YNEDT-02685; No of Pages 7 Nurse Education Today xxx (2014) xxx–xxx
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Attitudes toward simulation-based learning in nursing students: An application of Q methodology Eun Ja Yeun a,1, Ho Yoon Bang b,2, Eon Na Ryoo c,3, Eun-Ho Ha d,⁎ a
Department of Nursing, Konkuk University, 268 Chungwon-daero, Chungju, Chungbuk 380-701, Republic of Korea School of Medicine, Konkuk University, 268 Chungwon-daero, Chungju, Chungbuk 380-701, Republic of Korea Department of Nursing, Shinsung University, 1 Dahak-ro, Jungmi-myung, Dangjin-gun, Chungnam 343-861, Republic of Korea d Red Cross College of Nursing, Chung-Ang University, 84 Heukseok-Ro, Dongjak-Go, Seoul, 156-756, Republic of Korea b c
a r t i c l e
i n f o
Article history: Accepted 20 February 2014 Available online xxxx Keywords: Attitude Nursing education Nursing students Patient simulation
s u m m a r y SBL is a highly advanced educational method that promotes technical/non-technical skills, increases team competency, and increases health care team interaction in a safe health care environment with no potential for harm to the patient. Even though students may experience the same simulation, their reactions are not necessarily uniform. This study aims at identifying the diversely perceived attitudes of undergraduate nursing students toward simulation-based learning. This study design was utilized using a Q methodology, which analyzes the subjectivity of each type of attitude. Data were collected from 22 undergraduate nursing students who had an experience of simulation-based learning before going to the clinical setting. The 45 selected Qstatements from each of 22 participants were classified into the shape of a normal distribution using a 9-point scale. The collected data was analyzed using the pc-QUANL program. The results revealed two discrete groups of students toward simulation-based learning: ‘adventurous immersion’ and ‘constructive criticism’. The findings revealed that teaching and learning strategies based on the two factors of attitudes could beneficially contribute to the customization of simulation-based learning. In nursing education and clinical practice, teaching and learning strategies based on types I and II can be used to refine an alternative learning approach that supports and complements clinical practice. Recommendations have been provided based on the findings. © 2014 Elsevier Ltd. All rights reserved.
Introduction Background The rise in patient complexity, severity of conditions, and development of nursing interventions is increasingly demanding professional knowledge and skills that can best be addressed by nurses (Bremner et al., 2006). However, the difference between theoretical knowledge learned in the school setting and the demands of the actual clinical environment has challenged the application of theoretical knowledge to the clinical setting (Kaakinen and Arwood, 2009). In the current clinical environment, changes in social awareness increased with more people adopting the view that health is a basic human right.
⁎ Corresponding author at: Red Cross College of Nursing, Chung-Ang University, 84 Heukseok-Ro, Dongjak-Go, Seoul, 156-756, Republic of Korea. Tel.: +82 2 820 5991; fax: +82 2 824 7961. E-mail addresses: [email protected] (E.J. Yeun), [email protected] (H.Y. Bang), [email protected] (E.N. Ryoo), [email protected] (E.-H. Ha). 1 Tel.: +82 2 450 3033; fax: +82 2 450 4063. 2 Tel.: +82 2 2030 7598; fax: +82 2 2030 7749. 3 Tel.: +82 41 3501 161x4; fax: +82 41 3501 125.
Such changes have increased client demand for higher nursing quality and hence the pressure on nursing students to avoid mistakes and become skilled in more advanced nursing techniques (Park and Kim, 2000) has become the reason for an observation-based clinical practice. Therefore, due to the difficulties of practicing in the real clinical setting, simulation-based learning (SBL) has come to the fore as an alternative. SBL is a highly advanced educational method that promotes technical/ non-technical skills, increases team competency, and improves teamwork through health care team interaction in a safe environment with no potential for harm to the patient (Crea, 2011; Jefferies, 2005; Karkowsky and Chazotte, 2013; Smith et al., 2013). Students in a virtual situation that is designed to be similar to the environment of the clinical practice through simulators and standardized patients are able to respond to realistic scenarios and can perform patient care that they would otherwise not be able to experience in the clinical setting. This kind of learning environment allows the students to overcome the limitations of clinical practice, improves coping skills, hones critical thinking, refines decision making skills, and helps students to adapt quickly to the clinical setting (Maxson et al., 2011). Professors can observe the competency of each student through the activities of the student nurses, and can help with self-reflection and the repetitive learning through debriefing (Wotton et al., 2010). These benefits of SBL positively affect
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Please cite this article as: Yeun, E.J., et al., Attitudes toward simulation-based learning in nursing students: An application of Q methodology, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.008
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nursing students approaching the transition to registered nurses, which results in high quality of patient outcomes (McCaughey and Traynor, 2010; Smith et al., 2013). However, the obstacles including the high cost of the simulation mannequin, limitations in simulated scenarios closely mimicking realworld, many students compared to the number of equipped mannequin, the dearth of human resources involved with SBL, the inadequate realistic scenarios reflecting clinical settings, and the space shortage for simulation are major considerations in SBL into a curriculum (Crea, 2011; Gore and Schuessler, 2013; Seybert and Kane-Gill, 2011). In three studies, more than half of the students who participated in the simulations expressed negative opinions about the application of simulation experience to the real clinical setting, and experienced negative emotions such as stress, anxiety, and inadequacy during the simulations (Feingold et al., 2004; Lasater, 2007; McCaughey and Traynor, 2010). Even though students may experience the same simulation, their reactions are not necessarily uniform. Some students feel humiliated and embarrassed when they perform poorly or miss the point in front of the instructor or peers. Some students complain about the instructors' judgmental manner and taking a long time, which decreases student interest in SBL (Cantrell, 2008; Cook et al., 2013). A unilateral provision of SBL without consideration for students results in a negative effect on students' learning experience although it includes various advantages. However there are limited studies to investigate individual attitudes toward SBL in undergraduate nursing students. Therefore, it is important to survey the students' subjective attitudes toward the SBL experience to apply a student-centered teaching strategy in order to derive a positive learning experience for the student. The main objective of this study was to identify subjectivity including attitudes of undergraduate nursing students toward the SBL. Study Aims The aim of this study was to identify the perceived attitudes of undergraduate nursing students toward SBL, to understand the structure and characteristics of perception based upon attitudes, and to obtain baseline data to improve the education of nursing students using SBL. Methods Research Design This study applied a Q-methodological approach to explore and describe the attitudes