Due to the reported shortage of clinical placements opportunities and rising numbers of undergraduate nursing students and novice nurses (Boamah et al, 2021), many nurse educators have come to believe in the importance and applicability of patient simulation manikins, interactive virtual simulation scenarios (Redmond et al, 2018), and any other related activities to replace (Hayden et al, 2014) or supplement (Wolfgram and Quinn, 2012) clinical experiences. Clinical simulation, defined as the replication of patient scenarios to develop or practise skills (Hayden et al, 2014), has been reported to improve learning outcomes in many different areas (Cason et al, 2017; Kiernan and Olsen, 2020) and provides a safe environment for nursing students and professionals to practise and advance their knowledge, skills, and attitudes before implementing in a real clinical setting.
The field of wound care is one such clinical experience that could benefit from increased learning opportunities through simulation. In a Canadian survey, Abuleal (2018) found that 43% of upper-year nursing students and 46% of faculty were not satisfied with the quality of wound care education delivered. The same survey noted that 53% of student respondents were not satisfied with their knowledge of wound care products and 87% did not feel comfortable choosing which products to use. In another survey, Ayello et al (2005) found that 88% of certified wound, ostomy, and continence (WOC) nurses believed their undergraduate education did not provide them with sufficient knowledge on wound care principles and hands-on practice. Registered nurses' wound care scope of practice is usually limited to wound cleansing, packing, dressing changes, bandage application, and removal of stitches (Kielo-Viljamaa et al, 2022), but they should also be able to perform a comprehensive assessment, identify wound aetiology, and make referrals to a wound care specialist (such as a WOC nurse) (College of Nurses of Ontario, 2023). Novice registered nurses and student nurses are usually not required to possess the knowledge to address the needs of patients with complex wounds such as diabetic foot ulcers, venous leg ulcers, and surgical site infections, but they should be able to refer the patient to the appropriate specialist (College of Nurses of Ontario, 2023). Nursing entry-to-practice competencies in the area of complex wounds are very basic compared with advanced wound care practices taught in specialty post-licensure courses.
Nurses' inadequate wound care knowledge may also affect the quality of documentation. In one study, Gartlan et al (2010) found that nurses' documentation on wound characteristics was lacking both at admission and during dressing changes, particularly in their observation of wound dimensions, skin sensation, periwound characteristics, and the state of the wound bed. More recently, Redmond et al (2018) noted the mounting concerns within nursing education research over the preparedness of undergraduate nursing students to perform wound care. Findings from Abuleal (2018) and Ayello et al's (2005) surveys and Gartlan et al's (2010) study suggest that novice nurses are not adequately prepared at the undergraduate level with the knowledge and clinical decision-making skills to assess and manage individuals with wounds.
The use of clinical simulation in nursing education represents a widely researched field, and several studies have evaluated creative innovations to address the observed insufficiency of nursing wound care education and documentation (Roberson et al, 2008; Harding et al, 2014; Redmond et al, 2018; Redmond et al, 2020; Sezgünsay and Basak, 2020). Many in the wound care and nursing education fields view simulation as a useful tool to help nursing students develop clinical acumen and apply their knowledge in a safe, non-threatening environment without fear of mistakes that could harm patients (Jeffries, 2020). Sound clinical judgment informed by best evidence may reduce adverse patient outcomes (Aiken et al, 2003) and improve system efficiency (Benner et al, 2008).
Nursing clinical education delivered by trained facilitators via simulation is not limited to using manikins and may involve a variety of activities, including the use of electronic devices, realistic virtual environments, and roleplay (Barry Issenberg et al, 2005). Human simulators were used nearly 30 years earlier in medicine but did not appear in nursing education until the late 1990s (Hayden et al, 2014). Technological advancements have increased the sophistication of simulators available since then and simulation has become considered an integral practice in nursing education (Aebersold, 2018). Further illustrating the widespread use of simulation, a 2010 survey of undergraduate nursing programmes across the USA found that 87% used simulation in their programme (Hayden, 2010). More recently, a survey of undergraduate nursing programmes across Canada indicated that 73% of nursing schools increased their virtual simulation use during the COVID-19 pandemic (Canadian Association of Schools of Nursing, 2021).
