









































Volume 6 - No. 6 2018

Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 6 - No. 6 2018 

Anesthesia eJournal - Online
ISSN 2333-2611

Page 26

Using Video-Assisted Technology and Simulation to Transform a Nurse Anesthesia 
Machine and Equipment Course
Rachel Marie Smith-Steinert, DNP, CRNA1

Melissa Willmarth-Stec, DNP, CNM, APRN, FACNM, FAAN2

Affiliation:
1.  Assistant Program Director-Nurse Anesthesia, University of Cincinnati, College of Nursing
2.  Professor & Associate Dean for Evaluation and Educational Innovation, SUNY Downstate College of Nursing 

Funding/Conflict of Interest Disclosure: 
The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest

KEYWORDS: anesthesia, simulation, anesthesia machine, nurse anesthesia curriculum, nurse anesthesia

INTRODUCTION
Anesthesia safety has dramatically improved, and morbidity and mortality directly related to anesthesia are uncommon. 
Human error related to the misuse of the anesthesia machine and equipment, however, remains at 14% to 30% of all 
intraoperative problems.1 According to the American Society of Anesthesiologists Closed Claims Project database, injury 
claims related to anesthesia machines have decreased to 1% of total claims but the results continue to be disastrous.2 Patient 
outcomes in anesthesia-machine-related claims from 1990 to 2011 (n = 40) included anesthesia awareness (n = 9, or 23%), 
pneumothorax (n = 7, or 18%), and severe injury (death or permanent brain damage). The majority of these claims (85%) 
involved provider error with (n = 7) or without (n = 27) equipment failure.2 Understanding how to use the anesthesia 
machine and how to troubleshoot when problems arise are paramount for nurse anesthesia practice.

Abstract
Introduction: Understanding how to use the anesthesia machine and how to troubleshoot when problems arise are 
paramount for nurse anesthesia practice. Simulation can provide a low-risk setting that allows students to learn in an 
environment representative of operational conditions. The purpose of this article was first to determine if simulation was 
an appropriate teaching modality to incorporate into the anesthesia machine course and second to explore the outcomes 
of utilizing such a modality in a traditional course.
Methods: This 2 group post-test design measured anesthesia machine learning in a traditional classroom and after intro-
duction of simulated operating room experiences. Using the Food and Drug Administration (FDA)-approved anesthesia 
machine checklist, a simulation exercise was formulated to review the basic function of the machine. Students were divid-
ed into groups and taken to the hospital operating room twice. The first session reviewed the FDA checklist and focused 
on the components and their intended usage and proper function. The second session discussed plausible machine failure 
scenarios. Three written exams, a final oral exam, and course evaluations were used to measure pre- and post-exercise 
mastery of material, competency, student satisfaction, and confidence.
Results: There were no statistical differences in mastery of material or competency with the modified course. However, 
student satisfaction and perceived confidence increased.
Conclusion: Use of simulation in the nurse anesthesia machine and equipment course allowed students to practice infre-
quent events that have grave consequences. Changing the way that nurse anesthesia programs teach this course could not 
only provide safer, more competent providers but also improve anesthesia safety overall.

AEJ



Anesthesia eJournal                         www.anesthesiaejournal.com
Volume 6 - No. 6 2018 Page 27

One of the first courses in any nurse anesthesia curriculum is 
focused on the safe use of the anesthesia machine and equipment. 
Novice nurse anesthesia students must have a firm understanding 
of the function of the machine to begin to learn how to safely 
provide anesthesia. Traditionally, anesthesia machine and 
equipment courses have been taught with a didactic focus 
reinforced with some clinical observation time to see how the 
machine is used. The course can be difficult for students for 
numerous reasons. Students have usually had little to no exposure 
to anesthesia machines as registered nurses. The properties 
that guide the design and use of the machine are rooted in 
principles of chemistry and physics, both of which are scant in 
undergraduate nursing programs. The value of early observation 
time has been questioned owing to the novice student’s lack 
of anesthetic knowledge. Varying teaching modalities must be 
considered to ensure students master this vital material.
The most recent Institute of Medicine initiative, The Future of 
Nursing, endorses simulation as a teaching methodology of the 
future.3 Simulation can provide a low-risk setting that allows 
students to learn in an environment representative of actual 
operational conditions.4 A course using simulation and active 
learning exercises was created for novice nurse anesthesia students 
to improve course delivery and achievement of the student 
learning outcomes. The goals of this program were to increase 
understanding of the material, increase the students’ active 
participation, improve written and oral exam results, and improve 
student evaluations of the course. The purpose of this article was 
first to determine whether simulation was an appropriate teaching 
modality to incorporate into the anesthesia machine course and 
second to explore the outcomes of utilizing such a modality in a 
traditional course.
Malcolm Knowles, an American educator, is credited with the 
theory of andragogy, that is, the art and science of helping adults 
learn.5 Knowles believed that 6 factors distinguish the adult 
learner. Self-directedness; accumulation of past experience, which 
becomes a resource for learning; readiness to learn; application 
of knowledge, which is problem-centered; internal motivation 
to learn; and the need to know why something should be 
learned all shape the adult learner.6 Knowles’s assumptions of 
the adult learner are applicable to nurse anesthesia students. 
These assumptions of adult learning are often in conflict with 
a traditional, teacher-centered approach of didactic lecturing. 
In order for one to effectively teach adults, one must know how 
adults learn.
Clapper7 states in his review of literature concerning adult 
learning theory that adults learn from experience in a way that 
is simply not possible from instruction or information delivery 
alone. Clapper advises educators to put away PowerPoint 
(Microsoft) slide presentations and instead use project-based 
learning to teach for understanding. Clapper writes that health 
profession educators must move past old methodologies, despite 
their utility in the past.7

