Abstract
Simulation as a technology and holistic nursing care as a philosophy are two components within nursing programs that have merged during the process of knowledge and skill acquisition in the care of the patients as whole beings. Simulation provides opportunities to apply knowledge and skill through the use of simulators, standardized patients, and virtual settings. Concerns with simulation have been raised regarding the integration of the nursing process and recognizing the totality of the human being. Though simulation is useful as a technology, the nursing profession places importance on patient care, drawing on knowledge, theories, and expertise to administer patient care. There is a need to promptly and comprehensively define the concept of holistic nursing simulation to provide consistency and a basis for quality application within nursing curricula. This concept analysis uses Walker and Avant’s approach to define holistic nursing simulation by defining antecedents, consequences, and empirical referents. The concept of holism and the practice of holistic nursing incorporated into simulation require an analysis of the concept of holistic nursing simulation by developing a language and model to provide direction for educators in design and development of holistic nursing simulation.
Keywords
Rapid changes are occurring in health care and in clinical nursing education making it necessary to use innovative methods to prepare nurses for practice (Benner, Sutphen, Leonard, & Day, 2010; Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). It is estimated that in the United States alone, more than 500,000 new nurses will be needed to meet the demands of the population by 2020 (U.S. Department of Labor, Bureau of Labor Statistics, 2012). One approach to address this growing health care need is to educate nurses to meet and maintain competencies in increasingly complex situations. A holistic nursing approach to simulation-based learning (SBL) may facilitate improvement in the quality and safety of patient-centered care.
Simulation started as a novel supplement to traditional clinical experiences integrated into curricula in the 1960s (Aebersold & Tschannen, 2013). It has recently been cited by the National Council of State Boards of Nursing (NCSBN) as an effective replacement for up to half of the recommended clinical hours in prelicensure nursing education if quality simulation is used (Hayden et al., 2014). With the impactful conclusions of the NCSBN’s landmark simulation study, there is reason to believe many nursing programs will increase their use of simulation. With this anticipated change in practical learning, there needs to be clear definitions and understanding of simulation. While nursing simulation has been extensively defined in the literature (Bland, Topping, & Wood, 2011), holistic nursing simulation has not. There is a pressing need to promptly and comprehensively define the concept of holistic nursing simulation so that there is consistency and quality in application to nursing curricula if simulation is going to replace any portion of clinical hours. The aim of this concept analysis is to define holistic nursing simulation by developing a language and a visual model (Figure 1) to provide direction for nurse educators in design and development of holistic nursing simulation using Walker and Avant’s (2011) eight-step process:
Select a concept.
Determine the aims of the analysis.
Identify all uses of the concept.
Determine defining attributes.
Identify antecedents and consequences.
Construct a model case to illustrate what the concept is.
Construct borderline, related, illegitimate, and contrary cases to illustrate what the concept is not.
Define empirical referents.
Visual Depiction of Holistic Nursing Simulation
Literature Review Method
The nursing literature pertaining to holistic nursing simulation is scarce. The concepts of holistic nursing and simulation are frequently paired together but they appear to rarely be operationalized and no studies were identified that analyzed or defined holistic nursing simulation.
A comprehensive analysis of the databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Source: Nursing, Medline, The Educational Resources Information Center (ERIC), and Google Scholar was conducted with the ultimate goal of defining holistic nursing simulation. Electronic databases were search for peer reviewed, English language articles from 2005 to 2015 using keywords and keyword combinations including holistic care, holistic nursing, and simulation, nursing simulation, nursing education, and teaching methods. Reference lists of some of the articles provided the opportunity to identify other relevant articles that met the inclusion and exclusion criteria. The decision to use articles within the past 10 years was primarily due to a rapidly growing body of work on simulation. Studies were sought that focused on “holistic nursing simulation” which when search as a term resulted in zero citations. Additionally, online and university dictionaries and textbooks through the academic university library provided keyword and keyword combination definitions.