of undergraduate nursing students toward SBL. Q-methodology is useful to explore each person's subjective viewpoints and identify individual attitudes, feelings, perceptions, and values toward an object (Stephenson, 1982), and is an appropriate research method to clarify nursing student's attitudes toward SBL. Q Methodology To understand undergraduate nursing students' attitudes and perceptions toward SBL, Q-methodology was used. Q-methodology was introduced in 1935 by Stephenson. Qmethodology as an integrated research approach uniquely synthesizes the advantage of quantitative and qualitative methods (Akhtar-Danesh et al., 2008). This methodology provides a scientific method for identifying perception structures that exist within certain individuals or groups. The focus is on individuals' attitudes and perceptions that have been gained from personal experience, and feelings (Brown, 1980). Because Q-methodology deals with the measurable subjectivity of the individual, it is possible to measure subjective attitudinal structures. Subjectivity means nothing more than a person's communication of his/her point of view, and can be defined by internal factors: interpersonal relationships, individual attitudes, impressions, perceptions,
feelings, and opinions, rather than external facts (Akhtar-Danesh et al., 2008). A process of Q methodological study involves the following few steps: the construction of the concourse (Q population) through reviewing literature, obtaining written narratives, and in depth interview; a production process of statements known as the Qsample; selection of the sample of participants called the P-sample; and a process of Q-sorting using a bipolar Q-sort table designed as a grid. The collected data are generally analyzed by varimax rotation for factor analysis. Several factors are eventually identified and labeled by a team of domain experts. Consequently, diverse strategies based on labeled factors can be developed to change or reinforce individual attitudes and thoughts. Q-methodology is therefore an effective method to determine and convert subjective human perceptions into an objective outcome (Chinnis et al., 2001). Research Procedure Construction of Concourse (Q Population) The Q population consisted of statements gathered from the following processes. The first step was to assemble the Q population by reviewing the literature from previous studies, and analyzing the data to define the Q population of statements. The process of reviewing the literature related to SBL was conducted by three researchers involved in this study. The second step was to obtain written narratives from the undergraduate nursing students. For obtaining written narratives, all second year nursing students who had an experience of SBL were asked to fill in the five-item questions (‘What is a simulation?’, ‘How did you learn the word simulation?’, ‘What do you think of simulation?’, ‘What do you have in mind during the simulation?’, ‘What have you learned through the simulation?’) produced by the researchers based on literature review, and put into the researchers' mail box without the students' name. The 150 undergraduate nursing students voluntarily responded to the five-item questions. The third step, in-depth interviews were conducted to extract self-referent statements, and get more information about feelings and attitudes toward SBL from 23 undergraduate nursing students who willingly want to participate in indepth interviews than answering the five-item questions. Through these processes, a total of 190 statements were collected from the Q population after correcting redundant and unclear statements (Fig. 1). Q Sample The 190 statements were reviewed by three professors of nursing and one methodologist, and classified into four categories (definition, recognition, attitude, and effect) according to meaning and theme.
Literature review Reviewed the literature related to SBL by researchers
Written narratives Filled in the five-item questions by 150 nursing students
In-depth interviews Get more information toward SBL from23 nursing students
Developed a total of 190 statements Corrected redundant and unclear statements by researchers Fig. 1. The steps for construction of concourse.
Please cite this article as: Yeun, E.J., et al., Attitudes toward simulation-based learning in nursing students: An application of Q methodology, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.008
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Through this process, final panel of 45 Q samples were identified as the most representative and distinctive, and were chosen for use in the Q sorting process.
views and below −1.0 as negative views). A best estimate for each factor was calculated using factor weightings that demonstrate the extent of an individual Q sort in each factor (McParland et al., 2011).
Selection of Participants (P-sample) In order to recruit P-sample for Q sorting, second year undergraduate nursing students who had an experience of SBL and enrolled at a college of nursing in Seoul, Korea were asked to participate in Q sorting, and 22 participants were recruited to participate in the study. The 22 participants represented everyone who had attended the sorting process and completed the Q sorts.
Ethical Considerations The study was approved by the Institutional Review Board at the Konkuk University, and was conducted in accordance with the principles of the Helsinki declaration. All the information gathered was treated confidentially and anonymously. All participants had been provided an explanation about this data; that it would never be used for any other purpose, other than this research. A written informed consent form was obtained when the participants agreed to participate in this study, and this was duly obtained.
Q Sorting Sorting of the 22 participants produced 45 Q statements rated on a scale of 1–9 (Fig. 2). After each Q sort, participants were interviewed about the items they placed in the extreme columns: most disagree (− 4) and most agree (+ 4). The resultant Q sort would be a matrix representing the participant's operant subjectivity on the issue under consideration. Data collection was carried out from May to July 2012, and successfully collected from 22 participants. Validity and Reliability Validity of a Q study includes content, face and Q sorting validity. Reliability of Q sorting is verified using a test–retest procedure. Repeated Q sort is usually conducted at 1- and 2-week intervals (AkhtarDanesh et al., 2008). For content validity of statements, literatures associated with SBL were reviewed by the researchers in this study, and for face validity, statements were assessed by three professors of nursing and one methodologist as a team of domain experts. For Q sorting validity and reliability, final panel of 45 Q samples was tested by 5 volunteer students, and retested 2 weeks later. Data Analysis The pc-QUANL program (Van Tubergen, 1975) was used to analyze the Q sorts. pc-QUANL can be downloaded free from a Web site (http://www.kssss.org/pds_kssss.php) and refer to a Web site (http:// www.pcqsoft.com/) (Kim, 2008). Principal component analysis for factor analysis was established to reveal groupings or patterns in the data after each participant's score was entered into the database. Relevant to the analysis of Q sorts was the following three points; using eigenvalues of at least 1.0 for the final interpretation, conducting varimax rotation in order to maximize the variance between each factor, and adopting Z-score as a measure of standard deviation (statements with a Z-score above +1.0 as positive
Raw Scores No. of Cards Transformed Scores
-4 (2) 1
-3 (4) 2
(Strongly Disagree)
-2 (5) 3
-1 (7) 4
0 (9) 5
1 (7) 6
2 (5) 7
(Neutral)
Fig. 2. Forced distribution on Q-samples.
