Erasmus Mundus Master Course in Emergency and Critical Care Nursing

(EMECC NURSING)

“Using Simulation as a Learning Strategy in Perioporative Nursing Education”

Bishoy Awadalla

04/02/2016

Master´s Thesis

Erasmus Mundus Master Course in Emergency and Critical Care Nursing

Erasmus Mundus Master Course in Emergency and Critical Care Nursing

“Master Course in Emergency and Critical Care Nursing”

“Using Simulation as a Learning Strategy in Perioporative Nursing Education”

Name of Author Name of Supervisor Name of Co-supervisor

Bishoy Awadalla Prof. Dr. Prof. Dr.

José Amendoeira Marianne Pitkäjärvi

ACKNOWLEDGMENT

First and foremost, I feel always indebted to God who always supports me

everywhere I go.

Without a doubt, this could not have been accomplished without the contribution

and dedication of my entire dissertation committee supervisors for their guidance and

support in this venture. A special note of gratitude is extended to Prof. Dr. José

Amendoeira and Prof. Dr. Marianne Pitkäjärvi, my chairpersons, who willingly shared

their expertise and dedication to making health care better and safer through nursing

education.

I am particularly thankful for my parents’ and wife's enduring interest and

helpfulness in my achievement of this goal.

I also express my greatest appreciation to all nursing students at Metropolia

Helsinki of Applied Sciences who participated in the study for their cooperation.

ABSTRACT

Introduction: Simulation can be the answer to developing nursing students’

knowledge, skills, and attitudes, whilst protecting patients from unnecessary risks.

Simulation has been shown to be an effective learning environment for students to

learn and practice complex perioperative nursing. Purpose of the Study: To explore

the effect of using simulation as a learning strategy in perioperative nursing education.

Objectives of the study: To explore nursing students’ technical skills (TSs), non-

technical skills (NTSs) in addition to explore nursing students’ self confidence.

Design: A descriptive, exploratory design was used to investigate TSs, NTSs and self-

confidence levels using simulation training scenarios. Sample: A purposive sample

(44/158) of undergraduate nursing students who were conducting their perioperative

nursing education in autumn 2015. Setting: The study was conducted at Metropolia’s

simulation laboratory at Helsinki Metropolia University of Applied Sciences, Finland.

Methodology: PostOperative Simulation Sheet (POSS) consisted of two sections; the

first section was used to collect self reported data on socio-demographic variables,

The second section was divided into three parts; the first part was students’ self-

confidence tool, The second part was a perioperative TSs checklists consisted of two

checklists; the first one for intraoperative TSs, The second checklist for postoperative

TSs, The third part was a perioperative NTSs checklist. Results: nursing students

were confident with intra/postoperative simulation; For Intra and postoperative

simulation TSs and NTSs they were occurred with a good level. Conclusion The

simulation as a learning strategy has been shown to be effective in providing students

with a safe environment for learning perioperative patient care and has shown

potential in improving student’s learning outcomes such TSs, NTSs, and self

confidence.

Key words: Simulation, Technical skills (TSs), Non-technical Skills (NTSs),

Perioperative nursing.

LIST OF CONTENTS

Chapter Item Page

I Introduction 1

Purpose of study 2

Research question 3

Significance of the study 3

Definition of terms 5

II Review of Literature

Perioperative Setting 8

Patient Safety at Intra/Postoperative Phase 8

Simulation Training Benefits 9

Simulation Types 10

Perioperative Nursing Skills 11

Perioperative Patient Education 11

Positioning the Patient 11

Asepsis and Aseptic Practices in the OR 12

Asepsis and Aseptic Practices in the OR 12

Perioperative TSs 12

Perioperative NTSs and CRM 15

Self-confidence 16

Summary 17

III Subjects and Methods 18

Setting 18

Sampling 18

Research Design 18

Data Collection 19

Instruments 19

Data Analysis 20

Ethical Considerations 22

IV Results 23

V Discussion 31

VI Conclusion, and Recommendations 36

References 38

Appendices 47

LIST OF TABLES

Table Title Page

1 Frequency, and Percentage Distribution of Socio-demographic

Variables Related to Nursing Students or Observed Subjects (n=44).

25

2 Frequency Distribution of Students’ Self-Confidence in Relation to

Socio-Demographic Variables in Perioperative Simulation (n=44).

27

3 Frequency and Percentage Distribution of TSs Data Related to

Intraoperative Simulation (n=88).

28

4 Frequency and Percentage Distribution of TSs Data Related to

Postoperative Simulation (n=68).

29

5 Frequency and Percentage Distribution of NTSs related to Intra and

Postoperative Simulation (n=96).

30

LIST OF FIGURE

Figure Title Page

1 Simulation Model, Nursing Education Simulation Framework 4

LIST OF ABBREVIATION

ABCDE Airway, Breathing, Circulation, Disability, Exposure

AORN Association of periOperative Registered Nurses

AVPU Alert, Voice responsive, Pain responsive, or Unresponsive

BGL Blood Glucose Level

BL.P Blood Pressure

CRM Crisis Resources Management

ECG Electrocardiogram

ISBAR Identification, Situation, Background, Assessment, Recommendation

IV Intravenous

NLN National League for Nursing

NTSs Non Technical Skills

NESF Nursing Education Simulation Framework

OR Operating Room

PACU post Anaesthesia Care Unit

POSS PeriOperative Simulation Sheet

Pt Patient

SPSS Statistical Package for the Social Sciences

TSs Technical Skills

APPENDICES

Appendix Title Page

A PeriOperative Simulation Sheet, POSS 47

B Research Permit 52

C Students’ Informed Consent 53

D Permission Letter from National League for Nursing

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1

CHAPTER I

INTRODUCTION

Jeffries (2005) defined simulations as activities that mimic the reality of a

clinical environment and are designed to demonstrate procedures, decision-making

and critical thinking through techniques such as role playing and the use of devices

such as interactive videos or mannequins.

Gaba (2004) added that simulation is a technique, not a technology, to replace or

amplify real experiences with guided experiences, often immersive in nature, that

evoke or replicate substantial aspects of the real world in a fully interactive fashion.

Simulation for medical and healthcare applications has revolutionized the way

healthcare is taught. The number of centers with simulation labs has increased

considerably over the past decade, from a mere handful at the end of the past century

to alone over 800 in 2010 in the United States. Depending on the environmental

aspect replicated by a simulator, the devices can be classified as part-task trainer, low

fidelity screen-based simulators, intermediate fidelity simulators, high fidelity

mannequin-based simulators, virtual reality, and in its early stages, immersive virtual

environment (Gaba, 2004; Maran & Glavin, 2003).

Several textbooks and monographs have been released covering virtually every

aspect of simulation-based education. These are an excellent starting for anyone

considering implementing simulation as a medical education tool (Kyle & Murray,

2008; Riley, 2008).

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Perioperative phase involve the interaction of a multi-disciplinary team of

healthcare professionals, and communication can be complex, even for the simplest of

surgical procedures. Perioperative contexts are interdisciplinary, multispecialty, often

approaching providers at different levels of training, and involve patients in transit,

who are at risk of instability during this acute phase of care (Petrovic et al., 2012).

Simulation environments reduce and eliminate anxieties produced with

providing care for real patients. The health care settings which ―real life‖ clinical

experiences take place have a high level of acuity and complexity which can interfere

with a learner’s ability to transfer knowledge and skills from classroom and laboratory

settings which can be avoided with the simulated experiences and improving patient

safety (Halstead, 2009), Expose students to the same simulations ensure their

experiences are standardized which increases students’ self-confidence and decreases

anxiety (Walsh, 2010).

The skills requirements which can be enhanced with the use of simulation

include (situation awareness, decision-making, communication, team working and

leadership skills) all of these share a common thread in that they require active

listening and collaboration besides possession of the basic knowledge and skills. With

every training scenario it is best to have feedback and debriefing sessions that follow.

Feedback must be linked to learning outcomes and there must be effective debriefing

protocols following all simulation exercises (Gupta, Peckler, & Schoken, 2008)

Purpose of the Study:

To explore the effect of using simulation as a learning strategy in perioperative

nursing education.

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Objectives of the study:

1- To explore nursing students’ technical skills (TSs) and non-technical skills

(NTSs)

2- To explore nursing students’ self confidence.

Research Question:

How does the use of perioperative simulation training scenarios affect TSs,

NTSs and self confidence among nursing students who are conducting their

perioperative education at Helsinki Metropolia University of Applied Sciences,

Finland?

Significance of Study:

Perioperative environment is considered one of the most sophisticated and

challenging environment in acute care contexts where communication errors and

mistakes that could have serious and fatal implications. In fact, the most frequently

reported cause of sentinel events within U.S. hospitals is poor NTSs (Street et al.,

2011). Specifically, the risk for adverse events occurs more often for surgical patients

than in any other clinical specialty (Amato-Vealey, Barba, & Vealey, 2008).

