Creative Education
2014. Vol.5, No.3, 134-140
Published Online February 2014 in SciRes (http://www.scirp.org/journal/ce) http://dx.doi.org/10.4236/ce.2014.53021
134
The Changes of Nursing Students’ Assessment Skills at a
Simulated Setting: A Quasi Experimental Study
Yok Man Cymon Chan, Haobin Yuan
School of Health Sciences, Macao Polytechnic Institute, Macao, China
Received December 11th, 2013; revised January 11th, 2014; accepted January 18th, 2014
Copyright © 2014 Yok Man Cymon Chan, Haobin Yuan. This is an open access article distributed under the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited. In accordance of the Creative Commons Attribution Li-
cense all Copyrights © 2014 are reserved for SCIRP and the owner of the intellectual prop erty Yok Man Cymon
Chan, Haobin Yuan. All Copyri ght © 2014 are guarded by law and by SCIRP as a guardian.
Background: Structured and comprehensive assessment is critical to identify physical and psychological
problems and concerns experienced by patients. Simulation can be used for training students’ health as-
sessment skills as well as communication skills. Objectives: The purposes of this study were to determine
how students’ health assessment skills changed in a simulated setting. Method: A quasi experimental
study with one group repeated-measures design was conducted with a purposive sampling of 85 bacca-
laureate nursing students a t one nursing school in Macao. Two qualified tutors evaluated students’ health
assessment skills in terms of introduction and patient iden tification, symptom assessment, physical ex-
amination, patient education, history inquire and communication using the same criteria in each simula-
tion session . Results: The overall score of students’ health assessment skills increased from the first ses-
sion to the last session. Second-year students achieved higher overall scores of assessment skills than
third-year students in some simulated scenarios significantly even though they had less clinical practice
experience. Conclusions: Simulation using a human patient simulator helped students to transform
knowledge and skills to assess patient condition. Tutors should promote students’ intrinsic motivation for
learning, develop their potential and encourage them to keep their efforts in learning.
Keywords: Assessment; Baccalaureate; Nursing Student ; Simulation
Introduction
Health assessment is defined as an evaluation of the health
status of an individual by performing symptom assessment,
physical examination and history inquiry (Day, 2010). When
nurses interact with patients and provide care, the appropriate
assessment skills with obtaining a complete health history are
critical to identify physical and psychological problems and
concerns experienced by patients. Nurses should consider pa-
tients’ educational and cultural background and their language
proficiency, and pay close attention to the patient’s disabilities
or impairments in hearing, vision, cognitive and physical limi-
tations during health assessment (Pan, 2012). Although assess-
ment is an essential competency of nurses, little has been ac-
tually done by nurses in clinical settings. Secrest, Norwood, &
duMont’s (2005) survey showed that although 92.5% of physi-
cal assessment skills were taught in baccalaureate nursing pro-
gram, only 29% of nurses in clinical practice actually per-
formed those skills. Liu, Chen and Yang (2008) indicated that
the assessment skill deficiencies of new nurses included lack of
communication skills, incorrect physical examination technique,
and lack of comprehensive assessment and analysis of patient
condition. A gap may exist between what is taught in classroom
and what is actually performed in nursing practice. In Macao,
students usually prefer t o learn practical knowledge in an orga-
nized environment. The static manikins commonly have
been delivered under the direction or demonstration of teachers.
Students had less opportunity to learn or practice the skills in an
interactive environment. Preparation of students for a complex
health care environment requires that students are educated not
only in skills but also in communication and collaborative care.
An ongoing concern with nursing education is how to improve
students’ assessment skills using appropriate strategies as well
as knowledge application (Mei, He, Xie, Yang, & Duan, 2012).
Students should learn how to solve problems and practice over
and over in each trial while accepting and learning from their
mistakes until they become skilled. In this case, more active
teaching strategies, such as role play, case study, or standar-
dized patient teaching method, were used in course learning of
health assessment and showed that the experimental group got
the higher scores in both theory and skill exams than the control
group who served as a t raditional method (Chen, Cheng, Zhou,
Feng, & Dong, 2012; Pan, 2012; Yin et al., 2012).