As Curtin et al8 explain in their qualitative review of a simulation 
program, the 4 learning styles—visual, auditory, tactile, and 
kinesthetic—are all incorporated in a simulation activity. The 
authors explain how simulation promotes the learner’s knowledge 
acquisition on a deeper level by the activity of active participation. 

Likewise, Lasater et al9 describe how the active role permits 
deeper learning: understanding more, remembering longer, and 
more success in evaluation. In order for students to really learn, 
Lasater et al9 state that educators must provide an environment 
that is proper for learning and resides in adult learning theory. 
Zigmont6 also reiterates that simulation can allow a learner to 
move from basic knowledge to application, analysis, and finally 
synthesis, the highest level of comprehension. Simulation adheres 
to the 2 most important tenets of adult learning: hands-on 
experience in a safe environment and provided guided reflection.6

When reviewing the literature concerning the incorporation 
of simulation into curriculum, Issenberg et al’s10 expansive 
systematic review of 109 articles spanning from 1969 to 2003 
must be included. High-fidelity simulation is demonstrated to be 
educationally effective and complements but does not duplicate 
medical education in patient care settings.10 Issenberg at al10 state 
that simulation is best served to prepare learners to care for real 
patients. This review explains that simulation is an excellent tool 
to facilitate learning under the right quality conditions.
Grant et al11 echo the use of simulation in preparation for direct 
patient care, showing positive outcomes for learners involved 
in simulation activities before clinical practice commences. 
In a systematic review and meta-analysis by Cook et al,12 a 
comparison with no intervention and technology-enhanced 
simulation training in health profession education was examined. 
A follow-up systematic review was performed by Cook et al13 that 
reviewed 82 studies and included 3498 participants. This article 
showed that simulation-based medical education (SBME) is an 
effective instructional design feature. The authors concluded that 
educators should consider using this approach.13

In McGaghie et al’s14 systematic review, the meta-analysis was 
clear and unequivocal. Outcomes favor SBME, and a growing 
body of evidence suggests that clinical skills acquired via SBME 
transfer directly to patient care. The authors concluded that 
enhancement of the traditional clinical educational model with 
evidence-based practice like SBME should be a high priority for 
medical education policy and research.14

Learner satisfaction, confidence, and perceived competence 
are factors that are often discussed in the literature on the 
outcomes of simulation. In Harder’s15 systematic review, 23 
articles are reviewed that discuss the use of simulation in health 
profession education. In 21 of the studies, students evaluated 
their confidence and perceived skill level higher than did those 
who did not participate in simulations. Laschinger et al16 
specifically reviewed confidence, knowledge, and satisfaction 
in their systematic review. Learner satisfaction was increased 
with simulation when used to learn clinical skills, with learners 
reporting that the models made learning easier.16 Ruesseler et al17 
looked at the satisfaction of medical students after simulation 
training versus traditional clinical teaching. Statistically 
significant increases in satisfaction were noted for those students 
who completed simulations.17

A paucity of literature is available examining simulation use in 
nurse anesthesia education. However, in studies with anesthesia 
residents as participants, simulation has been demonstrated to 
be effective. Mudumbai et al18 examined anesthesia residents in 
a prospective, descriptive study that evaluated basic anesthesia 



