sociology
- Describe in detail the issue(s) addressed in this reading. Do you believe it is being addressed in an effective way? Please explain.
- Please elaborate on three (3) critical points you gathered from this reading and explain how this information is relevant in understanding human behavior.
- Do you believe this information will be useful in your profession ? Please explain.
- What do you believe would be the consequences if this issue was not addressed? Please elaborate
Vol.23 No. 3 ADULT LEARNING
Refereed Articles
Simulation Methodology in Nursing Education and
Adult Learning Theory
Abstract: Simulation is often used in nursing edu-
cation as a teaching methodology. Simulation is
rooted in adult learning theory. Three learning the-
ories, cognitive, social, and constructivist, explain
how learners gain knowledge with simulation expe
riences. This article takes an in-depth look at each
of these three theories as each relates to simu-
lation. Pedagogical approaches as well as ties to
simulation of each theory zare
addressed. Finally, the implica-
tions for research and practice in
health care and adult education are
discussed.
Keywords: adult education, learning
theory, simulation
S imulation has been definedby McGaghie (1999) as “a per-son, device, or set of condi-
tions which attempts to present [edu-
cation and] evaluation problems
authentically. The student or trainee
is required to respond to the prob-
lems as he or she would under natu-
ral circumstances” (p. 198). The his-
tory of simulation stretches back for
centuries. The earliest use of simulation can be traced
to the fields of military, aviation, and nuclear power
(Blackburn & Sadler, 2003; Bradley, 2006; Issenberg,
McGaghie, Petmsa, Gordon, & Scalese, 2005). The
military has used simulation the longest, dating back
to the 18th century (Bradley, 2006). Aviation pio-
neered the modern day use of simulation in the 1930s
(Scherer, Bruce, Graves, & Erdley, 2003). Simulation
has been used in these fields due to the fact that train-
ing or testing in these areas in the real world would be
too dangerous or costly.
Major movements of the late 20th century drove
the impetus toward the use of
simulation in the medical and
nursing communities. Changing
clinical experiences, shorter
times in training, and working
time restrictions created skill
deficiencies in medical students
(Bradley 2006; Issenberg et al.,
2005). In nursing, educators
struggled with questions of how
best to prepare competent nurse
clinicians and how to adequately
assess clinical skill performances
(Fbbert & Connors, 2004;
Gibbons et al, 2002; Stroud,
Smith, Edlund, & Erkel, 1999).
Then in 1999, the Institute of
Medicine (IOM) published To
Err Is Human (Kohn, Corrigan, & Donaldson, 1999),
a report that brought patient safety issues to the
forefront of health care and education. The report
estimated that 45,000 to 98.000 patients die each
WITH
SIMULATION,
STUDENTS ARE ABLE TO
PRACTICE A VARIETY OF
TASKS AND SKILLS, AND
I M P L E M E N T KNOWLEDGE
AND DECISION MAKING
W I T H O U T THE FEAR OF
CAUSING HARM TO THE
PATIENT.”
DOI: 10.1177/1045159512452848. From ^University of Pittsburgh, PA. Address correspondence to: Tonya Rutherford-Hemming, RN
EdD, ANP-BC, School of Nursing, Department of Health and Community Systems, University of Pittsburgh, 3500 Victoria Street, 415
Victoria Building, Office 421B, Pittsburgh, PA 15261; email: tor7@pitt.edu.
For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermission.nav.
Copyright © 2012 The Author(s)
129
ADULT LEARNING August 2012
year in the United States as a result of medical error.
Based on this staggering number, the IOM called for
systemic change in health care practices and argued
that interdisciplinary training should be a top priority
in educational institutions. The report highlighted the
potential benefits of teamwork and identified simulation
as a resource to address the needed reform.
Nishisaki, Keren, and Nadkarni (2007) declared,
“Healthcare, especially the complex hospital care
required to treat serious diseases, falls into the category
of a high-hazard industry like aviation, chemical
manufacturing, nuclear power generation, and the
military” (p. 226). Simulation provides a safe supportive
educational venue that cannot always be attained with
live humans (Blackburn & Sadler, 2003; Seropian,
Dillman, & Farris, 2007). With simulation, students
are able to practice a variety of tasks and skills, and
implement knowledge and decision making without
the fear of causing harm to the patient. In addition,
students attain the acquisition of skills through a
genuine life-like environment (Brannan, White, &.