The fidelity of a simulation refers to the degree of realism it represents (Feinstein and Cannon, 2001), but it is often misunderstood to mean the sophistication of the patient simulator, which is more accurately captured by the term ‘modality’ (Carey, 2023). Modality refers to the type of equipment used, such as a manikin, standardised patient, or model (Carey, 2023). Early simulation fidelity research by Feinstein and Cannon (2001) identified two components of simulation fidelity: the physical and functional characteristics. ‘Physical characteristics’ refers to the environmental and sensory features of a simulation and ‘functional characteristics’ describes the interpersonal and communicatory aspects (Feinstein and Cannon, 2001). Although many participants and educators prefer high-fidelity simulations, evidence does not support the assumption that a higher-fidelity simulation experience translates to improved learning outcomes (Feinstein and Cannon, 2001; Carey, 2023).
Arthur et al (2011) categorised the level of fidelity of human patient simulators based on their technological capacities to enhance realism. Single joints/limbs or static manikins that replicate the external anatomy but are not interactive were considered low-fidelity; manikins with basic, externally controlled, embedded software allowing for basic communication and body sounds were defined as medium-fidelity; and high-fidelity simulators were those that can be remotely controlled to allow for real-time manipulation of vocal or physiological responses (Arthur et al, 2011). A preliminary literature search has found the majority of wound care education researchers use high-fidelity simulation techniques to capture the multi-sensory aspects of a wound and the variety of decisions available to the learner.
There are different methods for delivering education using simulation described in the literature, including virtual simulation experiences (Redmond et al, 2018), clinical simulations (Sezgünsay and Basak, 2020) and standardised patients (Silva and Oliveira-Kumakura, 2018). This review plans to collate and describe all types of simulations to explore which is the most prevalent in the wound care simulation literature; which is the most practical, feasible, and valuable for nursing students or nurses and educators; and the strengths and weaknesses of each.
A variety of outcomes and assessment methods have been reported in the literature. Learning outcomes may include the perceived or explicitly measured knowledge gains as a result of a study's simulation intervention. Some studies have adopted validated performance evaluations (Sezgünsay and Basak, 2020), graded examinations and designed self-report surveys (Yilmazer et al, 2020) to evaluate students' learning experiences and/or their knowledge levels.
Given the diversity of pedagogical principles, curricula, evaluation methods, outcome measurements, and interventions within wound care simulation education research, a scoping review methodology was deemed best suited to the research question.
It is the goal of this review to assess and summarise the current body of research regarding simulation methods applied in nursing education related, but not limited to, wound assessment, prevention, and management learning outcomes. An additional goal of this review is to inform further research by the authors' research team. A review of the evidence is needed because, although many studies have described wound care educational interventions in nursing, there remains a wide variety in simulation, evaluation, and analysis methods used.
A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews and JBI Evidence Synthesis was conducted and no current or in-progress systematic reviews or scoping reviews on the topic were identified.
- How is clinical simulation being used to educate nurses about wound assessment and management?
- What is the reported impact of clinical simulation on learning outcomes, including knowledge, attitudes, confidence, and skills related to wound care, regardless of the assessment method used?
The proposed scoping review will be conducted in accordance with the Joanna Briggs Institute (JBI) methodology for scoping reviews (Peters et al, 2020).
This review will focus on studies of undergraduate nursing students and practising, licensed nurses or nursing assistants regulated to provide wound care. Studies of learners from other health professional programmes, non-health professional programmes, or graduate nursing programmes will be excluded.
The concept of interest in this review is wound care simulation. There have been a variety of creative simulation designs reported in the literature and as such, the literature search will not be limited to one particular type of simulation in order to capture this variety. In-person, virtual, patient-based, moulage-based (fake wounds created using make-up or special effects), and any other types of wound care simulation will be included. Interventions to be excluded will be those that deliver wound care education solely through lecture materials, whether those materials are in-person or virtual, or simulation interventions that do not focus on wound care.