The initial search using the keywords and combinations retrieved 822 articles from the databases. These citations included articles, books, and training manuals about simulation in aviation, computer science, marine ecosystems, and nursing. When the search was narrowed to “holistic nursing” AND “simulation” or gave a reasonable account of holism in relation to simulation, 109 articles were acquired. The search was further narrowed by combining terms “holistic nursing” AND “nursing simulation” AND “teaching methods or educational strategies” resulting in 102 articles, which then required further delineation. Abstracts of these articles were reviewed for this concept analysis. Fifty-eight abstracts from these articles were not specific to holistic nursing simulation and were excluded. For this concept analysis, 38 articles, 10 books, or book chapters are included along with one sentinel publication (Kolb, 1984).
Description of Uses of Concept
Holistic nursing has been used to define patient-centered care in which the nursing focus is on the patient as a unified whole being (Cordeau, 2010). Simulation has been used in a number of disciplines including aviation, health care, and in the military to train and educate personnel (Barry Issenberg, Mcgaghie, Petrusa, Lee Gordon, & Scalese, 2005; Jeffries, 2005; Reddy, 2006).
Simulation in nursing is a strategy to mirror a real situation with guided interactive experiences (Li, 2007). This concept analysis identifies the attributes, antecedents, and consequences and develops a definition of the concept of holistic nursing in SBL.
Significance of the Concept
Simulation as a technology and holistic nursing care as a philosophy are two components within nursing programs that have collided during the process of knowledge and skill acquisition to achieve the care envisioned by the American Holistic Nurses Association (Dossey & Guzzetta, 1995,) of the patient as a whole person. Simulation provides various opportunities for students to apply knowledge and skill through the use of simple reproductions of specific body sections to the high-fidelity simulators, standardized patients (SPs), and virtual clinics and offices (Moule, Wilford, Sales, & Lockyer, 2008). High-fidelity simulators, virtual clinics and offices, and SPs will be expanded on later in the article. The purpose of simulation is to provide the participant with the ability to engage in learning, problem-solving, critical-thinking, and decision-making in a safe and controlled environment (Jeffries, 2005; Rodgers, Adamson, & Jeffries, 2015; Wilford & Doyle, 2006).
The National League for Nursing/Jeffries Simulation theory, previously the Jeffries Simulation framework provides guidance for simulation structure, delivery, and outcome strategy. The five components of the National League for Nursing/Jeffries Simulation Theory combine to improve participant and organizational outcomes (Adamson, 2015, Jeffries, 2005, 2007; Jeffries & Rogers, 2012). Simulation provides opportunities within these safe environments that mimic real-life unexpected events. Concerns with simulation have been raised regarding the integration of the nursing process, specifically recognizing the totality of the human being, the interconnectedness of the environment with mind, body, spirit, emotions, social, and cultural relationships (Dossey & Guzzetta, 1995). Furthermore, the widespread move to integrate technology without the pedagogy of the nursing philosophy (Day-Black & Watties-Daniels, 2006; Parker & Myrick, 2009) is of concern.
Though simulation is very seductive as a technology, the nursing profession places a great deal of importance on care of the patient, drawing on knowledge, theories, and expertise to administer patient care. The concept of holism, and the practice of holistic nursing incorporated into the technology of simulation require that an analysis of the concept of holistic nursing simulation be framed for delivery within the curriculum. An analysis of the literature to determine the understanding and usefulness of this concept is imperative.
Defining Attributes
Defining attributes are the qualities most frequently associated with a concept (Walker & Avant, 2011). These are the characteristics of a concept that repeatedly appear in the literature. There are two primary defining attributes for holistic nursing simulation: simulation and holistic nursing. The defining characteristics within each of these two main attributes become more abstract when defining holistic nursing simulation.
The first attribute deemed necessary to clarify is holistic or holism, which is identified by this concept analysis as whole, harmony, and “mind, body and spirit” (Cumbie, 2001, p. 57). More recently, the literature also includes healing as a defining attribute of holistic or holism (Ernst, 2004; Jackson, 2004).
While most of the definitions of holism share the same attributes, nursing has applied it to the person. Nursing is certainly holistic, as the nursing profession has consistently viewed the individual as a whole being; concerned with mind, body, and spirit (Dossey & Keegan, 2009). Nursing promotes physical and psychological well-being with social–cultural awareness.