Regarding this, simulation offers the opportunity for nursing students to

practice skills, techniques, communication, problem solving and critical thinking in a

safe environment; it offers innovative ways of teaching students about real situation in

a controlled environment (Jeffries, 2009; Webster, 2009).

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Theoretical framework:

Figure 1: Simulation Model. )Jeffries, 2005).

The theoretical framework used to guide this study is the Simulation Model by

Jeffries (2005); Nursing Education Simulation Framework (NESF) can be used to

design, implement, and evaluate simulations used in nursing education. Components

of the framework include best practices in education, student factors, teacher factors,

simulation design characteristics, and outcomes.

This framework consists of three major components – outcomes, contextual

elements, and design elements (Jeffries & Rogers, 2007). The outcomes of a nursing

simulation include knowledge acquisition, skill performance, learner satisfaction,

critical thinking, and self-confidence. Contextual elements are the students and

teachers, their backgrounds and experiences, as well as educational practices

embedded in a particular setting. Design elements include objectives, fidelity, problem

solving, student support, and debriefing. The current study will focus on the

relationships between student factors (demographic characteristics) and three NESF

outcomes, namely TSs, NTSs and self-confidence

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Defining Theoretical Concepts

1. Data sources: Triangulation of data from designers, instructors and learners

improves a researcher’s ability to make inferences about the data as it relates to the

validation of the model (Richey, 2005).

1.1. Designer/facilitator Data; Demographic data including gender, ethnicity,

education, and design experience in both general and simulation-based courses

collected from the designer

1.2. Faculty/educational practices Data; Demographic data including gender,

ethnicity, teaching experience in traditional and simulation-based courses, highest

degree, and education in facilitating simulation-based education collected from the

faculty.

1.3. Student/participant data; Demographic data including gender, ethnicity,

educational background, prior experience with simulations.

2. Simulation design characteristics:

2.1. Objectives; Within the Jeffries framework, objectives must be clearly written to

allow students to participate effectively in the simulation The number of objectives

should be reflective of the complexity of the simulation but ideally no more than three

to four objectives should be included in a 20 -minute simulation (Jeffries, 2006;

Jeffries & Rogers, 2007).

2.2. Fidelity; Fidelity is defined as the level of realism found within a simulation both

in the technology used and in the environment within which the simulation occurs

(Jeffries, 2005).

2.3. Problem-solving; Another important simulation design feature is the opportunity

for problem solving. Within the framework, problem solving is viewed as decision

points that learners create for themselves (Jeffries, 2006).

2.4. Student support; Student support includes the cues provided during the simulation

(Jeffries & Rogers, 2007) as well as facilitation of guided reflection on decision-

making during debriefing (Jeffries, 2006).

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2.5. Debriefing; Debriefing allows students and faculty to review what happened

during the simulation and reflect on the meaning of events (Jeffries & Rogers, 2007).

The goals of debriefing are to provide emotional support to learners (Flanagan, 2008)

and help them achieve learning objectives (Glavin, 2008). Although debriefing is

considered an essential element of simulation-based learning, it remains a poorly

understood learning strategy (Dreifuerst, 2009).

3. Outcomes:

Other important features include matching objectives to a learner’s knowledge

and experience and including intended outcomes and expected behaviors eg.

Knowledge acquisition, skill performance, learner satisfaction, critical thinking, and

self-confidence (Jeffries, 2005; Jeffries & Rogers, 2007).

Defining Empirical Concepts:

1. Simulation: The use of a standardized patient simulation in perioperative context

to investigate TSs, NTSs, and self-confidence for Metropolia nursing students in

Finland.

2. Standardized Patients: Also known as simulated patients, or actors, these live

simulators can be utilized in teaching students. The use of standardized patients has

been found to help students gain self-awareness of their communication and clinical

strengths and weaknesses, and their reactions to stressful situations (Shemanko &

Jones, 2008). Volunteer actors from the study sample will play the role of patients in

intra/ postoperative simulation activities.

3. Clinical Scenario: The plan of an expected and potential course of events for a

simulated clinical experience. The scenario will occur in pre/postoperative simulation

context.

4. TSs: Post-Operative Simulation Sheet, (POSS), designed tool by the researcher in

collaboration with the facilitators including: first part will be for intraoperative

nursing skills which involve four main objectives the first is to achieve a successful

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negotiation regarding the roles (one item), the second objective is to explain the

process and progress of spinal anesthesia (six items), the third objective is to know

how to instruct the patient to a correct position (eight items), the fourth objective is to

perform the skin disinfection to the spinal anesthesia (seven items). The second part

will be for postoperative nursing skills which use, Airway, Breathing, Circulation,

Disability, Exposure, (ABCDE) assessment model: A for Airway with (two items), B

for Breathing with (two items), C for circulation with (five items), D for disability

with (four items), and E for exposure with (four items).

5. NTSs: A tool designed by the researcher in collaboration with the facilitators, POSS,

including: first category will assess two cognitive skills (situation awareness and

decision-making), the second category will assess two social skills (communication/

team-working and leadership) every individual skill is consisting of three sub-items.

6. Self-confidence: The National League for Nursing’s Student Satisfaction and Self-

Confidence in Learning questionnaire will be used to measure students’ perceptions of

their capabilities for delivering nursing interventions after a simulation experience

(NLN, 2004).

7. Briefing: Is the activity that coming before a simulation experience and that is led by

a perioperative teacher or a facilitator from Metropolia nursing school.

8. Debriefing: Is the activity that follows a simulation experience and that is led by a

perioperative teacher or a facilitator from Metropolia nursing school.

The expected results of the current study will provide information regarding TSs,

NTSs and students’ self-confidence in perioperative simulation environment which can

help in identifying areas of simulation training and education strategies at different

nursing institutions.

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CHAPTER II

LITERATURE REVIEW

This chapter presents a review of literature in relation to current nursing

simulation training scenarios, on perioperative setting, patient safety at

intra/postoperative phase, simulation training benefits, simulation types,

perioperative nursing skills, perioperative patient education, positioning the patient,

asepsis and aseptic practices in the operating room (OR), perioperative TSs, NTSs

and crisis resources management (CRM), self-confidence and summary.

1. Perioperative Setting

Perioperative context is considered a complex environment in which OR and

recovery nurses are essential to maintaining a safe environment for surgical patient.

Having a preplanned method of dealing with emergencies in simulation scenarios is

necessary in how to practice TSs and NTSs in critical situations, being prepared for

their occurrence taught nursing students about their responsibilities when caring for

patients during intra/postoperative phase (Mullen & Byrd, 2013; Thim et al., 2012).

2. Patient Safety at Intra/Postoperative Phase

The nursing care during and after surgery presents special challenges to

nurses on both the delivering and receiving teams. The surgical team is charged with

transporting the patient, along with clinical and monitoring equipment, from the OR

to the receiving unit, while simultaneously monitoring and performing additional

therapeutic tasks such as manual ventilation. Upon arrival at the receiving unit, Post

Anesthesia Care Unit, (PACU), the technology and support are transferred to local

systems while knowledge of the patient gained by the OR team during the procedure

is transmitted, in an environment that is often chaotic and busy, to a team largely

unfamiliar with the patient. It is not surprising, under these circumstances, that post

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operative nursing care is extensive with a lot of technical and nontechnical

challenges (Nagpal et al., 2011).

Barriers to safe, effective intra/postoperative care include the incomplete

transfer of information, communication issues (inaccurate information, lack of

consistency and organization, information overload) distractions (e.g., performing

clinical activities during the transfer of information), absent or inefficient execution

of clinical tasks, and poor standardization (Mistry et al., 2008). It is clear that,

pre/postoperative phases are fraught with technical and nontechnical errors and may

negatively impact patient safety and put them at higher risk for complications or

death (Segall et al., 2012), asking academics to disseminate TSs and NTSs using

perioperative simulation training scenarios.

3. Simulation Training Benefits

Simulation is a technique not a technology used to replace or amplify real

experiences with guided experiences that evoke or replicate substantial aspects of

the real world in a fully interactive manner (Gaba, 2004). Simulations are also

defined by Jeffries (2005) as activities that mimic the reality of a clinical

environment and are designed to demonstrate procedures, decision making, and

critical thinking through techniques such as role playing and the use of devices such

as interactive videos or mannequins‖. With simulation training, nursing students,

have the opportunity to develop and refine their skills without putting patients at risk

(Mullen & Byrd, 2013; Patow, 2005).

Simulation training also improves learning, helps participants learn how to

deal with unexpected events, develops teamwork and communication skills,

increases clinical self-confidence, and enhance performance, gives staff members

the opportunity to use problem-solving skills to determine what to do in real

situations involving actual patients and to apply what they have learned in a

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classroom to the workplace specially acute settings (Katz, Peifer, & Armstrong,

2010; Sadler, 2011).

During a simulation, staff members and students learn, practice, and repeat

events as often as is necessary to correct mistakes, perfect their skills, and optimize

clinical outcomes. In addition, staff members and students expand their experiences

with a range of simulated patients and procedures that they may not encounter

during their usual rotations. This is important preparation for emergency situations

in which a patient with a life-threatening, serious, or unstable condition may not get

a second chance (Sadler, 2011; Walsh, 2010; Webster, 2009).