The learning outcomes of interest include the knowledge, attitudes, and skills of nursing students and nurses, evaluated by themselves or by their teachers' assessments of their confidence, competence, performance, clinical decision-making, and any other metrics related to wound care (Sezgünsay and Basak, 2020). Throughout the literature, learning outcomes have mainly been reported by student performance on pre- and post-intervention tests assessing wound care knowledge (Redmond et al, 2018), validated measures of learning and knowledge (Silva and Oliveira-Kumakura, 2018; Sezgünsay and Basak, 2020), qualitative comments (Silva and Oliveira-Kumakura, 2018), and educators' evaluations (Sezgünsay and Basak, 2020). It is anticipated that studies will not need to be excluded based on the outcome of their intervention because it would be unusual for an educational intervention to not measure any sort of knowledge or attitude growth. The observed learning outcomes post simulation will be assessed no matter how they were measured and therefore both quantitative and qualitative data will be included in this review.
Emerging worldwide interests in simulation education have increased the importance of inclusive research to examine studies that are done in different languages and cultural contexts. Wound care education has much to learn with regard to how wound care provision is affected by various skin colours (Mukwende et al, 2020), differing cultural beliefs, resources accessible and available to patients, the kind of patient engagement strategy used (or not used), and interprofessional team practice (Gishen and Lokugamage, 2019). Most studies on the use of clinical simulation in wound care have been conducted in North America, Ireland, and Brazil but studies completed in other non-Western countries are equally of interest to the authors.
All databases will be searched from 1 January 2012, to the date of the final search (20 September, 2022).
Types of sources
This scoping review will consider all types of study designs to capture the various applications of clinical simulation in wound care education. Inclusion of qualitative studies will provide insights into learning experiences of using simulation (Yilmazer et al, 2020) in addition to quantitative evaluation of outcome-based performance (Sezgünsay and Basak, 2020).
The search strategy will aim to locate both published and unpublished studies, including grey literature and theses. An initial search of Ovid MEDLINE, the Cumulative Index of Nursing and Allied Health (CINAHL, EBSCO), and Education Resources Information Centre (ERIC, EBSCO) databases were undertaken to identify articles on the topic. The text words and synonyms contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for the PubMed database (see Box 1) with the assistance of a health sciences librarian. The search strategy, including all identified keywords and index terms, will be adapted for each included database and/or information source. The reference list of all included sources of evidence will be screened for additional studies.
Box 1.Search strategyThis exemplar search strategy is from the PubMed database, which yielded 151 studies:
- #1 ((simulation training[MeSH Terms]) OR (computer simulation[MeSH Terms])) OR (patient simulation[MeSH Terms])) OR (simulation)
- #2 ((( (models, educational[MeSH Terms])) OR (models, anatomical[MeSH Terms])) OR (model*))
- #3 moulage* or simulat*
- #4 “virtual reality” or “vr” or “augmented reality” or “ar” or “virtual patient*” or “standardized patient*” or “standardised patient*”
- #5 (Role Playing[MeSH Terms]) OR (“role play*” or “role-play*” or roleplay*)
- #6 ((Virtual Reality[MeSH Terms]) OR (augmented reality[MeSH Terms])) OR (mixed reality) #6 ((Virtual Reality[MeSH Terms]) OR (augmented reality[MeSH Terms])) OR (mixed reality)
- #7 ((educational technology[MeSH Terms]) OR (technology[MeSH Terms])) OR (technology)
- #8 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7
- #9 ((((((burns[MeSH Terms]) OR (diabetic foot[MeSH Terms])) OR (wound healing[MeSH Terms])) OR (surgical wound[MeSH Terms])) OR (wounds and injuries[MeSH Terms])) OR (pressure ulcer[MeSH Terms])) OR (wound*)
- #10 (students, nursing[MeSH Terms])
- #12 nurs*
- #13 education, nursing[MeSH Terms]
- #14 (teaching[MeSH Terms]) OR (curriculum[MeSH Terms])
- #15 #12 and #14
- #16 #15 or #13 or #10
- #17 #16 and #9 and #8
- #18 #16 and #9 and #8 Filters: in the last 10 years, English
Unpublished studies and reports will be searched for through the Open Grey and Google Scholar databases using the same index terms from the search strategy shown in Box 1. A generic web search will also be done to obtain any remaining grey literature not found in the databases.
