Human patient simulation (HPS) has emerged as an invaluable

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1 Human Patient Simulation Evaluation Rubrics for Nursing Education: Measuring The Essentials of Baccalaureate Education for Professional Nursing Practice Alison H. Davis, MSN, RN; and Laura P. Kimble, PhD, RN, FAHA ABSTRACT With the call for curriculum that meets the educational needs of nurses in the 21st century, the American Association of Colleges of Nursing provided nine essentials for baccalaureate nursing education in The Essentials of Baccalaureate Education for Professional Nursing Practice, which serves as a critical guide to inform and shape baccalaureate nursing program curricula. Nursing programs must demonstrate program outcomes that reflect all of the essentials. Human patient simulation was specifically acknowledged as an appropriate educational tool for meeting these needs. This article identifies and assesses six rubrics purported to measure outcomes of human patient simulation and evaluates how these rubrics measure outcomes reflecting the baccalaureate essentials. Psychometric data were limited for the majority of the rubrics, especially validity data. The rubrics consistently failed to measure Essentials V and VII. Suggestions for how these Essentials might be integrated into the existing rubrics are provided. Received: January 27, 2011 Accepted: May 25, 2011 Posted Online: July 15, 2011 Ms. Davis is PhD in Nursing student, and Dr. Kimble is Professor and Piedmont Endowed Chair in Nursing, Georgia Baptist College of Nursing of Mercer University, Atlanta, Georgia. The authors thank Dr. Susan Gunby for her scholarly advice and commitment to nursing education. The authors have no financial or proprietary interest in the materials presented herein. Address correspondence to Alison H. Davis, MSN, RN, Georgia Baptist College of Nursing of Mercer University, 55 East Paulding Drive, Suite 106, Dallas, GA 30157; aandgdavis@hotmail.com. doi: / Human patient simulation (HPS) has emerged as an invaluable tool for nurse educators who want to provide a realistic, challenging, controlled, and accessible experience for their nursing students. Although HPS has been used in medical education since the 1980s, nursing education has used HPS for less than 10 years, primarily within nurse anesthesia programs (Nehring & Lashley, 2004). Human patient simulation began to be integrated into nonanesthesia nursing programs approximately 5 years ago as the vast functions and benefits of this technologically advanced teaching tool were recognized more broadly in nursing education. Over time, the use of HPS in nursing education expanded to undergraduate nursing programs primarily due to the nursing faculty shortage, decreasing availability of clinical placements, difficulty accessing specific patient populations, and the growing awareness that HPS provided an active learning experience (Akhtar-Danesh, Baxter, Valaitis, Stanyon, & Sproul, 2009; Kardong-Edgren, Starkweather, & Ward, 2008). Furthermore, HPS enhanced faculty opportunities to provide a simulated clinical experience that encompasses the affective, cognitive, and psychomotor domains, which are all essential to nursing practice (Scheckel, 2009). As with HPS and other advanced technologies, nursing education has continued to expand. Due to the considerable size of the workforce, nursing has been provided with an opportunity to positively affect the future of the health care delivery system. The health care delivery system could be affected as decisions by nursing leadership transform it into a safer, higher quality, and financially responsible system for the American citizens (American Association of Colleges of Nursing [AACN], 2008). One must question what nursing level should be considered appropriate for nursing leadership for a graduate who will be making these transformative decisions regarding health care. The AACN has a history of advocating the baccalaureate degree as the entry-level degree for the professional nurse. In 1998, the AACN identified a need for an educational framework that would guide nursing education at the baccalaureate level. Therefore, in 1998, the AACN endorsed The Essentials of Baccalaureate Education for Professional Nursing Practice (hereafter referred to as The Essentials) as a means to provide Journal of Nursing Education Vol. 50, No. 11,

2 HUMAN PATIENT SIMULATION EVALUATION an educational framework and describe outcomes that were expected of baccalaureate degree nursing programs. The most recent version was endorsed in Currently, The Essentials serves as a critical guideline to inform and shape baccalaureate nursing program curricula. With the call for a curriculum that meets the educational needs of the 21st century, the AACN provided nine Essentials for baccalaureate nursing education; nursing programs must demonstrate program outcomes that reflect all of the Essentials. Within the document, HPS was specifically acknowledged as an appropriate educational tool for meeting the needs of the future of nursing education. The AACN (2008) stated: Simulation experiences augment clinical learning and are complementary to direct care opportunities essential to assuming