Molyneux and Lauder (2006) added that, simulation has been shown to

improve trainee performance and confidence when faced with a similar situation

again, and is found to be both beneficial and enjoyable by participants. Conducting

simulation in a team context allows the opportunity for team building and

development of interpersonal skills.

In that learning context, simulations safely identify problems that can happen

during emergencies and allow nursing students to evaluate their performance and

improve it without risking harm to patients. Surgical staff members must be able to

work as a team if an unexpected, life-threatening emergency occurs, and simulation

training scenarios can help them achieve this goal (Mullen & Byrd, 2013).

4. Simulation Types

High-fidelity simulations are simulations that utilize computerized

manikins; Mid-fidelity simulations are simulations that utilize standardized patients,

computer programs or video games; Low-fidelity simulations are simulations that

11

use role play, non-computerized manikins or task- trainers; Task-trainers are

simulators that are used to practice a skill such as an Intravenous (IV) arm that is

used to practice IV insertions skills; In-situ simulation refers to bringing the

simulation (and simulator) to the site where the learner is practicing. This could

occur in an emergency trauma bay or surgical suite (Kardong-Edgren et al., 2011).

5. Perioperative Nursing Skills

5.1. Perioperative Patient Education

Patient education is a major concern for perioperative nurses in pre/intra/post

surgical phases. It has shown that preoperative education can improve patient

outcomes and satisfaction with the surgical experience. Typical patient education

consists of pamphlets that are given to the patient before surgery and verbal

instructions from the physicians and nurses on the day of surgery. Having a well-

designed perioperative education enables OR nurses in surgery centers to provide a

thoughtful approach to perioperative teaching in a limited time (Association of

periOperative Registered Nurses AORN, 2009).

5.2. Positioning the Patient

The perioperative nurse involved in the intraoperative care is faced with

numerous issues and challenges. The nurse must consider the special positioning

needs for surgery and the equipment needed to promote the safest environment for

the patient. The safe transfer of the patient to the OR table and subsequent

positioning must be performed with an adequate number of personnel and

equipment. A sufficient number of staff members provide safety for both the patient

and the staff. Using good body mechanics is crucial. Most back injuries to staff are

the result of failing to summon enough help. Always be sure that you have sufficient

assistance staff (Dybec, 2004).

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5.3. Asepsis and Aseptic Practices in the OR

Preventing surgical site infection in the operating room is the primary goal

of the surgical team, and all activities performed by the team support this goal.

Some of these activities include patient risk assessment, environmental cleaning,

disinfection and sterilization of instrumentation, patient antibiotic prophylaxis, and

the use of standard precautions. The principles of aseptic technique play a vital role

in accomplishing the goal of asepsis in the OR environment. It is the responsibility

of each surgical staff member to understand the meaning of these principles and to

incorporate them into their everyday practice (Osman, 2000).

All surgical team members must practice these principles of aseptic

technique to help prevent the transfer of microorganisms into the surgical wound

during the perioperative period. It is the responsibility of the surgical team

members to develop a strong surgical conscience, adhering to the principles of

asepsis and rectifying any improper technique witnessed in the OR (Labrague,

Arteche, Yboa, & Pacolor, 2012).

5.4. Perioperative TSs

The Airway, Breathing, Circulation, Disability, Exposure ABCDE approach

is a strong clinical tool for the initial assessment and treatment of patients in acute

medical and surgical emergencies. It aids in determining the seriousness of a

condition and helping health care professionals focusing on the most life-threatening

clinical problems by prioritize the initial clinical interventions. Widespread

knowledge of and skills in the ABCDE approach is likely to enhance team OR TSs

and thereby improves patient safety (Thim, Krarup, Grove, Rohde, and Løfgren,

2012).

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The aims of the ABCDE approach are to provide life-saving treatment, to

break down complex clinical situations into more manageable parts, to serve as an

assessment and treatment algorithm, to establish common situational awareness

among all treatment providers, to buy time to establish a final diagnosis and

treatment (Thim et al., 2012).

5.4.1. Airway:

A reduced level of consciousness is a common cause of airway obstruction,

partial or complete. A common sign of partial airway obstruction in the unconscious

state is snoring. Untreated airway obstruction can rapidly lead to cardiac arrest. All

health care professionals, regardless of the setting, can assess the airway as

described and use a head-tilt and chin-lift maneuver to open the airway. With the

proper equipment, suction of the airways to remove obstructions, for example, blood

or vomit, is recommended. If possible, foreign bodies causing airway obstruction

should be removed. In the event of a complete airway obstruction, treatment should

be given according to current guidelines. In brief, to conscious patients give five

back blows alternating with five abdominal thrusts until the obstruction is relieved.

If the victim becomes unconscious, call for help and start cardiopulmonary

resuscitation according to guidelines (Koster et al., 2010).

5.4.2. Breathing:

In all settings, it is possible to determine the respiratory rate, inspect

movements of the thoracic wall for symmetry and use of auxiliary respiratory

muscles, and percuss the chest for unilateral dullness or resonance. Cyanosis,

distended neck veins, and lateralization of the trachea can be identified. If a

stethoscope is available, lung auscultation should be performed and, if possible, a

pulse oximeter should be applied. If breathing is insufficient, assisted ventilation

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must be performed by giving rescue breaths with or without a barrier device.

Trained personnel should use a bag mask if available (Thim et al., 2012)

5.4.3. Circulation

The capillary refill time and pulse rate can be assessed in any setting.

Inspection of the skin gives clues to circulatory problems. Color changes, sweating,

and a decreased level of consciousness are signs of decreased perfusion. If a

stethoscope is available, heart auscultation should be performed.

Electrocardiography monitoring and blood pressure measurements should also be

performed as soon as possible. Hypotension is an important adverse clinical sign.

The effects of hypovolemia can be alleviated by placing the patient in the supine

position and elevating the patient’s legs. An intravenous access should be obtained

as soon as possible and saline should be infused (Thim, Krarup, Grove, & Løfgren,

2010).

5.4.4. Disability:

The level of consciousness can be rapidly assessed using the, Alert, Voice

responsive, Pain responsive, or Unresponsive, (AVPU) method, where the patient is

graded as alert (A), voice responsive (V), pain responsive (P), or unresponsive (U).

Alternatively, the Glasgow Coma Score can be used. Limb movements should be

inspected to evaluate potential signs of lateralization. The best immediate treatment

for patients with a primary cerebral condition is stabilization of the airway,

breathing, and circulation. In particular, when the patient is only pain responsive or

unresponsive, airway patency must be ensured, by placing the patient in the

recovery position, and summoning personnel qualified to secure the airway.

Ultimately, intubation may be required. Pupillary light reflexes should be evaluated

and blood glucose measured. A decreased level of consciousness due to low blood

glucose can be corrected quickly with oral or infused glucose (Lockey et al., 2011).

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5.4.5. Exposure:

Signs of trauma, bleeding, skin reactions (rashes), needle marks, etc, must be

observed. Bearing the dignity of the patient in mind, clothing should be removed to

allow a thorough physical examination to be performed. Body temperature can be

estimated by feeling the skin or using a thermometer when available.

Thim et al., (2012) highly recommended that ABCDE as an approach is

definitely applicable in all clinical emergencies for immediate assessment and

treatment specially PACU setting which is considered one of the most vulnerable

environments in the hospital. High-quality ABCDE skills among all PACU treating

team members save valuable time and improve team performance. Dissemination of

knowledge and skills related to the ABCDE approach is a must.

5.5. Perioperative NTSs and CRM

NTSs can be defined as the cognitive, social and personal resource skills that

complement TSs and contribute to safe and efficient task performance; CRM is a

management system that makes use of all available resources, equipment,

procedures and people to promote safety and enhance efficiency of operations

(Gillon et al., 2012).

In-depth analysis of human performance in high-stakes situations was

pioneered and refined by the aviation industry when human factors (rather than

equipment failure) were found to be the most common cause of serious accidents

(Australian Civil Aviation Safety Authority, 2009).

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Suboptimal performance among highly trained pilots was not always the

result of lack of knowledge or deficiency in technical ability, but often due to

shortcomings in situational awareness, decision making, communication, team

working and/or leadership, which is called ―NTSs‖ (Helmreich & Foushee, 2010).

The importance of NTS in health care was recognized by anesthetists, who

developed the first formal medical NTS training course to improve patient safety.

The major domains of NTS used in CRM include situational awareness, decision

making, communication, team-working and leadership skills (Gaba, 2010).

CRM requires two sets of skills: both TS and NTS which are associated and

are not independent from each other. Both attributes are essential for patient safety

during perioperative crisis management (Riem, Boet, Bould, Tavares and Naik,

2012).