Anesthesia eJournal                         www.anesthesiaejournal.com
Volume 6 - No. 6 2018 Page 28

machine function and proper use. The authors created 
simulation scenarios in which participants had to troubleshoot 
machine malfunction in pairs. The authors suggested high-
fidelity simulation as a means to teach trainees equipment and 
machine function and examine management during a machine 
malfunction crisis. Park et al19 looked at crisis management in 
the novice anesthesia resident. Anesthesia residents completed 
either a traditional curriculum or one with added simulation 
to study infrequent but catastrophic events during anesthesia 
management. Hypotheses were confirmed that the addition of 
event-specific simulation accelerated the management skills for 
that specific event.19

METHODS
Institutional review board (IRB) approval was achieved before 
implementing this project. The project was granted IRB exemption 
status owing to its quality improvement nature. Consent was not 
necessary from participants owing to the quality improvement 
nature of the project; however, participants were informed of 
the project details, and clear objectives and desired outcomes 
were discussed. The setting of this project was a nurse anesthesia 
program in a college of nursing within a large, urban university. 
Students included in this project were 25 first-semester, novice 
nurse anesthesia students enrolled in the anesthesia machine and 
equipment course. Additionally, the students were registered nurses 
with 2 to 5 years of critical care nursing experience.
Planning for this project began 2 years before implementation, 
with a formal needs assessment. Students (n=25) completed 
a comprehensive survey in which they were asked, at the 
completion of the course, what could have made the material 
easier to comprehend. Students stated (84% of respondents) that 
machine component and function were difficult to understand 
when lectured on in class. Students requested to see a “live” 
machine function and malfunction in a safe environment. 
Additionally, faculty responses were solicited. All faculty (n=6) 
stated that simulation was an area the program needed to 
develop and explore how to incorporate into the curriculum. The 
director stated that program applicants often inquired about the 
use of simulation and its role in clinical preparedness. Developing 
simulation usage in the program was seen as paramount by 
the nurse anesthesia faculty. These results demonstrated the 
faculty’s desire to implement simulation as a component in the 
curriculum. Current students desired more hands-on time during 
the machine course and believed that additional time working 
on the machine checkout would improve comprehension and 
knowledge retention.
On the basis of these data, several changes were made to the 
anesthesia machine course. These changes were supported by 
the literature on adult learning theory and simulation utilization 
in health care education. Previously, the students spent the first 
weeks of the semester in the operating room. This activity was 
eliminated, which allowed more time for more active learning 
exercises with live machines. The course was examined to 
determine which lectures could be transferred from in-class 
lecture to an online delivery format. Lectures covering basic 
scientific principles, patient equipment, and fire and electrical 
safety were chosen for video conversion, thus decreasing lecture 
time by 16 hours.

Using the anesthesia machine checklist approved by the Food 
and Drug Administration (FDA), an active learning exercise 
was formulated to review the basic function of the machine. 
Students were divided into 4 groups with 6 students per group 
and were taken to the operating room twice for 1-hour periods. 
Participants were encouraged to watch an online video covering 
the basic FDA checkout of the Fabius GS anesthesia machine 
(Draeger) before their scheduled session. Each session was 
completed in small groups led by an instructor. The first session 
reviewed the FDA checklist with a focus on the components and 
their intended usage and proper function. Students reviewed the 
checkout procedure once, step by step, to show the appropriate 
function of each component of the machine. Students were able 
to ask questions and discuss each component (Figure 1). The 
second session discussed plausible machine failure scenarios. 
Students were then provided hands-on time to work in small 
groups to review the checkout procedure. Checklists using the 
FDA checkout of the anesthesia machine and possible anesthetic 
emergencies related to equipment error and misuse provided 
structure for these exercises (Figure 2).
During the modified course, the students completed the existing 
3 written exams given in the initial course. At the completion of 
the course, a uniform oral exam was conducted in the operating 
room during which students completed the FDA checklist 
from memory to demonstrate safety and proper function of the 
machine and answered questions on machine and equipment 
failure scenarios. Students simulated checking the machine, 
determining its safety for use, and preparing for the induction of 
a patient by using a low-fidelity mannequin. At the completion 
of the exam, the exercise was reviewed and students were given 
feedback on their performances. Time was also allotted for 
student questions to be answered.
The written exams, final oral exam, and student evaluations 
of the course were evaluated after implementation of the new 
curricular changes. The outcomes measured were mastery of 
material, competency, and student satisfaction and confidence. 
Mastery of course material was demonstrated by the 3 written 
exams. Competency using the anesthesia machine and 
troubleshooting problems with its function was shown in the 
oral exam performance. Student evaluations of the course were 
used to measure student satisfaction and confidence. Means 
of the results of the written and oral exams were compared by 
using an unpaired t-test to determine statistical differences 
after implementation of the program. Qualitative data from the 
student evaluation of the course were used to measure student 
satisfaction before and after implementation of the simulation 
and active learning exercises.
RESULTS
This quasi-experimental, nonequivalent control group design 
compared 2 groups of students: students from the previous 
semester enrolled in the lecture-based course and students from 
the simulation and active learning integrated course. Written 
exam scores were used to demonstrate student mastery of course 
material. The mean scores on the written exam for the pre-
intervention group were 81.36% for exam 1 (SD=4.58), 84.0% 
for exam 2 (SD=6.89), and 86.08% for exam 3 (SD=4.31). In 
the modified course, the mean scores for the written exams were 



