sight of voters, who voted through openings or holes six feet above the ground, and where many more Republican votes were thus given into the hands of the Democratic inspectors than were counted or returned by them.
Also the facts of the election in Waldo precinct, in Alachua county, where the passengers on an emigrant-train, passing through on the day of election, were allowed to vote.
Also the facts of the election in Manatee county, returning 235 majority for the Tilden electors, where there were no county officers, no registration, no notice of the election, and where the Republican party, therefore, did not vote.
Also the facts of the election in the third precinct of Key West, giving 342 Democratic majority where the Democratic inspector carried the ballot-box home, and pretended to count the ballots on the next day, outside of the precinct and contrary to law.