Self-confidence

Latham and Fahey (2006) state that ―nursing students often experience a

lack of self-confidence and hesitation when faced with increased responsibility and

accountability for patients’ health‖. Factors that influence the confidence of

student nurses range from achieving competence in a skill or set of skills to

achieving meaningful and effective communication with patients, relatives and

multidisciplinary team members. The achievement of competence in a skill or skill

set enables the student to develop personal and professional confidence and

develop their identity as a nurse (Edwards, Smith, Courtney, Finlayson, &

Chapman, 2004; Godson, Wilson, & Goodman, 2007).

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Summary

Simulation can be the answer to developing nursing students’ knowledge,

skills, and attitudes, whilst protecting patients from unnecessary risks. Simulation

has been shown to be an effective learning environment for students to learn and

practice complex and overlapping ethical dilemma skills sets and can be a platform

for learning to mitigate ethical tensions. Simulation training scenarios can be

applied in designing structured learning experiences, as well as be used as a

measurement tool linked to targeted teamwork skills and learning objectives.

Simulation itself is not new. It has been applied widely in the aviation industry also

known as CRM. Simulation helps to mitigate errors and maintain a culture of

safety, especially in acute health care setting like OR where there is zero tolerance

for any deviation from set standards.

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CHAPTER III

SUBJECTS AND METHODS

Setting

The study was conducted at Metropolia’s simulation center laboratory which is

located at Tukholmankatu on Meilahti campus; it consists of ten simulation rooms, six

debriefing rooms and three control rooms for monitoring. The current study was

conducted in a perioperative simulation environment at Helsinki Metropolia

University of Applied Sciences, Finland.

Sampling

A purposive sample (44/158) divided into 4 groups (11, 11, 14, and 8)

undergraduate nursing students who were conducting their perioperative nursing

curriculum in autumn 2015, voluntarily accepting to participate in this research after a

written consent, being familiar with the simulation lab at Helsinki Metropolia

University of Applied Sciences, Finland.

Research Design

A descriptive, exploratory design was used to investigate TSs, NTSs and self-

confidence levels using simulation training scenarios among nursing students at

Helsinki Metropolia University of Applied Sciences, Finland.

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Data Collection

For each perioperative simulation training scenario; data e.g. age, gender,

educational background, enrolled program, attendance time in the simulation

laboratory, hours spent in the simulation laboratory, health care working experience,

student’s role played during simulation scenarios in both intraoperative and

postoperative simulation training scenarios was asked by each student after a written

formal consent for volunteer sharing and video-taping the simulation training

scenarios; after that TSs and NTSs, were observed and recorded using the researcher’s

observation checklist assisted with video-taping. Self-confidence tool was completed

by students after each simulation experience. Each procedure period was started with

briefing, simulation session, then a debriefing session which encouraged well done

skills, using open ended questions and asking feedback.

Instruments

A tool consisted of two main parts the first part was designed by the

investigator to collect data related to TSs and NTSs; it was developed after extensive

literature review and submitted to a panel of three reviewers and experts in critical

care and perioperative nursing. Revision of the tool made based on feedback from

reviewers and before conducting the study. The other part used for collecting data

regarding students’ self-confidence adapted from (NLN, 2004).

The POSS (See Appendix A) consisted of two sections; the first section was

used to collect self reported data on socio-demographic variables related to the

observed subjects as age, gender, educational background, enrolled program,

attendance time in the simulation laboratory, hours spent in the simulation laboratory,

health care working experience, student’s role played during simulation in both

intraoperative and postoperative simulation training scenarios (See Appendix D) for

the Finnish version.

20

The second section was divided into three parts; the first part was students’ self-

confidence tool in perioperative simulation training with eight items adapted from

(NLN, 2004) (See Appendix D for permission letter), The second part was a

perioperative TSs checklists consisted of two checklists the first one for intraoperative

TSs using four main objectives the first was to achieve a successful negotiation

regarding the roles (one item), the second objective was to explain the process and

progress of spinal anesthesia (six items), the third objective was to know how to

instruct the patient to a correct position (eight items), the fourth objective was to

perform the skin disinfection to the spinal anesthesia (seven items) the second

checklist for postoperative TSs using ABCDE assessment model: A for Airway with

(two items), B for Breathing with (two items), C for circulation with (five items), D

for disability with (four items), and E for exposure with (four items). The third part

was a perioperative NTSs checklist (was used for intraoperative and postoperative

simulation scenarios) consisted of two categories: first category assessed two

cognitive skills (situation awareness and decision-making), the second category

assessed two social skills (communication/ team-working and leadership) each sub

category contains three sub items were evaluated by the researcher using correct mark

for correct done action (equal one) and incorrect mark for incorrect or not done action

(equal zero) (Briggs et al., 2015; Mullen & Byrd, 2013; Gillon et al., 2012; Carne,

Kennedy, & Gray, 2011; St. Pierre, Hofinger, Buerschaper, & Simon, 2011; Reader,

Flin, Lauche, & Cuthbertson, 2006; Fletcher et al., 2003).

The researcher used Metropolia’s simulation scenarios which involved 44

nursing students who conducting their perioperative curriculum. Students were

divided into four groups for two days (two groups per day) going through

perioperative simulation practice (one for intraoperative simulation skills occurred in

the 3rd

floor and the second for postoperative simulation skills occurred in the 5th

floor).

21

In the intraoperative simulation practice; three students from each group shared

to play the role of a nurse, anesthesiologist and a standardized patient. The

standardized patient was asked in the briefing session to act as a 55 years old cardiac

patient who was planned to undergo spinal anaesthesia for open inguinal hernia repair.

Observer students were asked to take notes in relation to their practice to be used later

in the debriefing session.

In the postoperative simulation practice: 3 students shared to play the role of a

nurse, a doctor and a standardized patient who act as semiconscious patient in PACU

on a simple mask oxygen with 99% O2 saturation, the patient was connected to

haemodynamic monitor and pulse oximetry, the patient was connected to one drain for

blood drainage. The pain scale is 7 over 10.

In both intra/postoperative scenarios with the all 4 groups; POSS checklists

were used by the investigator assisted by video-taping to investigate students’ TSs,

NTSs and self-confidence levels in both intra and postoperative settings (Mullen &

Byrd, 2013).

The rating scale for TSs, NTSs and self- confidence levels were as the

following: adapted from (Fletcher, 2004)

1-Less than (33.3%) was considered poor level:

(Simulation performance endangered or potentially endangered patient safety, serious

remediation was required).

2-From (33.3%) to (66.6%) was considered acceptable level: (Simulation

performance was of a satisfactory standard but some improvements were needed).

3-More than 66.6% was considered good level:

(Simulation performance was for a consistently high standard, enhancing patient

safety; it could be used as a positive example for others).

22

Data Analysis

The data was scored, tabulated and analyzed by using statistical package for the

social sciences (SPSS–version 21) descriptive statistics were utilized as standard

deviation, frequency, mean and percentage (Woolf, Keating, Burge, and Michael

2004).

As the simulation training scenarios were conducted in Finnish; the video-taping

material was analyzed for Ts and NTs with the help of thesis supervisor whose native

language is Finnish.

.

Ethical Considerations

The tools used in collecting subject variables, TSs and NTSs were developed

after extensive literature review with a help from thesis supervisors in addition to peer

reviews from perioperative and critical care nursing departments who shared in

revision before data collection to assure validity and reliability (See Appendix A).

A written formal research permit (See Appendix B) was obtained from the

ethics and research committee. Student informed consent (See Appendix C) was

sought and obtained from each participating subject after explaining the nature of the

study. Subjects' names were not written for the purpose of anonymity and

confidentiality. Subjects were free to withdraw from the study at any time. They were

assured that the results of the study would not be used for any performance evaluation.

Formal permission letter from NLN (2004) was obtained in November, 2015;

the tool was modified to collect data related to students’ self confidence (See

Appendix D).

23

CHAPTER IV

RESULTS

In this chapter, the data obtained from the POSS (See Appendix A) were

coded, tabulated, and analyzed. The analyzed data were presented in the following

order.

(A) The first section was devoted to self reported data that include socio-

demographic variables related to the observed subjects as age, gender, educational

background, enrolled program, attendance time in the simulation laboratory, hours

spent in the simulation laboratory, health care working experience, student’s role

played during both intraoperative and postoperative simulation training scenarios

(Table1).

(B)The second section was divided into three parts:

1. The first part presented self-confidence level with identified eight items related to

socio-demographic variables in perioperative (intra and postoperative) simulation

training scenarios (Table 2).

2. The second part presented a perioperative TSs data related to:

2.1. Intraoperative checklist with four main objectives the first objective (achieve

a successful negotiation regarding the roles; one item), the second objective

(explain the process and progress of spinal anesthesia; six items), the third

objective (know how to instruct the patient to a correct position; eight items),

the fourth objective (perform the skin disinfection to the spinal anesthesia;

seven items) (Table 3).

2.2. Postoperative TSs using ABCDE assessment model; A for Airway (two

items), B for Breathing (two items), C for circulation (five items), D for

disability (four items), and E for exposure (four items) (Table 4).