Bezanson, 2008; Decker, Sportsman, Puetz, & Billings,
2008; Lasater, 2007; Leigh, 2008; Wolf, 2008).
Simulation is now touted as a wonderful methodology
to use in teaching and evaluation. One of the reasons
for this is because simulation draws on a variety of
adult learning theories. But which learning theories
best explain and support how students learn from
simulation experiences? What is the process of learning
that occurs according to these theories? How is
simulation rooted in the learning theory? This article
discusses three learning theories related to simulation:
cognitive learning theory, social learning theory, and
constructivist learning theory. Each theory is examined
in terms of its basic assumptions related to learning.
The ways in which simulation is embedded in each
learning theory is described and explained. Finally,
simulation as it is currently used in medical and nursing
education is discussed along with the need for further
research in these areas as well as the field of adult
education.
Cognitive Learning Theory
In cognitive learning theory, the key to learning and
behavior involves the individual’s cognition, meaning
a person’s perception, thought, memory and ways
of processing and structuring information. Hence,
cognitive learning theory focuses on the internal mental
processes that are under the learner’s control (Feden,
1994; Merriam, Caffarella, & Baumgartner, 2007). In
contrast to the passive behaviorist view related to
learning and the external environment, the cognitivist
sees learning occurring within the individual’s internal
environment and is more concerned with what the
knowledge means to an individual versus the change in
behavior that may occur as a result of the knowledge.
Bode (1929), a Gestalt psychologist, was one of the
first to challenge the behavioral learning theory as
merely looking at partial events versus the whole
scenario to explain learning. Out of this thought grew
what is now known as the cognitive or information-
processing learning theory Gredler (1997) summarized
the basis of cognitive learning theory as follows:
“Essential components of learning are the organization
of the information to be learned, the learner’s prior
knowledge, and the processes involved in perceiving,
comprehending, and storing information” (p. 144), and
he contends that two key assumptions underlie the
cognitive or information-processing learning theory:
“(1) the memory system is an organized processor
of information, and (2) prior knowledge plays an
important role in learning” (p. 144).
Four perspectives outline the cognitive orientation
(Bastable, 1997; DeYoung, 2007). The first perspective
is perception. Learners may have various perceptions
of information. Because of this, the second perspective
of the theory, information processing, may differ from
individual to individual. In the cognitive learning
theory, the learning is influenced by the learner’s goals,
expectations, and experiences. In fact, experience often
decides how an individual learns and is the key to
learning.
The second perspective of the cognitive learning
theory involves information processing (Bastable,
1997; DeYoung, 2007). Information processing occurs
in stages; these stages include attention, processing,
memory storage, and action. After attention is given
to the information, the learner will begin to process
the information through sensory processing. Here,
information may be fleeting or it can proceed to
the next stage, memory storage. In memory storage,
information is encoded for short-term memory. If
information is not disregarded or forgotten at this point,
it is organized and stored into long-term memory The
fourth and final stage of the information-processing
perspective is action. Here the individual responds to
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Vol.23 No. 3 ADULT LEARNING
the information based on how it was processed and
stored.
Cognitive development is the third perspective of
cognitive learning theory. Cognitive development refers
to the qualitative changes in cognitive function that
occur as an individual grows and matures (Bastable,
1997). The most widely known psychologist to
produce work in this area is Piaget (1972). Utilizing
aspects from the behavioral and cognitive orientations,
Piaget expounded on the changes related to cognitive
function. Piaget not only believed that maturation
accounted for some of the internal cognitive structure
changes but also concluded that interaction with the
environment and exposure to increased experiences
played an important role. Piaget’s theory includes the
concepts of assimilation, or incorporating information
to fit an individual’s own cognitive framework, and
accommodation, changing one’s own cognitive
structures. Piaget identified and developed four stages
of cognitive development (sensorimotor, preoperational,
concrete operations, and formal operations); these
stages encompass infancy through adulthood.
