AN INDEPENDENT VOICE FOR NURSING

Simulating Care: Technology-Mediated

Learning in Twenty-First Century
Nursing Education nuf_250 34..38

Elizabeth Diener, PhD, RN, CPNP, and Nelda Hobbs, MSN, RN

Elizabeth Diener, PhD, RN, CPNP, is Assistant Professor of Nursing, Oklahoma City University, Kramer School of Nursing,
Oklahoma City, OK; and Nelda Hobbs, MSN, RN, is Instructor of Nursing, Oklahoma City University, Kramer School of
Nursing, Oklahoma City, OK.

Keywords PROBLEM. The increased reliance on simulation classrooms has proven

Caring, stimulation, student nurses,
clinical education
Correspondence
Elizabeth Diener, PhD, RN, CPNP,
Oklahoma City University, Kramer
School of Nursing, Oklahoma City,
OK
E-mail: ejdiener@okcu.edu
successful in learning skills. Questions persist concerning the ability of
technology-driven robotic devices to form and cultivate caring behaviors,
or sufficiently develop interactive nurse–client communication necessary
in the context of nursing.
METHODS. This article examines the disconnects created by use of simu-
lation technology in nursing education, raising the question: “Can learn-
ing of caring-as-being, be facilitated in simulation classrooms?”
FINDINGS. We propose that unless time is spent with human beings in
the earliest stages of nursing education, transpersonal caring relationships
do not have space to develop. Learning, crafting, and maturation of caring
behaviors threatens to become a serendipitous event or is no longer
perceived as an essential characteristic of nursing.
CONCLUSIONS. Technology does not negate caring–the isolation it
fosters makes transpersonal caring all the more important. We are called
to create a new paradigm for nursing education that merges Nightingale’s
vision with technology’s promise.

Nursing’s historical image is one of personal commu-
nication between caregiver and patient. Thought of as
a communicative form typically involving language,
care can be expressed through other forms as well.
One such communicative pathway, a caring con-
sciousness described by Watson (1999, 2008), provides
a formative basis of caring moments, those intervals in
human care when true and deep connections develop
between a provider and a receiver of care. Caring
behaviors must be nurtured and developed over time
while cultivated by caring practitioners and educators.
To this end, nursing faculty must contemplate the
educative place of caring in simulation environments.
For over four decades, nursing education has
employed simulation in nursing student instruction
(Jeffries, 2007; Nehring & Lashley, 2010). Static man-
nequins, appendage models, and nonrealistic devices
no longer meet the needs of technologically confident
students. Today’s students are comfortable with por-
table computing devices, advanced communication
technology, and instant response systems. Increased
demand for multifaceted technological equipment in
healthcare environments has resulted in the develop-
ment of simulation teaching strategies that create
interactive hands-on learning environments. As a
result of increased availability, high fidelity human
patient simulation (HFPS) is increasingly regarded as
an essential element of nursing education programs
(Nehring & Lashley, 2010; Starkweather & Kardong-
Edgren, 2008).
Patient simulation technology effectively fills skill
acquisition gaps left by changing clinical opportunities
for nursing students, increasing numbers of individu-
als entering nursing education programs, and corre-
sponding lags in the number of nurses pursuing
employment as faculty members. HFPS has proven

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© 2012 Wiley Periodicals, Inc.
Nursing Forum Volume 47, No. 1, January-March 2012
E. Diener and N. Hobbs
itself successful in learning skills, yet questions persist
concerning the ability of technology-driven robotic
devices to form and cultivate caring behaviors, or suf-
ficiently develop interactive nurse–client communica-
tion necessary in the context of nursing. This article
opens dialogue among nursing educators on whether
learning to care can be facilitated in clinical simulation
classrooms, and urges an examination of how tech-
nology is applied to nursing education.
Caring in the Context of Nursing
Caring has many applications, which complicates
discriminating how it is applied ideally in nursing.
Caring is a noun, an adjective, and a verb. It is as the
latter that caring posits itself in the realm of nursing.