Leading experts agree that humans need to be treated as a whole being. M. E. Rogers (1970), in her discussion of the “nature of the human beings” influenced the use of the word holistic in the profession of nursing. M. E. Rogers (1970) believed that the world was an interconnection of elements making a whole. The nurse’s role was further depicted by Levine (1973) as a profession that viewed each patient as a unique human being, which has been in sharp contrast to medicine, which historically viewed patients as fixed systems. The AHNA (1992) defined holistic as “. . . the state of harmony between mind, body, emotions and spirit in an ever changing environment.” This is consistent with the modern view of “holistic nursing” where the physical, psychosocial, cultural, and spiritual paths converge into one. Also noted as part of holism is healing which is defined by the AHNA Scope and Standards of Practice as “physical, mental, social and spiritual processes of recovery, repair, renewal and transformation that increases wholeness and often (though not invariably) order and coherence” (Mariano, 2013, p. 54).
The second attribute is SBL which has specific attributes that encompass areas as diverse as the modeling of natural or human physiologic systems, technologic reproductions of equipment and environments, or entire virtual worlds of computer-generated environments in which individuals can interact (Fanning & Gaba, 2008). The origin of simulation began as an experiential and situational learning theory (Fanning & Gaba, 2007; Kolb, 1984). This theory encompassed learning by doing, thinking, and assimilating learned behaviors, and it encompasses concepts of mastery and deliberate practice (Fanning & Gaba, 2008). The approach has now become an established pedagogy for teaching and learning clinical nursing knowledge and skills providing the learner with a safe, reality-based environment (Linder & Pulsipher, 2008). In 2005, Jeffries classified simulation as an active learning strategy, contributing to greater self-motivation, and understanding of cognitive and psychomotor skills by students.
Simulation provides the learner with the ability to role-play scenarios and examine or evaluate solutions within a controlled safe environment (Bland et al., 2011; Henneman et al., 2010; Jeffries, 2005; L. Rogers, 2011; Sando et al., 2013). Simulation is a technique that portrays or immerses the student into a guided learning experience (Aebersold & Tschannen, 2013). Simulation has various forms, including low-fidelity manikins for scenarios or high-fidelity computerized manikins (HFCM) that require faculty or staff to control the advanced technological capabilities that can illicit actual verbal and physiological responses. There are actors who are prepared and trained as SPs to portray the role of a patient or family member, and virtual hospitals and clinics that use avatars as patients. To date, there are few published simulation scenarios that are holistically focused (Cordeau, 2010). The published studies in nursing simulation have primarily focused on the care of the patient with specific physiologic or psychiatric problems (Cambell & Daley, 2009; Gasper & Dillion, 2012). They are segmented in delivery of knowledge and skill, focused on an individual system or concept (Dossey & Keegan, 2009).
Antecedents and Consequences
Antecedents
Antecedents are events or incidents that must happen prior to the occurrence of the concept (Walker & Avant, 2011). Identification of the antecedents and consequences of holistic nursing simulation also allows determination of the social context in which the concept is used. The antecedents below can be seen in the visual model (Figure 1). Currently, there are few pieces of literature to support most of the antecedents in their entirety, but there is evidence to support the rationale behind aspects of the antecedents.
A Need to Provide Additional or Complementary Experiences
The need to provide a holistic learning experience during a simulated scenario as the necessary nursing clinical experience is not readily available (Hayden et al., 2014). A search of multiple databases did not provide evidence of holistic nursing simulation scenarios. However, there are research studies that identify the need for inclusion of holistic principles or have embedded a few holistic concepts (Fabro, Schaffer, & Scharton, 2014; Gibson, Dickson, Lawson, Kelly, & McMillan, 2015).
Students’ Abilities to Synthesize Holistic Nursing Care Needs Further Development
The ability of students to weave components of care such as health promotion, healing techniques, complementary and alternative therapies, cultural diversity, and spiritual care together is not yet fully developed (Cordeau, 2010).