Although learning by doing is a long established means for
facilitating knowledge acquisition, it isn’t practical to engage in
skill training with real patients due to the increased protection
of patient rights and safety. The complexity of the current
health care systems makes it difficult to provide nursing stu-
dents with sufficient clinical experiences to ensure their com-
petency. Educators are challenged to find adequate clinical
experiences for their students. Simulation provides the oppor-
tunity for the learner to practice and learn in an environment as

Y. M. C. CHAN, H. B. YUAN
135
close to reality as possible and allows students to construct
knowledge and develop psychomotor skills in a safe environ-
ment (Sinclaire & Fergusion, 2009). Students interact with a
human patient simulator and discover critical assessment in-
formation in the same manner they would with real patients.
They had an opportunity to rehearse skills in a simulated envi-
ronment without fear of failure or compromising patient safety
(Bambini, Washburn, & Perkins, 2009).
As an experience learning, simulation using a human patient
simulator (the SimMan) which imitates patient condition with
physiological functions can be used for training health assess-
ment skills as well as communication skills (Haidar, 2009).
However, little current study discussed how to improve as-
sessment skills and knowledge application of medical-surgical
nursing using simulation in nursing students. The observational
measure wa s used in this study to discuss about the research
question as a difference in health assessment scores followed
by each simulation session.
Research Objective
The objective of this study was to determine how students’
assessment scores changed at a simulated setting followed by
each simulation session.
Method
A quasi experimental study with one group repeated-meas-
ures (from Session 1 to Session 5) design was conducted at one
nursing school in Macao. The scores measured in each simula-
tion session were compared within each tutorial group.
Samples
Purposive sampling was used to recruit Year 2 and Year 3
baccalaureate nursing students who passed course learning in
health assessment and me dical-surgical nursing. Totally there
were 115 students (54 in Year 2, 61 in Year 3). 90 of them (52
in Year 2, 38 in Year 3) voluntarily participated in this study.
Finally 85 students (49 in Year 2, 36 in Year 3) completed all
simulation sessions. Their average age was 20.24 (S.D. 1.46)
years old. Second-year students had 20 weeks of clinical expe-
rience while third-year students had 30 weeks of experience.
Teaching Protocol
The 36-hour simulation training was conducted as extracur-
ricular activities for promoting students’ health assessment
skills. The scenarios were designed by two qualified tutors
using a human patient simulator which is a computer-controlled
full-body manikin with a realistic upper airway, chest move-
ment, variable cardiac and breath sounds and a palpable pulse.
In each grade, 5 or 6 students worked in a group. Students di-
rectly interacted with a contextual patient scenario and per-
formed health assessment adhering to principles of safety. Role
play was used in “nurse-patient” communication. One student
served as a patient or a family member or a friend who pro-
vided personal information while the other students would be
the nurses wh o provided patient ca re. The tutors acted as facili-
tators to promote students’ learning. Each group simulation was
video-recorded for evaluating students’ performance in health
assessment. Table 1 showed the teaching protocol in each ses-
sion.
Instrument
Based on the Day’s (2010) health assessment guidelines, the
health assessment evaluation rubric (NAER) (an observational
measurement) was developed by two qualified tutors (see Ta-
ble 2). The face validity was approved by three experts in
health assessment and medical-surgical nursing. It was used to
evaluate students’ performance in health assessment in terms of
introduction and patient identification (2 items), symptom as-
sessment (2 items), physical examination (6 items), patient
education (1 item), history inquire (1 item) and communication
(2 items). It is ranked as three levels (2 excellent, 1 satisfact ory,
0 needs practices). The possible score ranges from 0 to 28. A
higher score indicates better performance in health assessment
(see Table 2).
In this study, the NAER was completed by two qualified tu-
tors for assessing the performance of each group. The inter-
rater reliabilities of the NAER were 0.818 (Session 1, P < 0.01),
0.814 (Session 2, P < 0.01), 0.812 (Session 3, P < 0.01), 0.801
(Session 4, P < 0.01) and 0.928 (Session 5, P < 0.01).
In addition, one open-end question (what do you think of si-
mulation in promoting your assessment skills?) was used to
describe students’ perceptions about the impact of simulation
experience on the development of health assessment.
