How to Design Unfolding Simulation Scenarios to Foster Critical Thinking Skills in Pre-Licensure Nursing Students

Pre-licensure nursing students can significantly benefit from simulation experiences that integrate unfolding case scenarios. These scenarios provide students with a dynamic view of a patient’s progression through various health states to strengthen their comprehension of continuity of care, which enhances their abilities to think critically. Educators must thoughtfully design these unfolding simulations to ensure a coherent and logical flow from one scenario to the next. This HealthySimulation.com article by Ciara Berry, MSN, RN, CHSE, CNEcl will explore the essential components of the simulation design process following the INACSL Healthcare Simulation Standards of Best Practices for the creation of effective unfolding simulation scenarios.

Needs Assessment and Objectives are a Must

Before the scenario is developed, a needs assessment should be conducted to determine what is required for the specific student population. Educators should identify which content areas to be addressed within the simulation and define the learning objectives for each stage of the scenario. They should also determine how many simulation scenarios will be used and how they will be spaced over time, such as within a single course, over a semester, or throughout the entire nursing program. Once these factors are established, objectives for each scenario can be defined.

It is important to consider the knowledge level of the learner as well. Each scenario is designed to ensure that the included content aligns with what learners have already been taught, unless the simulation is specifically intended to introduce new concepts. Scenarios should reinforce and build upon existing knowledge to allow learners to apply previously learned skills and information in a realistic clinical setting. However, if the goal of the simulation is to teach new content, educators should carefully construct the experience to facilitate learning with the utilization of the simulation as an active teaching tool. This intentional approach ensures that learners are challenged appropriately and can focus on how to apply their knowledge effectively.

Determine Fidelity and Modalities

To create an effective simulation, careful consideration must be given to fidelity—the level of realism within the scenario. Fidelity includes multiple components of the simulation process and is not exclusive to the type of simulator that may be used. The simulation modality determines whether the scenario will use high-fidelity manikins, standardized patients, or virtual simulation. Environmental fidelity assesses how closely the simulation environment replicates a real clinical setting (i.e. a birthing simulation being completed in a room that mimics a maternity ward). Psychological fidelity measures how well the scenario engages learners emotionally and cognitively. The enhancement of these elements as the scenario unfolds allows the simulation to develop into a more realistic experience. Learners become more engaged in the activity and make more realistic decisions, which improves their decision-making and clinical reasoning skills.

The decision on how to implement different methods of fidelity should be made after a careful evaluation of the resources available for your simulation program and should consider the experience level of the learner. For example, learners who have had less exposure to simulation activities may be overwhelmed by high levels of psychological fidelity incorporated into their activity. An example is a patient who frequently screams in pain, family members who interrupt care, or a death/dying scenario. An unfolding case study allows the educator to build on the incorporation of high-fidelity experiences so the learners can become acclimated to their role in simulation activities.

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Another design factor that educators should consider is the clinical environment of the case. Will the patient begin in a primary care clinic, progress to a hospital admission, and eventually require an emergency department visit? The design of such a trajectory allows students to understand how a patient’s condition evolves across various healthcare settings. Multiple modalities can be used to simulate this journey to create an immersive and dynamic learning experience. For instance, students may first engage with a virtual reality (VR) scenario to assess the patient’s initial presentation, which could then transition seamlessly into a standardized patient or simulator-based scenario to replicate the clinical environment.

This approach not only helps students grasp the continuum of care but also enables them to develop a deeper comprehension of how different clinical environments influence decision-making, patient management, and communication. By thoughtfully mapping out the patient’s progression across various stages of care, educators can ensure that students gain a comprehensive and realistic perspective on patient care. The use of multiple modalities also enhances engagement to foster critical thinking and adaptability.

The Incorporation of Content in Simulation Design

Once the number of scenarios has been determined, each must be developed in detail to include learning objectives specific to that stage of the case, scenario progression with changes in patient status and necessary interventions, and supporting documents such as provider orders, patient histories, lab results, and electronic health records. Each simulation should be built upon the last to ensure continuity of patient care and progressive skill development. Patient reports from each scenario should connect to the previous to allow the students to connect the dots from their past simulation experiences with the patient. Attention to detail is a must. In addition, a structured debriefing model should be used, and care should be taken to reinforce key takeaways from the scenario that may be relevant to the next.

Building upon knowledge through scenario-based learning is a valuable method for assessing whether learners can apply the information they have acquired throughout a course or program. For example, in a medical-surgical nursing course, a three-part simulation that focuses on IV placement can reinforce skill repetition with integrated didactic content. The first simulation might involve a basic IV placement on a mid-fidelity manikin, allowing learners to practice the technical skill in a controlled environment. In the second scenario, the complexity increases as learners must manage a disease process while addressing an IV infiltration that requires replacement.

By the third scenario, fidelity is further enhanced, incorporating additional complications related to the disease process, which could require the placement of a second IV line. Across all three scenarios, facilitators can evaluate learners’ proficiency in IV placement while also assessing their ability to apply the skill in a realistic clinical context. This progressive approach ensures that learners not only refine their technical skills but also develop the critical thinking and adaptability needed for real-world patient care. This same technique can be used to connect one disease process to another to reinforce the impact of clinical decision-making and patient education.

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Preparation and Evaluation of the Simulation Experience

Before full implementation, a pilot test should be conducted with the simulation faculty and team to help identify areas for improvement. This allows for adjustments in scenario clarity and flow, learner workload and time constraints, and realism and engagement levels. A pilot test ensures that the simulation is optimized for learning outcomes before implementation with learners.

Prework should be provided for each simulation scenario to reduce cognitive load and prepare the learners for the simulated experience. Consider the incorporation of a reflection on the previous simulation as part of the learner prework so they can begin to anticipate what they may encounter next. A structured briefing should be delivered on the day of the activity, and learners should be oriented to the simulation environment prior to participation in the experience.

Once the simulation is implemented, ongoing evaluation is essential to measure the effectiveness and impact. This can be done through student feedback on the learning experience, facilitator observations of student performance, and assessment of learning outcomes that includes critical thinking, clinical judgment, and teamwork skills. Regular updates and refinements based on evaluation results will help maintain the quality and effectiveness of the simulation over time.

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