Caring, used as a transitive verb, assumes the doing
mode, such as the giving of care in skilled, performa-
tive tasks. In contrast, when employed as an intransi-
tive verb, caring expresses the being mode of nursing:
caring as presence and connection. Both applications
define, and are fundamental to, the discipline of
nursing.
As a central focus of nursing, caring is recognized as
a concept and behavior of import for nursing educa-
tion. Past discussion and research on caring has con-
cluded that caring is a learned behavior acquired
primarily through modeling (Coyle-Rogers & Cramer,
2005). While not all theorists explicitly address caring,
it is an implicit component of nursing theory and
education (Brilowski & Wendler, 2005; Finfgeld-
Connett, 2008).
In both a historical and contemporary context,
caring has been described as the focal point of nursing
(Benner & Wrubel, 1989; Boykin & Schoenhofer,
2001; Leininger, 1984; Swanson, 1991; Watson, 1999,
2007, 2008). Nursing’s close relationship with caring
was forged by the writings of Florence Nightingale.
Nightingale called for “healing nurse-patient relation-
ships” created in an environment attentive to symme-
try and beauty, as well as the provision of “good” light,
hygiene, and air (p. 9). Her classic text, Notes on
Nursing (1969), provides direction for the application
of these elements; caring in its fundamental form leads
to a healing environment.
Nightingale’s writings have heavily influenced
North American nursing philosophical and theory
development for the past 50 years (Tomey & Alligood,
2006). Nursing philosophers Benner (1984), Leininger
(1984), and Watson (1979, 2008) describe care as the
crux of nursing. Benner’s From Novice to Expert
© 2012 Wiley Periodicals, Inc.
Nursing Forum Volume 47, No. 1, January-March 2012
Simulation and Caring in Nursing Education
describes caring as a vital component in skill acquisi-
tion for nurses, yet she moves beyond viewing care as
simply consisting of skill mastery. Caring is relational,
transformative, and integrative, and in most instances,
evolves into a more mature practice as the nurse
attains role proficiency (Benner, 1984; Benner &
Wrubel, 1989).
Madeleine Leininger (Leininger, 1984; Leininger &
McFarland, 2006) conceptualized care as a distinctive
attribute of the profession of nursing. Care is con-
ceived of as an essential human need across the life
span that is not fully actualized unless it is framed
within the cultural perspective of the client (Leininger
& McFarland, 2006). To fulfill this directive, knowl-
edge that is both academic and self-reflective of tran-
scultural values, beliefs, and practices of patient and
nurse must be examined. Culturally competent care
can only be achieved when the practitioner under-
stands the exchange between nurse–patient cultural
values.
Jean Watson’s Philosophy and Science of Caring (1979,
2008) explicates caring as a distinctive, synergistic,
and transpersonal relationship between nurse and
client. Guided by 10 carative factors, nurse and patient
cocreate a unique healing environment. Her later
work (1999, 2008) extends carative factors as caritas
processes, further explicating formation and enact-
ment of caring relationships. Watson’s philosophy
repositions caring from a narrow vision of self-other
connection to a view of caring as broad concentric
expansion beyond nurse–patient to community,
global, and universe-wide engagement.
Nursing theorists have described the primacy and
import of caring for nursing (Boykin & Schoenhofer,
2001; Lindstrom, Lindholm, & Zetterlund, 2006;
Newman, 2008; Swanson, 1991). Continued develop-
ment and expansion of caring theories demonstrate a
sustained belief in caring as an essential component of
nursing’s mission. Analyses of the concept of caring
(Bailey, 2009; Brilowski & Wendler, 2005; Finfgeld-
Connett, 2008; Sadler, 1997; Sherwood, 1997) have
consistently identified two fundamental attributes:
those of doing and being.
Technology in the Realm of Nursing Care
Technology’s place in nursing education is undeni-
able. Health care in the twenty-first century is
complex and technology-dependent. This will not
change. Previous dialogue concerning the interface
of traditional hands-on nursing practices and
35
Simulation and Caring in Nursing Education
technology-mediated nursing focused on whether
technology constitutes care. Rozzano Locsin (1995,
2001, 2005) and others (Mitchell, 2001; Purnell, 2001;
Schoenhofer, 2001; Turkel, 2001) have amply illus-
trated applications of technology as a doing practice of
care. Conclusions from research focusing on patient–
family perceptions of nurses’ caring behaviors are
closely correlated with patient condition; the more
critically ill a patient was, the higher were reports of
nurses’ caring behaviors as evidenced by technological
competence (Sherwood, 1997).
