09 simulationstudy vol40 web with cover

8/11/2019 09 SimulationStudy Vol40 Web With Cover

1/35

NCSBN RESEARCH BRIEF

Volume 40 | June 2009

The Effect of

High-Fidelity

Simulation on

Nursing Students

Knowledge and

Performance:

A Pilot Study


2/35

Report of Findings from

The Effect of High-Fidelity Simulationon Nursing Students Knowledge andPerformance: A Pilot Study

Principal Investigators

Frank D. Hicks, PhD, RN, Rush University College of Nursing, Chicago, IL

Lola Coke, PhD, RN, Rush University College of Nursing, Chicago, IL

Suling Li, PhD, RN, National Council of State Boards of Nursing, Chicago, IL

National Council of State Boards of Nursing, Inc. (NCSBN

)


3/35National Council of State Boards of Nursing, Inc. (NCSBN) | 2009

ii REPORT OF FINDINGS FROM THE EFFECT OF HIGH-FIDELITY SIMULATION ON NURSING STUDENTSKNOWLEDGE AND PERFORMANCE: A PILOT STUDY

Mission Statement

The National Council of State Boards of Nursing, composed of member boards, provides leadership to advance regulatory

excellence for public protection.

Copyright 2009 National Council of State Boards of Nursing, Inc. (NCSBN)

All rights reserved. NCSBN, NCLEX, NCLEX-RN, NCLEX-PNand TERCAPare registered trademarks of NCSBN andthis document may not be used, reproduced or disseminated to any third party without written permission from NCSBN.

Permission is granted to boards of nursing to use or reproduce all or parts of this document for licensure related purposes

only. Nonprofit education programs have permission to use or reproduce all or parts of this document for educational

purposes only. Use or reproduction of this document for commercial or for-profit use is strictly prohibited. Any authorized

reproduction of this document shall display the notice: Copyright by the National Council of State Boards of Nursing,

Inc. All rights reserved. Or, if a portion of the document is reproduced or incorporated in other materials, such written

materials shall include the following credit: Portions copyrighted by the National Council of State Boards of Nursing,

Inc. All rights reserved.

Address inquiries in writing to NCSBN Permissions, 111 E. Wacker Drive, Suite 2900, Chicago, IL 60601-4277. Suggested

Citation: National Council of State Boards of Nursing. (2009). Report of Findings from The Effect of High-FidelitySimulation on Nursing Students Knowledge and Performance: A Pilot Study. (Research Brief Vol. 40). Chicago: Author.

Printed in the United States of America

ISBN# 978-0-9822456-5-1



iiiTABLE OF CONTENTS

List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1I. Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Advantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Review of the Literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Variables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

II. Study Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

III. Research Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

IV. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Design and Sampling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Simulation only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Simulation and clinical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Clinical only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Outcome Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Knowledge Acquisition and Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Clinical Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Faculty Review of Videotaped Student Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Self-confidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Protection of Human Research Subjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

V. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Demographics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Knowledge Acquisition and Retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Clinical Performance Assessed with Standardized Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Self-confidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Course Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13VI. Limitations of the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

VII. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

VIII. Avenues of Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

IX. References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Appendix A: Chest Pain Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Appendix B: Shortness of Breath Scenario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Appendix C: Level of Consciousness Scenario. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Appendix D: Self-confidence Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

TABLE OF CONTENTS



ivLIST OF TABLES

LIST OF TABLES

Table 1. Demographics of Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Table 2. Written Exam Scores Before and After Simulation/Clinical Experiences . . . . . . . . . . . . . . . . 11

Table 3. Clinical Performance on Three Patient Care Scenarios Portrayed byStandardized Patients: Tape Review Checklist Rating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Table 4. Total Time to Complete Three Patient Care Scenarios Portrayed byStandardized Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Table 5. Dimensions of Perceived Confidence Before and AfterSimulation/Clinical Experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Table 6. Perceived Confidence Before and After Simulation/Clinical Experiences . . . . . . . . . . . . . . . 14

Table 7. Perceived Clinical Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Table 8. Perceived Simulation Experience (n=37) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Table 9. Student Learning Based on Self-Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17



vACKNOWLEDGMENTS

ACKNOWLEDGMENTS

This study would not have been possible without the support provided by the Rush University College of

Nursing (RUCON) and Rush University Simulation Laboratory (RUSL). The authors acknowledge the contri-

butions of the involved faculty, staff and students who expended time and energy to help implement the

study protocol. Specifically, the authors acknowledge the following individuals for their valuable contribu-

tions to the study: Marcia Bosek, PhD, RN, former associate professor, RUCON, Chris MacNeal, simulation

coordinator, RUCON and Lynn Richter, MSN, RN, APRN-BC, assistant professor, RUCON.

The authors also gratefully acknowledge Nancy Spector, PhD, RN, NCSBN, director, innovations, Kevin

Kenward, PhD, NCSBN, director, research, Maryann Alexander, PhD, RN, NCSBN, chief officer, nursing

regulation, and Mary E. Doherty, JD, BSN, RN, NCSBN, associate, nursing regulation for their support and

valuable feedback to the project, and Richard Smiley, MS, NCSBN, statistician, research, for his help with

the statistical analysis.


7/35



1INTRODUCTION

INTRODUCTION

Simulation, the art and science of recreating a

clinical scenario in an artificial setting, has been an

important aspect of nursing program curriculums for

decades (Gomez and Gomez, 1987). As an adjunct

to clinical experience, simulation has allowed

deliberate practice in a controlled environment.

Students are able to practice a procedure prior to

performance on a live patient. The value of this is

unquestionable. Recently, however, high-fidelity

simulation, with the increased level of sophistication

and realism it brings to the laboratory setting, has

elicited the possibility of simulation being used as

a substitute for actual clinical experience. This study

explores that concept.

High-fidelity simulation refers to structured student

learning experiences with the use of a technological-

ly advanced computerized mannequin, the Human

Patient Simulator (HPS). HPS is anatomically precise

and reproduces physiologic responses. Students

are administered sequential decision-making events

within an environment that mimics a clinical setting.

Instructors can control the mannequins responses

and the HPS can respond to interventions providedby the student (Gilley, 1990; Graedler, 1992; Lasater,

2007). Gaba (2004) describes simulation as a strat-

egy not a technology, to mirror, anticipate, or

amplify real situations with guided experiences in a

fully interactive way.

The subject of simulation and its uses in prelicensure

education is of prime significance to regulators.

From a regulatory perspective, simulation offers

advantages. It harbors patients from unnecessary

risk and/or discomfort, thus providing an elementof public protection. The increased opportunities to

encounter infrequent and atypical clinical problems

may better prepare new graduates for transition

into the workforce. It may also offer an alternative

for nursing programs dealing with a limited number

of clinical sites or clinical sites that have inadequate

learning opportunities. A goal of regulation is to

make certain that the future workforce has safe

and competent nurses. Thus, regulators are also

interested in ensuring that nursing students are pro-vided with optimal education experiences. Despite

its obvious benefits, there is a paucity of evidence

regarding the efficacy of high-fidelity simulation

as a teaching method beyond the acquisition of

psychomotor skills.

How well simulation assists students in acquir-

ing and integrating knowledge, skills and critical

thinking, and how it fares when compared to tradi-

tional clinical/real patient encounters, are a few of

the questions being asked by both educators and

regulators alike. It is unknown as to what degree

simulation learning is transferable to the clinical

area or if simulation learning is as effective as actual

clinical experience in developing professional judg-

ment. There is also little evidence demonstrating

how well it assists in building confidence. Because

of these questions and the lack of evidence to

answer them, it is unknown as to what degree high-

fidelity simulation would be an appropriate and

suitable substitute for real clinical experiences now

required by state regulations for nursing programs.

As the first step in addressing these questions, it is

important to determine if high-fidelity simulation

provides an effective learning strategy equivalent to

clinical experiences.



2BACKGROUND

BACKGROUND

Documented throughout the literature are the

advantages and disadvantages of high-fidelity sim-

ulation. The following list summarizes the pros and

cons of this methodology.

