The Impact of High Fidelity Simulation on Competency ...
The Impact of High Fidelity Simulation on Competency Skills among First Year Associate Degree Nursing Students: A Research Proposal
Jill McLaughlin
State University of New York Institute of Technology
Abstract
The impact of high-fidelity simulation on competency skills of first year associate degree nursing students will be examined through a descriptive study. Participants will be divided into two groups; one group will engage in simulation scenarios and attend traditional clinical, the other will attend traditional clinical only. Both groups will undergo identical testing of three nursing competency skills using the Objective Structured Clinical Examination tool. Findings will be disseminated through professional nursing journals and professional conferences.
The Impact of High Fidelity Simulation on Competency Skills among Associate Degree Nursing Students: A Research Proposal
Statement of the Problem
Barriers to clinical opportunities
Lack of faculty. There are a number of factors which create barriers for nursing students to obtain adequate clinical experiences. Over the last decade there have been significant media reports regarding the nursing shortage and the ability to educate new nurses. The American Association of Colleges of Nursing (AACN, 2011) reported that in 2010 over 67,000 applicants for nursing programs at the baccalaureate level and above were refused entry “due to an insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints”.
Lack of clinical opportunities. One of the identified areas of concern related to the education of new nurses is lack of clinical resources in the form of clinical sites, exposure to varied patient populations, and less exposure to nursing interventions (Elfrink, Kirkpatrick, Nininger, & Schubert, 2010; Hauber, Cormier, & Whyte, 2010; Lisko & O’Dell, 2010; Traynor, Gallagher, Martin, & Smyth, 2010). Clinical competency in nursing students is most likely to be assessed in the live clinical setting. Although individual task or interventions are taught in the lab setting, it is the clinical environment that provides nursing instructors with an ability to directly observe a student in action and to assess whether the student is achieving competency (O’Connor, 2001). With the loss of clinical sites, nursing programs must adopt strategies for alternate methods student assessment.
Theory-practice Gap
Inadequate time to develop skills. Acute problems needing prompt interventions may not occur when students are present in the clinical setting. Patients are at a higher acuity level and their treatments require complex care (Gillespie & Paterson, 2009). Nursing students may receive content in a lecture setting, but then are not able to bring that knowledge into clinical practice (Bambini, Washburn, & Perkins, 2009; Decker et al., 2008).
Significance
Appropriately developed scenarios provide an opportunity for students to demonstrate clinical skills without the presence of a live patient (Walton, Chute, & Ball, 2011). Simulation scenarios may be considered as an alternative, or additional, option to attain clinical competency (Decker et al., 2008). In the last decade high-fidelity simulation has become part of the solution for lack of clinical learning experiences. Integration of high-fidelity simulation into nursing education programs is widespread and seeks to augment student learning (Decker, Sportsman, Puetz, & Billings, 2008; Partin, Payne, & Slemmons, 2011). With the loss of clinical sites, nursing programs must adopt strategies for alternate methods of student assessment.
Enhancing Critical Thinking Skills
Assess and debrief. The literature reveals numerous advantages to using clinical simulation. The application of skills in a simulated environment provides benefits for both instructors and students. Instructors can assess each step of student performance, can examine student thinking, and can provide immediate debriefing at the end of the simulation experience Debriefing allows for remediation of mistakes made during the scenario and for more learning to occur (Jeffries, 2005; Traynor et al., 2010)
Repetition. Students’ anxiety is diminished as they are not working with a live patient and can have repeated practice with the same scenario uninhibited by actual patient responses (Brewer, 2011; Decker et al., 2008; Partin et al., 2011; Traynor et al., 2010; Tuoriniemi & Schott-Baer, 2008). Simulations provide an ideal arena to reenact situations that students may not otherwise be exposed to (Beddingfield, Davis, Gilmore, & Jenkins, 2011; Decker et al., 2008). It allows students to build on the skills they have and become more adept at critical thinking by understanding the reason why they perform certain interventions (Traynor et al., 2010).