The fourth and final perspective in cognitive learning
theory is called social cognition perspective, and it ties
the influence of social context to cognition (Bastable,
1997). Attribution theory, a well-known theory in
education, speaks to the social cognition theory
(Weiner, 1985). It incorporates behavior modification
by emphasizing the idea that learners are strongly
motivated by the pleasant outcome of being able
to feel good about themselves. Attribution theory
incorporates cognitive theory and self-efficacy theory
by emphasizing that learners’ current self-perceptions
will strongly influence the ways in which they will
interpret the success or failure of their current efforts
and hence their future tendency to perform these same
behaviors.
Ties With Simulation
Characteristics of a cognitivist-oriented learning
approach are seen when students participate in
simulation-type experiences. Here the learner has
control of the knowledge that is conceived. The locus
of control is internal, and learners are able to utilize
previous knowledge in the simulation experience.
In these ways, the essential components of cognitive
learning theory manifests itself.
Simulation provides excellent teaching environments
that link instruction with the cognitive processes of
perceiving, thinking, and processing information.
Eor example, the concept of meaningful learning is
achieved in simulation experiences. Students are able
to create knowledge using prior knowledge; they
assimilate new knowledge in the learning environment.
Reflective thinking can also be encouraged and used
in the simulation environment. Students can recall the
encounter, reflect on what happened, review what was
learned from the experience, and contemplate what
could have been done in other ways.
Finally, the educator in the simulated learning
environment structures the content of the learning
activity by creating an environment in which the
learner can process the skills or knowledge he or she
has mastered along with the skills or knowledge in
which he or she needs additional practice, instruction,
and comprehension. In this regard, the instructor is
facilitating a learning how to learn environment within
a cognitive construct.
Social Learning Theory
Social learning theory can be thought of as a
combination of ideas from the behaviorist and
cognitivist orientations (Merriam et al., 2007). In
social learning, people learn by observing others.
This learning may even be done by observation alone
without the need for rehearsal and imitation of the
behavior. The cognitive aspect of this approach surfaces
when the individual stores the image of the modeled
behavior and retrieves the image when later motivated.
Akhough Miller and DoUard were the first to explore
this theory of learning through observation, their ideas
stayed within the behaviorist orientation (Merriam et
al., 2007). Bandura (1977), who is credited for many of
the assumptions related to social learning, expounded
on the theory of social learning and included cognitive
processes into the approach, which separated the
theory from a purely behaviorist approach.
In his early studies, Bandura (1977) focused on the
aggressive behavior of children, believing aggression
is learned through a process called behavior modeling.
Bandura found that adolescents whose parents modeled
hostile attitudes demonstrated the same hostility This
example of behavior modeling occurred without the
adverse conditions typically thought to cause behavior
131
ADULT LEARNING August 2012
problems and conflicted with the then popular
Freudian belief that direct punishment for aggressive
acts would suppress such behavior.
These findings led to the famous Bobo doll
experiment (Bandura, 1977). In this experiment, one
group of children watched a video in which a model
aggressively attacked a plastic inflated clown called the
Bobo doll, whereas the other group of children was
exposed to models demonstrating no violent behavior
toward the doll. Children who viewed the violent
behavior of the models repeated this behavior to the
Bobo doll, whereas children who were not exposed
to the violent behavior did not. These results revealed
that observational learning occurs in the absence of
reinforcement, leading Bandura and colleagues to
conclude that new learned behaviors can occur without
rewards or actual performance.
This type of observational learning or modeling
is influenced by characteristics exhibited in the
behavior of the observer following the witnessed
behavior. The processes are attention, retention, motor
reproduction, and motivation (Bandura, 1977, 1993).
Bandura contends that humans learn by observing
others, but pointed out that role modeling is not
simply mimicking a response but a learned behavior
psychologically embedded into the brain. Bandura also
contends that people use the modeled behaviors they
have learned and apply them to situations as needed,
going beyond what has been seen and heard in the
modeled behaviors. Bandura emphasizes that although
observation starts the learning process, expertise is
developed through practice with external and internal
(self-regulatory) feedbacks.