Advantages

No direct risk to patients. Simulation offers

opportunities to practice rare and critical

events in a safe and controlled environment,

affording unlimited practice without risk to

patients (Gilley, 1990; Graedler, 1992; Maran

and Glavin, 2003, Decker, et al., 2008).

The potential to increase the speed of acqui-

sition of clinical skills to a defined level of

competence by allowing the opportunity for

repetitive practice at the learners own pace

(Maran and Glavin, 2003).

Team training. Scenario themes can focus on

understanding team collaboration and com-

munication (Ellis, et al., 2008; Lasater, 2007).

Can allow a standardized curriculum to be

developed as the same exact scenarios canbe presented to all learners. Simulation

reduces training variability and increases

standardization. With simulation, faculty can

guarantee the same experience for every

student (Maran and Glavin, 2003).

Reflective learning by facilitated debriefing

of scenarios and video feedback (Lederman,

1992; Gilley, 1990; Hertel and Millis, 2002;

Gaba, 2000).

Potential to decrease the number and effect

of errors through crisis resource management

(CRM) training (Ziv, et al., 2003).

Disadvantages

Equipment fidelity. Fidelity is the degree to

which the simulator itself replicates real-

ity. A major limitation of simulation is the

fidelity; no matter how high the fidelity is, it

is not real. It is often impossible to imitate

actual physiological signs or symptoms. For

example, it is impossible to display crackles

in the lung, when such a symptom would be

important to the scenario.

In addition to the need for high equipmentfidelity, simulation requires psychological

fidelity. This reflects the degree to which

the trainee perceives the simulation to be a

believable representation of the reality it is

duplicating. Students may not take it seri-

ously, since mistakes or errors have no real

consequences on patient safety.

Along with equipment and psychological

fidelity, simulation requires environmental

fidelity that is, the realism of the environ-ment in which the simulation takes place. For

example, emotional stress does not exist in

mannequins and standardized patients are

not really sick.

Cost. A study by McIntosh, et al. (2007)

calculated the set-up cost of a simulation

center was $876,485 (renovation of existing

facility, equipment). Fixed costs per year

totaled $361,425. Variable costs totaled $311

per course hour. The economic benefits of

increasing the number of billable teaching

hours per week are significant until about 21

hours (equivalent of three full or six and a

half day courses) per week (averaged over 52

weeks/year) when they started to taper off.

Lack of faculty time and training in simulation

instruction. Effective use of technology in

education depends on faculty readiness to

operate the tools for maximum educationalimpact. It is important to recognize the need

for faculty training in the specific demands

which simulation-based teaching imposes.

Access to the simulator is limited and depen-

dent on the availability of instructors and

operators. Simulation also limits the number

of students that can be taught at any one

time.

Negative transfer. Negative transfer occurs ifthe student learns something incorrectly due

to imperfect simulation. This most commonly

occurs because the instructor fails to make



3BACKGROUND

clear to the students the differences between

the training device and the real situation.

These differences are usually due to a lack of

physical or equipment fidelity. For example,

the different feel of intubating a mannequinor the artificial acceleration of tasks might

imprint incorrect clinical practices or proce-

dures (Bond, et al., 2007).

Certain assessments are not possible, such

as reflexes for example. Swelling and redness

does not appear, and the psychologic effects

of an illness and the emotional response of

the patient cannot be assessed using the

simulator (Lasater, 2007).

Review of the Literature

An examination of the literature related to simula-

tion reveals that despite a growing body of literature,

there is a substantial need for more evidence. Most

studies lack rigor, have small sample sizes, provide

little statistical analysis and conclusions are drawn

based on student perception.

Studies focusing on student reaction to the HPS

report positive responses to the simulation expe-rience. In a review of the literature conducted by

Ravert (2002), 75% of the studies reviewed con-

cluded that students pursuing a degree in one of

the health professions favored or highly favored

simulation as a teaching/learning tool. In a qualita-

tive study by Mikkelson, Reime and Harris (2007),

students (N=21) who experienced the simulation-

based training stated they had greater awareness

of the complexity of a health care condition and

it raised their awareness to aspects they had notthought of.

Two studies specifically examined the impressions

of undergraduate nursing students. Bearnson and

Wilker (2005) used an HPS to demonstrate medi-

cation side effects to students. Students reacted

favorably to the experience and reported increased

knowledge of medication side effects and an under-

standing of the differences in patient responses;

it also increased their ability to safely administermedications and their self-confidence in medication

administration skills. No tests were administered to

establish whether the students perception actually

correlated with increased knowledge. No control

group was used to compare responses. Statistical

analysis beyond calculating the means of nominal

data collected from a questionnaire with Likert

scales was not performed. In addition, the reportdoes not describe the number of students that par-

ticipated in the study.

Lasater (2008) also examined high-fidelity simula-

tion experiences on nursing students (N=8) and

its effect on the development of clinical judgment.

Students enrolled in a Nursing Care of the Adult

course were given weekly simulation experiences

as part of the course. After the completion of the

course, eight of the 15 students participated in a

focus group and discussed their experience with

the HPS. Several themes emerged, including simu-

lation integrates learning; it increased the breadth

of experiences the students were exposed to; and

the scenarios forced them to anticipate potential

problems. The investigator concluded that this last

theme, anticipation of potential problems, was an

indication that simulation fostered clinical judg-

ment. While the experience may have done so, the

small sample size and the lack of outcome data

measuring performance makes it difficult to drawa definite correlation between the HPS and clinical

judgment.

Several recent studies have attempted to determine

how simulation compares with traditional clinical

experience. The lack of consistency in the results,

however, makes drawing conclusions about simula-

tion difficult.

Alinar, Hunt, Gordon and Harwood (2006) com-

pared clinical performance of students in traditionalclinical settings with those that received clinical

experience (control) and clinical plus simulation

experience (experimental). Using a pretest/post-

test design, undergraduate nursing students (N=99)

were randomly assigned to one of these two groups.

Students were pre- and posttested using the

Objective Structured Clinical Examination (OSCE)

method. Students in both groups improved their

clinical performance; however, the experimental

group improved their performance on the OSCE 14to 18 percentage points (95% CI 12.52-15.85) com-

pared to seven to 18 points (95% CI 5.33-9.05) in the

control group. The 7.0 percentage point difference



4BACKGROUND

between the means (95% CI 4.5-9.5) was statistically

significant (p< 0.001).

Radhakrishnan, Roche and Cunningham (2007)

conducted the first study to test nursing student

performance with complex two-patient assign-

ment simulations. Undergraduate nursing students

(N=12) were randomized into a traditional clini-

cal experience (control) or a traditional clinical

experience plus simulation (intervention). Results

indicated that the intervention group had statisti-

cally significant higher scores in two specific areas

of clinical performance: safety (p



5STUDY GOALS

STUDY GOALS

Specific goals of the study were to:

Examine the differences between tradi-

tional clinical experience and simulation asteaching methods in prelicensure nursing

education;

Analyze how simulation training may impact

knowledge, clinical performance and confi-

dence levels of undergraduate students and

compare this with traditional clinical experi-

ence; and

Contribute to the body of knowledge on

the uses and limitations of simulation inprelicensure nursing education for both

regulators and educators.

These aims were accomplished by examining the

following:

Differences in pre- and postmultiple choice

exam scores in three groups of undergradu-

ate nursing students (clinical/simulation/

clinical plus simulation);

Differences in clinical performance betweenthree groups of undergraduate nursing

students (clinical/simulation/clinical plus

simulation); and

Differences in confidence levels among three

groups of undergraduate students (clinical/

simulation/clinical plus simulation).

Despite the fact that simulation is widely accepted

as an educational tool, little research has examined

the role of simulation in prelicensure nursing educa-

tion in relation to clinical experiences. Moreover, it

is unknown to what degree high-fidelity simulation

would be an appropriate and suitable substitute

for real clinical experiences required by regulatory

rules for these nursing programs. As the first step to

address this question, it is important to determine if

high-fidelity simulation provides an effective learn-

ing strategy.