3 (4) 8
4 (2) 9
(Strongly Agree)
Results Demographic Profile of the Participants Of the 22 participants in this study, 77% were females and 23% were males. They were ranging in age from 19 to 26. There were two factors of SBL perceptions that undergraduate nursing students recognized. The two factors occupy 50% of all variance and include factor I — 39% and factor II — 11%, respectively. In addition rather medium correlations among the two factors and 11 consensus items that signify similar thoughts were found. The two factors were interpreted based on typal array, extreme comments (most disagree and agree), and socio-demographic information. Details of demographics are presented in Table 1. Characteristics for Each Factor Factor I: Adventurous Immersion The 12 students who fit the factor I category were all in their second year, had an average age of 21 years and had a SBL experience of 15 months or more (Table 1). The participants who belonged to this category thought that debriefing helped by giving them a chance to look over their weaknesses through self-reflection (Z = 1.40), helped improve situation awareness and critical thinking (Z = 1.38). Furthermore, they also believed that SBL was more fun and interesting than the traditional form of lecture, which provided more motivation (Z = 1.27). Also, the participants opined that it reduced the gap between the clinical environment and school education (Z = 1.22), reduced anxiety by enabling them to experience before clinical practice (Z = 1.20) and increased their adaptability and their ability to cope in the clinical setting (Z = 1.03) (Table 2). A fuller synopsis of the characteristics of the factor I participants is provided in Table 3. The biggest difference in opinions of positive agreement between the two types was the response to the statement ‘experiencing clinical setting before clinical practice mitigates anxiety and tension related to clinical practice’ (difference = 1.74). The least agreement was in response to the statement ‘it is an embarrassment and a burden when the standardized patient acts irritably’ (difference = −2.23). Participant number 21 with the highest factor weight of 3.3956 stated that “the purpose of simulation is to find the shortcomings and overcome them, and it is necessary to do the simulations because it enables one to look back at one's own performance and it also increases the satisfaction of learning”. Participant number 2 stated, “It is hard to apply the theory learned in the classroom to the clinical environment but SBL lowers the difficulty,” and “It gives me the opportunity to assess the situation and gives me the time to look back on the nursing practice I performed.” Illustrative other comments loading on this factor included the following: “SBL is very important learning method to me. I could never have achieved successful clinical practice without simulation, SBL guided me what I have to do in a clinical setting.”
Please cite this article as: Yeun, E.J., et al., Attitudes toward simulation-based learning in nursing students: An application of Q methodology, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.008
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Table 1 Factor weights and characteristics of participants (N = 22). Type
Participant no.
Factor weights
Characteristics
Summary
I (n = 12) adventurous immersion
21 02 10 03 15 06 17 07 04 20 18 05 08 09 22 01 19 12 11 16 14 13
3.3956 2.7894 2.6365 1.9504 1.4819 1.1980 1.1080 1.0418 .9482 .7738 .7562 .6045 2.0618 1.7975 1.3498 1.2445 1.2982 .9762 .5702 .5059 .4851 .4575
Mean age = 21 (years) Female = 10 (83%) Male = 2 (17%) SBLE = 15 months
SBL is a new learning method. By actively accepting, and enjoying the learning process, we can achieve self-development
Mean age = 21 (years) Female = 7 (70%) Male = 3 (30%) SBLE = 13 months
A new learning method itself is important but these are more important to develop scenarios and hold competent professors in order to settle down SBL correctly and effectively.
II (n = 10) constructive criticism
SBL = simulation-based learning; SBLE = simulation-based learning experience.
“Nursing knowledge and performance that I have learned from simulation have been implemented in clinical practice. I could not perform nursing care if I did not participate in simulation.” The factor I individuals recognized that SBL is a new learning method and that, by actively accepting and enjoying the learning process, and showing a positive and accepting attitude, they could achieve selfdevelopment. Acknowledging these attributes, we named this factor as the ‘adventurous immersion’.
Factor II: Constructive Criticism Ten nursing students were categorized as factor II. They were all in their second year of nursing education, and had an average age of 21 years old and an average of 13 months experience with SBL (Table 1). The factor II participants stated that an accurate and reasonable simulation scenario that vividly reflects the actual situation must be developed before SBL can be enacted (Z = 1.88), SBL makes us learn and grow from mistakes (Z = 1.69), and can find out learner's strengths and weaknesses (Z = 1.51). They agreed that the instructor should be someone who has legitimate experience in clinical practice, can respond with agility to the changes in the clinical setting as well as the ability to collect data related to it, and has excellent clinical skills. Also, the instructor should be able to smoothly operate a high fidelity Human Patient Simulator (HPS) such as the 3G SimMAN, SimMAN, SimBaby, and Noelle (Z = 1.51). Factor II participants also described that simulation cannot replace the clinical practicum (Z = 1.35) (Table 2). The characteristics of the 10 factor II participants are summarized in Table 3. The item that produced a marked difference of positive agreement upon comparison of the factor II responses and factor I response was: ‘Professors need to know thoroughly how to operate the simulators, must be agile in clinical environments and have excellent nursing practice skills’ (difference = −1.08). Participant number 8, who displayed a factor weight of 2.0618, stated, “The 3G SimMAN shows the effects of nursing practice, which enables students to participate more sincerely, but when the scenario is hard and students are unable to resolve it, confidence decreases, and because of this problem, I have had difficulties in simulation.” Participant number 9 stated “SBL helps a lot before going to the hospital practicum but simulation alone cannot substitute for actual clinical practice.”
Illustrative other comments loading on this factor included the following: “How much we can learn through SBL depends on realistic scenarios.”
“Some professors are not confident to deal with simulators. It makes me frustrated.”
“Simulation is just a part of learning. Simulation is not the real clinical practice. Do not mix up simulation and clinical practice.” The collective opinions of the factor II participants revealed that they believed that a new way of learning itself is important but presenting an effective way of operating and developing scenarios, and having a competent instructor, are important aspects to help increase acceptance of SBL. The attributes of factor II were consistent with a designation of ‘constructive criticism’. Consensus Views of Perceptions toward SBL of Participants The common important factors regarding the attitude toward SBL among nursing students are summarized in Table 4. The following quotes summed up the feeling of the majority: being able to share the nursing practice and fill in for each others' weaknesses, being able to depend on each other psychologically gives stability, and by giving direct and indirect opportunity to nursing students rather than nurses who have a lot field experience, simulation is a very important learning method. Discussion SBL using a Human Patient Simulator is an effective tool to reinforce technical and nontechnical skills without patient harm in a safe health care environment, and can improve collaboration, critical thinking, as well as communication skills in patient care decision-making processes. In this study, the outcome was the discovery of two factors of participants, which we named the ‘adventurous immersion’ (factor I), and the ‘constructive criticism’ (factor II).
