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Evidence of clinical competence by simulation, a hermeneutical
observational study
Lejonqvist, Gun-Britt
2016-03
Lejonqvist , G-B , Eriksson , K & Meretoja , R 2016 , ' Evidence of clinical competence by
simulation, a hermeneutical observational study ' , Nurse Education Today , vol. 38 , pp.
88-92 . https://doi.org/10.1016/j.nedt.2015.12.011
http://hdl.handle.net/10138/223912
https://doi.org/10.1016/j.nedt.2015.12.011
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Evidence of clinical competence by simulation, a hermeneutical
observational study
Gun-Britt Lejonqvist
a,
⁎
, Katie Eriksson
b,1
, Riitta Meretoja
c,2
a
Arcada University of Applied Sciences, Jan-Magnus Janssons plats 1, 00550 Helsinki, Finland
b
Caring Science, Åbo Akademi University, Strandgatan 2, PB 311, 65101 Vasa, Finland
c
Corporate Headquarters, Helsinki University Hospital, HUS, PL 100, 00029, Finland
summaryarticle info
Article history:
Accepted 14 December 2015
Making the transition from theory to practise easier in nursing education through simulation is widely imple-
mented all over the world, and there is research evidence of the positive effects of simulation. The pre-
understanding for this study is based on a definition of clinical competence as encountering, knowing,
performing, maturing and developing, and the hypothesis is that these categories should appear in simulated
situations. The aim of the study was to explore the forms and expressions of clinical competence in simulated
situations and furthermore to explore if and how clinical competence could be developed by simulation.
An observational hermeneutic study with a hypothetic-deductive approach was used in 18 simulated situations
with 39 bachelor degree nursing students. In the situations, the scenarios, the actors and the plots were de-
scribed. The story told was “the way from suffering to health” in which three main plots emerged. The first
was, doing as performing and knowing, which took the shape of knowing what to do, acting responsibly, using
evidence and equipment, appearing confident and feeling comfortable, and sharing work and information with
others. The second was, being as encountering the patient, which took the shape of being there for him/her
and confirming by listening and answering. The third plot was becoming as maturing and developing which
took the shape of learning in co-operation with other students. All the deductive categories, shapes and expres-
sions appeared as dialectic patterns having their negative counterparts.
The study showed that clinical com petence can be made evident and developed by simulation and that the
challenge is in encountering the patient and his/her suffering.
© 2015 Elsevier Ltd. All rights reserved.
Keywords:
Clinical competence
Evidence
Hermeneutics
Nursing education
Observation
Simulation
Introduction
In nursing education there is an ongoing transition from traditional
teaching and learning to more self-directed learningdue to the develop-
ment of the Internet, learning platforms and new technology. Using
high-fidelity simulators offers students effective, holistic and active
learning (Cook et al. 2013, Schmidt et al. 2011, Murphy et al. 2011),
and enables them to experience a variety of realistic situations in safe
environments without jeopardizing patient safety. Simulation has be-
come a way to enhance and consolidate learning, since it allows multi-
ple learning objectives to be achieved simultaneously (Yeun et al. 2014),
and it has a clear impact on students' clinical competence (Gordon et al.
2009, Ironside et al. 2009, Gallo et al. 2014). The traditional teacher role
changes to that of a facilitator who provides the students with the
possibilities to learn. Since recent studies show that there is no single
teaching met hod that secures clinical competence and sa fe practise
(Cook et al., 2013, White et al. 2013), there is a need to find vali d
methods to evaluate simulation and its effect on clinical competence
and how it transfers to practise.
The Patient Safety Strategy (WHO 2004) together with the complex
and demanding nursing reality has brought simulation to nursing edu-
cation. This article continues the ongoing discussion about the use of
simulation to enhance clinical competence and presents one hermeneu-
tical observation study of second-year bachelor degree nursing students
in one university of applied sciences in Finland whic h is engaged in
simulation training.