6RESEARCH QUESTIONS

RESEARCH QUESTIONS

1. Are there differences in knowledge between

prelicensure nursing students exposed to

a traditional intensive care unit (ICU) clini-

cal experience, those that have had only a

simulation experience and those that have

had a combination of clinical and simulation

experiences?

2. Are there differences in clinical performance

between prelicensure nursing students

exposed to a traditional ICU clinical experience,

those that have had only a simulation experi-

ence and those that have had a combination of

clinical and simulation experiences?3. Are there differences in the levels of confi-

dence between prelicensure nursing students

exposed to a traditional ICU clinical experience,

those that have had only a simulation experi-

ence and those that have had a combination of

clinical and simulation experiences?



7METHODS

METHODS

Design and Sampling

The goal of this study was to compare the effec-tiveness of simulation to actual clinical experience

among students enrolled in a prelicensure nursing

curriculum. The specific objective was to examine

the effectiveness and applicability of high-fidelity

simulation alone and in combination with clinical

experience on knowledge acquisition/retention,

self-confidence and clinical performance of nursing

students.

A randomized controlled design with repeated

measures of pre- and posttreatment design wasused to address the aim of this study. The study was

reviewed and approved by the Institutional Review

Board of NCSBN and that of Rush University Medi-

cal Center.

All students in two separate cohorts (2006 and 2007)

of senior baccalaureate nursing students (n=92)

enrolled in a required critical care nursing course

at Rush University College of Nursing were asked

to participate. A total of 58 (cohort 1=23; cohort

2=25) chose to participate in the study. Students

who chose not to participate were assigned to the

usual treatment group, which for the course was the

simulation experience alone. After giving informed

consent and following the successful completion of

the three credit hour didactic portion of the course,

simple random selection was used to determine

group composition to one of the three practicum

experiences:

1. Clinical without simulation (30 hours of clini-cal preceptorship with a critical care nurse);

2. Simulation without actual clinical experi-

ences (30 hours of simulation); or

3. Simulation plus clinical experience (15 hours

of simulation and 15 hours of clinical without

simulation).

Measurements of knowledge acquisition and

retention, and self-confidence were taken before

beginning the didactic portion of the course andafter clinical or simulation experiences, while assess-

ment of clinical performance was taken after clinical

or simulation experiences (Figure 1).

Setting

The study was conducted at Rush University Col-lege of Nursing because it not only had full access

to a state-of-the-art simulation laboratory, but also

offered an undergraduate course in critical care

nursing, which was deemed appropriate given the

type of experiences that could be offered in the

simulation laboratory. RUSL is a state-of-the-art

simulation training center equipped with life-sized,

computer-controlled virtual patients capable of sim-

ulating nearly any acute and critical patient episode,

including allergic reactions, drug overdoses, respi-ratory distress, cardiac decompensation and acute

neurological events. Audio and video systems in the

adjoining classroom enables trainees and faculty to

observe teaching sessions, interact with the instruc-

tor and participate in guided performance feedback

sessions of the videotaped training session. Quali-

fied faculty with graduate preparation and expertise

in acute care clinical practice and simulation instruc-

tion implemented the study protocol.

Procedure

The course utilized for this project was modified

from an existing required course that consisted of

three credit hours of didactic instruction with no

planned simulation or clinical experiences. The new

course reflected a 40-hour (didactic) undergradu-

ate critical care course with a 30-hour simulation

experience. All didactic content in the course was

front-loaded followed by simulation and/or clinical

experiences. Didactic teaching was provided to allstudents in the form of lectures, required readings

and case studies.

The course occurred in the summer quarters after

the students successfully completed courses in

foundations of nursing, gerontological nursing,

basic medical-surgical nursing and psychiatric-

mental health nursing, which provided all students

with 270 hours of previous clinical experience. The

critical care course closely followed the American

Association of Critical Care Nursing core curricu-

lum, providing didactic content on all areas relative

to critical care nursing practice.



8METHODS

The following simulation and/or clinical experiences

were offered:

Simulation only

Students in this group were exposed to a variety

of critical care nursing scenarios that emphasized

assessment and fundamental intervention. Students

spent approximately 30 hours in the simulator work-

ing on the following scenarios:

A patient with a myocardial infarction (MI)

and cardiogenic shock; includes experiences

in cardiovascular assessment, homodynamic

monitoring and EKG interpretation and

arrhythmia interventions; A patient with acute respiratory distress;

includes experiences in respiratory assess-

ment, oxygen therapy and intubation/

mechanical ventilation; and

A patient with increased intracranial pressure

(ICP), includes experiences in neurological

assessment, basic intervention for changes in

level of consciousness (LOC) and ICP moni-

toring and interpretation.

Simulation and clinical

Students in this group spent 15 hours in the simula-

tor working on the scenarios described above and

then 15 hours (three five-hour sessions) in a critical

care clinical experience providing direct, super-

vised care to a variety of critically-ill individuals.

Every attempt was made to provide students with

experiences in assessment of the cardiovascular,

respiratory and neurological systems; hemodynam-ic and arrhythmia monitoring and interventions; and

oxygenation and mechanical ventilation.

Clinical only

Students spent 30 hours in a critical care unit

providing direct, supervised care to a variety of

critically-ill individuals. Every attempt was made to

provide students with experiences in assessment

of the cardiovascular, respiratory and neurological

systems; hemodynamic and arrhythmia monitoringand interventions; and oxygenation and mechanical

ventilation.

Each scenario ran for approximately five to 15 min-

utes, during which time the students were able to

ask questions of the patient; perform assessments

including vital signs, rhythm strips, heart and lung

sounds, and pupil changes; and provide interven-tions, including starting IVs and assisting with

suctioning, intubation, etc. The student perfor-

mance in each scenario was tape recorded for a

debriefing session that followed each scenario for

discussion of the case, including critical thinking,

group coordination and decision making. To imple-

ment the simulation scenarios, relevant factors that

facilitated effective simulation-based learning syn-

thesized by Issenberg, et al. in 2005 were adopted.

The factors included providing feedback; allowingrepetitive practice; offering scenarios that were with

a range of difficulty levels and clinical variations;

using multiple learning strategies in a controlled

environment; defining outcomes or benchmarks

prior to implementing scenarios; and using simula-

tors with high-fidelity.

Outcome Measures

Knowledge Acquisition and Retention

Knowledge acquisition and retention was assessed

with written examinations before and after clinical

and/or simulation experience. The scores from the

examination after clinical and/or simulation experi-

ence were used as proxy measures for knowledge

acquisition and retention, using pretest scores as

control. The pre- and postintervention examina-

tions were equivalent in content and were slightly

modified from existing examinations for the course.

The Cronbach alphas (KR-20) ranged from 0.6 to 0.7,

indicating this test produced repeatable measures

for this sample. All examinations were graded on a

scale from 0 100%, with higher scores indicating

higher levels of knowledge. The written examina-

tions consisted of 50 items reflecting the content

taught in the course.

Clinical Performance

Clinical performance was assessed based on thestudents performance on providing care during

three patient care scenarios, which were portrayed

by standardized patients. The three patient care



9METHODS

scenarios included: (1) New onset of chest pain; (2)

Sudden onset of shortness of breath; and (3) Acute

change in level of consciousness. Each of these

scenarios were developed to present the student

with a situation in which they must assess and beginprimary intervention. The scenarios were designed

to be approximately 15 to 20 minutes in length.

Scores for each scenario were generated from a

blueprint, which was developed by four nurses who

were experts in the care of critically-ill clients using

the nursing process as a guide. These blueprints

reflected the following principles:

The student asks appropriate, focused

questions that provide relevant information

leading to problem identification;

The student performs appropriate physical

assessments to confirm the patients subjec-

tive data and obtain objective data;

The student initiates basic nursing interven-

tions appropriate to the patients condition;

and

The student evaluates the effectiveness of

these interventions.

Three labs, with one lab for each of the three stan-

dardized patient encounters, were set up to mimic

a patient care environment equipped with essential

supplies and resources. A patient chart with relevant

information on the patient was available at the door

of the lab. Before beginning the individual evalu-

ation session, each student was provided with a

standardized orientation in verbal and written form.