the role of the professional nurse... Simulation experiences provide an effective, safe environment for learning and applying the cognitive and performance skills needed for practice. Reality-based simulated patient care experiences increase selfconfi dence in communication and psychomotor skills, and professional role development. (p. 4) As HPS has been accepted into nursing education, nursing research has increased and expanded to include the measurement of learning outcomes achieved with HPS. With the growing emphasis on HPS, it is important to evaluate HPS outcome measures to determine how well these rubrics quantify whether students meet the Essentials. Therefore, the purpose of this article is to review and discuss existing rubrics used to measure outcomes of HPS and to evaluate how these rubrics measure outcomes reflecting the baccalaureate Essentials. RUBRICS AND HUMAN PATIENT SIMULATION A rubric can be described as an assessment tool that divides assignments into specific components and objectives that provide acceptable and unacceptable criteria for student performance evaluation (Stevens & Levi, n.d.). The use of rubrics in nursing education has focused on the assessment of student performances in the clinical setting. Rubrics have permitted nursing faculty to evaluate specific tasks performed by nursing students that indicated successful and satisfactory clinical performance (Bonnel, 2009). With the acceptance of HPS into nursing education, rubrics have been developed that assess student performance and learning outcome attainment during HPS experiences. Nurse educators have used HPS as a replacement for clinical experiences that have become difficult to obtain due to the changing health care arena, nursing shortage, and nursing faculty shortage. Therefore, a rubric can be seen as a natural assessment tool for the evaluation of student performance in HPS due to characteristics that are comparable with clinical experiences. In HPS, as with clinical experiences, a rubric provides predetermined criteria and expectations that faculty recognize as met or not met during the experience. These clear delineations of student performances have served to facilitate student understanding of an HPS experience due to the clear guidelines set forth by the rubric. Whether used for a single student or a group, at the conclusion of the HPS experience, a debriefing session provides students and faculty the opportunity to review all aspects of the scenario. Rubrics have the ability to provide concept descriptions and evidence of concept understanding that facilitate faculty determining whether a student or group of students successfully completed the performance or learning outcomes (Lasater, 2007). Furthermore, nurse educators have used rubrics to facilitate communication among students that leads to the cultivation of critical thinking (Lasater, 2007). This is an important concept for nursing students to grasp as they prepare for practice. Rubrics and HPS have become a natural combination for the successful evaluation of students during and after an HPS experience. OVERVIEW OF THE ESSENTIALS The Essentials was developed in 2008 to include influential recommendations of cutting-edge nurse educators and documents that will shape the future of nursing education to include the Institute of Medicine s report on required curricular knowledge for health professionals (AACN, 2008). The curricular elements and framework have been developed to specify outcomes that are expected of students who graduate from baccalaureate nursing programs (AACN, 2008). The nine Essentials for baccalaureate education have been reported as: Essential I: Liberal Education for Baccalaureate Generalist Nursing Practice. A solid base in liberal education provides the cornerstone for the practice and education of nurses. Essential II: Basic Organizational and Systems Leadership for Quality Care and Patient Safety. Knowledge and skills in leadership, quality improvement, and patient safety are necessary to provide high-quality health care. Essential III: Scholarship for Evidence-Based Practice. Professional nursing practice is grounded in the translation of current evidence into one s practice. Essential IV: Information Management and Application of Patient Care Technology. Knowledge and skills in information management and patient care technology are critical in the delivery of quality patient care. Essential V: Health Care Policy, Finance, and Regulatory Environments. Health care policies, including financial and regulatory, directly and indirectly influence the nature and functioning of the health care system and, therefore, are important considerations in professional nursing practice. Essential VI: Interprofessional Communication and Collaboration for Improving Patient Health Outcomes. Communication and collaboration among health care professionals are critical to delivering high-quality and safe patient care. Essential VII: Clinical Prevention and Population Health. Health promotion and disease prevention at the individual level and population level are necessary to improve the population health and are important components of baccalaureate generalist nursing practice. Essential VIII: Professionalism and Professional Values. Professionalism and the inherent values of altruism, autonomy, human dignity, integrity, and social justice are fundamental to the discipline of nursing. Essential IX: Baccalaureate Generalist Nursing Practice. The baccalaureate-graduate nurse is prepared to practice with patients, including individuals, families, groups, communities, 606 Copyright SLACK Incorporated