Evolution to Social Cognitive Theory
Bandura later studied human adaptation and
change that occurs through cognitive, vicarious, self-
regulatory, and self-reflective processes. The theory
is rooted in agentic perspective, meaning people are
self-organizing, proactive, self-reflecting, and self-
regulating (Bandura, 1986, 2001). “Broadly speaking,
agency is the capability of individual human beings
to make choices and to act on these choices in ways
that make a difference in their lives” (Martin, 2004, p.
135
). Furthermore, it is a dynamic interplay between
personal, behavioral, and environmental influences that
affect human functioning. People are not just reactive
organisms shaped and shepherded by environmental
forces or driven by concealed inner impulses but are
producers as well as products of social systems.
Bandura (1986) realized that the breadth of this
research and theory extended beyond the boundaries
of social learning, so relabeled his theoretical approach
from social learning to social cognitive theory. He
explained, “The social portion of the terminology
acknowledges the social origins of much human
thought and action; the cognitive portion recognizes
the influential causal contribution of thought processes
to human motivation, affect, and action” (p. xii).
One of the core features of human agency in
social cognitive theory is the human ability to have
intentionality and forethought (Bandura, 1986). This
allows people to direct their own course of action as
well as set goals and challenges for themselves. Based
on the consequences of the course of action, people
are then able to regulate their behavior and motivation.
If the consequence of their action is felt in a positive
light, then people will continue those actions. Perceived
negative reactions will have the opposite effect and
deter people from continuing those actions.
Social cognitive theory contends that the idea of
self-efficacy, or the belief that one is capable of
performing in a certain manner to attain certain
goals, is the foundation of human agency “Unless
people believe they can produce desired results and
forestall detrimental ones by their actions, they have
little incentive to act or to persevere in the face of
difficulties” (Bandura, 2001, p. 10). Self-efficacy dictates
many facets of life—thinking, motivation, vulnerability,
and decision making.
Ties to Simulation
Students in health education are often expected
to model the behavior of the instructor. This is the
backbone of apprenticeship training—learning in the
social context by observing techniques, skills, and
behaviors. However, changes in patterns of health care
and decreased exposure to patients are giving students
less opportunity for apprenticeship training. Simulations
can be a viable solution to this problem. With
simulation, a clinical atmosphere can be constructed
to create a life-like environment where apprenticeship
training can occur. Instructors can role model and
mentor, and students can emulate the procedures,
skills, and behaviors that have been modeled. In this
regard, students combine role modeling behavior
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Vol. 23 No. 3 ADULT LEARNING
with cognitive learning in a simulated environment to
deepen their understanding of knowledge.
Constructivist Learning Theory
Constructivists believe that knowledge is constructed
when an individual attaches meaning to an experience
or activity (Merriam et al., 2007; Torre, Daley, Sebastian,
& Elnicki, 2006). This is the basic assumption of
the constructivist learning theory, but constructivist
theory branches into more perspectives than most
other learning theories. Regardless of the perspective,
constructivists agree that learning is an active versus
passive endeavor that includes dialogue, collaborative
learning, and cooperative learning (Merriam et al.,
2007).
There are two different thoughts as to where
constructivism occurs—personally or socially. With
personal constructivism, learning is constructed within
the individual and based on prior knowledge, whereas
social constructivism posits that learning is constructed
in a social environment. The foundation of personal
constructivism can be traced back to Piaget (1972),
whereas Vygotsky (1978) is responsible for much of the
ideas related to social constructivism.
With personal constructivism, the learner attaches
meaning using previous knowledge and experience; an
internal change in cognitive schemata occurs as a result
of the learner’s connection to the current environment.
However, social constructivism results from individuals
dialoguing about problems in a social environment.
Here is where Vygotsky’s activity theory (also known
as situated cognition) surfaces. Activity theory surmises
that a participant’s relationship with the objective world
is always mediated by activity (Vygotsky, 1978; Wilson,
2005). People do not simply passively absorb, and react
to, stimuli from the environment; they actively explore
and transform their material and social environments.
In this active process, people produce and reproduce
culture and consciousness.