Anesthesia eJournal                         www.anesthesiaejournal.com
Volume 6 - No. 6 2018 Page 29

80.36% for exam 1 (SD=3.77), 80.43% for exam 2 (SD=6.32), 
and 84.96% for exam 3 (SD= 6.36). An unpaired t-test was 
used to determine whether the changes in exam scores were 
statistically significant. For all 3 written exams, there was no 
statistically significant difference in scores from before to after 
the intervention. Therefore, mastery of the course material was 
unchanged.
Results of the oral exam were used to demonstrate competency in 
troubleshooting and determining functionality of the anesthesia 
machine in the lecture-based course as well as the simulation 
and active learning integrated course. The mean result on the oral 
exam before the intervention was 92.5% (SD= 4.89) and that 
after the intervention was 94.25% (SD= 5.06). Using the unpaired 
t-test, the difference between the 2 groups was statistically 
insignificant. Thus, the ability to demonstrate competency after 
the course was modified was unchanged.
University course evaluations are used annually to determine 
student satisfaction with the course and to give students an 
opportunity to give feedback to the instructor. These qualitative 
and quantitative data are compiled at the conclusion of the 
course. Before the intervention, 82% of the students agreed with 
the statement that “course material was presented at an adequate 
pace.” Qualitative data after intervention revealed statements such 
as:

• “Reviewing the machine checkout in small groups would be 
helpful. This information was overwhelming.”

• “I think I would retain more information if I could have 
touched the machine.”

• “It’s difficult to see and hear the components of the machine 
with 25 people in the room.”

• “It would be nice to go over the checkout and have more 
hands-on time.”

Nine of 25 students (36%) commented on the need for more 
hands-on time with the machine and the instructor.
After changes were made to the course, 91.7% (n=12) of the 
respondents strongly agreed with the statement, “[the] course 
material was presented at an adequate pace,” and 100% of 
the respondents strongly agreed with the statements, “this 
course strengthened my knowledge base and clinical skill as an 
anesthesia provider” and “physical and learning resources were 
adequate to meet course objectives.” Qualitative data included:

•  “Going to the OR [operating room] in small groups was 
beneficial.”

• “I feel adequately prepared to manage the machine.”
• “Going to the OR with the instructor, for hands-on time with 

the machines, was helpful.”
Overall, the qualitative data showed increased satisfaction with 
the course and improved confidence of the students after the 
active learning exercises.
DISCUSSION
The results of this quality improvement initiative indicated that 
the use of simulation in the machine course was beneficial to 
student outcomes. Although the results were equivalent in terms 

of mastery of information and demonstrated competency on the 
basis of the results of the written and oral exams, improvements 
were noted in active participation, student satisfaction, and 
confidence with program implementation. Similar improvements 
were noted by Harder15 and Lashinger et al.16 These results and 
the literature support the use of simulation and active learning 
exercises in the anesthesia machine and equipment course.
The limitations of this project include threats to internal validity 
such as selection bias. The design did not allow the same groups 
of students to be surveyed on both courses, before and after the 
intervention, because of the nurse anesthesia curriculum. Each 
group of anesthesia students is composed of different age groups, 
genders, previous experiences, and learning styles. Therefore, the 
group comparison was also biased by the composition of the class. 
Additionally, only first-year, novice nurse anesthesia students 
are enrolled in the course. Although the student input from the 
evaluations was helpful, this was the first course the students 
had taken in the nurse anesthesia program. Therefore, they did 
not have other nurse anesthesia machine courses with which to 
compare this experience. Threats to external validity were minimal 
because cohorts of nurse anesthesia students nationwide are 
required to meet similar standards for admission into programs. 
Therefore, this sample can be considered representative of cohorts 
across programs.
This intervention was strongly based on the addition of 
simulation to the course. For most of this project, the simulation 
laboratory was in its formative phase, under construction, with 
equipment slowly being purchased. Low-fidelity mannequins 
were used because of their portability to the operating room. 
More realistic and accurate scenarios should be developed 
with high-fidelity equipment. Simulation equipment and 
laboratory space is an immense investment for programs; high-
fidelity mannequins cost close to $100,000. The cost benefit 
for anesthesia programs must be evaluated before making this 
investment.
There exists a paucity of research using computer adaptive 
technology and simulation in nurse anesthesia curricula. Any 
research in this field will advance this area of study. Future areas 
to further develop this project would include increased lectures 
online, availability of videos covering machine troubleshooting, 
and further troubleshooting scenarios with higher fidelity 
mannequins. Developing more realistic scenarios incorporating 
rare events such as power outages, machine failure, and various 
equipment malfunctions could give novice students experience 
that they may never encounter in their training with live 
patients in the operating room. Recording the oral exams and 
allowing students to watch their performance may also aid in the 
debriefing phase and provide more valuable feedback.
Simulation has been shown in the literature to improve the 
performance of health care providers, providing valuable 
experience in a low-risk setting. Although rare, anesthesia 
machine and equipment errors can result in disastrous 
consequences, causing patient injury and death. The Institute of 
Medicine’s20 recent report describes the importance of improving 
patient safety in health care through the use of educational 
technologies to improve teaching and competence. Use of 
simulation in the nurse anesthesia machine and equipment course 