24

3. The third part presented a perioperative NTS data related to a checklist was used

for intraoperative and postoperative simulation scenarios consisted of two

categories: first category assessed two cognitive skills (situation awareness and

decision-making), the second category assessed two social skills (communication/

team-working and leadership) each sub category contains three sub items were

evaluated by the researcher (Table 5).

The first section was devoted to self reported data that include socio-

demographic variables related to the observed subjects.

Table (1) shows that nursing students’ total age mean is 25.73±6.92 years old;

youngest age group had the highest frequency 27/44 (61%), and oldest age group

had the lowest frequency 8/44 (18%). There were more females 42/44 (95%) than

males 2/44 (5%). Student who came from high school educational background had

the highest frequency 28/44 (64%); for vocational and university degree students,

they had the same frequency 8/8 (18%). Student nurses who enrolled nursing

program were 23/44 (52%) followed by public health 16/44 (36%) and then who

enrolled midwifery and paramedics programs were 3/44 (7%) and 2/44 (5%)

respectively. Nursing students spent in the simulation lab a total time mean with

3.61±2.67 times, and those who spent less than four times were the highest 29/44

(66%). The total mean of spent hours in the simulation lab was 8.95±6.83 hours,

and those who spent between 6 to 10 hours in the simulation lab were 19/44 (43%)

and for those who spent more than 10 hours were the lowest 11/44 (25%). The total

mean of health care experience years among nursing students was found to be

1.00±2.13 years; students with less than one year healthcare experience were the

highest frequency with 33/44 (75%) and who had one year experience and more

were 11/44 (25%). Nursing students roles during intraoperative simulation training

scenarios were as the following nurses 8 (18%), patients 4 (9%), observers 32

(73%) and during postoperative simulation training scenario were as the following

nurses 9 (20%), patients 6 (14%), and observers 29 (66%).

25

Table 1

Frequency, and Percentage Distribution of Socio-demographic Variables Related to

Nursing Students or Observed Subjects (n=44)

Demographic Variables n=44 (%) Mean± SD

Age

Less than 25 years old

From 25 to 30 years old

More than 30 years old

27

9

8

61

21

18

25.73±6.92

Gender

Male

Female

2

42

5

95

Educational background

Vocational

High school

University degree

8

28

8

18

64

18

Enrolled program

Nursing

Paramedics

Midwifery

Public health

23

2

3

16

52

5

7

36

Attendance time in the simulation laboratory

Less than 4 times

4 times and more

29

15

66

34

3.61±2.67

Hours spent in the simulation laboratory

Less than 6 hours

From 6-10 hours

More than 10 hours

14

19

11

32

43

25

8.95±6.83

Health care working experience

Less than one year

One year and more

33

11

75

25

1.00±2.13

Student’s role in intraoperative simulation training scenario

Nurse

Patient

Observer

8

4

32

18

9

73

Student’s role in postoperative simulation training scenario

Nurse

Patient

Observer

9

6

29

20

14

66

26

(B) The second section was divided into three parts:

B.1. the first part presented students’ self-confidence in relation to socio-

demographic variables in perioperative (intra and postoperative) simulation.

Table (2) shows students’ self-confidence (not confident, neutral, or confident) in intra

and postoperative simulation training. The majority of nursing students’ answers were

(confident) ranging from 42/44 (95.5%) to 43/44 (98%), the (neutral) answers ranging

from 1/44 (2%) to 2/42 (4.5%); all (not confident) category answers were zero in both

intra and post operative simulation.

27

Table (2)

Frequency Distribution of Students’ Self-Confidence in Relation to Socio-Demographic

Variables in Perioperative Simulation (n=44)

Demographic Variables

Self-confidence frequency

Intraoperative simulation Postoperative simulation

Not

Confident

Neutral Confident Not

Confident

Neutral Confident

Age

Less than 25 years old

From 25-30 years old

More than 30 years old

0

0

0

1

0

0

26

9

8

0

0

0

1

1

0

26

8

8

Gender

Male

Female

0

0

0

1

2

41

0

0

1

1

1

41

Educational background

Vocational

High school

University degree

0

0

0

0

1

0

8

27

8

0

0

0

0

1

1

8

27

7

Enrolled program

Nursing

Paramedics

Midwifery

Public health

0

0

0

0

0

0

1

0

23

2

2

16

0

0

0

0

2

0

0

0

21

2

3

16

Attendance time in the simulation laboratory

Less than 4 times

4 times and more

0

0

0

1

29

14

0

0

2

0

27

15

Hours spent in the simulation laboratory

Less than 6 hours

From 6-10 hours

More than 10 hours

0

0

0

0

1

0

14

18

11

0

0

0

0

2

0

14

17

11

Health care working experience

Less than one year

One year and more

0

0

0

1

33

10

0

0

1

1

32

10

Student’s role in intraoperative simulation training

scenario

Nurse

Patient

Observer

0

0

0

0

0

1

8

4

31

0

0

0

1

0

1

7

4

31

Student’s role in postoperative simulation training

scenario

Nurse

Patient

Observer

0

0

0

0

0

1

9

6

28

0

0

0

0

0

2

9

6

27

28

B.2.1 The second part presented perioperative TSs data related to intraoperative

checklist with four main objectives among 4 groups.

Table (3) illustrates that the total overall performance was 59/88 (67%) a good

performance level. For both the second and the fourth objectives the performance was

18/24 (75%) and 21/28 (75%) respectively which is considered a good level; the third

objective was achieved with a moderate level 18/24 (59.4%), and finally the first

objective had the lowest score 1/4 (25%) a poor level.

Table 3

Frequency and Percentage Distribution of TSs Data Related to Intraoperative

Simulation (n=88)*

Objectives

Total

1.Negotiation 1/4 (25%)

2.Process explanation 18/24 (75%)

3.Instruct pt. for proper position 19/32 (59%)

4.Skin disinfection 21/28 (75%)

Total 59/88 (67%)

* Indicates the total number of intraoperative TSs.

29

B.2.2. The second part also presents postoperative TSs using ABCDE assessment

model; A for Airway (two items), B for Breathing (two items), C for circulation (five

items), D for disability (four items), and E for exposure (four items).

Table (4) shows that, the total overall performance of postoperative TSs is

54/68 (79%) which is considered good performance level. The highest scores was in

both airway and breathing management 8/8 (100%) and the lowest score was in both

disability and exposure 13/16 (81%).

Table 4

Frequency and Percentage Distribution of TSs Data Related to Postoperative

Simulation (n=68)*

* Indicates the total number of postoperative TSs.

ABCDE approach

Total

1.Airway 8/8 (100%)

2.Breathing 8/8 (100%)

3.Circulation 19/20 (95%)

4.Disability 13/16 (81%)

5.Exposure 13/16 (81%)

Total 54/68 (79%)

30

B.3. The third part presents intra and postoperative NTSs using four items;

situation awareness, decision making, communication/team working and leadership.

Table (5) indicates that the total overall performance of both intra and post

operative NTSs is 88/96 (92%) which is considered a good performance level. For

NTSs done in both intra and postoperative simulation was equal 44/48 (92%) which is

good level also. The lowest performance went to decision making with 20/24 (83%)

which is still considered good performance. For both situation awareness and

communication/teamwork were the same result of 23/24 (96%) also considered good

performance.

Table 5

Frequency and Percentage Distribution of NTSs related to Intra and Postoperative

Simulation (n=96)*

NTSs

Intraoperative

simulation

Postoperative

simulation

Total

1.Situation awareness 12/12 11/12 23/24 (96%)

2.Decision making 11/12 9/12 20/24 (83%)

3.Communication/team-work 11/12 12/12 23/24 (96%)

4.leadership 10/12 12/12 22/24 (92%)

Total 44/48 (92%) 44/48 (92%) 88/96 (92%)

* Indicates the total number of intra and postoperative NTSs.

31

CHAPTER V

DISCUSSION

The NESF was used to guide this study; the framework suggests that TSs,

NTSs and self-confidence toward simulation are the result of a combination of factors,

including teacher factors, educational practices, simulation design characteristics, and

student factors (Jeffries, 2005). The current study only focused on the relationships

between student factor (demographic characteristics) and three NESF outcomes,

namely TSs, NTSs and self-confidence.

The study results showed the majority was females, almost two-thirds of the

study sample was less than 25 years old with approximate a same portion of a high

school educational background. More than half of students enrolled nursing program.

Students who attended simulation lab for four times and more and less than six hours

represented around one-third of the study sample. Finally, three-quarters of the sample

had a heath care working experience with less than one year.

In this study students were confident with intra/postoperative simulation

scenarios experience as a learning strategy on the self-confidence rating scale (NLN,

2004).

No significant correlations were found among the demographic variables of

age, gender, educational background, enrolled program, attendance time and hours in

the simulation lab, health care working experience and students’ self-confidence.

32

Overall, the simulation activity showed a clear benefit as evidenced not only

by personal observations, but also by student reported improvements in self-confidence

during perioperative simulation experience.

