The benefits and best practices for simulation outlined by the International Nursing Association for Clinical Simulation and Learning (INACSL) provide a strong foundation for developing simulation programs in nursing but have lacked data on specific best practices around role creation and assignment.  

To close that gap and identify the most effective approach, a team at Baylor University developed a new strategy for role assignment in simulation using the concept of “two heads are better than one.” They detailed the findings from their pilot program in a recent article in the Journal of Nursing Education. 

What Does the Research Show?

The idea that two people working together can outperform one working independently has been around since the 1900s and has been backed by several studies. Still, researchers at Baylor believe this is the first time the concept has been applied to any healthcare simulation-based education activities.  

In traditional simulations, roles have been assigned in two main ways:

1. Students are given a primary and secondary nurse roles or,

2. Students are given predetermined roles where they are responsible for typical nursing-specific duties, including assessment, documentation, procedures, and medication administration.

Though students often point out that the distribution of tasks between multiple students isn’t a realistic representation of what happens in the field, time, space, and resource constraints often mean multiple participants must be scheduled in one simulation scenario.  

This portioning of duties encourages students to divide and conquer rather than delegate and prioritize. Unfortunately, this also can pose a challenge to ensuring that students have an equal opportunity to learn from simulation, as the benefits are often directly tied to their level of involvement.

How Does the Strategy Work?

Two students are assigned to act as one nurse in the Two-Heads-Are-Better-Than-One strategy (2HeadR>1). The two must collaborate and verbalize, using the Think Aloud (TA) technique to articulate the thinking behind their actions. When there is a difference in opinion, the two must align on a single perspective to proceed with the care of the simulated patient. If the students split off and start to work separately, they are gently reminded by the simulation facilitator over an intercom to act as one.

“Having the two students act as one nurse forces them to stick together and prioritize,” said Jeanne Carey, R.N., certified healthcare simulation educator and director of simulation at Baylor’s nursing school. “Prioritization is something they had struggled with, but it’s one of the most important skills they will need when they graduate and start practicing as a nurse.”

In a typical 2HeadsR>1 implementation, students come to the simulation center in their clinical group with their instructor, with eight students typically assigned to a four-hour block of time. The simulation facilitator explains the strategy to students in a pre-briefing session, and then numbers are drawn to determine working pairs and simulation order. When students are not actively participating, they observe a live video stream from the debriefing room down the hall. This observational portion of the simulation has the added benefit of allowing students an opportunity to analyze the scenarios in a non-pressured environment.

As the simulation continues, the simulation facilitator and clinic faculty member have three options if one of the students starts to lead the pair in the wrong direction and can choose to either allow the scenario to unfold, have the simulation education and offer cues to correct, or stop the scenario and discuss during a debriefing session.

Students who have a comfortable working relationship previous to the exercise may perform at a higher level than a team who is less familiar with the other. Likewise, similar competency levels yield better joint decisions than one individual.

After the simulation, there is a debriefing session where reflective learning gives students time to discuss alternate choices and to share their thoughts about the experience. 

What Do These Findings Mean?

Implementing the 2HeadsR>1 strategy is relatively simple as it requires similar resources to typical simulation role assignments. As a result, simulation facilitators need minimal training, and students typically acclimate to the new approach quickly.

Feedback from students and educators was overwhelmingly positive. For example, students shared comments on post-simulation evaluation forms that increased confidence and decreased anxiety because they had a peer. Similarly, facilitators and clinical faculty members reported they were able to have richer debriefing sessions since the TA technique allowed them to have insights into the thought process behind the student’s actions and, if things went wrong, to understand when and how the student’s reasoning may have gone astray.