Technological competence without an accompany-
ing ethic of care incorporating affective behaviors is
only mechanistic proficiency (Locsin, 2005). Caring, if
viewed from nursing’s perspective, must encompass
humanistic principles that converge to cocreate
transpersonal relationships between nurse and patient
(Benner, 1984; Boykin & Schoenhofer, 1993; Eriks-
son, 1990; Leininger, 1978; Watson, 1979). As tech-
nology becomes a greater part of nursing care delivery,
so must the discipline re-invision the features of caring
for twenty-first-century nurses.
Simulation as a Learning Methodology in
Nursing Education
Over the last century, nursing has evolved from a
profession requiring nurses to provide basic care and
hygiene into a complex profession requiring sophisti-
cated assessment skills as well as proficiency with
advanced technology. In today’s healthcare atmo-
sphere, nurses must be prepared to meet challenging
patient care issues, make sound clinically based deci-
sions, and maintain technological proficiency (Rhodes
& Curran, 2005). Technologically-driven healthcare
environments must use a variety of formats to educate
nurses (Brenner, Aduddell, Bennett, & VanGeest,
2006; Rhodes & Curran, 2005). Increases in complex-
ity of clinical nursing skills mandate that nursing
education embrace simulated learning environments
(Jeffries, 2007).
Currently, simulation has three categories of com-
plexity: low, medium, and high fidelity. Static manne-
quins represent low-fidelity simulation and are used
to learn skills that are performed as tasks not neces-
sarily requiring critical thinking (Seropian, Brown,
Gavilanes, & Driggers, 2004). Medium-fidelity man-
nequins provide a more realistic experience and allow
assessment of vital signs, and heart and lung sounds.
High-fidelity simulators imitate actual clinical situa-
tions through realistic patient responses to nursing
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© 2012 Wiley Periodicals, Inc.
Nursing Forum Volume 47, No. 1, January-March 2012
E. Diener and N. Hobbs
interventions. HFPS provides active learning in a safe
setting, allowing students to apply and analyze care
given in a controlled situation. HFPS allows students
to experience fidelity and realism (Seropian et al.,
2004).
Technology-mediated static and medium-fidelity
simulation labs provide nursing students with case
scenarios. Intended to replicate situations commonly
found in clinical practice, simulation labs address
aspects of conduct in nursing, such as skill attainment,
critical thinking, and professional confidence driven by
learner needs. Communication, a necessary skill in the
provision of care, takes place in the context of devel-
oping peer working relationships and team building,
not in developing meaningful nurse–patient interac-
tion. Indeed, a medium-fidelity mannequin’s mute and
malleable presence in nursing education can give stu-
dents the erroneous impression that real patients are as
acquiescent, submissive, and voiceless.
Engagement occurring with high-fidelity simula-
tion experience provides opportunities for students to
gain a greater understanding of skill application and
analysis in an artificially created clinical milieu (Stark-
weather & Kardong-Edgren, 2008). Analysis of simu-
lation scenarios by students and nurse educators
allow integration and assimilation of the lived expe-
rience of being a nurse (Seropian et al., 2004). Imme-
diate feedback following simulation experiences is a
key component for student learning. More recently,
high-fidelity mediated robotics (mannequins) incor-
porating vocal interaction have been developed in
attempts to create more realistic contexts of nurse–
client relationships.
Learning to Care in Simulation Environments
Ample evidence exists that technology represents
the twenty-first century doing behaviors of nursing
care and that this particular nuance of care can be
learned (Locsin, 1995, 2001, 2005). Simulation tech-
nology lends itself particularly well to skill acquisition
learning and is enhanced by the application of voice-
modulated scenarios. Critical to learning in simulation
environments, as well as in traditional clinical prac-
tice, is the place of reflection as an educative method.