allows students to practice infrequent events that have grave 
consequences. Changing the way nurse anesthesia programs 
teach this course could not only provide safer, more competent 
providers but also improve anesthesia safety overall.
SUMMARY OF KEY POINTS
Simulation has been shown in the literature to improve the 
performance of health care providers, providing valuable 
experience in a low-risk setting. Although rare, anesthesia 
machine and equipment errors can result in disastrous 
consequences, causing patient injury and death. 

• Understanding how to use the anesthesia machine and 
troubleshoot when problems arise is paramount for nurse 
anesthesia practice.

• Use of simulation in the nurse anesthesia machine and 
equipment course allows students to practice infrequent 
events that have grave consequences.

• Although increased mastery of material was not demonstrated 
to improve, confidence and satisfaction were increased.

• Changing the way nurse anesthesia programs teach this 
course could not only provide safer, more competent 
providers but also improve anesthesia safety overall.

Simulation Session One Activities
• Reviewed all steps of FDA Anesthesia Machine Checkout Procedure
• Demonstrated automated and manual check of anesthesia machine
• Located backup cylinder supply and emergency airway equipment
• Discussed location and proper function of the following internal components

1. Cylinder supply (high pressure leak determination)
2. First stage regulator
3. Oxygen flush
4. Flowmeters
5. Pressure sensor shutoff valve
6. Oxygen supply alarm
7. Proportioning system
8. Auxiliary flowmeter

• Reviewed proper function and check of the following external components
1. Vaporizer (filling, changing, checking for a leak, competency)
2. Absorber (changing canister, determining exhaustion & desiccation)
3. Ventilator
4. Scavenger system (suction supply, competency of positive and negative pressure relief 

valves)
5. Breathing system (low pressure leak determination)

• Reviewed setting and tested function of following alarms
1. Positive pressure alarm
2. Volume alarms
3. Pressure alarms
4. Subatmospheric pressure alarm
5. Oxygen analyzer
6. Machine power failure alarm

• Reviewed function of various OR tables
• Reviewed inclusion of ASA monitors and determined competency

Figure 1. Simulation Session One on the Fabius GS Anesthesia Machine (Draeger).
Abbreviations: ASA, American Society of Anesthesiologists; FDA, Food and Drug Administration; OR, oper-
ating room.

Anesthesia eJournal                         www.anesthesiaejournal.com
Volume 6 - No. 6 2018 Page 30



Simulation Session Two Activities
• Discuss and demonstrate possible machine component failures and troubleshooting

1. Look for vaporizer and nitrous flowmeters being “left on”
2. Troubleshooting machine automated tests (internal software checks)
3. Calculating oxygen cylinder and emergency supply
4. Deciphering safety of pipeline supply
5. Determining conditions when one would switch from pipeline to cylinder supply
6. Troubleshooting suction issues
7. Replace all “missing hoses” correctly
8. Mimic obstruction in ventilator hoses (clinical scenarios when this might occur)
9. Mimic obstruction in scavenger hoses (clinical scenarios when this might occur)
10.  Putting together breathing circuit components correctly
11. Replacing galvanic/paramagnetic oxygen supply monitor
12. Recognizing exhausted/expired carbon dioxide absorber canister
13. Recognize high and low pressure leaks

	Is the leak acceptable? Quantify the leak
	Where is the location of the leak?
	How to “fix” the leak

Figure 2. Session 2 on the Fabius GS Anesthesia Machine (Draeger).

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Volume 6 - No. 6 2018 Page 31



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