Background
Simulation Developing and Providing Evidence of Clinical Competence
Simulation is rooted in Aristotle and Socrates and in experiential
learning (Lyons 2012). Mechanical dummies, and models for arms and
legs have been used to train and demonstrate clin ical competence,
and previously role play, case studies and using study mates as patients
Nurse Education Today 38 (2016) 88–92
⁎ Corresponding author. Tel.: +358 40 7200708.
E-mail addresses: gun-britt.lejonqvist@arcada.fi (G.-B. Lejonqvist),
katie.eriksson@abo.fi (K. Eriksson), riitta.meretoja@hus.fi (R. Meretoja).
1
Tel.:+358400360721.
2
Tel.:+358503265192.
http://dx.doi.org/10.1016/j.nedt.2015.12.011
0260-6917/© 2015 Elsevier Ltd. All rights reserved.
Contents lists available at ScienceDirect
Nurse Education Today
journal homepage: www.elsevier.com/nedt
in clinical scenarios were common. Computer-assisted simulation was
introduced in the 1980s (Nehring & Lashley 2009, Khalaila 2014), and
its benefits in teaching an d in learning important nursing skills are
widely recognised (Solnick & Weiss 2007 , Cant & Cooper 2010,
Stanford 2010, Yuan et al. 2011, Rochester et al., 2012, Skrable &
Fitzsimons 2014). Simulation requires a paradigm shift from teaching
to learning, stressing teamwork and co-operation. The shift from pas-
sive, receptive and content-driven learning to dynamic, active and re-
flective learning affects identity construction and professionalism
(Berragan 2011).
Simulation or scenario learning combines acting and real life. Simu-
lation has the features of a play, as it follows a script; there is a cast, dif-
ferent roles and even costumes, and the performances in the scenarios
are referred to in a dramaturgical language (Taylor 2014). At the same
time, simulation brings real life into realistic learning environments,
by offering authentic learning experiences and by providing possibilities
for the students to reflect upon and develop their clinical competence
(Hinchcliffe, 2014). Defining the objectives and the stages of the learn-
ing process is reminiscent of the action-based learning cycle of Kolb
(Kolb & Kolb 2005), where reflection follows every stage of learning,
as every simulation is followed by a debriefing (Levett-Jones & Lapkin
2014).
Simulation offers safe training of skills, problem solving, critical
thinking, decision making, c ommunication, and group- and team-
work (Robinson-Smith et al. 2009, Burns et al. 2010, Alfes 2011,
Garrett et al. 2011). The emotional aspect of encountering patients
and the affective compon ent of learning are still hard to achieve
(McCaughey & Traynor 2010, Berragan 2011, McGarry et al. 2014),
but considering these limitations, simulat ion can be u sed as a substi-
tute for clinical work practise placem ents by offering students equal
possibilities to learn (Khal aila 2014). Training in safe environments
develops self-confidence, decreases anxiety when encounter ing
real patients, enhances competence and makes students better pre-
pared for clinical practise (McCallum 2007, Gordon & Buckley 2009,
Roberts et al. 2009, Kameg et al. 2010, Yuan et al. 2011, Jensen
2012, McGarth et al. 2012, Reid-Searl et al. 201 2, Thomas & Mackey
2012). Simulation can be used in nursing education at all levels, e.g.
by varying the aims so more adv anced students can develop
prioritising and delegating skills, whilst beginners can concentrate
on simple scenarios (Kaplan & Ura 2010, Pearson & McLafferty
2011, Tosterud et al. 2013).