Training of standardized patients and faculty evalu-

ators have been reported elsewhere by the studyinvestigators (Bosek, et al., 2007). The evaluation

process lasted from the moment the student entered

the room to begin the encounter with the standard-

ized patient until stopped by the faculty evaluator.

The faculty evaluator could also act as a physician or

other health care provider, as appropriate. Once the

evaluation was completed, it could not be modified.

No guidance from faculty was provided during the

performance. Students were not aware of the man-

ner by which they were being scored. If a studentperformed a particular technique incorrectly, he or

she was provided with constructive feedback after

all three standardized patient scenarios had been

completed. Performance of the three groups of stu-

dents was compared to determine if there was an

advantage of high-fidelity simulation-based learn-

ing over actual clinical experience or vice versa.

Faculty Review of Videotaped Student

Performance

The performance of each student was videotaped

for further analysis of professional behaviors, assess-

ment, accuracy of intervention and total time from

encounter to implementation of intervention. Two

study investigators (who were also faculty members)

evaluated all taped scenarios on participants based

on a 28, 29 or 30-item evaluation tool, depending

on the scenario (Appendix A, B, and C). The toolsconsisted of four dimensions: (1) Patient-nurse rela-

tionship; (2) Symptom recognition; (3) Assessment;

and (4) Intervention. Each action was evaluated

as Inadequate, Somewhat inadequate, Not

attempted, Somewhat adequate, or Ade-

quate. The reliabilities (Cronbachs alphas) of the

tools were 0.723 for chest pain, 0.787 for shortness

of breath and 0.782 for loss of consciousness sce-

narios. In addition, the total time from initial contact

to the end of the interaction was measured usingthe video recorder timer. Examinations routinely

undergo extensive psychometric evaluation and

reliabilities have ranged from 0.6 to 0.7 on these

examinations in the past.

Self-confidence

A Likert-type self-confidence scale (Hicks, 2006)

consisting of 12 items was created to measure this

variable (Appendix D). The response option of each

item ranges from 1 (strongly disagree) to 4 (strongly

agree), with higher scores indicating greater self-

confidence. The Cronbachs alphas of the scale on

the current data were 0.93 for pretest and 0.96 for

posttest, which demonstrates high internal consis-

tency reliability. The items reflected the following

four dimensions:

1. Accurately recognizing a change in condi-

tions of patients with common critical care

issues;2. Performing basic physical assessments for

condition of patients with common critical

care issues;



10METHODS

3. Identifying basic nursing interventions for

conditions of patients with common critical

care issues; and

4. Evaluating the effectiveness of interventions

for conditions of patients with common criti-

cal issues.

Protection of Human ResearchSubjects

For the purpose of this study, the following proce-

dures were instituted to protect the human subjects:

1. The project coordinator informed prospec-

tive subjects in writing of the purposes of thestudy, the nature of their involvement, and the

potential benefits and risks if they chose to

participate. The subjects were also informed

that taking part in the research was entirely

voluntary and they may withdraw from the

study at any time without anyone objecting and

without penalty or loss of any benefits to which

they were otherwise entitled. The subjects

were told that they may or may not personally

benefit from taking part in the research, but

the knowledge obtained may lead to a better

understanding of the role of simulation in nurs-

ing education.

2. Once the potential subjects were fully informed

of their rights, written informed consent was

then obtained from individuals who agreed

to participate in the study by the project

coordinator.

3. To ensure confidentiality, code numbers were

assigned to each subject. Only the codenumber appeared on the questionnaires and

records. A master list of names, addresses and

code numbers were maintained separately from

the collected data, in the event that follow-up

was needed. This list was available only to

the investigators and was destroyed following

completion of the study. Confidentiality was

also guaranteed in that data were reported as

group data only.

Data Analysis

Multivariate analyses of variance with repeated

measures were performed to examine differences

among groups in outcome measures before (i.e.,

didactic instruction) and after clinical and/or simu-

lation experience. The outcome variables included

scores of written examinations, self-confidence and

the indicators of the clinical performance with stan-

dardized patient scenarios among the three groups.

The independent variables included time and group

factors. Potential confounding variables and inter-

actions between main factors were examined prior

to the analysis of the group differences. All values

were represented as mean; standard deviation and

mean differences were considered significant for a

P value less than 0.05. Bonferroni corrections were

applied as appropriate.



11RESULTS

RESULTS

Since two cohorts of students (2006 and 2007) were

enrolled in the study, as the first step in the analysis,

the cohorts were examined to see if there were any

differences between the two groups. No statistical

differences were identified. Thus, in the subsequent

analysis, the two cohorts of students were com-

bined and analyzed as one group.

Demographics

Of the 58 students that participated in the study,

the majority were female (84.5%) and white (73.7%)

with an average age of 26.8 years. More than half of

the students (59%) already had a bachelors degreein other fields and 30% had working experience

in heath care. Approximately one-third (30.2%) of

the students had some experience in health care,

such as working as a nursing assistant or technician

in a lab. Three of the students who were assigned

to the combo group had previous experience with

simulation. There were no statistically significant

differences in these demographic variables among

the groups (Table 1). These variables had no signifi-

cant confounding effects in the analyses of groupdifferences.

Knowledge Acquisition and Retention

Students received didactic instruction for two

weeks, after which they took a multiple choice exam

Table 1. Demographics of Participants*

Simulation(n=19)

Clinical(n=19)

Combo(n=20)

Total(N=58)

Age in years (Mean and SD) 25.7 (6.1) 26.8 (6.7) 28.0 (5.5) 26.84 (6.1)Female 89.5% 79.0% 85.0% 84.5%

White 68.4% 73.4% 75.0% 73.7%

With previous degree in other fields 52.6% 47.1% 50.0% 59.0%

With previous work experience in health care 22.2% 43.8% 26.3% 30.2%

*No significant differences were found among groups in age, gender, race, having previous degrees in other field or

having previous working experience in health care.

Table 2. Written Exam Scores Before and After Simulation/Clinical Experiences

Simulation*(n=19)

Clinical*(n=19)

Combo*(n=20)

Total*(N=58)

Exam Scores Mean SD Mean SD Mean SD Mean SD

Pre- 94.0 4.7 94.7 2.7 94.2 4.3 94.3 4.0

Post- 77.9 10.1 83.8 6.6 82.3 9.9 81.3 9.3

*All Ps



12RESULTS

Table 3. Clinical Performance on Three Patient Care Scenarios Portrayed by Standardized Patients: Tape Review Checklist Rating1

Clinical Simulation Combo Probability

Inadequate,Somewhat

Inadequate orNot Attempted

Somewhat

Adequate orAdequate

Inadequate,Somewhat


Somewhat

Adequate orAdequate

Inadequate,Somewhat


Somewhat

Adequate orAdequate

Chest pain symptoms 57% 43% 61% 39% 50% 50% 0.0001

Chest pain assessment 38% 63% 42% 58% 38% 63% 0.0139

Chest pain intervention 27% 73% 26% 74% 22% 78% 0.5496

Chest pain relationship 28% 72% 33% 62% 24% 76% 0.3237

Overall chest pain 36% 64% 39% 61% 33% 67% 0.1063

Shortness of breathsymptoms

32% 68% 45% 50% 39% 61% 0.1952

Shortness of breathassessment

38% 62% 44% 53% 35% 65% 0.0358

Shortness of breathintervention

23% 77% 39% 57% 35% 65% 0.0047

Shortness of breathrelationship

24% 76% 28% 66% 19% 81% 0.2063

Overall shortness ofbreath

31% 69% 42% 58% 33% 67% 0.0002

Loss of consciousnesssymptoms

25% 75% 24% 76% 26% 74% 0.9339

Loss of consciousnessassessment

39% 61% 43% 57% 38% 62% 0.6361

Loss of consciousnessintervention

30% 70% 40% 60% 29% 71% 0.0777

Loss of consciousnessrelationship

3% 97% 5% 95% 5% 95% 0.7206

Overall loss ofconsciousness

29% 71% 33% 66% 28% 71% 0.1686

Overall 32% 68% 34% 66% 32% 68% 0.1485

1This table was constructed by counting the number of people who were rated as inadequate, somewhat adequate, not attempted, somewhat adequate or adequate

for each of the criterion in the three scenarios. The frequencies for each criterion were then summed to form four dimensions: patient-nurse relationship; symptomrecognition; assessment; and intervention. The five categories of adequateness were then collapsed into two categories. The totals for each of the dimensions were thenconverted into percentages. The percentages for each of the dimensions, therefore, do not represent the percent of students in each group (clinical, simulation, combo);rather, it represents how often students were rated in a particular category.