Depth and Accuracy of Scenarios That Meet Defined Standards
The depth of the simulated scenario must meet standards in order for students to learn to deliver care in an integrated holistic environment. The International Nursing Association for Clinical Simulation and Learning has established simulation standards for participants (Sittner et al., 2015). Realistic simulations will provide the most authentic learning for students and yield results consistent with the students’ ability to empathetically care for an SP as if they would for an actual patient (Berg, Majdan, Berg, Veloski, & Hojat, 2011).
Students’ Foundational Knowledge
Students must bring foundational knowledge to apply to holistic care during simulations. Foundational knowledge and awareness of self, others, and the environment provide the nursing student with an understanding of the “caring and healing” relationship required in holistic nursing simulation (Cumbie, 2001). This foundational knowledge will vary based on the level of nursing student; but at a minimum, it includes a basic understanding of holistic care, medical terminology, and physiological processes.
Measureable Holistic Objectives With Validated Evaluation Tools
Measurable, achievable, and holistic objectives must be created and communicated with all participants (Lioce et al., 2013), and evaluation tools must be validated (Boese et al., 2013).
Adequate Training for Simulated Patients and Technology to Create Believable Scenarios
SP and HFCM facilitators should have preparation, training, and technology to competently portray holistic principles of their character. Simulation facilitators are required to be proficient in the “complexity of simulation” (Boese et al., 2013, p. S23; Li, 2007; Sittner et al., 2015).
Debriefing Facilitation Preparation
Debriefing facilitators must be adequately trained in holistic principles for a quality debriefing session. Debriefing requires exploration of actions utilized or not, gaps in knowledge and skills of the participant, as well as reflection of the simulated experience (Decker et al., 2013; Sittner et al., 2015).
Consequences
Consequences are events that occur as a result of the occurrence of the concept (Walker & Avant, 2011). The consequences of holistic nursing simulation are congruent with the consequences of quality nursing education, which is appropriate considering Hayden et al.’s (2014) landmark research supporting replacing traditional clinical hours with simulation. The crucial objective is to produce safe, holistic, competent nurses capable of critical thinking and clinical decision making. The consequences can be seen in the holistic nursing simulation model (Figure 1).
Acquisition and Synthesis of Knowledge to Care for a Whole Being
The simulated experience allows the student to acquire and synthesize knowledge in a planned and coordinated pattern, encompassing the person as a whole being. Achieving desired patient outcomes through SBL includes “viewing the patient holistically” (Lioce et al., 2013, p. S16).
Knowledge, Skills, Attitudes, and Personal Growth
The holistic nursing simulation facilitates knowledge, skills, attitude, and personal growth of the student.
Critical Thinking and Clinical Decision Making
Holistic nursing simulation is the basis for learning how to integrate a way of thinking, practicing, and reflecting on patient care (Dossey & Keegan, 2009). Should the delivery of holistic simulation not occur, the lack of transference of these principles may be a predictor of poor patient outcomes (Fore & Sculli, 2013).
Increased Competence and Confidence
Increased competence and confidence in future clinical, didactic, and professional nursing practice that includes prioritizing and conducting holistic care (Decker et al., 2013).
Improved Patient Outcomes
Because of holistic nursing simulation experiences, future patients will likely receive holistic care in routine and emergent situations. This will ultimately work to improve patient outcomes for future patients’ minds, bodies, and spirits.
Example Cases of Holistic Nursing Simulation
Cases are created as exemplars to illustrate what the concept is and what it is not (Walker & Avant, 2011). Walker and Avant (2011) promote development of a model case, which includes the defining attributes of holistic nursing and simulation as well as exemplars that are differing degrees of the concept: related, borderline, illegitimate, and contrary (Walker & Avant, 2011). The cases for holistic nursing simulation are vital to differentiate the proper and improper uses of the term “holistic nursing simulation.” There is a tendency in nursing to label everything as holistic and many ideas as simulation, these cases will help clarify the appropriate use of the concept of holistic nursing simulation.