Other Constructivist Learning Perspectives
As previously mentioned, the constructivist learning
theory has numerous ties to other perspectives in
learning. This is especially true in adult learning where
a constructivist nature is manifested in transformational
learning, experiential learning, reflective practice, and
situated learning.
Personal transformation and social transformation
involve a cognitive change in the way meaning
is constructed; therefore, it is easy to connect
transformational learning theory to the constructivist
paradigm. Experiential learning, including the methods
associated with the reflective and situative paradigms
(reflective practice and situated cognition), is also
connected to constructivist learning theory
Experiential learning is learning by doing. Here
the individual attaches meaning while experiencing
the situation and constructs knowledge; in this way,
experiential learning is intertwined with constructivist
theory Dewey (1938), who studied the idea of
experiential learning, posits that learning occurs when
there is continuity and interaction. This means that the
individual takes each experience and connects what
was learned to current and future events.
Scholars agree with Dewey (1938) that people learn
from experience, but there is disagreement about how
learning occurs in experience (Merriam et al, 2007).
Because of this, two additional frameworks, reflective
practice and situated cognition, developed from
experiential learning theory—both with a focus toward
reflection and how it fosters learning, and both with
a construct of meaning. One of the frameworks is a
model developed by Kolb (1984), who believes learning
from experience involves a concrete experience with
reflective observation, cognition, and behavior. Kolb
sees experiential learning as a cyclical phase involving
these concepts.
Boud and Walker (1991) augment Kolb’s (1984)
reflective practice model related to experiential
learning. They include context as an additional aspect
that shapes an individual’s learning in experience,
along with emotion and the influence that it exerts
on reflection. This reflective practice model—further
developed by an earlier source. Schon (1983)—involves
returning to and replaying the experience, attending to
the feelings the experience provoked, and reevaluating
the experience. “This process of reflection may occur
during or after the experience in question. Reflection
on action is thinking through a situation after it has
happened. Reflection in action is thinking about actions
as they are performed” (Torre et al, 2006, p. 904).
Situated cognition is the second framework that
stems from experiential learning theory. As previously
mentioned, situated cognition (activity theory) is one
133
ADULT LEARNING August 2012
form of social constructivism where the focus of
learning is tied to the situation and the community of
practice in which it occurs (Bradley & Postlethwaite,
2003; Vygotsky, 1978). Fenwick (2003) contends that
knowledge is not transferred to another situation
after it is learned but rather “part of the very process
0Î participation in the immediate situation” (p. 25);
a person learns when there is a combination of
interaction with the community, “the tools at hand”
(p. 25), and the activity at hand. As opposed to the
reflective practice model that is viewed as an internal
process of learning, the situated cognition model
focuses on the external relationships that process
learning.
Ties With Simulation
How does the constructivist orientation relate to
simulation? It connects in a variety of ways. Simulation
creates an environment for active learning to occur; the
student constructs knowledge by attaching meaning
to the simulation experience and connecting the
knowledge learned to a current or future situation
with a patient. This construction of knowledge can
be from a personal constructive orientation or a social
constructive orientation. Simulation can be created for
one person or a group of students who work together.
Either way, there is certain to be dialogue, collaborative
learning, and cooperative learning between the student
and instructor, or the student with other students and
the instructor.
Simulation provides an opportunity for experiential
learning to occur. It creates an atmosphere where
internal and external processes of learning can occur.
It constructs an environment for reflective thinking to
take place, challenging the student to contemplate how
he or she might act and think differently if approached
with a similar situation in the real-world setting.
Debriefing after the simulation experience can give a
student or group of students the opportunity to recall
the encounter, reflect on what happened, review what
was learned from the experience, and contemplate
what could have been done in other ways.