For example, there are four criteria used to assess symptom recognition in the chest pain scenario. The number of students who were rated in each category is presentedbelow. Adding the results for the four criterion resulted in the 19 students in the simulation group being rated unsatisfactory 46 times and satisfactory 30 times. Thisconverts to percentages of 61% and 39%, respectively.

Footnote Table A

Symptom Recognition Criteria InadequateSomewhatInadequate

NotAttempted

SomewhatAdequate

Adequate Total

Age in years (Mean and SD) 19 19

Female 13 3 3 19

White 2 15 2 19

With previous degree in other fields 1 15 1 2 19

With previous work experience inhealth care

3 43 6 24 76

Footnote Table B

SymptomRecognition

Inadequate, SomewhatInadequate or Not Attempted

Somewhat Adequateor Adequate

Frequency 46 30

Footnote Table C

SymptomRecognition

Inadequate, SomewhatInadequate or Not Attempted

Somewhat Adequateor Adequate

Percentage 61% 39%



13RESULTS

Table 4. Total Time to Complete Three Patient Care Scenarios Portrayed by Standardized Patients*

Simulation Clinical Combo All (n=57)

Total time to complete chest pain scenario in minutes 8.75 9.38 9.10 9.07Total time to complete shortness of breath scenario in minutes 8.97 8.76 8.91 8.88

Total time to complete loss of consciousness scenario in minutes 8.60 10.08 10.28 9.64

*No group differences were found in the time needed to complete the scenarios between groups.

of the time the students in each group were rated

by faculty as not performing at satisfactory levels

across all scenarios. Students performed best on

level of consciousness relationship items and worst

on recognizing chest pain symptoms.

There were some statistically significant differ-

ences between the groups of students at the 95%

confidence level. The areas of differences included

recognizing chest pain symptoms, chest pain assess-

ment, assessing shortness of breath, shortness of

breath intervention and the overall shortness of

breath items.

While the overall differences between the three

groups were not statistically significant, studentsin the combo and clinical groups were consistently

rated higher by faculty reviewing the videotapes

than students in the simulation group.

Regarding the time needed to complete the scenar-

ios, the students took an average of 9.07 minutes to

complete the chest pain scenario; 8.88 minutes for

the shortness of breath scenario; and 9.64 minutes

for the loss of consciousness scenario. Although the

simulation group used a shorter period of time to

complete two out of the three scenarios, the differ-ences were not statistically significant (Table 4).

Self-confidence

After receiving theoretical instruction of the critical

care content in the course, on average, students felt

somewhat confident in taking care of critically-ill

patients (average self-confidence =3.53 on a scale

of 1-4). No significant differences in self-confidence

were found at pretest among all groups. At pretest,

the students were more confident in recognizing

symptoms (mean=3.55), conducting assessment

(mean=3.70) and evaluation (mean=3.55) than pro-

viding intervention (mean=3.30) (all Ps



14RESULTS

that the simulation experience provided them with

opportunities to improve learning, the feedback

received from the instructor during the simulation

was helpful to learning and the simulation scenarios

exposed them to cases with increasing levels of dif-ficulty. About one-third of the students (29.5%) in

the simulation group felt that the simulator did not

have a high level of realism. There were no statisti-

cally significant differences in simulation experience

between the simulation and the combo groups

(Table 8).

All students evaluated the effect of the clinical/sim-

ulation experience on their learning with a 14-item

questionnaire using a scale of strongly disagree,

disagree, agree or strongly agree. The majority ofthe students either agreed or strongly agreed that

the clinical/simulation experience had enhanced

their skills in many aspects of nursing practice,

including physical and psychosocial assessment,

problem solving and decisionmaking, understand-

ing the basis for intervention, and developing the

role within the profession. About one-fifth (16.6%)

of those in the clinical only group did not feel the

course enhanced their skills in developing a plan of

action. The same percentage also did not feel thecourse helped them collaborate with others.

Table 6. Perceived Confidence Before and AfterSimulation/Clinical Experiences

Simulation*(n=19)

Clinical(n=19)

Combo*(n=20)

Mean Mean Mean

Pre- 3.65 3.39 3.52

Post- 3.99 3.54 3.88

Increase in confidence 0.34 0.15 0.36

*All Ps



15RESULTS

Table 7. Perceived Clinical Experience

Variables

Clinical Group Combo Group

StronglyDisagree

Disagree AgreeStronglyAgree

StronglyDisagree


Clinical expectations were clearly statedand reasonable.

5.9% 47.0% 47.0% 55.0% 45.0%

Clinical expectations were consistentwith course objectives.

11.8% 52.9% 35.3% 45.0% 55.0%

Clinical expectations were appliedequally to all students.

5.9% 5.9% 35.3% 52.9% 50.0% 50.0%

Clinical faculty were available forconsultation and assistance.

11.8% 29.4% 58.8% 40.0% 60.0%

Clinical faculty interacted non-judgmentally with students from a varietyof backgrounds.

5.9% 41.2% 52.9% 40.0% 60.0%

Clinical faculty were receptive to viewsthat differed from their own. 6.3% 12.5% 31.3% 50.0% 5.0% 45.0% 50.0%

Clinical faculty were knowledgeableabout clinical practice.

35.3% 64.7% 35.0% 65.0%

Clinical faculty provided an environmentconducive to learning.

41.2% 52.8% 30.0% 70.0%

Clinical faculty interacted in a respectful,non-threatening manner.

47.1% 52.9% 40.0% 60.0%

Clinical faculty took advantage of new orunexpected learning opportunities.

11.8% 35.3% 52.9% 45.0% 55.0%

Clinical faculty challenged me to test myown critical-thinking and problem-solving

skills.

232.5% 29.4% 47.1% 30.0% 70.0%

Clinical faculty facilitated faculty orstudent conferences that enhancedlearning.

42.9% 57.1% 44.4% 55.6%

Clinical staff or preceptors weresupportive to students.

41.2% 58.8% 35.0% 65.0%

Clinical staff or preceptors wereknowledgeable about clinical practice.

35.3% 64.7% 35.0% 65.0%

Clinical staff or preceptors interactednon-judgmentally with students from avariety of backgrounds.

42.9% 57.1% 44.4% 55.6%

Clinical staff or preceptors interacted in arespectful, non-threatening manner. 42.9% 57.1% 22.2% 77.8%

Clinical written assignments weremeaningful to my learning.

40.0% 60.0% 46.2% 46.2%

I received sufficient and timely feedbackto know how I was doing.

8.3% 33.3% 58.3% 55.6% 44.4%

My clinical evaluation was accurate andfair.

27.8% 72.8% 50.0% 50.0%

Clinical experiences were equitablydistributed amongst students.

11.8% 52.9% 35.30% 57.9% 36.8%

My clinical assignments were consistentwith my abilities.

6.3% 43.8% 50.0% 65.0% 35.0%

I had opportunity to collaborate withother health care providers.

50.0% 50.0% 75.0% 25.0%

This clinical rotation provided me with avariety of learning experiences.

11.8% 17.7% 17.7% 52.9% 5.0% 35.0% 60.0%



16LIMITATIONS OF THE STUDY

LIMITATIONS OF THE STUDY

The present study has certain limitations that need

to be taken into account when considering the

study and its contributions. The instruments used

were created to fit the purpose of this study. While

the reliabilities are acceptable and the face validi-

ties are strong, the construct validities have yet to

be established.