Model Case
A junior-level nursing student, Jill, participates in a summative holistic nursing simulation experience. A set of measurable objectives for the simulation was given to the class a month ahead of time to allow for preparation. The objectives for the holistic nursing simulation address physical, psychosocial, spiritual, and cognitive care. However, the details of the situation were not shared with students, to simulate real-life nursing experiences.
On arrival to the simulation, the night nurse, a faculty member from the simulation center, provides Jill with a sign-off report, before Jill enters an SP’s room. The SP is on a nitroglycerin drip for acute coronary syndrome and complains of a headache, nausea, increased financial stress because of this hospitalization, and is in tears because she has just learned that her partner was in a car accident on the way to visit her. Jill implements the nursing process with the SP by first doing a thorough assessment, then sets measurable goals, implements interventions aimed at the SP’s physical and emotional distress, and evaluates all aspects of the implemented plan.
Jill prioritizes the nursing case based on Maslow’s hierarchy of needs, knowledge of the pathophysiology and psychology of the SP’s condition, and her previous experiences. Based on her educational foundation, Jill first ensures that the patient is not exhibiting any signs of decreased cardiac perfusion or other complications of acute coronary syndrome. Next, Jill assesses and manages the SP’s headache and nausea using pharmacological and nonpharmacological interventions. Once the SP reports a tolerable level of pain and absence of nausea, Jill sits at the bedside to fully assess the emotional and spiritual distress reported and demonstrated by the SP. Throughout the experience, Jill integrates patient teaching based on her knowledge of the SP’s reported available resources and learning style preferences from her initial assessment. The SP expresses appreciation for the thoughtful education related to cardiovascular health, pain control, and additional resources available for the SP and her partner following the recent accident. Additionally, Jill consults the hospital chaplain and social worker to follow up with the patient.
Following the simulation, Jill joins the other students who cared for an SP with the exact same situation for debriefing led by fully trained simulation faculty members. Jill and her classmates express feeling they were required to synthesize what they have been learning in all of their courses over the past 3 years. They also verbalized implementation of the nursing process to address the SP as a whole person, and not just as a physical ailment or psychological concern. Jill and her classmates explain that there were a number of times during the simulation that they were not sure of what the best course of action would be and that they all handled these situations differently. Jill and her classmates describe the value they feel in being able to make clinical decisions independently in a setting that would not put the patient in any harm if they made the wrong choice. Finally, the students each are required to watch the video recording of their encounter and write a reflection with a holistic focus on their performance related to each of the objectives for the assignment.
The following week in clinical, Jill reports a change in her approach to holistic care for her patients. She attributes this to her learning experiences and reflection of the holistic nursing simulation event.
Analysis of Model Case
Jill’s story is a model case because it exemplifies all of the defining attributes of holistic nursing simulation. Additionally, a number of the antecedents and consequences are evident throughout the discussion of Jill’s holistic nursing simulation experience. Jill uses her previous nursing knowledge to prioritize and implement care of the physiological, psychological, and spiritual needs of the SP. Additionally, she continued her learning in the debriefing section of the event. Her future practice can potentially improve because of her experience with this holistic nursing simulation.
Borderline Case
Stephanie is a nurse midwife student. Stephanie has been preparing for her summative evaluation at her university’s simulation center. She has been given objectives that encompass physiological, psychological, social, spiritual, and cultural aspects of advanced nursing care of women. Stephanie’s simulation involves an office visit for a patient with a chief complaint of uncontrollable nausea and vomiting during the first trimester of pregnancy. The SP is also tearful and upset because she is out of vacation time and she cannot afford to miss any more work. Stephanie acts quickly and prioritizes the physical assessment of the mother, identifying a recent weight loss of 3 pounds and mild hypotension with tachycardia. Stephanie determines that she has moderate dehydration and fluids are the best course of action, but not needed emergently. Stephanie gives the SP an antiemetic and arranges for the SP to get an intravenous fluid bolus in the hospital’s short stay unit. The patient arranges for a ride to come pick her up and take her to the hospital.