Intra and postoperative simulation TSs among Metropolia nursing students

constituted almost one-third of the whole study sample which is considered good level

of performance (Simulation performance was for a consistently high standard,

enhancing patient safety; it could be used as a positive example for others). For intra

and postoperative simulation NTSs, they were occurred with a good level as well.

Comparison with Literature

Students’ perception of self-confidence after simulated experiences has been

one of the focuses in nursing literature (Childs & Sepples, 2006; Jeffries, 2007;

Lasater, 2007; Norman, 2012; Reilly & Spratt, 2007; Prescott & Garside, 2009;

Scherer, Bruce, & Runkawatt, 2007). The results of this study were consistent with

findings from the previous reports. A systematic review based on current available

literature on simulation and nursing education indicated that simulation is useful in

creating a learning environment that contributes to TSs, NTSs and self-confidence

(Norman, 2012).

Prescott and Garside (2009) explored the experiences of simulation among 45

second year diploma nursing students. The findings showed widespread agreement that

simulation is a productive learning strategy and builds confidence. After the

simulation, the majority of students agreed that their confidence had increased.

Although many students at initial interview commented that simulation was

frightening, they reported that as they gained more experience in the simulation

environment, they felt significantly more confident.

33

In a study conducted by Foot (2007) supporting the current study in a

manner that nursing students can develop new TSs and NTSs through repeated

experience with simulation, allowing repeated exposure to both common and rare

clinical scenarios. Conducting simulation in a team context allows the opportunity for

team building and development of interpersonal skills.

It is of interest to notice a good correlation performance level in both TSs and

NTSs in the current study which goes with another study conducted by Briggs et al.

(2015). Another study conducted by Gillon (2012) supporting the current study in

recognizing the importance of NTSs in education and training in acute environments as

simulation has been shown to improve trainee performance and confidence when faced

with a similar situation again, and is found to be both beneficial and enjoyable by

participants. Conducting simulation in a team context allows the opportunity for team

building and development of interpersonal skills.

Implications

Nurse educators face the challenge of how to best equip nursing students to

care for patients in an increasingly complex healthcare environment. This challenge is

intensified by the shortage of nursing faculty, increasing acuity of patient illnesses, and

rapid technological changes in the health care setting. Innovative teaching strategies

and modalities are essential in engaging students in active learning and bridging the

gap between theory and practice (Feingold, Calaluce, & Kallen, 2004; Benner,

Sutphen, Leonard, & Day, 2010).

The findings of this study may be used as a foundation to integrate simulation

into a nursing curriculum. A well-designed simulation has been shown to be effective

in providing students with a safe environment for learning patient care and has shown

potential in improving student’s learning outcomes such as clinical judgment, self

confidence, and satisfaction (Jeffries & Rogers, 2007; Maran, & Glavin, 2003). Benner

34

et al. (2010) emphasized the importance of experiential teaching and learning and

situated cognition (thinking in action); high fidelity simulation has consistently linked

this instructional strategy to a broad experiential learning perspective. Collaborative

simulations such as role playing may improve communication and ultimately improve

patient care (Tuoriniemi & Schott-Baer, 2008). Overall, simulations facilitate the

application of theory into practice.

Although every effort was made to eliminate any difficulty for conducting this

study, inevitably certain limitations were beyond control and some were simply

oversight. Despite these limitations, some other unique strengths were noted.

Limitations of the study were as follows:

1- For the program timing limitation, completing the thesis over a relatively short

period of time, and nursing school scheduling constriction, the study involved a

purposive sample 44/158 of nursing students who started their perioperative

simulation training curriculum in January 2015.

2- The researcher was not able to conduct any further comparison group differences

because of the previous limitations in addition to small sample size resulted in

limited generalizability.

3- Nursing students, in some times, are not so familiar with the simulation lab

resources.

4- The researcher was in need for immediate translation from Finnish to English

language in order to cope with the simulation scenarios which is considered

language barrier.

5- This study conducted over intensive 2 days from 9 am till 4 pm which was

considered very tough work for students and the researcher as well.

35

Some unique strengths of this study should be noted:

1- The study was conducted with multinational experiences (Finnish, Portuguese,

Egyptian academic experiences).

2- The study assessed TSs, NTSs, and self -confidence in both intra and post

operative settings.

3- TSs and NTSs were assessed by using an observational checklist in addition to

advanced multi video-taping.

4- The study was conducted in a simulation centre which has been systematically

designed over a period of 10 years.

5- The study was conducted in a community of scholars who have been continuously

involved with research that contributes to the evidence based use of the simulation

method.

36

CHAPTER VI

CONCLUSION AND RECOMMENDATION

Innovative teaching modalities are increasingly available to nurse educators.

With decreased availability of clinical sites (Nehring, 2008), nurse educators need to

evaluate these modalities to understand how they can best prepare future nurses for

practice. This study showed that the majority of the participating students were

confident in their simulation activity experience; both TSs and NTSs were performed

in good performance levels. Further research will help facilitate the understanding of

the effectiveness of simulation and identify best practices for its use in nursing

education.

Recommendations for Future Research

1. Research

Future studies are needed to investigate the impact of teacher factors,

educational practice and design characteristics on other learning outcomes. Learning

outcomes such as learning knowledge, skill performance, and critical thinking, as

illustrated in the Jeffries (2005) framework, should be evaluated using a larger sample

size, diverse simulated scenarios, and all levels of nursing students. Another

recommended direction for future study is to explore the sustainability of the impact of

simulation and to investigate if the impact translates to real-life clinical situations.

2. Practice

Students may perceive an increase in confidence because of being in a

controlled, supervised setting where they can do no harm. Perhaps the increase of

confidence is not realized until the student experiences a real-life situation like the one

in the simulation. More research needs to be conducted to examine the transferability

37

of the impact from the simulation experience into real clinical situations in different

clinical settings.

3. Education

It should ongoing goal for the nursing faculty to determine the best use of the

simulators to promote student learning outcomes. While this can be a goal in education,

there has not been any formal evaluation using standardized instruments/tools for the

assessment of outcomes in simulation and student perceptions toward simulation. The

findings of this study may help to give insights for the BSN program of any nursing

institution to fully integrate simulation into the nursing curriculum for all levels of

nursing students.

4. Technology

As simulation technology is rapidly expanding, nursing programs are making

large investments in this technology, which has great potential for undergraduate

nursing programs. With simulation technology, undergraduate students can gain and

improve skills in a safe, non-threatening, experiential environment that also provides

opportunities for decision making, critical thinking, and team building. Managing how

to use simulation technology correctly is considered to be a challenge and an

opportunity at the same time for nursing schools, educators, and students; Managing to

do it in the appropriate way is considered sort of art.

38

References

Amato-Vealey, E., Barba, M. P., & Vealey, R. J. (2008). Hand-off communication: A

requisite for perioperative patient safety. AORN Journal, 88(5), 763-774.

Association of periOperative Registered Nurses (2009). Benefits of preoperative

education for adult elective surgery patients. AORN J. 90(3):381-7. doi:

10.1016/j.aorn.2009.06.022

Australian Civil Aviation Safety Authority (2009). Human factors (HF) and non-

technical skills (NTS) training for regular public transport (RPT) operations.

CAAP-SMS-3(0).

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for

radical transformation. Stanford, CA: Jossey-Bass Publish.

Briggs, A., Raja, A. S., Joyce, M. F., Yule S. J., Jiang, W, Lipsitz, S. R., and Havens, J.

M. The RoleofNontechnicalSkillsinSimulated Trauma Resuscitation. J Surg

Educ. ;72(4):732-9. doi: 10.1016/j.jsurg.2015.01.020.

Carne, B., Kennedy, M., & Gray, T. (2011). Review article: Crisis resource management

in emergency medicine.EMA.,24(1), 7-13emm9. DOI: 10.1111/j.1742-

6723.2011.01495.x

Childs, J. & Sepples, S. (2006). Clinical teaching by simulation: lessons learned from a

complex patient care scenario. Nursing Education Perspectives, 27(3), 154-158.

39

Dreifuerst, K.T. (2009). The essentials of debriefing in simulation learning: a concept

analysis. Nursing Education Perspectives, 30(2), 109-114.

Dybec, R. B. (2004). Intraoperative Positioning and Care of the Obese Patient. Plastic

Surgical Nursing, 24(3), 118-122

Edwards, H., Smith, S., Courtney, M., Finlayson, K., & Chapman, H. (2004). Impact of

clinical placement location on nursing students competence and preparedness for

practice. Nurse Education Today, 24(4), 248-255.

Feingold, C., Calaluce, M., and Kallen, M. (2004). Computerized patient model and

simulated clinical experiences: Evaluation with baccalaureate nursing students.

Journal of Nursing Education, 43(4), 156-163.

Flanagan, B. (2008). Debriefing: theory and technique. In R.H. Riley (Ed.), Manual of

Simulation in Healthcare (pp. 155 – 170) Oxford: Oxford University Press.