Please cite this article as: Yeun, E.J., et al., Attitudes toward simulation-based learning in nursing students: An application of Q methodology, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.008
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Table 2 Q-statements and typal array of Z-scores. Item
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q 10 Q 11 Q 12 Q 13 Q 14 Q 15 Q 16 Q 17 Q 18 Q 19 Q 20 Q 21 Q 22 Q 23 Q 24 Q 25 Q 26 Q 27 Q 28 Q 29 Q 30 Q 31 Q 32 Q 33 Q 34 Q 35 Q 36 Q 37 Q 38 Q 39 Q 40 Q 41 Q 42 Q 43 Q 44 Q 45
Q-statements
Z-score
Since it is a virtual reality experience, artificial control is possible. By knowing the exact learning object, can increase the learning achievement. It is a learning method that applies theory to practice. Can learn responsibility and teamwork from efficient division of roles. By increasing the ability to cope, I can quickly adapt to the clinical setting. Simulation feels so much like reality that I tend to concentrate without even realizing. It is embarrassing and burdensome when the standardized patient acts too sensitive. It helps in improving circumstantial judgment and critical thinking. Debriefing helps with self-reflection, which makes up for my fault. By experiencing the clinical setting beforehand, it relieves anxiety due to the actual practicum. Makes me feel as though I am a nurse. Helps with understanding the role of a nurse. Gives the opportunity to become close with friends. Do mind to catch the intention of the professor than patient care during simulation. Since it is such a costly mannequin, I take careful precautions not to break it. It creates anxiety because it feels as though I'm on a stage. It is more pressure working as a team than working alone. I worry about revealing my weaknesses to the standardized patient. Since I can learn more diverse clinical techniques, I am more confident. Simulation and the actual clinical setting are very different in reality. Preliminary studying is important for an effective simulation and it takes extracurricular time and effort. It prompts learning motive because it is more fun and interesting than a lecture. I am afraid that the same situation might happen in the actual clinical setting. It gives a positive pressure to perform accurate nursing practice. It is a waste of time compared to lectures and since it is not a direct nursing experience, it is not of much help. The restrictions on time, place, and equipment for simulation decrease learning effect. Asks too much of the students in a short period of time. It is questionable whether or not simulation-based learning is really needed. Simulation-based learning is needed more for the nurse than for the student. Effective debriefing enables self-reflection and increases learning satisfaction. By working in a given scenario, it makes me fall into mannerisms and decreases the effects of learning. The method of learning is related to the prevention of medical accidents and patient safety. It makes me learn and grow from mistakes. It is important to develop scenarios that are accurate and trustworthy which take into account the clinical setting. By interacting with the standardized patient, I can solve the problem, and increase communication skills and interpersonal relationships. It enables interaction between the professor and student. The student themselves can assess the patient according to the situation. Since it is not real situation, not serious and no sense of reality. Can find out learner's strengths and weaknesses. The professor must be familiar with the simulators, must be quick about the clinical setting, and must be an expert in clinical practice. The professor can also indirectly experience the clinical setting through simulation. It fills the limitations that cannot experience directly in clinical practice. It decreases the gaps between school education and the clinical setting. I tend to focus more on running the whole scenario rather than on the simulation. Simulation cannot replace the clinical practicum.
Factor I participants believed that, distinct from the traditional oneway listening form of lecture, SBL allows direct participation and nursing intervention through the presented situations, which allows the student to experience the dynamic clinical environment and experience motivation to learn voluntarily. Robinson et al. (2011) conducted a study in which 82 second-year student pharmacists evaluated their
Factor I (n = 12)
Factor II (n = 10)
−0.45 0.62 0.84 0.70 1.03 0.27 −0.49 1.38 1.40 1.20 0.95 0.87 0.09 −1.18 −1.72 −1.53 −1.20 −0.98 0.85 −0.57 0.19 1.27 −1.66 −0.06 −1.55 −1.01 −1.23 −1.89 −1.30 1.23 −1.03 −0.15 1.19 0.28 0.74
−0.34 0.66 0.69 0.86 0.13 −0.47 1.75 0.43 1.41 −0.54 −0.15 0.30 −0.36 −0.19 −1.65 0.66 −1.94 −0.84 −0.04 0.75 −0.38 0.52 −0.68 0.34 −1.96 −1.24 0.81 −1.62 −1.43 0.43 −0.25 −0.92 1.69 1.88 0.10
0.35 0.74 −0.67 0.98 0.42
−0.23 −0.98 −1.47 1.51 1.51
−0.12 1.03 1.22 −0.34 −0.74
−0.12 0.35 −0.35 0.00 1.35
cognitive skills and drug arbitration in a virtual emergency situation. Ninety three percent of the students accurately recognized the presented situations and 83% considered the SBL to be very similar to the actual situation and a very effective learning tool. Factor I believed that hands-on practice facilitated a more enjoyable learning experience, and regarded SBL as a more lively and effective
Table 3 Differences between factors I and II. Item
Q-statements
Q 10 Q 37 Q 43 Q 11 Q 40
By experiencing the clinical setting beforehand, it relieves anxiety due to the actual practicum. The student themselves can assess the patient according to the situation. It decreases the gaps between school education and the clinical setting. Makes me feel as though I am a nurse. The professor must be familiar with the simulators, must be quick about the clinical setting, and must be an expert in clinical practice. Simulation and the actual clinical setting are very different in reality. It is important to develop scenarios that are accurate and trustworthy which take into account the clinical setting. Asks too much of the students in a short period of time. Simulation cannot replace the clinical practicum. It creates anxiety because it feels as though I'm on a stage It is embarrassing and burdensome when the standardized patient acts too sensitive.