Prioritization and interventions. Simulation scenarios allow for experiential learning in a controlled and safe environment. Partin, Payne, and Slemmons (2011) found that students participating in simulation had an increase in knowledge and were better able to prioritize care. Employers now expect new graduates to function at a higher level than was expected in the past (Jeffries, 2005).
Purpose
The intent of this proposal is to determine the effect of high-fidelity simulation learning environments on competency skills among associate degree first year nursing students.
Research Question
Can high-fidelity simulation be used to effectively increase clinical competence in nursing students?
Definition of Terms
High-fidelity Simulation
High-fidelity simulation utilizes lifelike computerized mannequins which can be preprogrammed with clinical scenarios. The responses to interventions mimic responses an actual patient may have based on the interventions the student chooses (Decker et al., 2008)
Competency
Decker et al. (2008) define competency as the development of knowledge and psychomotor skills which can be applied in context to a given situation. A tool to measure competency is the Objective Structured Clinical Examination (OSCE)
Theoretical Frameworks
Benner’s Novice to Expert Theory
Clinical competency of nurses is outlined in the five levels that Benner describes as novice, advanced beginner, competent, proficient, and expert. Student nurses begin as novices because they have little or no clinical experience. Knowledge is theoretical as opposed to practical; students progress to advanced beginner through the acquisition of clinical skills and benefit from the assistance of a mentor (Benner, 1984). Students perform tasks because of knowledge they have obtained, but may not know why they are performing them. Mentors may be few in many healthcare settings so new graduates need to have more experiential opportunities while in the nursing program (Gillespie & Paterson, 2009). The higher stages of competency reflect progression achieved after years of work experience and as such will not be incorporated into this research proposal.
Benner’s theory and simulation use. As students begin to care for patients in the clinical area, they gain experience, whether it is through the implementation of an intervention written up in their preclinical care plan, or through an unanticipated outcome. However, many scenarios do not present themselves during the clinical rotation and maintaining patient safety is paramount (Decker et al., 2008; Larew, Lessans, Spunt, Foster, & Covington, 2006). High-fidelity simulation offers students an opportunity to actively participate in a learning activity that can contribute to their understanding of what is taught in the classroom. Larew, Lessans, Spunt, Foster, and Covington (2006) applied Benner’s theory to a study which included the differing levels of competency as applicable to nursing students. The study determined that simulation scenarios offered a more successful experience when verbal prompts were individualized to the level of the student. The authors concluded that there was a need for simulation protocol that would allow for the differing levels of clinical competency so as to provide a comfortable learning environment. Participation by students as developers of a simulation added to the experiential learning garnered.
Situated Cognition
Situated cognition, also known as situated learning, refers to a learning theory which calls for active learning in a real-life, or authentic situation, such as a high fidelity simulation scenario (Onda, 2011). As it pertains to nursing students, situated cognition assists the learner to incorporate theory based knowledge into a practical context in order to become adept at clinical reasoning and problem solving (Gillespie & Paterson, 2009; Onda, 2011). The learner experiences the situation and through interaction, learns from it. It is similar to the Novice to Expert theory in that it involves a hands on approach.
Situated cognition and simulation. Onda (2011) states that nursing students can benefit from a safe environment, such as a simulation scenario, to practice their skills. In an exploratory study conducted to evaluate simulation use in nursing curriculum, situated learning theory was the framework used (Elfrink et al., 2010). Scenarios were developed which required learners to share knowledge and provide meaning and usefulness to what they had learned in the classroom.
Literature Review
Background
High-fidelity simulators are programmable mannequins which respond physiologically to clinical interventions implemented by the user. It offers nursing students an opportunity, in a risk-free environment, to experience clinical situations that they might not come across while in the clinical rotation (Bambini, Washburn, & Perkins, 2009; Beddingfield et al., 2011; Brewer, 2011; Decker et al., 2008; Liaw et al., 2010; Onda, 2011; Reid-Searl, Eaton, Vieth, & Happell, 2011; Tuoriniemi & Schott-Baer, 2008).