Fletcher G, Flin R, McGeorgeP.Glavin, R., Maran, N., & Patey, R. (2003). Anaesthetists’

non-technical skills (ANTS): evaluation of a behavioural marking system. Br J

Anaesth, 90(5), 580-8

Fletcher, G., Flin, R., McGeorge, P., Glavin, R., Maran, N., & Patey, R. (2004). Rating

non-technical skills: developing a behavioural marker system for use in

anaesthesia. Cogn Tech Work. 6: 165–171 DOI 10.1007/s10111-004-0158-y

Foot C. (2007). Simulation for team crisis management training in critical care medicine

— where have we been, where are we now and where are we going? Aust Anaes:

87-93.

40

Gaba, D. M. (2010). Crisis resource management and teamwork management in

anaesthesia. Br J Anaesth; 105: 3-6.

Gaba, D. M., (2004). The future vision of simulation in health care. Qual Saf Health

Care;13(1):12-20.

Gillon, S. Radford, S., Chalwin, R., DeVita, M., Endacott, R. and Jones, D. (2012).

Crisis resource management, simulation training and the medical emergency team.

Crit Care Resusc 14 (3), 227–235.

Glavin, R. (2008). Developing your teaching role in a simulation centre. In R.H. Riley

(Ed.), Manual of Simulation in Healthcare (pp. 115 – 123) Oxford: Oxford

University Press.

Godson, N. R., Wilson, A., & Goodman, M. (2007). Clinical education: evaluating

student nurse learning in the clinical skills laboratory. British Journal of Nursing,

16(5), 942-945.

Gupta, A., Peckler, B., and Schoken, D. (2008). Introduction of hi-fidelity simulation

techniques as an ideal teaching tool for upcoming emergency medicine and trauma

residency programs in India. J Emerg Trauma Shock.;1:15–8

Halstead, J. A. (2009). Evidence-based teaching and clinical simulation. Clinical

Simulation in Nursing Education, 2(1), 5-8

Helmreich, R. L., Foushee, H. C. (2010). Why CRM? Empirical and theoretical bases of

human factors training. In: Kanki BG, Helmreich RH, Anca JM, editors. Crew

resource management. 2nd ed. London: Academic Press, 2010.

41

Jeffries, P. R. (2005). A Framework for designing, implementing, and evaluate

simulations used as teaching strategies in nursing. Nurs Educ Perspect, 26(2) 96-

103.

Jeffries, P. R. (2006). Designing Simulations for Nursing Education. Annual Review of

Nursing Education, 4, 161-177.

Jeffries, P. R. & Rogers, K. J. (2007). Theoretical Framework for Simulation Design. In

P.R. Jeffries (Ed.), Simulation in Nursing Education: From Conceptualization to

Evaluation (pp. 21-33). New York, NY: National League for Nursing.

Jeffries, P. R. (2009). GUEST Editorial: Dreams for the Future for Clinical Simulation.

Nursing Education Perspectives (30)2, 71-71. doi: http://dx.doi.org/10.1043/1536-

5026-030.002.0071

Kardong-Edgren, S., Hanberg, A., Dodge Ackermann, A., Alinier, G., Anderson, M.,

Fowler Durham, C., Van Gele, P. (2011). Supplement. Clinical Simulation in

Nursing, (4S) Supplement, S1-S20.

Katz, G. B., Peifer, K. L., and Armstrong, G. (2010). Assessment of patient simulation

use in selected baccalaureate nursing programs in the United States. Simulation in

Healthcare, 5, 46-51.

Koster, R.W., Baubin, M. A., Bossaert, L. L., et al (2010). European Resuscitation

Council Guidelines for Resuscitation 2010. Section 2. Adult basic life support and

use of automated external defibrillators.Resuscitation;81(10):1277–1292.

Kyle, R. & Murray, W. (2008). Clinical Simulation, 1st Edition from Elsevier Store.

ISBN-9780080556970.

42

Labrague, L. J., Arteche, D. L. , Yboa, B. C. & Pacolor, N. F. (2012). Operating Room

Nurses’ Knowledge and Practice of Sterile Technique. J Nurs Care 1:4

http://dx.doi.org/10.4172/2167-1168.100013

Lasater, K. (2007). Clinical judgment development: Using simulation to create an

assessment rubric. Journal of Nursing Education, 46(11), 496-503.

Latham, C., and Fahey, L. (2006). Novice to expert advanced practice nurse role

transition: guided self-reflection. Journal of Nursing Education, 45(1), 46- 48.

Lockey A, Balance J, Domanovits H, et al., editors (2011). Advanced Life Support ERC

Guidelines 2010 Edition. Belgium: European Resuscitation Council.

Maas, N. A. and Flood, L. (2011). Implementing High-Fidelity Simulation in Practical

Nursing Education. Clinical Simulation in Nursing, 7(6), e229-35.

Maran, N., and Glavin, R. (2003). Low- to high-fidelity simulation--a continuum of

medical education?. Medical Education, 37 22-28.

Mistry, K., Jaggers, J., Lodge, A., Alton, M., Mericle, J., Frush, K., and Meliones, J.

(2008). Using Six Sigma® methodology to improve handoff communication in

high-risk patients. In: Advances in Patient Safety: New Directions and Alternative

Approaches. Rockville, MD: Agency for Healthcare Research and Quality.

Molyneux M, Lauder G. A (2006) national collaborative simulation project: paediatric

anaesthetic emergencies. Paediatr Anaesth; 16: 1302.

Mullen, L., & Byrd, D. (2013). Using Simulation Training to Improve Perioperative

Patient Safety. AORN J 97; 419-427. Published by Elsevier, Inc., on behalf of

AORN, Inc. http://dx.doi.org/10.1016/j.aorn.2013.02.001

43

Nagpal, K., Abboudi, M., Fischler, L., Schmidt, T., Vats, A., Manchanda, C., Sevdalis,

N., Scheidegger, D., Vincent, C., & Moorthy, K. (2011) Evaluation of

postoperative handover using a tool to assess information transfer and teamwork.

Ann Surg ;253:(83), 1–7

National League for Nursing (NLN) (2004). Retrieved December 17, 2015 available at:

http://www.nln.org/professional-development-programs/research/tools-and-

instruments/descriptions-of-available-instruments.

Nehring, W. (2008). U.S. Boards of Nursing and the use of high-fidelity patient

simulators in nursing education. Journal of Professional Nursing, 24(2), 109-117.

Norman, J. (2012). Systematic Review of the Literature on Simulation in Nursing

Education. ABNF Journal, 23(2), 24-28.

Osman, C. 2000). Asepsis and Aseptic Practices in Operating Room.

Patow, C. A. (2005) Advancing medical education and patient safety through simulation.

Patient Safety & Quality Healthcare.

http://www.psqh.com/marapr05/simulation.html.

Petrovic, M. A., Aboumatar, H., Baumgartner, W. A., Ulatowski, J. A., Moyer,

J., Chang, T. Y., Camp, M. S., Kowalski, J., Senger, C. M., and Martinez, E. A.

(2012). Pilot implementation of a perioperative protocol to guide operating room-

to-intensive care unit patient handoffs. J CardiothoracVascAnesth, 26(1), 11-16

doi: 10.1053/j.jvca.2011.07.009

Prescott, S., & Garside, J. (2009). An evaluation of simulated clinical practice for adult

branch students. Nursing Standard, 23(22), 35-40.

44

Reader, T., Flin, R., Lauche, K., Cuthbertson, B. H. (2006).Non-technical skills in the

intensive care unit. Br J Anaesth, 96(5): 551-559.

Reilly, A. & Spratt, C. (2007). The perceptions of undergraduate student nurses of high

fidelity simulation-based learning: a case report from the University of Tasmania.

Nurse Education Today, 27(6), 542-550.

Richey, R.C. (2005). Validating Instructional Design and Development Models, in

Innovations in Instructional Technology, J.M. Spector, C. Ohrazda, A. Van

Schaack, & D.A. Wiley, editors. Mahwah, NR: Lawrence Erlbaum Associates,

Publishers , pp. 171- 185.

Riem, N., Boet, S., Bould, M. D., Tavares, W. and Naik, V. N. (2012) Do technical skills

correlate with non-technical skills in crisis resource management: a simulation

study. British Journal of Anaesthesia 109(5): 723–8. doi:10.1093/bja/aes256

Available at: http://bja.oxfordjournals.org/

Riley, R. H. (2008). Mannual of simulation in healthcare. (1sted.). New York. Oxford

university press

Sadler D. (2011). Rise above, overcome mistakes in the OR. OR Today;11(2):37-38.

Scherer, Y.K., Bruce, S.A., & Runkawatt, V. (2007). A comparison of clinical simulation

and case study presentation on nurse practitioner students' knowledge and

confidence in managing a cardiac event. International Journal of Nursing

Education Scholarship, 4(1), 1-14.