Certain languages are being excluded from the search at this point. A previous search strategy (the same as that shown in Box 1 but without the English filter) yielded studies in English, Portuguese, Spanish, and Hungarian. However, since no two members of the research time have the same degree of fluency in a second language, only studies in English will be screened. Included studies will be limited to those published in 2012 to 2022.
The databases to be searched include MEDLINE/PubMed, CINAHL, ERIC, and the Scientific Electronic Library Online (SciELO) via Web of Science.
Following the search, all identified citations will be collated and uploaded into the Covidence systematic review management software (www.covidence.org) to remove duplicates and track the staging of article review (title and abstract or full text). Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria of the review. Potentially relevant sources will be retrieved in full through institutional access and moved into the full text screening stage within Covidence. The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of sources of evidence at full text that do not meet the inclusion criteria will be recorded and reported in the scoping review. Any disagreements that arise between the reviewers at each stage of the selection process will be resolved through discussion, or with an additional reviewer/s. The results of the search and the study inclusion process will be reported in full in the final scoping review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping review (PRISMA-ScR) flow diagram (Tricco et al, 2018). Studies that pass full-text screening for inclusion will be added into EndNote 20 2021 (Clarivate Analytics, PA, USA) in order to easily be inserted into the scoping review manuscript.
Included studies will not be critically appraised since scoping reviews do not require the same degree of evidence certainty that systemic reviews do (Peters et al, 2020). We do not feel critical appraisal would be feasible for this review due to the wide variety of analysis methods and interventions used in published wound care simulation literature. Additionally, the inclusion of both grey and published literature in this review would make a consistent critical appraisal tool impossible.
Data will be extracted from papers included in the scoping review by two independent reviewers using a data extraction tool developed by the reviewers (Box 2). The data extracted will include specific details about the participants, concept, context, study methods and key findings relevant to the review question.
Box 2.Data extraction instrumentThe following information will be extracted from included papers:
- Title, authors, year of publication, country of publication, country of study (if different from publication)
- Population, context, sample size
- Methods used to assess intervention
- Intervention (concept) – include duration, type of simulation, techniques used, wound type
- Measurement tool
- Results – include statistics, outcomes, aggregate qualitative data
- Conclusion – describe authors' overarching findings
- Implication for educational practices
- Useful quotes to include in manuscript (if any)
- Reviewer comments (if any)
Since the developed extraction tool is novel, the first three studies extracted will be discussed and extraction forms compared to assess for reviewer calibration. The results of data extractions will be summarised in a spreadsheet to assist with data synthesis.
The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included evidence source. Modifications will be detailed in the scoping review. Any disagreements that arise between the reviewers will be resolved through discussion, or with an additional reviewer. If appropriate, authors of papers will be contacted to request missing or additional data, where required.
Data analysis and presentation
Findings will be presented in narrative, diagrammatic, and tabular form. Tables and diagrams will be used to show counts and summaries of the data where appropriate. A narrative summary will accompany the tables and diagrams to relate findings to the review question.
This review is currently in the stage of selecting articles and all necessary searches of the published literature have been done. A search of the grey literature is yet to be done. The COVID-19 pandemic has made it abundantly clear how necessary it is to provide nursing students and RNs high-quality simulation experiences, either to enhance or substitute clinical education. This review seeks to consolidate the available literature on using simulation to teach nursing wound care and will provide educators and researchers with an important summary of available pedagogical techniques.
This review will also be used to help inform the development of future wound care simulation interventions by our research team by listing all the interventions used in the literature and how they were studied.
- Wound care education within undergraduate nursing programmes and continuing on-the-job education is failing to prepare nurses for real-life wound care practice
- A variety of education methods currently aim to address this educational gap
- There are no clear summaries of the educational methods available to nurses to learn wound care
- This review will inform the field of wound care simulation research in nursing education on the currently used teaching strategies and their benefits
CPD reflective questions
- Think about the way you learned about wound care in your nursing education
- Do you think your nursing education prepared you to tend to wounds once you entered nursing practice?
- Are you aware of the wide variety in educational methods used to teach wound care to nursing students and nurses?
- Would you feel confident teaching wound care to students or a fellow nurse?