Research
Researchers in the field of high-fidelity simulation and its use in nursing education call for more substantive data to support the use of simulation as an option to augment traditional clinical offerings (Beddingfield et al., 2011; Decker et al., 2008; Elfrink et al., 2010; Liaw et al., 2010; Reid-Searl et al., 2011)
Benefits
Simulation experiences may increase clinical confidence which in turn may have a positive effect on clinical performance (Bambini et al., 2009). Clinical sites are becoming more difficult to find and simulation offers a potential solution (Bambini et al., 2009; Decker et al., 2008; Onda, 2011; Tuoriniemi & Schott-Baer, 2008).
Challenges
High-fidelity simulators are expensive. Faculty must be trained on the devices and scenarios developed or purchased (Brewer, 2011; Jeffries, 2005; Tuoriniemi & Schott-Baer, 2008). College resources such as funds for nursing programs and the number of nursing faculty are decreasing (Beddingfield et al., 2011; Tuoriniemi & Schott-Baer, 2008)
Theory
Benner’s Novice to Expert theory is recurrent in the literature, as students initially performed interventions in simulations based on knowledge rather than understanding of the situation (Bambini et al., 2009; Gillespie & Paterson, 2009). Scenarios which are based on varying levels of clinical competency and challenged students at their level facilitated learning best (Larew et al., 2006). Situated cognition borrows from the Novice-to-expert theory and calls for learning to take place in an authentic environment (Gillespie & Paterson, 2009). Onda (2011) states that “…simulation can, and does, address and help to narrow this theory-practice gap” (p.e2). Through the provision of scenarios which meet the skill level of the student, the student can progress in their clinical skills (Onda, 2011).
Tools to measure outcomes
There is no universal tool to evaluate students during high-fidelity scenarios (Brewer, 2011). Jeffries (2005) suggests the use of checklists to measure competency of clinical skills. The Objective Structured Clinical Examination (OSCE) is a tool that has been used since 1975 to assess medical students’ performance in the clinical setting. It has since been used internationally for other healthcare professions and is considered to be highly reliable (McWilliam & Botwinski, 2012; Zayyan, 2011). The OSCE is an objective performance test which can be used to measure the theory to practice learning. It is important to include competencies derived from the program’s objectives in order to ensure its validity and reliability (McWilliam & Botwinski, 2012).
Methodology
Design
This is a descriptive cross-sectional study which will compare competency skills of nursing students who attend high-fidelity simulation sessions and clinical rotation, and competency skills of nursing students who attend clinical rotation only. After one clinical rotation consisting of eight weeks, participants will rotate and those who did not attend high-fidelity simulation sessions will be provided an opportunity to do so.
Setting
The study will take place at a two year community college which has an established nursing program and a well-equipped modern simulation laboratory. Data collection will occur in the college’s skills assessment laboratory as this is a room accessible to all participants.
Population
Sample. The population consists of first year associate degree nursing students in a medical-surgical care clinical rotation. A convenience sample of students in the program will be invited to participate. Those who agree will be placed on an alphabetized roster. A power analysis would be completed prior to the start of the study to determine sample size. Participants must have successfully completed course requirements including laboratory and clinical experiences.
Assignment. Students will be placed into group A or B by alternating group assignments. For example, the first person on the list will be assigned to group A, while the second person will be assigned to group B. Group A will consist of students who will participate in a high fidelity simulation scenario prior to their clinical rotation while group B will consist of students who do not participate in simulation prior to their clinical rotation.
Ethical considerations. Prior to implementation of the study, approval must be obtained from the college institutional review board. Informed consent will be completed by participants and data will be encoded to ensure confidentiality. Participation is voluntary and students may withdraw from the study at any time. Participants will be made aware that participation has no impact on their grades. All participants will have an opportunity to participate in simulation scenarios after study is completed.
Consent Form
Study Title: The Impact of Clinical Simulation on Competency Skills among Associate Degree Nursing Students
Investigator: Jill McLaughlin, RN, BSN
You have been invited to participate in a study on the use of clinical simulation and its impact on competency skills. The information collected will assist us in identifying educational programs that may be further developed to increase the level of competency skills among associate degree nursing students.