Evidence of Clinical Competence
A recent concept analysis of nursing competence by Smith (2012)
shows what is needed when entering nursing practise, and the results
are highly relevant for definitions of clinical competence. Smith
summarises nursing competence as motivation, including integrating
knowledge into practise, experience, critical thinking skills, caring, com-
munication, supportive environm ent and professionalism including
confidence, safe practise and holistic care. Clinical competence is simi-
larly defined as the application of skills in all domains of the practise
role, a combination of knowledge, and skills and attitudes basic for emo-
tionally intelligent nursing, which grow and deepen with experience
from different contexts (Meretoja et al. 2004, Till ey 2008, Cas sidy
2009). In these contexts, clinical competence needs to be demonstrated
and made visi ble. The competence needs to become evident, which
means it becomes clear, obvious and indisputable (
Scott & McSherry
2008, Eriksson 2010). In bein g evident, students combine scientific
knowledge and skills based on values and caring ethics (Avis &
Freshwater 2006).
Evidence implies students' seeing and understanding what the
patient needs, knowing how to meet those needs, expressing and
performing, and when required revising t heir actions (Eriksson
2010).
The Study
Aim
In an earlier empirical inductive study which asked third-year bach-
elor nursing students (n = 21), preceptors (n = 21) and nursing
teachers (n =9)todefine clinical competence, the responses revealed
that in practise such competence comprises encountering, knowing,
performing , maturing and developing/improving. Competence could
be seen both as a stage and as an ongoing process, comprising an onto-
logical (general) and contextual dimension (Lejonqvist et al. 2011).
From this pre-understanding, and viewing each simulated situation
as a play, the aim of this study was to explore the forms and expressions
of clinical competence in contextual simulated situations, and further-
more to find out how clinical competence cou ld be developed by
simulation.
The study posed the following questions:
-How are encountering, knowing, performing, maturing and devel-
oping shaped and made evident in simulated situations?
-Can clinical competence be facilitated by simulation?
Design
An observational hermeneutic study was used, inspired by Gadamer
(1996), with a hypothetico-deductive approach. In this study, the meth-
od was used with meaningful material and actions (Føllesdal 1994). The
pre-understanding – viewing clinical competence as encountering,
knowing, performing, maturing and developing – is based on earlier
empirical research (Lejonqvist et al. 2011) and formed the deductive
categories for the analyses. Understanding proceeded hypothetico-
deductively. Understanding is based on rational assumptions or quoting
Gadamer; “agreement is the basis for understanding” (1996). Simula-
tion learning and performing have many parallels (Taylor 2014), the sit-
uations were viewed as scenarios/plays, which allowed the researcher
to look at them from outside in, as watching a theatre play. The play
was allowed to absorb the researcher so it was apprehended as reality.
Neither the actors nor the observer existed, only what was played out,
the meaning. Through deduction, the evidence (what was known) be-
came visible. (Gadamer 1996, Eriksson et al. 2010). The situations
were video-taped and could be watched again and again until every-
thing was unfolded, or quoting Ödman (1979) “the interpreted had
been given a meaning”.
Sample and Data Collection
The sample comprised all 47 second year bachelor degree nursing
students from a university of applied sciences in Helsinki. The students
had previously been in simulation to demonstrate their basic clinical
competence. They were now preparing for medical and surgical prac-
tise. For the simulation, the students were divided into four groups
and the time span was 4 days, each group participating for 1 day.
Three students were absent and two of the recordings failed (n =39).
The situations were videotaped with the equipment normally used in
the simulation centre. The recorded situations numbered 18 over
4 days in February 2012, lasting a total of 4 h and 25 min. The students
entered the stage in pairs (10 times) and 3 at a time (8 times). Each sit-
uation lasted for 10–19 min, on average 15 min, and the situations were
all stopped by the two te achers responsible for the simulation. The
debriefing sess ions after each situation lasted an average of 20 min,
but these sessions were not part of the analysed material.
Ethical Considerations
The WMA Declaration of Helsinki (2013) and the ethical procedures
required by the university were followed, an d the research was ap-
proved by the ethical board. Each student was informed about the aim
89G.-B. Lejonqvist et al. / Nurse Education Today 38 (2016) 88–92
of the study, that participation was voluntary and that their identity
would not be revealed. All students signed a letter of consent giving
permission to record and for research purposes review and analyse
the tapes and publish the results. The supervising teachers provided
the researcher with the recordings, which have only been viewed by
the researcher and will be kept safe, until destroyed.