Q 20 Q 34 Q 27 Q 45 Q 16 Q7
Z-score factor I
Z-score factor II
Difference
1.20 0.74 1.21 0.94 0.42
−0.53 −0.98 −0.35 −0.15 1.50
1.74 1.72 1.56 1.09 −1.08
−0.57 0.28 −1.23 −0.74 −1.52 −0.48
0.75 1.88 0.81 1.35 0.65 1.74
−1.32 −1.59 −2.04 −2.09 −2.18 −2.23
Please cite this article as: Yeun, E.J., et al., Attitudes toward simulation-based learning in nursing students: An application of Q methodology, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.008
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learning tool than traditional lecture-based learning. A study conducted by Fernandez et al. (2007) reported that the majority of student enjoyed the simulator. Over 90% would like to participate in simulation in the future if given the choice. Wotton et al. (2010) reported that more than 90% of students thought SBL is extremely enjoyable and even felt enthusiasm, and almost 95% of students were absorbed in simulation. This group, in particular, delineated the importance of debriefing through statements such as ‘Debriefing helps with self-reflection and helps overcome one's weaknesses’, and ‘Effective debriefing enables self-reflection and increases learning satisfaction’. Debriefing especially can evaluate nursing roles played out by individuals and as a team. Going over the learning objectives and having a lively debate about the core of nursing practice enable adjustments and continuous education. A study conducted by Cantrell (2008) reported that debriefing facilitates that students integrate the clinical practice and nursing knowledge learned in the class when debriefing is immediately implemented after simulation. Furthermore, students preferred debriefing to be held as soon as simulation is completed and they believed immediate debriefing enhanced their learning. Another study conducted by Savoldelli et al. (2006) reported that using recorded videotapes for debriefing can improve nontechnical skills. However, Fanning and Gaba (2007) insisted that debriefing carefully contemplated students' learning style is more important to boost learning effect. Consequently, the time for debriefing, the use of tools for debriefing, and students' learning style should be considered to increase students' positive learning outcomes when planning a debriefing. Over all, the type I participants constituted a group of students who recognized simulation as a new learning method, and who experienced a motivation to self-develop through their active engagement in this learning and self-reflection concerning their performance, and who highlighted the importance of debriefing. Therefore, the teaching and learning strategies for factor I are to promote self-learning motivation through the application and development of diverse and advanced SBL methods. Using diverse methods of briefing based on students' learning style are also a stratagem for this group. Factor II participants were categorized as the ‘constructive criticism’. They recognized a primary problem in the SBL. For the right settlement of SBL, they preferred a realistic scripted scenario that was close to the actual clinical setting developed by instructors with abundant clinical experience and academic competency. In reality, students can apply the theory and knowledge learned in classrooms for clinical decision-making through realistic scenarios. According to research by Tokunaga et al. (2010) to quickly identify drug treatment effects and adverse effects, patient simulators that considered student competency were used for pharmacology students. A patient simulator for this should be able to increase the ability to assess clinical settings, critical thinking, recognition of change in the patient condition, setting nursing priority and problem solving skills, and monitor responses for nursing by students (Rosen et al., 2008; Seybert et al., 2008). By monitoring their nursing practice it could be decided whether it was adequate or inadequate, could be used to evaluate personal or
team strengths and weaknesses, and provide some reflection for the future. By looking at these details, the factor II responses suggest a precondition for the right outcome of SBL and provide productive pathway directions for instructors. Also, SBL is a great catalyst that helps clinical practice, although it cannot be used as a substitute for actual clinical setting. Therefore, the teaching and learning strategies for factor II individuals should not focus on the perceived imposing barriers of the SBL, but should involve a sharing of the learning preparations and curriculum. This group, in particular, highlights the importance of simulated scenarios and proficient instructors in SBL. To achieve this, development of diverse scenarios which are associated with actual clinical setting and hire of well-trained instructors are necessary. Implications for Nursing Education The improvement in undergraduate nursing students' technical and nontechnical skills including psychomotor skills without patients harm in a safe environment is the biggest benefit of SBL. Although the benefits of SBL are abundant, students' feelings and attitudes regarding SBL are not identical. Two factors revealed in this study showed how SBL is important, how SBL affects nursing students, how SBL must be going to, and what instructors should be done for successful SBL. Nursing educators particularly involved in SBL should reflect nursing students' attitudes in order to encourage and inspire students to be more engaged in SBL with willingness. Strengths and Limitation There were several strengths of this study. Teaching and learning strategies based on factors I and II can be used to refine an alternative learning approach that supports and complements clinical practice. Also, the identified thoughts and views of the students can promote a constructive instructor–student dialogue that centers on SBL. In spite of these strengths, attitudes toward SBL between nursing students and educators or instructors could be different. Although the subjectivity of nursing college students toward SBL is important, knowledge of the views and the attitudes of the instructor who takes the lead in the students learning is needed to help guide the desired outcome of SBL. Conclusion The major finding of this study is noteworthy for its findings of students' subjective attitude toward SBL for successful simulation. Nursing educators should understand and approach what have had a students' subjectivity toward SBL. Nursing educators particularly involved in SBL should endeavor to develop realistic scenarios. Inviting clinical nurses or consulting clinical specialists to reflect actual clinical setting would be helpful to develop diverse and realistic scenarios. Debriefing session
Table 4 Consensus items and average Z-scores between two factors. Item
Q-statements
Average Z-score
Q 33 Q9 Q 39 Q 38 Q 26 Q 23 Q 29 Q 17 Q 15 Q 25 Q 28
It makes me learn and grow from mistakes. Debriefing helps with self-reflection, which makes up for my fault. Can find out learner's strengths and weaknesses. Since it is not real situation, not serious and no sense of reality. The restrictions on time, place, and equipment for simulation decrease learning effect. I am afraid that the same situation might happen in the actual clinical setting. Simulation-based learning is needed more for the nurse than for the student. It is more pressure working as a team than working alone. Since it is such a costly mannequin, I take careful precautions not to break it. It is a waste of time compared to lectures and since it is not a direct nursing experience, it is not of much help. It is questionable whether or not simulation-based learning is really needed.
1.44 1.40 1.25 −1.07 −1.12 −1.17 −1.36 −1.57 −1.69 −1.75 −1.75
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by skilled instructor is essential to promote students' self-reflection. Nursing schools should encourage instructors to complete continuing education for debriefing, but also share new information about SBL with others. Recommendations for Further Research Based on the findings, the study would be developing the customized program for teaching and learning strategies on SBL. Consideration of students' learning style and its application to SBL will be a good strategy for improving the students' learning outcomes. Attitudes toward SBL between nursing students and educators or instructors could be different. Hence, further studies using the co-orientation approach which is a methodology to investigate communal meanings, consensus or conflict, and estimates of others' perceptions to identify the subjective attitudes toward SBL of nursing educators and students could help ease these limitations. Acknowledgment The authors wish to thank the subjects who participated in the study. This study was supported by Konkuk University. References Akhtar-Danesh, N., Baumann, A., Cordingley, L., 2008. Q-methodology in nursing research: a promising method for the study of subjectivity. West. J. Nurs. Res. 30 (6), 759–773. http://dx.doi.org/10.1177/0193945907312979. Bremner, M.N., Aduddell, K., Bennett, D.N., VanGeest, J.B., 2006. The use of human patient simulators: best practices with novice nursing students. Nurse Educ. 31 (4), 170–174. Brown, S.R., 1980. Political Subjectivity: Application of Q Methodology in Political Science. Yale University Press, New Haven, CT. Cantrell, M.A., 2008. The importance of debriefing in clinical simulations. Clin. Simul. Nurs. 4 (2), 19–23. http://dx.doi.org/10.1016/j.ecns.2008.06.006. Chinnis, A.S., Summers, D.E., Doerr, C., Paulson, D.J., Davis, S.M., 2001. Q methodology—a new way of assessing employee satisfaction. J. Nurs. Adm. 31 (5), 252–259. Cook, D.A., Brydges, R., Zendejas, B., Hamstra, S.J., Hatala, R., 2013. Mastery Learning for Health Professionals Using Technology-Enhanced Simulation: A Systematic Review and Meta-Analysis. Acad. Med. http://dx.doi.org/10.1097/ACM.0b013e31829a365d (Epub ahead of print). Crea, K.A., 2011. Practice skill development through the use of human patient simulation. Am. J. Pharm. Educ. 75 (9), 188. http://dx.doi.org/10.5688/ajpe759188. Fanning, R.M., Gaba, D.M., 2007. The role of debriefing in simulation-based learning. J. Soc. Simul. Healthc. 2 (2), 115–125. http://dx.doi.org/10.1097/SIH.0b013e3180315539.
