Human patient simulation is increasingly becoming an integral component of nursing education based on a variety of professional, educational, social, economic, political, and safety factors propelling its use. Yet the pedagogical science to support education with simulation remains underdeveloped. Scholarship on presence in virtual simulations has shown positive impact on learning outcomes. Yet presence as a variable of potential impact on learning outcomes with dynamic, scenario based, high fidelity human patient simulation (HF-HPS) has been little studied.
The aim of this grounded theory study was to examine the nature of presence in baccalaureate nursing students participating in HF-HPS and to develop a conceptual model that could explain the dimensions and determinants of presence as they may impact learning outcomes. A total of 36 simulation encounters were observed including 16 simulations from the sample of baccalaureate prelicensure nursing students, 12 simulations from the comparative sample of experienced registered nurses and 8 simulations from a comparative sample of second degree prelicensure nursing students. From these encounters, interviews were conducted with 60 nursing students from the primary sample and with comparative samples of 30 professional nurses, 32 second degree nursing students, 20 educators and 3 administrators for a total sample size of 145 participants.
The nature of presence was found to be a dynamic state of being with a centricity between the simulation and the natural environment where students perceived the stimuli from one environment as salient over the other. The results revealed that presence was experienced in the domains of exocentricity, endocentricity, or bicentricity relative to the perceived salience of the simulation environment. Furthermore, the presence of students in scenario based HF-HPS was impacted by pedagogical factors, individual student factors, and group factors. Pedagogical factors found in this study included simulation design, stream of stimuli, and instructional process. Individual factors included personality characteristics, referential experiences, preconceptions, emotional responses, and entry competencies. Group dynamics and group structure were also found to be determinative of the nature of presence in HF-HPS.
The Nature and Determinants of Presence Model emerged from the study data to explain the articulation of the determinants of presence, the nature of presence, and learning outcomes. In this model, pedagogical, individual, and group factors are theorized to be determinative of the centricity of presence. Furthermore, presence centricity is theorized to impact learning outcomes. The Nature and Determinants of Presence Model in HF-HPS is presented to further guide research on presence as a factor that may impact learning outcomes in HF-HPS. This model is also offered to support continued development of a pedagogical science for education with clinical simulation.