No inter-rater reliabilities were established. Inter-rater reliability is the degree of agreement among

raters. It gives a score of how much homogeneity, or

consensus, there is in the ratings given by judges. It

Table 8. Perceived Simulation Experience (n=37)

Variables

Simulation Combo

StronglyDisagree


StronglyDisagree


The feedback I received fromthe instructor during the learningexperience was helpful to my learning.

47.1% 52.9% 55.0% 45.0%

The simulation experience providedme with opportunities to improve mylearning.

52.9% 47.1% 35.0% 65.0%

The simulation scenarios exposed me tocases with increasing levels of difficulty.

23.5% 76.5% 35.0% 65.0%

The simulator was able to adapt tomultiple learning strategies.

6.7% 40.0% 53.3% 6.7% 60.0% 33.3%

The simulation scenarios exposed meto a variety of situations that I may

encounter in practice.

5.9% 35.3% 58.8% 50.0% 50.0%

The simulation experience providedindividualized learning.

11.8% 41.2% 47.1% 10.0% 50.0% 40.0%

The simulation experience provided astandardized experience for my studentgroup.

41.2% 58.8% 5.0% 55.0% 40.0%

The learning outcomes were clearlyidentified.

52.9% 47.1% 10.0% 60.0% 30.0%

The simulation experiences wereappropriate to my level of learning.

52.9% 47.1% 50.0% 50.0%

I had the opportunity to engage in

making nursing decisions across a widerange of difficulty levels. 52.9% 41.2% 40.0% 60.0%

I had opportunities to activelyparticipate in the scenarios.

5.9% 41.2% 52.9% 35.0% 65.0%

The simulation experience adapted tomy unique learning needs.

5.9% 47.1% 41.2% 5.3% 42.1% 52.6%

The simulation experience allowed forcomplex clinical tasks to be brokendown into their component parts foreducational mastery.

11.8% 52.9% 47.1% 5.0% 50.0% 45.0%

The simulator had a high level ofrealism.

11.8% 17.7% 41.2% 29.4% 5.0% 10.0% 55.0% 35.0%

is useful in refining the tools given to human judges,

e.g., by determining if a particular scale is appro-

priate for measuring a particular variable. If various

raters do not agree, either the scale is defective or

the raters need to be retrained.

While the study was designed as a randomized trial,

it was not double blind. Although the faculty evalu-

ators were not informed of the group membershipof the students, it is possible they might have recog-

nized students through informal interactions and/or

during the teaching-learning process. It would have




Table9.

Stud

entLearningBasedonSelf-Evaluation

Clinical

Simulation

Combo

Asaresulto

fthisexperience:

Strongly

Disagree

Disagree

Agree

Strongly

Agree

Strongly

Disagree

Disagree

Agree

Str

ongly

Agree

Strongly

Disagree

Disagree

Agree

Strongly

Agree

Ienhancedm

yskillsinphysical

assessment.

100.0

%

9.1

%

9.1

%

81.8

%

100.0

%

Ienhancedm

yskillsinpsychosocial

assessment.

7.7

%

15.4

%

76.9

%

35.7

%

64.3

%

35.7%

64.3

%

Ienhancedm

yskillsindiagnosing

problemsorneeds.*

46.2

%

53.8

%

10

0.0

%

9.1

%

90.9

%

Ienhancedm

yskillsinproblems

olving

anddecision

making.

8.3

%

8.3

%

16.7

%

75.0

%

10

0.0

%

100.0

%

Ienhancedm

yskillsindevelopingaplan

ofaction.

7.7

%

25.0

%

58.3

%

10

0.0

%

15.4%

84.6

%

Ienhancedm

yskillsinidentifyingand

evaluatingou

tcomes.

7.7

%

30.8

%

61.5

%

8.3

%

91.7

%

7.1

%

92.9

%

Ienhancedm

yskillsinapplying

psychosocial

interventions.

7.1

%

23.1

%

69.2

%

33.3

%

66.7

%

40.0%

60.0

%

Ienhancedm

yskillsinteachingpatients

orgroups.

7.1

%

35.7

%

50.0

%

7.7

%

38.5

%

53.9

%

6.7

%

40.0%

53.3

%

Ienhancedm

yskillsindocumenting

information.

7.1

%

28.6

%

64.3

%

26.7

%

73.3

%

18.8

%

37.5%

43.8

%

Ienhancedm

yskillsinunderstandingthe

basisforinterventions.

7.7

%

92.3

%

7.7

%

92.3

%

9.1

%

90.9

%

Ienhancedm

yskillsinworkingwith

diversepopu

lationsorgroups.

7.7

%

23.1

%

69.2

%

16.7

%

33.3

%

50.0

%

14.3%

85.7

%

Ienhancedm

yskillsincollaboratingwith

others.

8.3

%

8.3

%

8.3

%

75.0

%

8.3

%

10

0.0

%

8.3

%

91.7

%

Ienhancedm

yskillsindelegatingnursing

caretoothers.

7.7

%

7.7

%

53.9

%

30.8

%

16.7

%

75.0

%

6.7

%

53.3%

40.0

%

Ienhancedm

yskillsindevelopingmyrole

withintheprofession.

8.3

%

16.7

%

75.0

%

10

0.0

%

8.3

%

91.7

%

*p=0.0

2




been ideal to have the evaluators completely blind

of the study design, however, due to the number of

faculty needed for the study, it was not feasible to

do so.

There was also considerable previous clinical expe-

rience among the students. All of the students had

270 hours of previous clinical experience before

taking the course. Three of the students also had

previous experience with a simulator. These previ-

ous experiences make if difficult to understand the

true effects of simulation and clinical experience on

clinical performance.

Another limitation of this study includes external

validity, or the generalizability of the study. Therewere only 58 students who participated, dispersed

among three groups of 19, 20 and 19 students each.

An example of how the small sample size limits the

conclusions that can be drawn can be examined by

looking at differences between the groups in the

number of students who had a previous degree.

The simulation group had 5.5% more students with

previous degrees than the clinical group. It may be

that having a previous degree would increase a per-

sons confidence, but 5.5% in this study representsonly one person out of the group. While in a larger

sample, a 5.5% difference in prior experience may

affect confidence, in this study, it is unlikely that one

persons background would have much effect.

A question can also be raised as to whether the

study is actually measuring confidence or more

generally measuring attitudes and other common

mechanisms toward clinical performance. The study

assesses confidence globally, with a few scale items

that ask participants to report on their confidenceor efficacy without regard to specific performance

tasks. At this level of self-reporting, it is expected

that confidence can not reliably be separated from

other personal determinants, such as self-concept,

anxiety, self-confidence and background.



19DISCUSSION

DISCUSSION

As this study indicates, evaluating the impact of

simulation-based training on clinical performance

remains a significant challenge. Given the limitations

of this study, the effects of simulation on nursing

students clinical performance remains inconclusive.

In terms of knowledge retention, students actually

decreased their knowledge as measured by a 50-

item test. However, differences between the three

groups of students were not statistically significant.

The clinical performance demonstrated by simu-

lation-based assessment between the groups with

simulation-based learning, a combination of simula-

tion-based and bed-side actual clinical experience,and bed-side actual clinical experience alone also

indicated no differences between the groups in

terms of overall means of the ratings. However,

students in the combo group tended to receive

the highest scores followed by those in the clinical

group. Replicating the study with larger samples

and across different settings would probably elu-

cidate whether or not such a tendency was due to

chance or not.

For beginning senior level nursing students in either

the simulation-based learning or a combination of

simulation-based and bed-side learning, actual

clinical experience showed a statistically significant

increase in their self-confidence of taking care of

critically-ill patients. However, the perceived abili-

ties and confidence of participants are of no value if

higher level problem solving, decision making and

psychomotor skills are not evident through replica-

tion in clinical practice.



20AVENUES OF FUTURE RESEARCH

AVENUES OF FUTURE RESEARCH

While the effects of simulation remain elusive, this

study lays the foundation for further research. The

findings tease us with the notion that clinical expe-

rience in combination with simulation training may

provide the best performance outcomes. Addition-

al research with large cohorts of learners and the

knowledge gained from this study can provide bet-

ter evidence as to the benefits of simulation-based

training.