Date Collection and Analysis
Health assessment skills were evaluated at the end of each
simulation session prior to debriefing. Two tutors completed
the scoring of the NAER for each group and provided the ra-
tionale for each score assigned. Differences in interpretation
were discussed and negotiated until similar rational for scores
given could be verbalized. The average scores of two tutors
were calculated. The repeated measures analysis of variance
(RM-ANOVA) was used to assess differences of health as-
sessment within groups as well as across time for simulation.
Independent samples t-test was carried out to compare the mean
scores of the NAER between Year 2 a nd Year 3 students. Addi-
tionally, the open-ended question was completed at the end of
the last simulation session. All responses were summarized by
their meanings with analysis of frequency.
Ethical Considerations
The research process was discussed by the workgroup for
academic affaires and approved by the board of management of
the institute. Participants were provided with a complete expla-
nation about the objective and process of the study. The written
consent from each participant was obtained. All participants
were entirely voluntary and had the freedom to withdraw from
the study at any time. Confidentiality and autonomy were as-
sured. Only aggregate data would be reported.
Results
The overall score of a ssessment skills increased from the first
session to the last session, especially in communication and
symptom assessment (see Table 3). Second-year students
achieved higher overall scores of assessment skills in Session 2,
4 and 5 than third-year students significantly. They presented
better physical examination in each session, and better commu-
nication and patient education in Sessio ns 3, 4 and 5 (see Table
4).

Y. M. C. CHAN, H. B. YUAN
136
Table 1.
The teaching protocol in each simulation session.
Content ( Le arning hours)
Cuing questio ns
Learning activities
Assessment
Session 1
Surgery care (7 hours)
A 42
-year-old woman has complained the severe pain in the lower
quadrant of the abdomen for 6 hours. She has had nausea and vomiting for
two days. She was pale and painful.
She was admitted to surgery department.
The doctor o rdered a complete blood p icture, and renal and liver function
test, and amylase level and other blood tests. The y are all in the normal range
except for his white blood count. The white bloo d count is 12
,700/mm3.
The client was diagnosed with appendicitis and needs an emergency
appendectomy immediately.
What makes you think it was
appendicitis?
What kinds of
contingencies or
emergencies may happe n at this
moment?
How do you assess the patient’s
condition?
In each se ss i on, the learning
activities are the fol low ings:
Preparation for learning: case
clarification followed by
cuing question s, and
informa t i on searching for
learning. (2 hours)
Symptom assessment:
studen
ts explored the main
complai nt s and the provoking
and relieving factors.
(0.5 hour)
Physical examination:
Students conducted the
physical examination
meanwhile the results of
laboratory were present.
(0.5 hour)
Patient education: Students
identified t
he abnormal signs
and symptoms, and provi ded
an appropriate explanation for
the clients. (0.5
- 1 hour)
History inquire s: St udent s
took health history and
managed any patient
condition, such as pai n,
breathless, vomiting, nausea,
cough, thir s t and hunger
.
(0.5 hour)
Nursing diagnoses: Based on
the results of health
assessment and laboratory
examinat i on, students defined
the problems which required
nursing care and their
priorities.
(0.5 hour)
Reflection: Students reflected
on their performance and
wrote a reflection paper. The
reflection questions are:
(1)
What were the knowledge and
skills you used in this se s sion?
(2)
What needs to be
improved in t he next sessi on
?
(2.5
- 3 hours)
In each session,
two tutors
observed students’
performance and
eva
luated their
assessme nt skill s
using the
health
assessment
evaluation ru bric
,
and gave the
comments on
students’ learning
activities.
Session 2
Chronic obstructive pulmonary disease (COPD) (7 hours)
A 68
-year-old man, was diagnosed with COPD 10 years ago. He has a
40
-year smoking history (i s still sm oki ng) and has been hospitalized twice
due to chest infections during the last 12 months. He has trouble getting his
breath. The physician prescribed the low
-flow oxygen therapy. His FEV1 is
26% and FEV1/FVC is 38%. SpO
2 is 83%, Two hours later, SpO2 is 80%.