Stephanie is quite anxious about making the correct medical decisions, so she forgets to sit and talk with the SP. Throughout the exam, Stephanie uses a variety of therapeutic communication techniques, both verbal and nonverbal. However, due to the stress of the simulation activity, Stephanie is unable to respond to all of the SP’s nonverbal cues and the holistic dimensions of the SP’s health.
During debriefing, Stephanie highlights her confidence with making the correct medical decisions, but acknowledges a deficit in caring for all dimensions of her SP’s health. Stephanie vows to improve her holistic care in future simulations and clinical experiences.
Analysis of Borderline Case
Stephanie’s story is considered a borderline case of holistic nursing simulation because it embodies many of the antecedents and one of the main defining attributes of holistic nursing simulation, but not all necessary attributes. The simulation experience presented opportunities for the student to demonstrate all aspects of holistic care and the debriefing took place to compound the learning process. Additionally, Stephanie will alter her practice to be more holistic and comprehensive in the future because of this scenario. However, it is still lacking the defining attribute of demonstration of application of the nursing process to all dimensions of health for the SP.
Contrary Case
Harold is a sophomore nursing student. Harold goes to the simulation center with his classmates to complete mandatory skills check-offs. Students were previously shown a demonstration of each skill, given preset checklists with step-by-step instructions for each skill, and instructed to practice prior to check-offs. On check-off day, Harold brings supplies that he purchased that identically match the supplies with which he practiced. Harold and the other students move through each room of the simulation center and perform the various skills in front of faculty members as well as a video recording device. While completing each skill, Harold verbalizes his actions and rationale, but does not interact with his simulated patients.
Analysis of Contrary Case
Harold’s story is an example of a contrary case because the defining attributes are not present. While the location and variety of skills may in some ways appear to have similarities with holistic nursing simulation, there is no evidence of simulation, patient interaction, holistic nursing care, or application of clinical decision making.
Related Case
Carmine, a nurse practitioner student, participates in high-fidelity simulation event. Carmine receives a call from a simulation center staff nurse who is requesting immediate assistance with her patient due to drastic vital sign changes. On arrival to the HFCM’s room, Carmine jumps into action asking for pertinent findings and assessing the patient. Carmine auscultates the HFCM’s heart, revealing a regular heart rate of 178 beats per minute. Carmine orders an electrocardiogram, which reveals supraventricular tachycardia. At this time, Carmine gives a verbal order for the staff nurse to get adenosine for the patient. Carmine administers the adenosine and watches the monitor for the HFCM’s response. The heart rate improves to 106 beats per minute, and the rhythm converts to sinus tachycardia. There is minimal verbal and nonverbal interaction with the HFCM, despite the fact that the HFCM has capabilities to communicate.
On completion of the simulation, Carmine participates in debriefing activities. She reflects on her actions, the timeliness of her actions, second thoughts, and overall feelings about the scenario. Carmine notes that she feels much more prepared to handle this type of emergency in the future because of this high-fidelity simulation.
Analysis of Related Case
Carmine’s story with high-fidelity simulation is related to holistic nursing simulation, but they are not the same concepts. High-fidelity simulations focus on stimulating students’ application of foundational knowledge through use of their senses as they assess lifelike physiologic responses (Bland et al., 2011), and are not necessarily focused on care of the holistic patient. This case is related to holistic nursing simulation because they have many overlapping components, but there is no evidence of holistic nursing, one of the defining attributes. “Related cases have names of their own” (Walker & Avant, 2011, p. 165). In this case, high-fidelity nursing simulation is a term in itself. If Carmine also interacted with the family during the emergency situation or with the patient following the traumatic event, then spiritual and psychological care may very well have been involved, thereby making this more of a holistic nursing simulation.
Illegitimate Case
Samuel is an actor who just became “Nurse Michael” in a new television series chronicling the multiple dimensions of nursing practice in the hospital. Nurse Michael is a night shift nurse on a traumatic brain injury unit. As part of his role, Samuel assesses his patients holistically and is often seen sitting at the patients’ bedsides, addressing physiologic emergencies, discussing spiritual preferences, and implementing care that is specific to the patients’ cultural needs. Samuel portrays his character in a believable way, but comments in an interview with a morning talk show that he has “no idea about half of the words” coming out of his mouth and has “yet to hear any noises” when using his stethoscope.