21REFERENCES

REFERENCES

Aliner, G., Hunt B., Gordon R. and Harwood C. (2006). Effectiveness of intermediate-fidelity simulation

training technology in undergraduate nursing education. J Adv Nurs, 54(3), 359-369.

Bandura, A. (1986). Social foundations of thought and action: A social cognitive. Englewood Cliffs,

NJ: Prentice Hall.

Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review,

84(2), 191-215.

Bearnson, C.S. and Wiker, K.M. (2005). Human patient simulators: A new face in baccalaureate nursing

education at Brigham Young University. J Nurs Educ, 44(9), 421-425.

Becker, K.L., Rose, L.E., Park, H. and Shatzer, J.H. (2006). The teaching effectiveness of standardized

patients. J Nurs Educ, 45(4),103-111.

Bond, W.F., et al. (2007). The use of simulation in emergency medicine: A research agenda. Acad Emerg

Med, 14(4), 353364.

Bosek, M.S., Li S. and Hicks F.D. (2007). Working with standardized patients: A primer. Int J Nurs Educ

Scholarsh, 4(16).

Boulet, J.R., Murray, D., Kras, J., Woodhouse, J., McAllister, J. and Ziv, A. (2003). Reliability and validity of

a simulation-based acute care skills assessment for medical students and residents.

Anesthesiology, 99(6),1270-1280.

Chopra, V., Gesink, B.J., DeJong, J., Spierdijk, J. and Brand, R. (1994). Does training on an anaesthesia

simulator lead to improvement in performance? Br J Anaesth, 73(3), 293-297.

Cioffi, J., Purcal, N. and Arundell, F. (2005). A pilot study to investigate the effect of a simulation strategy

on the clinical decision making of midwifery students. J Nurs Educ, 44(3), 131-134.

Clark, M.C., Owen, S.V. and Tholcken, M.A. (2004). Measuring student perceptions of clinical competence.

J Nurse Educ, 42(12), 548-554.

Day, L. (2007). Simulation and the teaching and learning of practice in critical care units. Am J of Crit Care,

16(5), 504-507.

Decker, S., Sportsman, S., Puetz, L. and Billings, L. (2008). The evolution of simulation and its contribution

to competency. J Contin Educ Nurs, 39(2), 74-80.

Ellis, D., Crofts, J.F., Hunt, L.P., Read, M., Fox, R. and James, M. (2008). Hospital, simulation center, and

teamwork training for eclampsia management: A randomized controlled trial. Am J Obstet

Gynecol, 111(3), 723-731.

Gaba, D.M. (2000) Anaesthesiology as a model for patient safety in health care. BMJ, 320(7237), 785788.



22REFERENCES

Gaba, D.M. (2004). The future vision of simulation in health care [Electronic version]. Qual Saf Health Care,

13(Suppl. 1), i2-i10.

Galbraith, M.W. (Ed). (2004). Adult Learning Methods: A guide for effective instruction (3rd ed.)

(pp. 261-281). Florida: Krieger.

Gomez, G.E., and Gomez, E.A. (1987). Learning of psychomotor skills: Laboratory versus patient care

setting. J Nurs Educ, 26(1), 20-24.

Gredler, M. (1992). Designing and evaluating games and simulations: A process approach. London, UK:

Kogan Page.

Hertel, J.P. and Millis, B.J. (2002). Using simulations to promote learning in higher education: An

introduction. Sterling, VA: Stylus.

Hicks, F.D. (2006). Clinical Decision-Making Self-Confidence Scale.

Hogan, M.P., Pace, D.E., Hapgood, J. and Boone, D.C. (2006). Use of human patient simulation and the

situation awareness global assessment technique in practical trauma skills assessment. J Trauma,

61(5), 1047-1052.

Issenberg, S.B., McGaghie, W.C., Petrusa, E.R., Lee Gordon, D. and Scalese, R.J. (2005). Features and uses

of high-fidelity medical simulations that lead to effective learning: A BEME systematic review.

Med Teach, 27(1), 10-28.

Jarzemsky, P.A. and McGrath, J. (2008). Look before you leap: Lessons learned when introducing clinical

simulation. Nurs Educ, 33(2), 90-95.

Lane, C. and Rollnick, S. (2007). The use of simulated patients and role-play in communication skills

training: A review of the literature to August 2005. Patient Educ Couns, 67(1-2), 13-20.

Lasater, K. (2007). High-fidelity simulation and the development of clinical judgment: Students

experiences. Journal of Nursing Education, 46(6), 269-276.

Lauber, J. K. (1987). Cockpit resource management: Background studies and rationale. In H. W. Orlady &

H. C. Foushee (Eds.). Cockpit resource management training (Tech. Rep. No. NASA CP-2455).

Moffett Field, CA: NASA Ames Research Center.

Lederman, L.C. (1992). Debriefing: A critical reexamination of the post experience analytic process with

implications for its effective use. Simul Gaming, 23(2), 145-160.

Long, R.E. (2005). Using simulation to teach resuscitation: An important patient safety tool. Crit Care Nurs

Clin North Am, 17(1), 1-8, ix.

Lundberg, K.M. (2008). Promoting self-confidence in clinical nursing students. Nurs Educ, 33(2), 86-89.

Maran, N.J. and Glavin, R.J. (2003). Low- to high-fidelity simulation A continuum of medical education?

Med Educ, 37(Suppl. 1), 2228.



23REFERENCES

Mcintosh, C., Macario, A., Flanangan, B. and Gaba, D.M. (2005). Simulation: What does it really cost?

Poster session presented at the SimTecT 2005 Healthcare Simulation Conference, Brisbane,

Australia.

Mikkelsen, J., Reime, M.H. and Harris, A.K. (2007). Nursing students learning of managingcross-infections Scenario-based simulation training versus study groups. Nurs Educ Today,

28(6), 664-671.

Moule, P., Wilford, A., Sales, R. and Lockyer, L. (2008). Student experiences and mentor views of the use of

simulation for learning. Nurs Educ Today, 28(7), 790-797.

Radhakrishnan, K., Roche, J.P. and Cunningham, H. (2007). Measuring clinical practice parameters with

human patient simulation: A pilot study. Int J Nurs Educ Scholarsh, 4(1).

Ravert, P. (2002). An integrative review of computer-based simulation in the education process. ComputInform Nurs, 20(5), 203-208.

Scalese, R.J. Obeso, V.T. and Issenberg, S.B. (2008). Simulation technology for skills training and

competency assessment in medical education. J Gen Intern Med, 23 (Suppl. 1), 46-49.

Shavit, I., Keidan, I., Hoffman, Y., Mishuk, L., Rubin, O., Ziv, A. and Steiner, I.P. (2007). Enhancing patient

safety during pediatric sedation. The impact of simulation-based training of

nonanesthesiologists. Arch Pediatr Adolesc Med, 161(8), 740-743.

Tuoriniemi, P. and Schott-Baer, D. (2008). Implementing a high-fidelity simulation program in a communitycollege setting. Nurs Educ Perspect, 29(2), 105-109.

Wilson, M., Shepherd, I., Kelly, C. and Pitzner, J. (2005). Assessment of a low-fidelity human patient

simulator for the acquisition of nursing skills. Nurs Educ Today, 25(1), 56-67.

Ziv, A., Wolpe, P.R., Small, S.D. and Glick, S. (2003). Simulation-based medical education: An ethical

imperative. Acad Med, 78(8), 783788.