Data Analyses
The data analysis was based on a pre-understanding of clinical com-
petence (Lejonqvist et al. 2011) and performed according to the herme-
neuti cal method inspired by Gadamer (19 96) with a hypothetico-
deductive approach (Føllesdahl 1994). The first hermeneutical circle
started from a holistic, inductive and intuitive vision of the scenarios
identifying the wh ole sto ry. The second circle, the hypothetico-
deductive circle moved through the deductive categories; encountering,
knowing, performing, developing and maturing, placing the forms and
expressions of clinical competence in them. After placing the parts, the
whole scenario was returned to in order to check the logic and mean-
ingfulness of the categorisation. In the third s ubject-objective circle
the new pre-understanding, the scenarios and actions were combined
and in a final interpretation where three basic plots of the story were
created.
During the analysis process, notes of each scenario were made but
instead of transcribing the observations verbatim, the recording was ob-
served several times to identify and describe the scenarios, the actors
and the plot. Each situation represented a story and in watching the
stories again and again, moving from the whole story to the parts and
back to the whole again, the different categories of clinical competence
became visible. Putting words to observations is crucial, and this hap-
pened in a dialogue between the pre-understanding and the observa-
tions. The observations were based on the roles of the actors, the
scenario, what was said and done, why it wa s said and done, and
what the atmosphere was during the situation. The analyses of the
tape were do ne by one researcher (GB), but the transcribed notes as
the interpretation of the results were verified by the other researchers
(KE and RM).
The Scenarios
In this simulation a problem and process-based method was used,
which placed focus on the learning process and viewed the students
as active and information seeking. The students acted based on contin-
uous assessment of the patient to meet the caring needs. The scenarios
and objectives developed by the teachers reflected a realistic clinical
practise, which began with a brief report of the clinical status of the pa-
tient. The scenarios developed in response to student interventions, and
the high-fidelity simulator was programmed to trend the scenarios.
Findings that could not be simulated were recorded as blood glucose,
temperature and sweating, and level of consciousness.
Five different scenarios were simulated: 1) man, age 53 sufferi ng
from pneumonia and asthma with deteriorating breathing problems;
2) woman, age 83 suffering from coronary disease, diabetes and hyper-
tonia complaining of chest pains and nausea; 3) man, age 56 heavy
drinker suffering from diabetes and pancreatitis, vomiting and needing
a nasogastric tube; 4) man, age 76 suffering from COPD, diabetes, hang-
ing left corner of the mouth, left arm without strength and difficulties in
speaking, and 5) man, age 66 having gone through a knee operation, un-
able to urinate, suffering from stomach pain and pain in the knee.
The Stage, the Actors and the Plot
The stage was a patient room. The patient, a high-fidelity mannequin
operated by two teachers, was in bed surrounded by monitors and
equipment. As in a play, the students had to wait their turn, enter the
stage (simulation centre), play their role after a designed script dressed
in a costume (nursing uniform) whilst being watched and getting feed-
back from an audience. The students identified with the roles which in-
fluenc ed their performance a nd made them who they were (Taylor
2014). The patient provided the students with information about his/
her health both verbally and by vita l signs. The students performed
based on their knowledge, their observations, assessment and the infor-
mation from the patient. They were alone in the situation but could con-
sult a “doctor” if needed.
The actors were the patient (teachers) and the students. The role as
the leading actor differed in the different situations, sometimes being
the patient, but more often one of the students depending on experi-
ence, clinical competence and confidence.
Results
The Forms and Expressions of Clinical Competence
Based on the pre-understanding, all the deductive categories defin-
ing clinical competence became evident in the simulated situations.
The overall story that could be found when viewing the scenarios was
“the way from suffering to health”. Clinical competence was formed
and expressed differently depending on the situations and the perfor-
mance of the students. The clinical competence demonstrated appeared
in dialectic patterns showing good clinical competence and lack of it.