Analysis of Illegitimate Case
Samuel’s case is an illegitimate case because it does not contain either of the defining attributes of the concept of holistic nursing simulation. Additionally, it does not contain any of the antecedents or consequences either. This is an illegitimate example because the focus is on acting, not on thought development, clinical decision making, and execution of holistic care. Simulation can be defined as a false portrayal or pretending (“Simulation,” n.d.). An actor playing a nurse would illegitimately describe his or her work as holistic nursing simulation, even if the portrayal encompasses many of the attributes of a professional nurse.
Empirical Elements of Holistic Nursing Simulation
The final step in analyzing the concept of holistic nursing simulation is to identify “the empirical referents for the defining attributes” (Walker & Avant, 2011, p. 168). The defining attributes of holistic nursing simulation are more complex than the individual components and must be combined to fully define holistic nursing simulation. The following are the measurable indicators of holistic nursing simulation (Figure 1):
Students participate in simulated experiences that have measurable objectives addressing application of the nursing process to the physiological, psychosocial, cultural, and spiritual needs of an SP or HFCM.
During simulation scenario, the student must use clinical decision making and critical thinking to prioritize among all of the needs of an SP or HFCM, applying the theoretical foundations of holistic nursing practice learned in school and the wisdom gained from previous clinical experiences.
Successful completion of the measurable objectives addressing all dimensions of nursing care can be validated with interrater reliability among those trained in simulation education.
The student has limited knowledge of the scenario, similar to a real-world patient situation—no two simulations will be identical, despite close adherence to scripts and training by the SPs and HFCM commanders.
The learning process continues after the scenario is completed. During the debriefing, students reflect on accomplishment of the holistic objectives and their feelings following their performance.
Implications for Nursing
Holistic practice in nursing simulation has the potential to enhance clinical judgment and provide effective decision making (Dossey, Luck, Schaub, & Keegan, 2013). The idea of holistic care or holism should be taught early in nursing curricula. Application of holistic care should be a part of nursing practice, research and education as an adjunct to fundamentals and should begin in the undergraduate curriculum and be continued through graduate education (Dossey et al., 2013). Future research studies would support the use of simulation to educate future nurses on holistic care while enhancing clinical decision making.
Conclusion
Based on the concept analysis conducted, an operational definition of holistic nursing simulation is as follows: The integration of clinical decision making and holistic nursing care encompassing a simulated patient’s mind, body, and spirit, facilitating learning in a safe and controlled environment with the goal of quality professional nursing care to improve patient outcomes. If simulation continues to replace clinical experiences, then a clear definition of holistic nursing simulation is vital as a foundational benchmark in the effective replacement of traditional clinical hours with simulation. Structuring a plan for incorporation of holism into SBL is an important step toward safe nursing outcomes.
Holistic nursing simulation allows for improved outcomes that can benefit patients, students, and faculty. For students learning is safe, realistic, and allows for debriefing and reflection. Patients in the community ultimately benefit from higher quality care from nursing students and new graduate nurses because of the integrative learning from holistic nursing simulation. Last, educators have measurable objectives from which they can evaluate students’ performance and provide unique feedback, which in turn helps students and ultimately patients. Because holistic nursing simulation presents all of these benefits, this concept analysis and operational definition provide a starting point for implementation of holistic nursing simulation and a common language for discussing what we have termed “holistic nursing simulation.”
While the majority of academic nursing institutions have some elements of SBL, there is a shortage of simulation scenarios that demonstrate the integration of holism: mind, body, and spirit. This concept analysis also provides a base for future research and offers consistent measurable means for evaluation of current and future simulation methods. The limited body of knowledge on holistic nursing simulation needs further studies that explore the use of holism through varied simulated experiences and in varied setting. Consistency in holistic nursing simulation and the development of new holistic nursing experiences will better prepare the next generation of nurses and advanced practice nurses for high-quality, holistic care.