3 DAVIS & KIMBLE and populations across the lifespan and across the continuum of health care environments. The baccalaureate graduate understands and respects the variations of care, the increased complexity, and the increase use of health care resources inherent in caring for patients (AACN, 2008). The essentials have been constructed to define curricular outcomes that will be expected of graduates who attended a baccalaureate nursing program. However, Essential IX has further been developed to explain the expectations for generalist nursing practice at the conclusion of a baccalaureate nursing program. Furthermore, Essential IX integrated the delineated knowledge, performance skills, and attitudes that were found in Essentials I through VIII (AACN, 2008). Each Essential includes rationales that provide enhanced clarity and evidence needed for inclusion into the education of today s nursing students who will become the future of nursing. The AACN has discussed the fact that nurse educators could obtain the outcomes of The Essentials with a multitude of content approaches that will continue to evolve over time as new knowledge develops concerning the health care delivery system and technology (AACN, 2008). The use of HPS has the potential to help faculty attain the Essentials in their student learning outcomes. Human patient simulation has been presented as a new and emerging teaching tool that has a variety of applications for nursing practice. Furthermore, HPS has the ability to provide cognitive, psychomotor, and affective learning experiences that can be directly correlated with the knowledge, skills, and attitudes included in Essentials I through VIII. These Essentials have been identified by the AACN as providing the framework and curricular outcomes necessary for successful practice as a baccalaureateprepared nurse in today s fluid health care environment. EVALUATION RUBRIC DISCOVERY METHOD Focusing on nursing student evaluation rubrics measuring learning outcomes or effectiveness of HPS, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database and the journal Clinical Simulation in Nursing were searched using the following search terms: evaluation instruments and simulation, evaluation rubrics and simulation, rubrics and simulation, and student evaluation and simulation. The publication dates for the literature search included the years 1988 through 2011, which is the default search period for CINAHL. Clinical Simulation in Nursing began publication in 2006, so the search encompassed all issues of this journal published through The search strategy yielded 381 articles. These articles were screened and selected for review based on the following criteria: the article described a rubric for evaluating simulation learning, and the rubric was specifically designed for use in nursing education and not for other health professions such as medicine. Four articles meeting these criteria were identified for review. In addition, one of the articles identified in the search was a review article by Kardong-Edgren, Adamson, and Fitzgerald (2010) that contained evaluation instruments for medical students as well as nursing students. This review article was used to locate additional evaluation rubrics specific to nursing student evaluation. From the literature search, six rubrics were identified. Of note, all identified rubrics were published in 2005 or later, likely reflecting the relatively recent focus on the evaluation of student performances during HPS in nursing education. Literature published prior to 2005 focused more on what HPS was and how to use the technology. OVERVIEW OF HUMAN PATIENT SIMULATION EVALUATION RUBRICS Nurses have used the affective, psychomotor, and cognitive domains in their everyday practice. Therefore, nursing students should be assessed on how well they demonstrate these domains while participating in HPS (Scheckel, 2009). Evaluation rubrics for the assessment of nursing students performance should provide insight into the cognitive, psychomotor, and affective learning outcomes to provide the total picture of student learning (Kardong-Edgren et al., 2010). Therefore, each of the rubrics will be described including their psychometric characteristics. In 2006, Clark developed a Clinical Simulation Grading Rubric to evaluate student outcomes during an obstetrical HPS. Clark (2006) emphasized the rubric was applicable to HPS experiences other than obstetrics. Clark (2006) incorporated Benner s (1984) novice-to-expert theory into the rubric as the theoretical base. Also, five of Bloom s cognitive domain categories were integrated into the rubric for the language base for the rubric including the words knowledge, comprehension, application, analysis, and synthesis. The task-specific rubric involves faculty evaluations of student performance