The study requires you to attend a skills lab at the completion of your clinical rotation which will take approximately 45 minutes to complete.
Data collected will be coded and not linked to your name or any of your personal information. All data will be collected by Jill McLaughlin and certified lab personnel, and stored on a password protected computer, and then encrypted. Coding sheet will be kept locked in a separate location.
Your participation in this study is voluntary and you may withdraw at any time.
You may ask me any questions about the study or about being a participant. I can be reached at (999) 999-9999.
I have read this consent form and voluntarily consent to participate in this study.
Subject Signature Date
I have explained this study to the above subject and have obtained informed consent.
Investigator’s Signature Date
Instrument
The Objective Structured Clinical Examination (OSCE) is a performance-based tool that is used to identify competency in nursing. It allows structured measurement of specific components and can be used to demonstrate analysis and synthesis of information, rather than the lower order thinking of knowledge recall. The OSCE has been tested with various populations in different settings and has been demonstrated to have a high degree of validity and reliability ((McWilliam & Botwinski, 2012; Selim, Ramadan, El-Gueneidy, & Gaafer, 2012; Walsh, Bailey, Mossey, & Koren, 2010; Zayyan, 2011).
Procedure
Participants in Group A will participate in three simulation scenarios during which each of the three skills to be tested will be implemented. The first three weeks of the clinical rotation will take place in the simulation lab. Group A will then finish their clinical rotation at a local hospital. Group B will spend eight weeks at the same local hospital for their clinical rotation. At the conclusion of the clinical rotation, participants will be given random appointment times to come to the lab for skills testing.
The OSCE tool is used to assess the level of competency in three nursing skills: tracheostomy care, urinary catheter insertion, and gastric tube feeding. All skills will be performed on static mannequins. Data will be collected at one point in time for each of two student groups. Three nursing skills would be tested with a 10 minute time limit for each and a five minute break between each skill. A timekeeper will be present. The skills would be derived from clinical student objectives and the test checked for reliability and validity.
Data will be collected by skills lab personnel using the OSCE tool. Lab personnel will be trained in the use of the OSCE tool. The skills lab will be utilized only for the purpose of conducting OSCE on the day of testing. Students from both groups will be given the same written and verbal instructions as to how testing will occur. Equipment and personnel will also be identical for both groups.
Plan for Analysis
Descriptive statistics will be utilized to compare the skill performance of participants who participated in high-fidelity simulation prior to clinical and those who did not. The three skills will be listed in table format, tracheostomy care, urinary catheter insertion, and gastric tube feeding. The t-test for independent groups will be used to identify differences between the groups.
Discussion
Simulation in nursing education is has been present for a long time, but high fidelity simulation has become more popular in recent years owing to the advances in technology. Currently, there is a need for further research on the topic of high fidelity simulation and its effectiveness in enhancing competency in clinical nursing skills. The results of this proposal may add to this body of evidence.
The research proposal would be offered to scholarly journals for acceptance; the National League of Nursing’s (NLN) journal, Nursing Education Perspectives, a national peer-reviewed journal, Sigma Theta Tau International Journal of Nursing Scholarship, and Teaching and Learning in Nursing, which is the journal specific to associate degree nursing. Other potential journals are the Journal of Nursing Education, Journal of Advanced Nursing, Clinical Simulation in Nursing, and Critical Care Nurse, all of whom have published articles on simulation in nursing. With today’s technology, and the world wide web, many, if not most of the articles in these journals are available internationally.
The target audience will be nurse educators, college administrators of nursing programs, clinical simulation specialists, and graduate/doctorate level students of nursing. National conferences by accredited bodies of learning, and simulation would also be a means of disseminating the research proposal. The NLN also hosts annual education summits and clinical specialty immersion experiences where this particular topic would be of interest to those attending.
References
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Selim, A. A., Ramadan, I. H., El-Gueneidy, M. M., & Gaafer, M. M. (2012). Using objective structured clinical examination (OSCE) in undergraduate psychiatric nursing education: Is it reliable and valid?. Nurse Education Today, 283-288. Retrieved from nedt
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