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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 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
54
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).
2
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.
3
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).
4
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
5
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).
6
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
7
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.
8
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
9
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
10
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).
12
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).
13
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
14
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).
15
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).
16
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).
17
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.
18
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.
19
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
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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
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