The arterial blood gases are reported as pH 7.25, bicarbonate (
3
HCO
−
) 23
mEq/L, PaCO
2 55 mmHg, PaO2 56 mmHg.
What are the meanings of FEV1,
FEV1/FV
C, SpO2
and blood gas
report?
What kinds of
contingencies or
emergencies may happe n at this
moment?
How do you assess the patient’s
condition?
Session 3
Gastrointestinal bleeding (7 hours)
A
73-year-old man, presented to clinic with 2 hours of massive rectal
bleeding. He had an abrupt onset of passi ng a large amount of red blo od with
clots from the rectum. He had no abdominal pain, but he began to experience
dizziness and unsteady gait. Digi
tal rectal examination revealed no mass or
tenderness, but bright red blood coated the exam glove.
Laboratory s tudies:
The hemoglobin level dropped from 10. 4 g/dL to 7.8
g/dL. Nasogastric aspirate produced bile
-stained gastri c cont ent s but no
blood. He had
never undergone colon cancer screening. He had been
diagnosed with chronic liver disease for 5 years. He has had no excessive
alcohol or tobacco use . The physic i an ordered a proctoscopy i n t he
emergency departme nt .
What
is the possible reason for
the bleeding?
Why is a proctoscopy
performed?
What kinds of
contingencies or
emergencies may happe n at this
moment?
How do you assess the patient’s
condition?
Session 4
Myocardial infarction (7 hours)
A 72
-year-old man, complained of acute chest pain. He was admitted to the
emergency departme nt . He had spent t he afternoon cleaning out the rooms
and has had chest pain for the last four hours. The pain is knife
-like,
unrelieved by rest.
The patient becomes restless, and
sounds a nxi ous. SpO2 is 93%. The
electrocardiogram (ECG)
showed ST segment ele vation, T wave i nversion
and Pathologic Q waves (
duration > 0. 04 seconds or >25% of R-wave
amplitude
) on II, III, AVF leads. Blood tests showed high levels of serum
creatine ki
nase (CK)-MB is 45 U/L (norm 0 - 23 U/L).
Why does the client have chest
pain?
Is it the possibility of cardiac
dysthymia? Why?
What kinds of
contingencies or
emergencies may happe n at this
moment?
How do you assess the patient’s
condition?
Session
5 Critical care: Trauma (8 hours)
A 32
-year-old man was injure d w hile working in a high place. He fell and
slid against a sharp
stone on his way down, landing almost i n a standing-up
position and then slumping to the ground. He ha d multiple scr apes over his
anterior torso and a large gash over his right anterior upper thigh
(near the groin) which was bleeding profusely.
His friends called an
ambulance.
The client became increasingly disoriented on the way to
hospital.
The clie nt was admitted to the eme rgency room. SpO2 is 93%. Skin
was cold and clammy, and nail beds, palms, and muc ous membranes were
pale. He had multipl
e abrasions over his chin, neck, ante r i or thorax, and
abdomen. A 15 cm
-long, 2.5 cm-deep laceration was noted in the right
inguinal region, ext ending into t he right, upper thigh.
What would happen after severe
bleeding?
What additional data would you
colle
ct? Why?
What kinds of
contingencies or
emergencies may happe n at this
moment?
How do you assess the patient’s
condition?
Regarding students’ written comments, students indicated
that simulation enhanced their auscultation skills (70.6%) and
their abilities to prioritize the problems (78.8%), to assess the
client systematically (76.5%), to manage contingencies and
emergencies (74.1%), to collaborate with others effectively
(50.6%). However, 71.8% students considered it was difficult
to emulate the lived experience using the SimMan because of
the slow response to inquiries and no facial expression.
Discussion
The findings indicated that simulation using a human patient
simulator facilitated students’ health assessment skills, espe -
cially in communication and symptom assessment. It is possi-
bly caused by scenario design and learning activities in simula-
tion. The scenarios used in this study were designed to reveal
the ability of students to make sense of data, not only in how to

Y. M. C. CHAN, H. B. YUAN
137
Table 2.
Nursing assessment evaluation rubric.