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Attitudes toward simulation-based learning in nursing students: An application of Q methodology Eun Ja Yeun a,1, Ho Yoon Bang b,2, Eon Na Ryoo c,3, Eun-Ho Ha d,⁎ a
Department of Nursing, Konkuk University, 268 Chungwon-daero, Chungju, Chungbuk 380-701, Republic of Korea School of Medicine, Konkuk University, 268 Chungwon-daero, Chungju, Chungbuk 380-701, Republic of Korea Department of Nursing, Shinsung University, 1 Dahak-ro, Jungmi-myung, Dangjin-gun, Chungnam 343-861, Republic of Korea d Red Cross College of Nursing, Chung-Ang University, 84 Heukseok-Ro, Dongjak-Go, Seoul, 156-756, Republic of Korea b c
a r t i c l e
i n f o
Article history: Accepted 20 February 2014 Available online xxxx Keywords: Attitude Nursing education Nursing students Patient simulation
s u m m a r y SBL is a highly advanced educational method that promotes technical/non-technical skills, increases team competency, and increases health care team interaction in a safe health care environment with no potential for harm to the patient. Even though students may experience the same simulation, their reactions are not necessarily uniform. This study aims at identifying the diversely perceived attitudes of undergraduate nursing students toward simulation-based learning. This study design was utilized using a Q methodology, which analyzes the subjectivity of each type of attitude. Data were collected from 22 undergraduate nursing students who had an experience of simulation-based learning before going to the clinical setting. The 45 selected Qstatements from each of 22 participants were classified into the shape of a normal distribution using a 9-point scale. The collected data was analyzed using the pc-QUANL program. The results revealed two discrete groups of students toward simulation-based learning: ‘adventurous immersion’ and ‘constructive criticism’. The findings revealed that teaching and learning strategies based on the two factors of attitudes could beneficially contribute to the customization of simulation-based learning. In nursing education and clinical practice, teaching and learning strategies based on types I and II can be used to refine an alternative learning approach that supports and complements clinical practice. Recommendations have been provided based on the findings. © 2014 Elsevier Ltd. All rights reserved.
Introduction Background The rise in patient complexity, severity of conditions, and development of nursing interventions is increasingly demanding professional knowledge and skills that can best be addressed by nurses (Bremner et al., 2006). However, the difference between theoretical knowledge learned in the school setting and the demands of the actual clinical environment has challenged the application of theoretical knowledge to the clinical setting (Kaakinen and Arwood, 2009). In the current clinical environment, changes in social awareness increased with more people adopting the view that health is a basic human right.
⁎ Corresponding author at: Red Cross College of Nursing, Chung-Ang University, 84 Heukseok-Ro, Dongjak-Go, Seoul, 156-756, Republic of Korea. Tel.: +82 2 820 5991; fax: +82 2 824 7961. E-mail addresses: [email protected] (E.J. Yeun), [email protected] (H.Y. Bang), [email protected] (E.N. Ryoo), [email protected] (E.-H. Ha). 1 Tel.: +82 2 450 3033; fax: +82 2 450 4063. 2 Tel.: +82 2 2030 7598; fax: +82 2 2030 7749. 3 Tel.: +82 41 3501 161x4; fax: +82 41 3501 125.
Such changes have increased client demand for higher nursing quality and hence the pressure on nursing students to avoid mistakes and become skilled in more advanced nursing techniques (Park and Kim, 2000) has become the reason for an observation-based clinical practice. Therefore, due to the difficulties of practicing in the real clinical setting, simulation-based learning (SBL) has come to the fore as an alternative. SBL is a highly advanced educational method that promotes technical/ non-technical skills, increases team competency, and improves teamwork through health care team interaction in a safe environment with no potential for harm to the patient (Crea, 2011; Jefferies, 2005; Karkowsky and Chazotte, 2013; Smith et al., 2013). Students in a virtual situation that is designed to be similar to the environment of the clinical practice through simulators and standardized patients are able to respond to realistic scenarios and can perform patient care that they would otherwise not be able to experience in the clinical setting. This kind of learning environment allows the students to overcome the limitations of clinical practice, improves coping skills, hones critical thinking, refines decision making skills, and helps students to adapt quickly to the clinical setting (Maxson et al., 2011). Professors can observe the competency of each student through the activities of the student nurses, and can help with self-reflection and the repetitive learning through debriefing (Wotton et al., 2010). These benefits of SBL positively affect
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nursing students approaching the transition to registered nurses, which results in high quality of patient outcomes (McCaughey and Traynor, 2010; Smith et al., 2013). However, the obstacles including the high cost of the simulation mannequin, limitations in simulated scenarios closely mimicking realworld, many students compared to the number of equipped mannequin, the dearth of human resources involved with SBL, the inadequate realistic scenarios reflecting clinical settings, and the space shortage for simulation are major considerations in SBL into a curriculum (Crea, 2011; Gore and Schuessler, 2013; Seybert and Kane-Gill, 2011). In three studies, more than half of the students who participated in the simulations expressed negative opinions about the application of simulation experience to the real clinical setting, and experienced negative emotions such as stress, anxiety, and inadequacy during the simulations (Feingold et al., 2004; Lasater, 2007; McCaughey and Traynor, 2010). Even though students may experience the same simulation, their reactions are not necessarily uniform. Some students feel humiliated and embarrassed when they perform poorly or miss the point in front of the instructor or peers. Some students complain about the instructors' judgmental manner and taking a long time, which decreases student interest in SBL (Cantrell, 2008; Cook et al., 2013). A unilateral provision of SBL without consideration for students results in a negative effect on students' learning experience although it includes various advantages. However there are limited studies to investigate individual attitudes toward SBL in undergraduate nursing students. Therefore, it is important to survey the students' subjective attitudes toward the SBL experience to apply a student-centered teaching strategy in order to derive a positive learning experience for the student. The main objective of this study was to identify subjectivity including attitudes of undergraduate nursing students toward the SBL. Study Aims The aim of this study was to identify the perceived attitudes of undergraduate nursing students toward SBL, to understand the structure and characteristics of perception based upon attitudes, and to obtain baseline data to improve the education of nursing students using SBL. Methods Research Design This study applied a Q-methodological approach to explore and describe the attitudes of undergraduate nursing students toward SBL. Q-methodology is useful to explore each person's subjective viewpoints and identify individual attitudes, feelings, perceptions, and values toward an object (Stephenson, 1982), and is an appropriate research method to clarify nursing student's attitudes toward SBL. Q Methodology To understand undergraduate nursing students' attitudes and perceptions toward SBL, Q-methodology was used. Q-methodology was introduced in 1935 by Stephenson. Qmethodology as an integrated research approach uniquely synthesizes the advantage of quantitative and qualitative methods (Akhtar-Danesh et al., 2008). This methodology provides a scientific method for identifying perception structures that exist within certain individuals or groups. The focus is on individuals' attitudes and perceptions that have been gained from personal experience, and feelings (Brown, 1980). Because Q-methodology deals with the measurable subjectivity of the individual, it is possible to measure subjective attitudinal structures. Subjectivity means nothing more than a person's communication of his/her point of view, and can be defined by internal factors: interpersonal relationships, individual attitudes, impressions, perceptions,