during an HPS scenario in six categories. These categories include patient assessment, history gathering, critical thinking, communication, patient teaching, and laboratory data and diagnostic studies collection. The faculty member objectively rates the student s performance on a scale of 1 to 5. Total assigned scores can range from 6 to 30. Each performance level has specific behaviors that must be observed for the student to achieve a specific score. Higher scores indicate a stronger response to the scenario and measure appropriateness of the care provided by the student. Furthermore, the rubric allows nursing faculty to assess levels of nursing experience in students. Nursing students who achieved a lower score were thought to have brought a lower or beginning level of nursing experience to the HPS experience. Content validity was established with a panel of experts. When the rubric was used for student outcomes assessment, interrater reliability was reported as 0.64 to 0.74 (Gantt, 2010). Gantt (2010) reported using the Clinical Simulation Grading Rubric for performance evaluations of nursing students in simulations from associate degree and baccalaureate degree programs. While using the rubric, Gantt (2010) discussed some pros and cons of the rubric. There was a problem with faculty readily assigning scores at the beginning of HPS scenarios. This problem was easily addressed by ensuring faculty were familiar with the HPS scenarios and grading rubric before actual student observations were made. Also, Gantt (2010) found that the addition of focused documentation and questions to the end of the rubric led to further clarification of student rationales for their behavior within the scenario, which led to a more accurate score assignment by faculty. Finally, Gantt (2010) indicated the establishment of interrater reliability by faculty assessors before student assessment was crucial for consistent grading and Journal of Nursing Education Vol. 50, No. 11,

4 HUMAN PATIENT SIMULATION EVALUATION establishing a cut-off score for what constituted a passing grade for student performance. Herm, Scott, and Copley (2007) developed a Simulation Evaluation Rubric that was based on clinical course objectives from two adult nursing courses that were thought to be essential for successful faculty evaluation of student HPS performance. These key concepts included cognitive and psychomotor domains of critical thinking and decision making, as well as psychomotor skills. The final simulation rubric consisted of eight categories for assessing students learning outcomes with HPS. These eight categories were safety, communication and professional boundaries, physical assessment, interventions, pain assessment, administration of medications, documentation, and critical thinking and decision making (Herm et al., 2007). Each category had specific subscales of specific behaviors related to the major concept. For example, the safety competency included identifying the patient, hand washing, use of body mechanics, and patient safety measures. Each of the categories was scored dichotomously as met or not met (Herm et al., 2007). However, no explanation was provided on what percentage of essential concepts was required for a student to have demonstrated mastery of the entire competency. The authors reported consistency between faculty raters for the rubric, but no specific reliability data were reported. No validity data for the rubric were reported. The Lasater Clinical Judgment Rubric was developed to evaluate single episodes of clinical judgment during an HPS scenario by nursing students (Lasater, 2007). The author used Tanner s (2006) clinical judgment model for the framework of the rubric. The rubric contains four phases of clinical judgment: noticing, interpreting, responding, and reflecting. These four phases encompass the major components of clinical judgment found in complex patient situations that nursing students will encounter as they evaluate changes in patient status and experience novice reactions concerning an appropriate plan of action for providing patient care (Lasater, 2007). Furthermore, this rubric contained the cognitive, psychomotor, and affective domains of learning. There were 11 total dimensions of each four phases of clinical judgment that were scored as exemplary, accomplished, developing, or beginning. The noticing dimension focused on observation, recognition of deviation, and information seeking by students. The interpreting dimension included prioritizing data and interpreting data. The responding dimension focused on mannerisms, communication skills, interventions/flexibility, and use of nursing skills. The reflecting dimension included evaluation and plan for improvement. The assigned scores ranged from 5 to 33, with a maximum of 44 indicating exemplary performance (Lasater, 2007). Although the author provided a range of scores for the rubric, the scoring system was not clearly described. Reliability and validity data were not provided for the rubric. In 2007, Radhakrishman, Roche, and Cunningham developed an evaluation rubric entitled the Clinical Simulation Evaluation Tool (CSET). The CSET was based on clinical practice parameters and examined these