Student name
:
Date
Scenario #
:
Items
2 = Excellent
1 = Satisfac t ory
0 = Need practice
Score
Introduction and patient identification
Self
-introduction
Identify the patient
Very appropriate wording
Identify the patient correctly
Appropria t e wording
Identify the patient correctly
Not do
Symptom as sessment
Assess symptoms (including posi tion,
severity, quality, du ration and timing)
Assess the provoking and r elieving factors
Very appropriate wording
Assess all relevant and important
data correctly
Appropria t e wording
Assess abou t 80% of import ant
data correctly
Inappropriate wordi ng
Assess less than 80% of
important data or irrelevan
t data
Not do
Physical examination
Check blood pr essure, pul s e, heart a nd
respiratory rate
Auscultate the
lung, he art and bowel sounds
Inspect abdomen
Observe ski n color, range of motion of joints,
eyes and mouths
Recognize the abnormal signs
Verbalize the causes for abnormal signs
Correct a nd comprehensive
physical examination
Concern the patient’s response
and provide t he appropriate
management timely
Recognize all abnormal signs and
verbalize the potential causes
correctly
Correct physical examination, but
partly complete (a bout 80%)
Concern the patient’s response,
but mana gement is not
appropriate
Recognize the abnormal signs,
but explanation of causes is 80%
correct
less than 80% of correct physical
examination
Appear not to know which data is
important
No response t o the patient ’s
concerns or provide the i ncorrect
intervention
Not do
Patient educ ation
Explain patient condition
Very appropriate and
understandable wording
Concern al l i mportant data
Appropria t e and understandable
wording
Concern a bout 80% of important
data
Concern few important data
(<80%)
Incorrect explanation
Not do
History inquire
History taking (including disease, medicine,
allergy, operation, family health, special
dietary, religion)
Complete history taki
ng
Clear and structured wording
About 80% history taking
Clear and appropriate wording
Incomplete history taking (<80%)
Unclear/ i nappropriate wording
Not do
Communication
Communication with the patient
Communication in the team
Communicate effectively
Check for understanding
Successful and clear direction to
team
More open
-ended questions used
Generally co mmu n i cat e wel l , bu t
partly successful (about 80%)
Clear direction to team
Few open
-ended questions used
Ineffective commutation
(<80% understandabl
e)
Unclear direction to team
No open
-ended question
Total score
Table 3.
Changes of mean scores in nursing assessment (N = 85).
Nursing Assessment Item mean (S.D.) RM-ANOVA
Greenhouse-Geisser Value
Session 1 Session 2 Session 3 Session 4 Session 5
Introduction 0.77 (0.55) 1.46 (0.39) 1.60 (0.36) 1.62 (0.40) 1.49 (0.59) F = 44.984
P = 0.000
Symptom assessment 0.91 (0.37) 0.67 (0.37) 1.01 (0.3 4) 1.30 (0. 42) 1.50 (0.38) F = 73.460
P = 0.000
Physical examination 0.80 (0.31) 1.02 (0.40) 1.02 (0.49) 1.13 (0.38) 1.46 (0.38) F = 43.231
P = 0.000
Patient education 0.38 (0.36) 0.72 (0.46) 0.50 (0.52) 0.85 (0.61) 1.30 (0.44) F = 68.892
P = 0.000
History inquire 1.26 (0.63) 0.95 (0.48) 1.00 (0.63) 1.01 (0.47) 1.12 (0.45) F = 5. 726
P = 0.001
Communication 0.65 (0.28) 0.72 (0.25) 0.79 (0.27) 0.89 (0.41) 1.09 (0.38) F = 4.127
P = 0.007
Overall score 0.80 (0.15) 0.91 (0.22) 1.03 (0.27) 1.20 (0.31) 1.33 (0.35) F = 66.533
P = 0.000

Y. M. C. CHAN, H. B. YUAN
138
Table 4.
Comparison of scores of health assessment skills between Year 2 and Year 3 students in each session.
Health assessment Mean (S.D.)