24APPENDIX A: CHEST PAIN SCENARIO

APPENDIX A: CHEST PAIN SCENARIOAppendix A: Evaluation of Videotapes Chest Pain Scenario

Criteria Chest Pain Scenario InadequateSomewhatInadequate

NotAttempted

SomewhatAdequate Adequate

Patient-nurse relationship

1. Called the patient by his/her name. -2 -1 0 1 2

2. Informed him/her the purpose of the encounter. -2 -1 0 1 2

3. Demonstrated professional demeanor when approaching andcommunicating with patient.

-2 -1 0 1 2

4. Was calm and reassuring. -2 -1 0 1 2

5. Demonstrated empathy and respect. -2 -1 0 1 2

Symptom Recognition

6. Acknowledged chest pain as abnormal finding. -2 -1 0 1 2

7. Acknowledged non-verbal patient reaction to pain by

verbalizing patients discomfort. -2 -1 0 1 2

8. Acknowledged the patients anxiety and reassures the patientappropriately.

-2 -1 0 1 2

9. Recognized patients history -2 -1 0 1 2

Assessment

10. Elicited when pain started. -2 -1 0 1 2

11. Elicited quality of the pain. -2 -1 0 1 2

12. Elicited what makes pain better or worse. -2 -1 0 1 2

13. Elicited if pain radiates. -2 -1 0 1 2

14. Elicited severity of pain. -2 -1 0 1 2

15. Elicited information about headache. -2 -1 0 1 2

16. Took BP. -2 -1 0 1 2

17. Took pulse. -2 -1 0 1 2

18. Took respiration. -2 -1 0 1 2

19. Palpated skin and notes skin color. -2 -1 0 1 2

20. Auscultated lung fields thoroughly. -2 -1 0 1 2

21. Reassessed chest pain after giving nitroglycerin. -2 -1 0 1 2

22. Reassessed vital signs after nitroglycerin. -2 -1 0 1 2

Interventions

23. Placed patient in high Fowlers position. -2 -1 0 1 2

24. Placed oxygen nasal cannula and turns on the flow meterto 2l/min.

-2 -1 0 1 2

25. Explained findings to the patient. -2 -1 0 1 2

26. Gave Nitroglycerin SL. -2 -1 0 1 2

27. Described all interventions and their rationale to the patient. -2 -1 0 1 2

28. Recognized need to report findings to the physician. -2 -1 0 1 2

29. Provided adequate report of findings when promptedby instructor (i.e., physician report).

-2 -1 0 1 2

Participant Number:_______________________________________________ Total time to complete scenario: ________________

Scenario: _____________________________________________________________________________

Inappropriate/illogical actions: 1.___________ 2.___________ 3. ___________ 4.____________

Other appropriate actions: 1.___________ 2.___________ 3. ___________ 4.____________



25APPENDIX B: SHORTNESS OF BREATH SCENARIO

APPENDIX B: SHORTNESS OF BREATH SCENARIOAppendix B: Evaluation of Videotapes Shortness of Breath Scenario

Criteria Shortness of Breath Scenario InadequateSomewhatInadequate

NotAttempted





3. Demonstrated professional demeanor when approachingand communicating with patient.

-2 -1 0 1 2


Symptom Recognition

5. Acknowledges shortness of breath (SOB) as anabnormal finding.

-2 -1 0 1 2

6. Acknowledges non-verbal patient reaction to SOB. -2 -1 0 1 2

7. Acknowledges patients fear and reaction to pain. -2 -1 0 1 2

8. Recognizes patients history. -2 -1 0 1 2

Assessment

9. Assessed onset of SOB. -2 -1 0 1 2

10. Assessed character of SOB. -2 -1 0 1 2

11. Assessed intensity of SOB. -2 -1 0 1 2

12. Assessed contributory factors for SOB. -2 -1 0 1 2

13. Assessed associative factors for SOB. -2 -1 0 1 2

14. Took BP. -2 -1 0 1 2

15. Palpated radial pulse. -2 -1 0 1 216. Took respiration. -2 -1 0 1 2

17. Auscultated lung fields thoroughly. -2 -1 0 1 2

18. Inspected nail bed and lips for cyanosis. -2 -1 0 1 2

19. Determined level of assistance patient needs for returningto bed.

-2 -1 0 1 2

20. Determined SpO2. -2 -1 0 1 2

21. Checked postoperative dressing. -2 -1 0 1 2

Interventions

22. Assisted patient back to bed. -2 -1 0 1 2

23. Placed patient in high Fowlers position. -2 -1 0 1 2

24. Placed oxygen nasal cannula. -2 -1 0 1 2

25. Instructed the patient on focused breathing. -2 -1 0 1 2


27. Recognized need to report findings to the physician. -2 -1 0 1 2

28. Provided adequate report of findings when promptedby instructor (i.e., physician report).

-2 -1 0 1 2

29. Repeated physicians orders. -2 -1 0 1 2


Scenario: _____________________________________________________________________________





26APPENDIX C: LEVEL OF CONSCIOUSNESS SCENARIO

Appendix C: Evaluation of Videotapes Level of Consciousness Scenario

Criteria Change in Level of Consciousness Scenario InadequateSomewhatInadequate

NotAttempted





3. Demonstrated professional demeanor when approaching andcommunicating with patient.

-2 -1 0 1 2


5. Demonstrated empathy and respect.

Symptom Recognition

6. Acknowledged change in level of consciousness (LOC) as anabnormal finding.

-2 -1 0 1 2

7. Determined level of arousal. -2 -1 0 1 2

8. Acknowledged confusion/disorientation. -2 -1 0 1 2

9. Acknowledged patients history as contributing factor. -2 -1 0 1 2

Assessment

10. Assessed orientation three times. -2 -1 0 1 2

11. Took blood pressure. -2 -1 0 1 2

12. Took pulse. -2 -1 0 1 2

13. Took respiration. -2 -1 0 1 2

14. Checked pupil reaction. -2 -1 0 1 2

15. Assessed upper extremity (UE) strength. -2 -1 0 1 216. Assessed lower extremity (LE) strength. -2 -1 0 1 2

17. Assessed upper extremity (UE) sensation. -2 -1 0 1 2

18. Assessed lower extremity (LE) sensation. -2 -1 0 1 2

19. Inspected face for symmetry. -2 -1 0 1 2

Interventions

20. Placed patient on back. -2 -1 0 1 2

21. Raised head of bed angle (HOB) to 45 degrees. -2 -1 0 1 2

22. Placed oxygen nasal cannula. -2 -1 0 1 2


24. Recognized need to report findings to physician. -2 -1 0 1 2

25. Provided adequate report of findings when prompted byinstructor (i.e., physician report).

-2 -1 0 1 2

26. Repeated physician orders. -2 -1 0 1 2

27. Side rails up. -2 -1 0 1 2

28. Reoriented patient to person, place, and time (PPT). -2 -1 0 1 2


Scenario: _____________________________________________________________________________



APPENDIX C: LEVEL OF CONSCIOUSNESS SCENARIO



27APPENDIX D: SELF-CONFIDENCE SCALE

Appendix D: Self-confidence Scale

Not at allconfident

Somewhatnot confident

Somewhatconfident

Moderatelyconfident

Veryconfident

1. How confident are you that you can recognize signs andsymptoms of a cardiac event?

1 2 3 4 5

2. How confident are you that you can recognize signs andsymptoms of a respiratory event?

1 2 3 4 5

3. How confident are you that you can recognize signs andsymptoms of a neurological event?

1 2 3 4 5

4. How confident are you that you can accurately assess anindividual with chest pain?

1 2 3 4 5

5. How confident are you that you can accurately assess anindividual with shortness of breath?

1 2 3 4 5

6. How confident are you that you can accurately assess an

individual with changes in mental status?1 2 3 4 5

7. How confident are you that you can appropriately intervene foran individual with chest pain?

1 2 3 4 5

8. How confident are you that you can appropriately intervene foran individual with shortness of breath?

1 2 3 4 5

9. How confident are you that you can appropriately intervene foran individual with changes in mental status?

1 2 3 4 5

10. How confident are you that you can evaluate the effectivenessof your interventions for an individual with chest pain?

1 2 3 4 5

11. How confident are you that you can evaluate the effectivenessof your interventions for an individual with shortness of breath?

1 2 3 4 5

12. How confident are you that you can evaluate theeffectiveness of your interventions for an individual withchanges in mental status?

1 2 3 4 5

APPENDIX D: SELF-CONFIDENCE SCALE


35/35

111 E. Wacker Drive, Suite 2900Chicago, IL 60601-4277312.525.3600312 279 1032 f

09 simulationstudy vol40 web with cover

Documents