parameters during more complex HPS scenarios that involved two patients. The rubric s clinical performance categories included safety and communication; assessment and critical thinking; diagnosis and critical thinking; interventions, evaluation, and critical thinking; and reflection and critical thinking (Radhakrishman et al., 2007). These categories encompassed the cognitive and psychomotor learning domains. Each of these categories contained subscales of required behaviors that students had to meet. For example, under safety and communication, the student had to perform proper hand hygiene before patient care for each patient. As students met the expected behaviors, points were (or were not) assigned on the tool. The total number of possible points that could be awarded was 68, with a higher score indicating better clinical performance. No cut-off score for a passing performance was provided, nor were any reliability or validity data reported. Todd, Manz, Hawkins, Parsons, and Hercinger (2008) produced an evaluation rubric that assessed student performance during HPS. The authors based the Simulation Evaluation Instrument on specific behaviors identified by the AACN core competencies document produced in These behaviors demonstrated the cognitive, psychomotor, and affective domains of learning and included critical thinking, communication, assessment, and technical skills (Todd et al., 2008). The authors identified 22 additional behaviors for rubric inclusion and categorized theses under one of the four AACN behaviors. For example, under the main heading of assessment, obtains pertinent subjective and objective data was included as a subheading, along with performing a systematic follow-up assessment (Todd et al., 2008). The authors noted that each behavior was scored as either 0, if the student did not meet the competency, or 1, if the competency was demonstrated. Also, the competency could be scored as not applicable. To obtain a final score, the number of items deemed as applicable to the HPS scenario was multiplied by However, what denoted a passing grade for the evaluation rubric was clearly described by the authors as 75%. Content validity was established with a panel of experts. Interrater reliability was reported as 0.84 to In 2008, Gore, Hunt, and Raines described the development of the Safe Human Patient Simulation and Clinical Evaluation Tool. No information about the theoretical basis of the rubric was provided. The evaluation tool was author-developed and included measurable objective categories for scoring students. These categories included safety and communication; assessment and critical thinking; diagnosis and critical thinking; interventions, evaluation, and critical thinking; and reflection and critical thinking. Each of these categories included subcategories of required behaviors. These behaviors reflected the cognitive and psychomotor learning domains. For example, under safety and communication, students needed to perform hand hygiene before and after patient care. The possible scores ranged from 0 to 38, with higher scores indicating better clinical performance. No cut-off score for a passing grade was provided, nor were reliability or validity data provided. MEASUREMENT OF THE ESSENTIALS Supporting the curricular framework proposed by the AACN, when faculty integrate HPS into the curriculum, positive nursing student learning outcomes must be documented. Each Essential has specific content that builds on one another to provide an optimal learning environment for baccalaureate-prepared 608 Copyright SLACK Incorporated

5 DAVIS & KIMBLE nurses. The rubrics that are structured around meeting the essentials have the ability to provide evidence of positive student learning outcomes via HPS outcomes evaluation. With the development of the Clinical Simulation Grading Rubric, Clark (2006) successfully provided a rubric that measured several of the Essentials. Essential I was seen in the overall persona of the rubric due to its ability to measure intellectual and practical skills that are at a higher order of thinking. Liberal education has provided this level of critical thinking to baccalaureate-prepared students. Furthermore, this rubric involves the cognitive domain that incorporated inquiry, analysis, critical thinking, and communication for evaluation (AACN, 2008). The rubric evaluated Essential II by whether the student has recognized assessment changes for the provision of safe nursing care. Essential III was measured as the rubric assessed the evaluation of outcomes of the patient care provided by the student. Essential IV was measured as students successfully integrated the use of patient monitors in their assessment, due to the demonstrated use of patient technology. Finally, Essential VI was measured as the rubric evaluated whether the student had appropriately reported patient condition changes to other members of the health care team. The Simulation Evaluation Rubric developed by Herm et al. (2007) further demonstrated the measurement of the Essentials. As with the previous rubric, Essential I was integrated into the rubric through the demonstration of liberal education skills. Safety during medication administration was