Reflection as a pedagogical application in nursing edu-
cation has appeared in the literature for over 20 years
(Burnard, 1988). Clinical reflection most often takes
the form of journaling, but can employ other expres-
sive venues such as art, poetry, photography, or music.
Faculty use reflective activities to engage students in
E. Diener and N. Hobbs
contemplating multifaceted aspects of clinical nursing
practice (Bauman, 2008).
How does learning to care, when applied to the
being aspects of the concept, translate in simulation
learning environments? Forming caring relationships,
enacting caring presence, and employing transper-
sonal caring requires reciprocity that is not developed
between students and simulated patient. In an age of
avatars, Webkins, and virtual environments, simula-
tion technology becomes just another venue of
gaming. Relationships are contrived and patients are
plastic. If patients live, students have won “the game.”
Tears shed when simulation patients die may be more
about performance stress and “losing” a game than
losing a human being.
Twenty-first century nursing is situated in a land-
scape where care and skill are needed in equal
measure. Technology does not negate caring; indeed,
the isolation it fosters makes the significance of
transpersonal caring all the more important. As edu-
cators in a domain of humanistic science, the charge
is to guide twenty-first century nursing education
within a caring curriculum using technology wisely
and appropriately. We are called to create a new para-
digm for nursing education that merges Nightingale’s
vision with technology’s promise.
Facilitating development of caring behaviors in
nursing students must move beyond simulation labs to
engage live patients and cultivate caring behaviors
modeled by nurse educators. Caring begins in school.
Students who have never experienced a caring edu-
cation are unlikely to recognize the healing aspect care
brings to practice environments. In similar fashion,
unless time is spent with human beings in even the
earliest stages of nursing education, transpersonal
caring relationships do not have space to develop.
Learning, crafting, and maturation of caring behaviors
becomes a serendipitous event or, more concerning, is
no longer perceived as an essential characteristic of
nursing.
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References
Bailey, D. (2009). Caring defined: A comparison and analy-
sis. International Journal for Human Caring, 13(1), 16–31.
Bauman, S. (2008). Improving our stories. Nursing Science
Quarterly, 21(3), 260–267.
© 2012 Wiley Periodicals, Inc.
Nursing Forum Volume 47, No. 1, January-March 2012
Simulation and Caring in Nursing Education
Benner, P. (1984). From novice to expert: Excellence and power in
nursing practice. Menlo Park, CA: Addison-Wesley.
Benner, P., & Wrubel, J. (1989). The primacy of caring: Stress
and coping in health and illness. Menlo Park, CA: Addison-
Wesley.
Boykin, A., & Schoenhofer, S. (1993). Nursing as caring: A
model for transforming practice. New York: National League
for Nursing Press.
Boykin, A., & Schoenhofer, S. (2001). Nursing as caring: A
model for transforming practice. Sudbury, MA: Jones and
Bartlett.
Brenner, M., Aduddell, K., Bennett, D., & VanGeest, J.
(2006). The use of human patient simulators: Best prac-
tices with novice nursing students. Nurse Educator, 31(4),
170–174.
Brilowski, G., & Wendler, M. (2005). An evolutionary
concept analysis of caring. Journal of Advanced Nursing,
50(6), 641–650.
Burnard, P. (1988). The journal as an assessment and evalu-
ation tool in nursing education. Nurse Education Today, 8,
105–107.
Coyle-Rogers, P., & Cramer, M. (2005). The phenomena of
caring: The perspectives of nurse educators. Journal for
Nurses in Staff Development, 21(4), 160–170.
Eriksson, K. (1990). Nursing science in a Nordic perspective.
Systematic and contextual caring science: A study of the
basic motive of caring and context. Scandinavian Journal of
Caring Sciences, 4, 3–5.
Finfgeld-Connett, D. (2008). Meta-synthesis of caring in
nursing. Journal of Clinical Nursing, 17(2), 196–204.
Jeffries, P. (2007). Simulation in nursing education from concep-
tualization to evaluation. New York: National League of
Nursing.