feelings, and opinions, rather than external facts (Akhtar-Danesh et al., 2008). A process of Q methodological study involves the following few steps: the construction of the concourse (Q population) through reviewing literature, obtaining written narratives, and in depth interview; a production process of statements known as the Qsample; selection of the sample of participants called the P-sample; and a process of Q-sorting using a bipolar Q-sort table designed as a grid. The collected data are generally analyzed by varimax rotation for factor analysis. Several factors are eventually identified and labeled by a team of domain experts. Consequently, diverse strategies based on labeled factors can be developed to change or reinforce individual attitudes and thoughts. Q-methodology is therefore an effective method to determine and convert subjective human perceptions into an objective outcome (Chinnis et al., 2001). Research Procedure Construction of Concourse (Q Population) The Q population consisted of statements gathered from the following processes. The first step was to assemble the Q population by reviewing the literature from previous studies, and analyzing the data to define the Q population of statements. The process of reviewing the literature related to SBL was conducted by three researchers involved in this study. The second step was to obtain written narratives from the undergraduate nursing students. For obtaining written narratives, all second year nursing students who had an experience of SBL were asked to fill in the five-item questions (‘What is a simulation?’, ‘How did you learn the word simulation?’, ‘What do you think of simulation?’, ‘What do you have in mind during the simulation?’, ‘What have you learned through the simulation?’) produced by the researchers based on literature review, and put into the researchers' mail box without the students' name. The 150 undergraduate nursing students voluntarily responded to the five-item questions. The third step, in-depth interviews were conducted to extract self-referent statements, and get more information about feelings and attitudes toward SBL from 23 undergraduate nursing students who willingly want to participate in indepth interviews than answering the five-item questions. Through these processes, a total of 190 statements were collected from the Q population after correcting redundant and unclear statements (Fig. 1). Q Sample The 190 statements were reviewed by three professors of nursing and one methodologist, and classified into four categories (definition, recognition, attitude, and effect) according to meaning and theme.
Literature review Reviewed the literature related to SBL by researchers
Written narratives Filled in the five-item questions by 150 nursing students
In-depth interviews Get more information toward SBL from23 nursing students
Developed a total of 190 statements Corrected redundant and unclear statements by researchers Fig. 1. The steps for construction of concourse.
Please cite this article as: Yeun, E.J., et al., Attitudes toward simulation-based learning in nursing students: An application of Q methodology, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.008
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Through this process, final panel of 45 Q samples were identified as the most representative and distinctive, and were chosen for use in the Q sorting process.
views and below −1.0 as negative views). A best estimate for each factor was calculated using factor weightings that demonstrate the extent of an individual Q sort in each factor (McParland et al., 2011).
Selection of Participants (P-sample) In order to recruit P-sample for Q sorting, second year undergraduate nursing students who had an experience of SBL and enrolled at a college of nursing in Seoul, Korea were asked to participate in Q sorting, and 22 participants were recruited to participate in the study. The 22 participants represented everyone who had attended the sorting process and completed the Q sorts.
Ethical Considerations The study was approved by the Institutional Review Board at the Konkuk University, and was conducted in accordance with the principles of the Helsinki declaration. All the information gathered was treated confidentially and anonymously. All participants had been provided an explanation about this data; that it would never be used for any other purpose, other than this research. A written informed consent form was obtained when the participants agreed to participate in this study, and this was duly obtained.
Q Sorting Sorting of the 22 participants produced 45 Q statements rated on a scale of 1–9 (Fig. 2). After each Q sort, participants were interviewed about the items they placed in the extreme columns: most disagree (− 4) and most agree (+ 4). The resultant Q sort would be a matrix representing the participant's operant subjectivity on the issue under consideration. Data collection was carried out from May to July 2012, and successfully collected from 22 participants. Validity and Reliability Validity of a Q study includes content, face and Q sorting validity. Reliability of Q sorting is verified using a test–retest procedure. Repeated Q sort is usually conducted at 1- and 2-week intervals (AkhtarDanesh et al., 2008). For content validity of statements, literatures associated with SBL were reviewed by the researchers in this study, and for face validity, statements were assessed by three professors of nursing and one methodologist as a team of domain experts. For Q sorting validity and reliability, final panel of 45 Q samples was tested by 5 volunteer students, and retested 2 weeks later. Data Analysis The pc-QUANL program (Van Tubergen, 1975) was used to analyze the Q sorts. pc-QUANL can be downloaded free from a Web site (http://www.kssss.org/pds_kssss.php) and refer to a Web site (http:// www.pcqsoft.com/) (Kim, 2008). Principal component analysis for factor analysis was established to reveal groupings or patterns in the data after each participant's score was entered into the database. Relevant to the analysis of Q sorts was the following three points; using eigenvalues of at least 1.0 for the final interpretation, conducting varimax rotation in order to maximize the variance between each factor, and adopting Z-score as a measure of standard deviation (statements with a Z-score above +1.0 as positive
Raw Scores No. of Cards Transformed Scores
-4 (2) 1
-3 (4) 2
(Strongly Disagree)
-2 (5) 3
-1 (7) 4
0 (9) 5
1 (7) 6
2 (5) 7
(Neutral)
Fig. 2. Forced distribution on Q-samples.