used to measure Essential II. Essential III was integrated into the rubric as the student used current evidence and clinical judgment into the practice of medication administration based on patient situations. Furthermore, Essential VI was measured as the nursing student worked with interprofessional teams regarding medication side effects. The Lasater Clinical Judgment Rubric (Lasater, 2007) also successfully integrated the Essentials into the rubric. Essential I was measured as the inclusion of the evaluation of inquiry, analysis, critical thinking, and communication into the rubric (AACN, 2008). Essential II was measured as the rubric looked at ways in which the student displayed leadership and safety in planning appropriate care and interventions for a patient. To measure the ability to integrate evidence-based practice by a student as delineated by Essential III, the rubric evaluated students for the ability to evaluate patient outcomes to the care provided and compared the outcomes to nursing knowledge, research, experience, and intuition (Lasater, 2007). Essential IV was evaluated as the rubric incorporated whether students monitored objective data. Essential VI was measured as students were evaluated for their ability to work within health care teams. Finally, Essential VIII was measured with the inclusion of the student s ability to perform a self-analysis of their nursing performance that indicated willingness to ongoing improvement and professional nursing values. The Clinical Simulation Evaluation Tool developed by Radhakrishman et al. (2007) included the measurement of the Essentials. As with the prior evaluation rubrics, Essential I was measured with the provision of liberal education qualifications. Specifically, these elements included critical thinking and communication specifically (AACN, 2008). Patient and TABLE Summary of Evaluation of Identified Rubrics Safe Human Patient Simulation & Clinical Evaluation Tool Simulation Evaluation Instrument Clinical Simulation Evaluation Tool Lasater Clinical Judgment Rubric Simulation Evaluation Rubric Clinical Simulation Grading Rubric Rubric Characteristics Reviewed None reported None reported None reported Interrater reliability: 0.85 to 0.89 Interrater reliability: established Reliability Interrater reliability: 0.64 to 0.74 (Gantt, 2010) Yes No No No Yes No Validity established Cognitive, psychomotor Cognitive, psychomotor Cognitive, psychomotor, affective Cognitive Cognitive, psychomotor Cognitive, psychomotor, affective Leaning domain evaluated Essential I X X X X X X Essential II X X X X X X Essential III X X X X X X Essential IV X X X X Essential V Essential VI X X X X X Essential VII Essential VIII X X Journal of Nursing Education Vol. 50, No. 11,

6 HUMAN PATIENT SIMULATION EVALUATION student safety were measured for Essential II. Essential III was an evaluation of the ability of the student to ensure interventions of care translated current evidence into practice. Finally, Essential VI was measured by whether students practiced delegation to other members of the health care team. In the Simulation Evaluation Instrument developed by Todd et al. (2008), Essential I was measured as students integrated their intellectual and practical skills that were on a higher level of critical thinking to perform accurate patient assessments (AACN, 2008). A focus on medication administration safety allowed for the measurement of Essential II. Evidence-based practice has been evaluated in the rubric with the inclusion of whether nursing students performed appropriate procedures that were based on current evidence for skill performance. Essential IV was measured as whether nursing students used patient equipment appropriately. Communication within the health care team was evaluated in the rubric that measured Essential VI. As nursing students were evaluated on their promotion of realism and professionalism, Essential VIII was included in the rubric. As with the prior rubrics, the inclusion of liberal education for the provision of critical thinking in Essential I was measured in the Safe Human Patient Simulation and Clinical Evaluation Tool developed by Gore et al. (2008). Furthermore, Essential II was evaluated in the tool as students were assessed for the inclusion of patient safety practices in the provision of nursing care. Essential III promoted the inclusion of evidence into practice, as well as the evaluation of outcomes of care. This tool included both of these elements as students were evaluated. Finally, Essential IV was measured when nursing students were assessed for the accurate utilization of personal digital assistants (PDAs) for the retrieval of medication administration information. The Table summarizes the information contained in the rubrics. BACCALAUREATE ESSENTIALS NOT MEASURED BY THE RUBRICS Essentials V and VII were not measured by any of the rubrics. Essential V entails the aspects of health care policy, finance, and regulatory environments (AACN, 2008). This aspect of nursing has the potential to be vital to the success of the future of nursing as health care continues to experience change in the provision of patient care. Therefore, an evaluation rubric should be developed that has