Segall, N., Bonifacio, A.S., Schroeder, R. A., Barbeito, A., Rogers D., Thornlow, D. K.,

Emery, J., Kellum, S., Wright, M.C., & Jonathan, B. Mark, J. B. (2012). Can We

45

Make Postoperative Patient Handovers Safer? A Systematic Review of the

Literature. Anesth Analg; 115:102–15. DOI: 10.1213/ANE.0b013e318253af4b

Shemanko, G., & Jones, L. (2008). To simulate or not to simulate: That is the question.

In R. Kyle & W. Murray (Eds.), Clinical Simulation: Operations, Engineering and

Management (Chapter 8). New York: Elsevier, Inc.

St. Pierre, M., Hofinger, G., Buerschaper, C., & Simon, R., (2011). Crisis management in

Acute Care setting: Human factors, team psychology, and patient safety in a high

stakes environment (2nd

ed.). Heidelberg Dordrecht London New York: Springer

publisher

Street, M., Eustace, P., Livingston, P., M., Craike, M., J., Kent, B., & Patterson, D.

(2011). Communication at the bedside to enhance patient care: A survey of nurses'

experience and perspective of handover. International Journal of Nursing

Practice, 17(2), 133-140.

Thim, T., Krarup, N. H., Grove, E. L., Lofgren, B. (2010) ABCDE – a systematic

approach to critically ill patients. Ugeskr Laeger.;172(47):3264–3266.

Thim, T., Krarup, N. H., Grove, E. L., Rohd, C. V., Lofgren, B. (2012). Initial

assessment and treatment with the Airway, Breathing, Circulation, Disability,

Exposure (ABCDE) approach. Int J Gen Med. 5: 117–121.

doi: 10.2147/IJGM.S28478.

Tuoriniemi, P., & Schott-Baer, D. (2008). Implementing a high-fidelity simulation

program in a community college setting. Nursing Education Perspectives, 29(2),

105-109.

46

Walsh, M. (2010). Using a simulated learning environment. Emergency Nurse, 18, 12-

16.

Webster, M. R. (2009). An innovative faculty toolkit simulation success. Nurse

Educator, 34, 148-149.

Woolf P., Keating A., Burge C., and Michael Y. (2004). Statistics and Probability Primer

for Computational Biologists". Massachusetts Institute of Technology, BE 490/

Bio7.91.

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Appendix A

(Perioperative Simulation Sheet, POSS)

First Section

Socio-Demographic Data Regarding Nursing Students at Helsinki

Metropolia University of Applied Sciences

1-Age: ……………. years

2-Gender: 1-Male 2-Female

3-My educational background is:

1-Vocational 2-High school 3-University degree

4-I am currently enrolled in the following program:

1-Nursing 2-Paramedic

3-Midwivery 4-Public health

5-I attended …………times till now in the simulation laboratory.

6-I spent …………..hour/s till now in the simulation laboratory.

7-I have a health care working experience for ……years…….months.

8-My role in the intraoperative simulation event is:

1-A nurse 2-A patient 3-An observer

9-My role in the postoperative simulation event is:

1-A nurse 2-A patient 3-An observer

48

Second Section

First Part: Student Self-Confidence Tool in Perioperative Simulation

Adapted with permission from National league for nursing (NLN, 2004)

Instructions: This questionnaire is a series of statements about your personal attitudes

about the instruction you receive during your simulation activities. Each item represents a

statement about your attitude toward your self-confidence. Please indicate your own

personal feelings about each statement below by marking the numbers that best describe

your beliefs.

Self-confidence in Simulation Learning

1

Disagree

2

Undecided

3

Agree

1-I am confident that I am mastering the clinical skills of

the simulation activity that my teacher presented to me.

2-I am confident that this simulation covered important

content necessary for the mastery of perioperative

curriculum.

3-I am confident that I am developing the skills and

obtaining the required knowledge from this simulation to

perform necessary tasks in a clinical setting.

4-My teacher used helpful resources e.g. (gloves, gowns,

drapes) to teach the simulation.

5- It is my responsibility as a student to learn what I need

to know from this simulation activity.

6-I know how to get help when I do not understand the

concepts (objectives) covered in the simulation.

7-I know now how to use simulation activities to learn

important aspects of clinical skills.

8-It is the teacher’s responsibility to tell me what I need

to learn of the simulation activity content during class

time.

49

Second Part: Perioperative Technical Skills Checklist

(1) Intraoperative Technical Skills Checklist

Mark for correct done action=1; Mark for incorrect or not done action=0.

Item Comment

1: Negotiate successful regarding the nursing roles

1-Negotiate regarding the roles of nurses

2: Explain the process and progress of spinal anesthesia

1-Explain where the anesthetic solution will be placed

2-Explain what the position will be like

3-Explain that the site of the puncture must be disinfected

4-Explain the significance of the correct position

5-Explain that the nurse is by the patient at all times

6-Instruct the patient to breath normally and keep eyes open

3: Know how to instruct the patient to a correct position

1-Ensure that the monitoring devices remain attached to the patient

during positioning

2-the anesthetic nurse is always face-to-face with the patient

3-The circulating nurse supports the patient

4-the back is as close to the edge of the operating table

5-Chin and knees are towards the chest

6-The shoulders are in direct line (vertically)

7-Pillow against the stomach for the patient to ‖hug‖

8-The circulating nurse supports the patient by the shoulders and

behind the knees

4: Perform the skin disinfection to the spinal anesthesia

1-Protect the patients from getting wet by the disinfectant

2-The nurse is able to correctly open the container with the disinfectant

and to poor it on the swabs

3-The nurse is able to currently don on the gloves

4-The nurse is able to identify the disinfection site

5-Consider the direction of the flow of the disinfectant

6-Perform the disinfection correctly

7-Remove the protective sheets without breaking down the sterility

50

(2) Postoperative Technical Skills Checklist

Mark for correct done action= 1; Mark for incorrect or not done action= 0.

*BL.P:Blood Pressure; *ECG: Electrocardiogram; *BGL:Blood Glucose Level;

*AVPU: Alert, responds to Voice, responds to Pain, Unresponsive.*Pt: Patient

priority Postoperative Technical skills Categories Comment

Airway 1-Assure air way patency

2-Check O2 saturation using pulse oximetry

Total

Breathing 1-Assess chest movement

2-Monitor respiratory rate

Total

Circulation 1-Assess pt’s pulse

2-Check BL.P.*

3-Check wound site

4-Assess urine output

5-Administer intravenous solutions

Total

Disability 1-Assess consciousness level (AVPU*)

2-Check B.G.L.*

3-Check pt’s* general wellbeing

4-Proper Pt’s positioning

Total

Exposure 1-Head to toe examination

2-Keep the pt warm

3-Secure pt safety using trolley side rails

4-Assess pain level

Total

Total Score of TS

51

Third Part: Perioperative Non-Technical Skills Checklist

(For both Intra & Postoperative Simulation Activities)

Mark for correct done action=1; Mark for incorrect or not done action=0.

*ISBAR: (I) Identification (S) situation, (B) background, (A) assessment, (R) recommendation.

Non technical skills Categories Scoring

First category (Two cognitive skills) Comment

1-Situation awareness

1- Calling for help &Gathering information

2-Recognising & understanding the setting

3-Anticipating& avoiding fixation

Total

2-Decision-making

1-Identifying options

2-Balancing risk & selecting options

3-Re-evaluating

Total

Total of total for the first category

Second category (Two social skills) Comment

3-Communication /

Team work

1-Coordinating activities with team members

2-Exchanging information (ISBAR* model)

3-Communicating with the patient

Total

4-leadership

1-Planning & preparing

2-Prioritising& distributing workload

3-Identifying & utilizing resources

Total

Total of total for the second category

Total score of NTS

52

Appendix B

Research Permit

Appendix C

53

Students’ Informed Consent

54

Appendix D

Permission Letter from ―National League for Nursing‖

www.nln.org

800-669-1656 | 2600 Virginia Avenue, NW, Washington, DC 20037

November 18, 2015 Dear Mr. Bishoy Awadalla, It is my pleasure to grant you permission to use the "Educational Practices Questionnaire," "Simulation Design Scale" and "Student Satisfaction and Self-Confidence in Learning" NLN/Laerdal Research Tools within your graduate work for the Helsinki Metropolia University Nursing Program. In granting permission to use the instruments, it is understood that the following caveats will be respected: 1. It is the sole responsibility of (you) the researcher to determine whether the NLN instrument is appropriate to her or his particular study. 2. Modifications to an instrument may affect the reliability and/or validity of results. Any modifications made are the sole responsibility of the researcher. 3. When published or printed, any research findings produced using an NLN instrument must be properly cited. If the content was modified in any way, this must also be clearly indicated in the text, footnotes and endnotes of all materials where findings are published or printed. I am pleased that materials developed by the National League for Nursing are seen as valuable, and I am pleased that we are able to grant permission for the use of the "Educational Practices Questionnaire," "Simulation Design Scale" and "Student Satisfaction and Self-Confidence in Learning" instruments for your important work to advance the science of nursing education. Regards,

M. Elaine Tagliareni, EdD, RN, CNE, FAAN Chief Program Officer