Leininger, M. (1978). Transcultural nursing: Concepts, theories
and practices. New York: John Wiley & Sons.
Leininger, M. (Ed.) (1984). Caring: The essence of nursing and
health. Detroit, MI: Wayne State University Press.
Leininger, M., & McFarland, M. (Eds.) (2006). Culture care
diversity and universality. Sudbury, MA: Jones and Bar-
tlett.
Lindstrom, U. A., Lindholm, L., & Zetterlund, J. (2006).
Theory of caritative caring – Katie Eriksson 1943–present.
In A. Tomey & M. Alligood (Eds.), Nursing theorists and
their work (pp. 109–209). St. Louis, MO: Mosby Elsevier.
Locsin, R. (1995). Machine technologies and caring in
nursing. Image: Journal of Nursing Scholarship, 27(3), 201–
203.
Locsin, R. (2001). Advancing technology, caring and nursing.
Westport, CT: Auburn House.
Locsin, R. (2005). Technological competency in nursing. India-
napolis, IN: Sigma Theta Tau International.
Mitchell, G. (2001). Pictures of paradox: Technology,
nursing and human science. In R. Locsin (Ed.), Advancing
technology, caring and nursing (pp. 3–11). Westport, CT:
Auburn House.
Nehring, W., & Lashley, F. (2010). High-fidelity patient simu-
lation in nursing. Sudbury, MA: Jones and Bartlett.
Newman, M. (2008). Transforming presence: The difference that
nursing makes. Philadelphia: F.A. Davis.
Nightingale, F. (1969). Notes on nursing: What it is and what it
is not. Mineola, NY: Dover Publications.
37
Simulation and Caring in Nursing Education
Purnell, M. (2001). The language of nursing: A technology
of caring. In R. C. Locsin (Ed.), Advancing technology,
caring and nursing (pp. 3–11). Westport, CT: Auburn
House.
Rhodes, M., & Curran, C. (2005). Use of the human patient
simulator to teach clinical judgment skills in a baccalau-
reate nursing program. Computers, Informatics, Nursing:
CIN, 23(5), 256–262.
Sadler, J. (1997). Defining professional nurse caring: A tri-
angulated study. International Journal for Human Caring,
1(3), 12–21.
Schoenhofer, S. (2001). A framework for caring in a tech-
nologically dependent nursing practice environment. In
R. Locsin (Ed.), Advancing technology, caring and nursing
(pp. 3–11). Westport, CT: Auburn House.
Seropian, M., Brown, K., Gavilanes, J., & Driggers, B.
(2004). An approach to simulation program develop-
ment. Journal of Nursing Education, 43(4), 170–184.
Sherwood, G. (1997). Meta-synthesis of qualitative analyses
of caring: Defining a therapeutic model of nursing.
Advance Practice Nursing Quarterly, 3(1), 32–42.
38
© 2012 Wiley Periodicals, Inc.
Nursing Forum Volume 47, No. 1, January-March 2012
E. Diener and N. Hobbs
Starkweather, A., & Kardong-Edgren, S. (2008). Diffusion
of innovation: Embedding simulation into nursing
curricula. International Journal of Nursing Education
Scholarship, 5(1), 1–11.
Swanson, K. M. (1991). Empirical development of a middle-
range theory of caring. Nurse Researcher, 40(3), 161–
166.
Tomey, A. M., & Alligood, M. R. (2006). Nursing theorists and
their work. St. Louis, MO: Mosby Elsevier.
Turkel, M. C. (2001). Challenging contemporary practices in
critical care settings. In R. C. Locsin (Ed.), Advancing
technology, caring and nursing (pp. 133–145). Westport, CT:
Auburn House.
Watson, J. (1979). Nursing: the philosophy and science of caring.
Boston, MA: Little Brown.
Watson, J. (1999). Postmodern nursing and beyond. London,
UK: Harcourt-Brace.
Watson, J. (2007). Nursing: Human science and human care—A
theory of nursing. London, UK: Jones and Bartlett.
Watson, J. (2008). The philosophy and science of care. Boulder,
CO: University of Colorado Press.