Session 1 Session 2 Session 3 Session 4 Session 5
Introducti on and pa tie nt
identification
Year 2 0.66 (0.57) 1.58 (0.35) 1.59 (0.31) 1.69 (0.35) 1.71 (0.29)
Year 3 0.92 (0.46) 1.30 (0.40) 1.62 (0.43) 1.53 (0.45) 1.17 (0.75)
Independent samples t-test t = −2.264
P = 0.026
t = 3.352
P = 0.001
t = −0.328
P = 0.744
t = 1.921
P = 0.058
t = 4.109
P = 0.000
Symptom assessment
Year 2 0.74 (0.32) 0.71 (0.59) 1.00 (0.36) 1.49 (0.28) 1.62 (0.22)
Year 3 1.13 (0.33) 0.60 (0.33) 1.20 (0.28) 1.04(0.44) 1.33 (0.48)
Independent samples t-test t = −5.497
P = 0.000
t = 1.456
P = 0.149
t = −2.781
P = 0.149
t = 5.367
P = 0.000
t = 3.381
P = 0.001
Physical examination
Year 2 0.95 (0.24) 1.21 (0.34) 1.14 ( 0 .49) 1.26 ( 0.41) 1.60 ( 0.23)
Year 3 0.60 (0.26) 0.76 (0.33) 0.86 (0.46) 0.96 (0.26) 1.27 (0.46)
Independent samples t-test t = 6.437
P = 0.000
t = 6.113
P = 0.000
t = 2.670
P = 0.009
t = 3.977
P = 0.000
t = 3.871
P = 0.000
Patient education
Year 2 0.40 (0.38) 0.67 (0.47) 0.61 (0.51) 1.16 (0.48) 1.45 (0.36)
Year 3 0.36 (0.33) 0.79 (0.43) 0.34 (0.49) 0.44 (0.52) 1.10 (0.48)
Independent samples t-test t = 0.465
P = 0.643
t = −1.174
P = 0.244
t = 2.398
P = 0.019
t = 6.576
P = 0.000
t = 3.733
P = 0.000
History inquire
Year 2 1.53 (0.56) 1.15 (0.46) 1.29 (0.60) 1.10 (0.50) 1.16 (0.54)
Year 3 0.90 (0.54) 0.68 (0.36) 0.63 (0.45) 0.91 (0.39) 1.06 (0.29)
Independent samples t-test t = 5.149
P = 0.000
t = 5.119
P = 0.000
t = 5.576
P = 0.000
t =1.983
P = 0.051
t = 1.180
P = 0.242
Communication
Year 2 0.70 (0.32) 0.76 (0.18) 0.86 (0.25) 1.06 (0.25) 1.23 (0.34)
Year 3 0.57 (0.20) 0.69 (0.33) 0.69 (0.28) 0.67(0.48) 0.91 (0.35)
Independent samples t-test t = 2.289
P = 0.025
t = 1.326
P = 0.189
t = 2.930
P = 0.004
t = 4.326
P = 0.000
t = 4.246
P = 0.000
Overall score
Year 2 0.80 (0.12) 1.00 (0.13) 1.08 (0.25) 1.36 (0.25) 1.47 (0.20)
Year 3 0.79 (0.12) 0.79 (0.25) 0.98 (0.29) 0.97 (0.23 1.13 (0.42)
Independent samples t-test t = 0.104
P = 0.918
t = 4.743
P = 0.000
t = 1.737
P = 0.086
t = 7.376
P = 0.000
t = 4.604
P = 0.000
assess the patients and set priorities but also in how to provide
patient education on complex topics. Students used analytic
thinking and clinical reasoning processes to interpret the mean-
ings of obtained data, and chose the appropriate response to
patient condition meanwhile they also need communicate with
the patient in understandable way. The interaction with the
realistic scenarios enabled students to “understand” patient’s
feelings and realize the severity and urgency of patient condi-

Y. M. C. CHAN, H. B. YUAN
139
tions, and “read” the patient’s responses to the intervention.
This experience can help students to bridge the theory practice
gap by transferring cognitive learning into practical experience.
Health assessment skills were increased by assessment of the
relevant data, a logical interpretation and reasoning and accu-
rate judgments.