integrated the evaluation of a working knowledge of this information. Nurses with a knowledge base inclusive of the organization of health care services, reimbursement, and regulatory agencies will be instrumental for the future of health care. As nurses understand this complex topic, they will be influential in shaping the environment, quality, and safety of the environment in which they will practice (AACN, 2008). Furthermore, as nurses become more involved with this process, the caring values of the profession will be inclusive in health care policies for the assurance of advocacy for all patient populations. Clinical prevention and the health of the population was defined by Essential VII (AACN, 2008). According to The Essentials, the promotion of health, disease, and the prevention of injury across the patient s lifespan are essential elements that should be included into baccalaureate nursing practice at all levels (AACN, 2008). Therefore, the inclusion of Essential VII should be integrated into the evaluation rubrics for HPS. Several of the evaluation rubrics included the evaluation of patient teaching. However, the teaching was not on a tertiary level. The evaluation of tertiary prevention could be included and evaluated as a nursing student performed discharge care if the HPS scenario were designed in this manner. Also, prevention at the community level was not seen in the evaluation rubrics. Both of these aspects of nursing should be included in the evaluation of Essential VII due to the nature of health care. As previously stated, health care has been in a state of constant change. As nurses evaluate these changes, the need to provide care in arenas other than the hospital should be considered. As patients continue to live longer with chronic diseases, the need for community care will be an integral aspect of nursing. CONCLUSION Human patient simulation has been increasingly used in nursing education to meet the variety of challenges that are faced by today s nursing faculty. As HPS has grown in use, so has the need and desire for reliable and valid evaluation rubrics to reinforce the value of this technologically advanced teaching tool. At this point in nursing educational research, there were several rubrics located for student learning outcome evaluation. However, the majority of the rubrics were in pilot form. The rubrics needed additional psychometric development to provide evidence that they are reliable and valid rubrics. In addition, the rubrics did not thoroughly address each of the domains of learning that are essential to student learning and nursing practice; the affective domain was only addressed in two of the rubrics. Therefore, developers of future rubrics should make every attempt to integrate all three domains of learning within the evaluation. Further refinement might also include behaviors reflecting Essentials V and VII. For HPS to achieve its full potential as a teaching modality, strong evaluation methods will be required. Until HPS is rigorously evaluated, HPS integration into nursing curricula will continue to be the roller coaster ride of anecdotal acceptance rather than evidence-based integration into nursing education. REFERENCES Akhtar-Danesh, N., Baxter, P., Valaitis, R.K., Stanyon, W., & Sproul, S. (2009). 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Clinical Simulation in Nursing, 4, e57-e64. doi: /j.ecns Copyright SLACK Incorporated

7 Herm, S.M., Scott, K.A., & Copley, D.M. (2007). Sim sational revelations. Clinical Simulation in Nursing Education, 3, e25-e30. doi: / j.ecns Kardong-Edgren, S.E., Adamson, K.A., & Fitzgerald, C. (2010). A review of currently published evaluation instruments for human patient simulation. Clinical Simulation in Nursing, 6, e25-e35. doi: / j.ecns Kardong-Edgren, S.E., Starkweather, A.R., & Ward, L.D. (2008). The integration on simulation into a clinical foundations of nursing course: Student and faculty perspectives. International Journal of Nursing Education Scholarship, 5(1), Lasater, K. (2007). Clinical judgment development: Using simulation to create an assessment rubric. Journal of Nursing Education, 46, Nehring, W.H., & Lashley, F.R. (2004). Current use and opinions regarding human patient simulators in nursing education: An international survey. Nursing Education Perspectives, 25, Radhakrishnan, K., Roche, J.P., & Cunningham, H. (2007). Measuring clinical practice parameters with human patient simulation: A pilot study. International Journal of Nursing Education Scholarship, 4(1), Scheckel, M. (2009). Selecting learning experiences to achieve curriculum outcomes. In D.M. Billings & J.A. Halstead (Eds.), Teaching in nursing: A guide for faculty (3 rd ed., pp ). St. Louis, MO: Elsevier Saunders. Stevens, D.D., & Levi, A.J. (n.d.). Introduction to rubrics: An assessment tool to save grading time, convey effective feedback and promote student learning. Retrieved from overview.html Tanner, C.A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45, Todd, M., Manz, J.A., Hawkins, K.S., Parsons, M.E., & Hercinger, M. (2008). The development of a quantitative evaluation tool for simulations in nursing education. International Journal of Nursing Education Scholarship, 5(1), 1-17.