The forms and expressions of competence are shown in Table 1 below.
In the simulated situations the students performed in a role. The per-
formance depended on how confident and how comfortable they were
in the situation. Based on their knowledge and skills, they managed the
situation by actively participating, volunteering and wanting to perform
nursing and caring activities. They managed the equipment and proce-
dures, worked together with the other/s, consulted and delegated. In
encountering the patient, they were present, they showed interest, lis-
tened to the patient and acted according to the patient's problems and
needs in wanting the best for the patient. Maturing and development
were least seen in single scenarios but showed in the students' asking
questions, sharing knowledge, verifying with peers, consulting and sug-
gesting actions. They foresa w and prepared based on observations,
knowledge, and learning from the situation.
All the main categories, the forms and expressions of competence
also had their negative counterparts, where students were uninterested,
passive, withdrawing, isolated and uncomfortable depending on lack of
knowledge, skills or self-confidence.
In the hermeneutical int erpretation of the way from suffering to
health, three basic plots were found: 1) doing as performing and know-
ing. The students were working evidence-based and responsibly, man-
aging technology and skills, feeling confident and comfortable sharing
information and working together with others; 2) being as encounter-
ing. The students were present, interested in and confirming the patient
by listening and responding, and 3) becoming as maturing and develop-
ing. The students were co-acting and learning together and developing.
All students were engaged to some extent in doing according to their
own skills; most of them also were being there for the patient whilst
fewer could be seen in the process of becoming by developing and ma-
turing in these single scenarios.
Facilitating Development of Clinical Competence in Simulation
Development of clinical competence was seen from the first to the
last case performance during one day. Watching others simulate and
participate in debriefings made th e activities of the students clearer
and safer, and probably affected the performances later during the day
even if the scenarios changed. Being aware of each student's knowledge
and skills, the teachers designed the scenario. The teachers facilitated
the situations, and depending on their performance the students were
challenged to develop their individual clinical competence. On the stu-
dents' way to clinical competence, the teachers were simplifying or
90 G.-B. Lejonqvist et al. / Nurse Education Today 38 (2016) 88–92
complicating the scenarios, giving or withholding information, and con-
tinuing or ending the situation thus enabling learning to take place. The
scenario wa s facilitated by adding more challenging symptoms and
signs, thus trusting the students to manage the situation, or it was
made simpler and easier to manage by giving additional instructions
and information about the patient.
The “case” was continued until the students were using their whole
potential and learning new things, thus developing their clinical compe-
tence. The “case” was ended when the students could not manage it any
more in order to avoid the feeling of failure.
Discussion
Using a hermeneutic method with a hypothetic-deductive approach
to observations of simulated situations is challenging. However the re-
sults of this study show that simulation offers safe tr aining of skills,
problem solving, critical thin king, decision making, communica tion,
and group- and teamwork, which are well in line with earlier research
(Robi nson-Smith et al. 2009, Bu rns et al. 2010, Alfes 2011, Garrett
et al. 2011). We also found that, in well-designed simulation training,
evidence of clinical competence as encountering, knowing, performing,
maturing, and developing can be made visible in different simulated
contexts, and thereby trained. We also found that a few students did
not feel comfortable or confident in the situation, which was revealed
as ignoring the patient, being uninterested and not responsible, or as
withdrawing from the situation. Simulation training requires not only
that students identify with their roles, and allow themselves to be influ-
enced, taking the play as “reality” (Gadamer 1996), but also that they
have the knowledge and skills needed in the situation, since they need
to feel safe and be prepared. Simulation can be seen as a play, a perfor-
mance, but even so it holds all the elements and possibilities needed to
evaluate and develop clinical competence, and as such is a valuable
teaching and learning method in nursing education. The challenge lies
in encountering the suffering of the p atient (McCaughey & Traynor
2010, Berragan 2011, McGarry et al. 2014) with compassion, walking
with the patient, and that is where the ethics of caring and the caring
abilities really show (Eriksson 2006). This implies reaching the level
where the play no longer exists but only the meaning (Gadamer 1996).