In the literature, the ties between simulation and
constructivist learning theory are evident. Haigh (2007)
analyzed the learning of undergraduate students in a
midwifery program based on human activity theory
She found that because these students participated in
a simulated clinical experience, they were more apt to
experience deliberation and deep learning. Research
by Zigmont, Kappus, and Sudikoff (2011b) provided
a theoretical foundation in adult and experiential
learning that can be used by educators to develop
and facilitate simulation courses. Duggan, Bradshaw,
Carroll, Rattigan, and Altman (2009) found that medical
students who participated in a self-reflective exercise
after a simulated learning experience were more apt to
recognize attitudes about disability in relation to pain,
everyday life, and treatment. In fact, debriefing after a
simulated experience has been found to be the most
important part of the learning experience because it
provides time for reflection to occur (Arafeh, Hansen, &
Nichols, 2010; Morgan et al, 2009; O’Brien & Pedicino,
2011; Zigmont, Kappus, & Sudikoff, 2011a). In all these
studies, the foundation of learning is constructivist
learning theory
Implications for Research and Practice in
Health Care and Adult Education
The use of simulation in medical and nursing
education has occurred for years (Bradley, 2006;
McFetrich, 2006; Sinz, 2007). Yet, there are gaps in the
literature pertaining to the use of simulation in these
areas. In a critical review of the research on simulation-
based medical education found in the literature from
2003 to 2009, McGaghie, W. C. (1999) identified 12
features and best practices that educators should
know and use. These include feedback, deliberate
practice, curriculum integration, outcome measurement,
simulation fidelity, skill acquisition and maintenance,
mastery learning, transfer to practice, team training,
high-stakes testing, instructor training, and educational
and professional context. However, with each of
these areas, the authors also acknowledged gaps in
understanding warranting more study. Some of the gaps
include quality and models of feedback, dose-response
relationships, best learning modalities, measures of
outcome, conditions of training, mechanisms and
conditions related to skill maintenance and decay,
mastery standards, pathways of learning from the
simulation laboratory to the patient bedside, team
training skills, test mechanisms, and teaching skills of
instructors.
In nursing education, simulation is being used more
frequently in the classroom and in clinicals to combat
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Vol.23 No. 3 ADULT LEARNING
the diminishing numbers of clinical sites, fewer
clinical hours, and the shortage of nursing faculty
and preceptors (Simpson & Courtney 2002). The
National Council of State Boards of Nursing (2011)
is now conducting a landmark, national, multisite,
longitudinal study of simulation use in prelicensure
nursing programs throughout the country to examine
the knowledge and clinical competency outcomes of
students when simulation technology is used in the
place of clinical experiences. The National League for
Nursing (2011) has launched a 3-year study that will
lay the groundwork for the use of simulation-based
assessment in prelicensure nursing programs. Brewer
(2011) acknowledges the need for additional research
related to simulation, citing the scarce quantitative
research that exists and the shortage of proven tools
to use for validation. Virtually no studies, outside of
Bramble (1994), have investigated transfer of learning
from the simulation laboratory to the patient bedside.
Other authors (May Park, & Lee, 2009) note the need
for additional studies that have more rigorous designs
with control or comparison groups with certain types
of simulation.
Adult education encompasses medical and nursing
education. Although calls for additional research in
these areas tend to focus on teaching and learning
outcomes with students when simulation is used, the
field of adult education can be broadened by further
research to determine additional learning theories
applicable with simulation. Research is also needed
to determine how adult learners process information
during simulation exercises and to determine whether
simulation is superior to other methods of instruction.
Conclusion
Simulation is a technology used in a variety of
educational curriculums. With its strong ties to
adult learning, it can enhance instructor teaching
and facilitate student learning. Used for decades in
medical and nursing education, simulation is now
standard practice in many programs. However, there
is a critical need for continued evaluation of the use
and effectiveness of simulation in improving learning
outcomes and performance in actual clinical practice in
health care education. There is an additional need for
adult education to understand the learning processes
that surround simulation.
Conflict of Interest
The author(s) declare no potential conflicts of inter-
est with respect to the authorship and/or publication of
this article.
Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.
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Tonya Rutherford-Hemming is a faculty and Skills
Lab and Simulation coordinator at the University of
Pittsburgh School of Nursing, working collaboratively
with faculty to design and utilize simulation in nursing
education in the classroom and clinical arena. She
also produces and disseminates research in the area of
simulation in nursing education. Her area of interest
in simulation research is related to transfer of learning,
specifically whether and how transfer of learning
occurs from the simulation laboratory to the clinical
bedside—a topic that is seriously lacking in the nursing 137 Copyright of Adult Learning is the property of American Association for Adult & Continuing Education and its
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