The reflections offered a unique way for students to critically
analyze their own performance. Students engaged in introspec-
tive learning to self-correct. The reflections focused on students’
primary misconceptions, anything they missed in report or oth-
er information they needed from report or the patient to act
more effectively, and what they should do differently the next
time while emphasizing what was correct, appropriate and safe.
It allows the student to clarify their thinking and link the simu-
lation to real situation while reinforcing specific knowledge,
and to discuss how to intervene professionally in complex clin-
ical situations (Gaberson & Oermann, 2010). In this case, stu-
dents learned from previous experience and paid close attention
to patients’ concerns. They assessed the relevant and important
data and explained them to the patient using understandable
wording as managing the contingencies and emergencies. They
presented better communication skills and patient education
across the time of simulation.
Previous studies reported the consistent findings. Kaddoura
(2010) reported that simulation prepared new nursing graduates
well to care confidently for critically ill patients, and helped
them learn to make sound clinical decisions to improve patient
outcomes. Zheng et al. (2010) found that students’ performance
was significantly improved in application of theoretical know-
ledge, health education and humanistic care after one-semester
of simulation. More than 95% of students agreed that feedback
sessions confirmed management of patients’ problems, helped
to develop rationale for actions (Wotton, Davis, Button, &
Kelton, 2010).
However, students indicated that the SimMan is not realistic
enough. The SimMan had its own inherent limitation. It may do
not duplicate the experience of working with a live patient. By
responding to a situation during the scenario, the “patient” pro-
vided instant feedback; through which students saw the out-
comes of their interventions. It was suggested that forthright
feedback from the facilitator was needed to enhance the realism
of the scenario with physical props and psychosocial interac-
tions (Birkhoff & Donner, 2010).
The interesting finding in this study was that second-year
students achieved higher overall scores of health assessment in
some sessions than third-year students. They presented better
physical examination in each simulation session, and better
communication and patient education in some sessions. It may
be caused by the different learning effort of students. The tutors’
comments showed that second-year students valued the newly
learned knowledge and applied it in the simulated scenarios.
They did good preparation for learning and engaged in group
learning, deep discussion and reflection. They try their best to
make the physical examination comprehensive while concern-
ing the patient’s response and providing the appropriate man-
agement. However, third-year students did not have a deep
memory and understanding of some knowledge that they
learned in their previous two years, and did not do a full know-
ledge review and a good skill preparation for the simulated
learning. Their assessment was not comprehensive while their
explanations to abnormal sign and symptoms were incorrect or
ambiguous. Sometime they could not recognize some severe
arrhythmias. Thereby, they got the lower scores in physical
examination, patient education and communication compared
with the second-year students. For ensuring the quality of learn-
ing, students should have good preparation for knowledge and
skills, be self-motivated and keep responsible for their own
learning. Tutors should promote students' intrinsic motivation
for learning and develop their potential efforts in learning dur-
ing simulation.
Limitations
The generalization of the findings was limited because a
small purposive sample was recruited from one research setting.
The new developed health assessment evaluation rubric was
only used in medical-surgical care; the generalizability of fur-
ther studies needs to be considered in other area of nursing care,
such as long-term care or community care. As a confounding
variable, the mixed role play of students (patients or family
members and nurse) may affect the effective “nurse-patient”
communication and thus influence the accuracy and scores of
health assessment.
Recommendations
The performance indicators of the health assessment evalua-
tion rubric require more research to address content and con-
struct validity in different nursing contexts in order to more
accurately reflect the current understanding of each aspect of
health assessment. As transfer of skill from the simulated envi-
ronment to the clinical setting is essential, follow-up studies
need to be concerned with the impact of using simulation on
students’ performance in clinical placement.
Conclusion
Simulation using a human patient simulator offered a realis-
tic learning environment for students to develop their health
assessment skills. Most of students appreciated that simulation
facilitated their knowledge application, assessment and com-
munication skills and group collaboration, but using manne-
quins did not replace working with live patients. Forthright
feedback from the facilitator was needed to enhance the realism
of the scenario . Tutors should promote students’ intrinsic mo-
tivation for learning and develop their potential and efforts in
learning. The questionnaire needed to be carried out to investi-
gate students’ perceptions about the impact of simulation expe-
rience on the development of health assessment.
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