In simulated situations, students develop not only their manual clin-
ical skills but also their team-work competence, their reporting and
consulting, and they gain reinforcement in their learning proc esses
both from teachers and from fellow students. In simulations, the stu-
dents have the possibilities to repeat and to watch others and their
own performances, and the awareness of knowledge gaps becomes ob-
vious, which in turn leads to learning activities. The teachers facilitate
learning by simplifying or complicating the situation of the patient by
designing scenes according to the level of the clinical competence of
each student , which can challe nge them to do their very best and in
that way develop clinical competence. This requires trust, time, space
and equipment, small student groups and well-trained teachers,
which provides an effective, although expensive, way to learn a nd
teach.
In this study of clinical competence, performing became most evi-
dent. This compares well with what is evaluated in both simulation
and practical training (While 1994, Berragan 2014).
Simulation can be used to evaluate clinical competence, and when
there is a lack of good and varying clinical training places, simulation
is a good alternative. It can be used to check students' clinical compe-
tence before graduation and offer possibilities to develop it if needed.
Although simulation is the best alternative, it cannot replace practical
training. However, simulation can make the transition from theory to
clinical practise easier as it gives students the possibilities to train safely
and to develop the self-confidence they need in practise, even if it is
never the same as practise.
Limitations
The limitation of the study lies in its transferability due to the small
sample size and the context of one specific university. Still, the richness
in the findings and the similarity to other research results support its va-
lidity. The researcher's pre-understanding (Lejonqvist et al. 2011
), fa-
miliarity with simulation teaching, the students' curriculum and the
simulation centre were used in interpreting the situations. This can be
seen both as a strength and as a weakness, but, as Gadamer (1996)
states, prejudices are important in the interpretation, since they form
the basis for understanding. This study also supported the results in
the above-mentioned study in defining clinical competence, but at the
Table 1
Evidence of clinical competence in simulated situations.
Deductive categories of clinical competence Shapes of clinical competence Expressions of clinical competence
Encountering/Not encountering Confirming Greeting the patient by name, touching, meeting the patients eyes, listening,
answering and believing the patient
Ignoring Talking over the patients head, not listening, not answering, talking to the patient
in a disparaging way
Showing interest Listens to the patients story, asks questions, fulfils wishes
Uninterested Does not listen to the patient, asks no questions, “drives his/her own race”
Knowing/Not knowing Being responsible/ Knows own limitations, asks for help, consults, and checks
Un-responsible Acts without knowing, does not work aseptically, does not check medication
Acting evidence-based Bases actions on knowledge, informs co-workers and the patients, interprets vital
signs and acts based on them, can foresee what is going to happen and prepares
Not evidence-based Acts on routine, gives no information or explanations to actions, does not answer
questions, cannot foresee course of events, works unsystematically and unorganised
Knowing technology and techniques Manages equipment and procedures
Technology and techniques unknown Needs help from other students, makes mistakes and endangers patient safety
Performing/
Not performing
Acting confident Knows what to do, acts consequently, interacts with the patient and other students,
knows manual skills, has good routines
Not confident Does not know what to do, waits for order, does not acknowledge the patient, little
interaction, uncertain about manual skills, works unsystematically
Feeling comfortable/
Uncomfortable
Enjoys the situation, acts naturally
Nervous, does not engage in the situation, laughs and acts un-naturally
Being connective and sharing Team-work abilities, informs, delegates, gives suggestions, supports and confirm
“Loner”
Prefers working alone, does not share information, does not delegate, picks tasks,
withdraws from the group/other
Maturing, developing/not maturing,
not developing
Learning Taking advice, asking questions, discussing alternatives and giving suggestions,
active and willing to do
Stagnation Being passive, waiting for other/s initiative, unwilling to act
91G.-B. Lejonqvist et al. / Nurse Education Today 38 (2016) 88–92
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