3 (4) 8
4 (2) 9
(Strongly Agree)
Results Demographic Profile of the Participants Of the 22 participants in this study, 77% were females and 23% were males. They were ranging in age from 19 to 26. There were two factors of SBL perceptions that undergraduate nursing students recognized. The two factors occupy 50% of all variance and include factor I — 39% and factor II — 11%, respectively. In addition rather medium correlations among the two factors and 11 consensus items that signify similar thoughts were found. The two factors were interpreted based on typal array, extreme comments (most disagree and agree), and socio-demographic information. Details of demographics are presented in Table 1. Characteristics for Each Factor Factor I: Adventurous Immersion The 12 students who fit the factor I category were all in their second year, had an average age of 21 years and had a SBL experience of 15 months or more (Table 1). The participants who belonged to this category thought that debriefing helped by giving them a chance to look over their weaknesses through self-reflection (Z = 1.40), helped improve situation awareness and critical thinking (Z = 1.38). Furthermore, they also believed that SBL was more fun and interesting than the traditional form of lecture, which provided more motivation (Z = 1.27). Also, the participants opined that it reduced the gap between the clinical environment and school education (Z = 1.22), reduced anxiety by enabling them to experience before clinical practice (Z = 1.20) and increased their adaptability and their ability to cope in the clinical setting (Z = 1.03) (Table 2). A fuller synopsis of the characteristics of the factor I participants is provided in Table 3. The biggest difference in opinions of positive agreement between the two types was the response to the statement ‘experiencing clinical setting before clinical practice mitigates anxiety and tension related to clinical practice’ (difference = 1.74). The least agreement was in response to the statement ‘it is an embarrassment and a burden when the standardized patient acts irritably’ (difference = −2.23). Participant number 21 with the highest factor weight of 3.3956 stated that “the purpose of simulation is to find the shortcomings and overcome them, and it is necessary to do the simulations because it enables one to look back at one's own performance and it also increases the satisfaction of learning”. Participant number 2 stated, “It is hard to apply the theory learned in the classroom to the clinical environment but SBL lowers the difficulty,” and “It gives me the opportunity to assess the situation and gives me the time to look back on the nursing practice I performed.” Illustrative other comments loading on this factor included the following: “SBL is very important learning method to me. I could never have achieved successful clinical practice without simulation, SBL guided me what I have to do in a clinical setting.”
Please cite this article as: Yeun, E.J., et al., Attitudes toward simulation-based learning in nursing students: An application of Q methodology, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.008
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Table 1 Factor weights and characteristics of participants (N = 22). Type
Participant no.
Factor weights
Characteristics
Summary
I (n = 12) adventurous immersion
21 02 10 03 15 06 17 07 04 20 18 05 08 09 22 01 19 12 11 16 14 13
3.3956 2.7894 2.6365 1.9504 1.4819 1.1980 1.1080 1.0418 .9482 .7738 .7562 .6045 2.0618 1.7975 1.3498 1.2445 1.2982 .9762 .5702 .5059 .4851 .4575
Mean age = 21 (years) Female = 10 (83%) Male = 2 (17%) SBLE = 15 months
SBL is a new learning method. By actively accepting, and enjoying the learning process, we can achieve self-development
Mean age = 21 (years) Female = 7 (70%) Male = 3 (30%) SBLE = 13 months
A new learning method itself is important but these are more important to develop scenarios and hold competent professors in order to settle down SBL correctly and effectively.
II (n = 10) constructive criticism
SBL = simulation-based learning; SBLE = simulation-based learning experience.
“Nursing knowledge and performance that I have learned from simulation have been implemented in clinical practice. I could not perform nursing care if I did not participate in simulation.” The factor I individuals recognized that SBL is a new learning method and that, by actively accepting and enjoying the learning process, and showing a positive and accepting attitude, they could achieve selfdevelopment. Acknowledging these attributes, we named this factor as the ‘adventurous immersion’.
Factor II: Constructive Criticism Ten nursing students were categorized as factor II. They were all in their second year of nursing education, and had an average age of 21 years old and an average of 13 months experience with SBL (Table 1). The factor II participants stated that an accurate and reasonable simulation scenario that vividly reflects the actual situation must be developed before SBL can be enacted (Z = 1.88), SBL makes us learn and grow from mistakes (Z = 1.69), and can find out learner's strengths and weaknesses (Z = 1.51). They agreed that the instructor should be someone who has legitimate experience in clinical practice, can respond with agility to the changes in the clinical setting as well as the ability to collect data related to it, and has excellent clinical skills. Also, the instructor should be able to smoothly operate a high fidelity Human Patient Simulator (HPS) such as the 3G SimMAN, SimMAN, SimBaby, and Noelle (Z = 1.51). Factor II participants also described that simulation cannot replace the clinical practicum (Z = 1.35) (Table 2). The characteristics of the 10 factor II participants are summarized in Table 3. The item that produced a marked difference of positive agreement upon comparison of the factor II responses and factor I response was: ‘Professors need to know thoroughly how to operate the simulators, must be agile in clinical environments and have excellent nursing practice skills’ (difference = −1.08). Participant number 8, who displayed a factor weight of 2.0618, stated, “The 3G SimMAN shows the effects of nursing practice, which enables students to participate more sincerely, but when the scenario is hard and students are unable to resolve it, confidence decreases, and because of this problem, I have had difficulties in simulation.” Participant number 9 stated “SBL helps a lot before going to the hospital practicum but simulation alone cannot substitute for actual clinical practice.”
Illustrative other comments loading on this factor included the following: “How much we can learn through SBL depends on realistic scenarios.”
“Some professors are not confident to deal with simulators. It makes me frustrated.”
“Simulation is just a part of learning. Simulation is not the real clinical practice. Do not mix up simulation and clinical practice.” The collective opinions of the factor II participants revealed that they believed that a new way of learning itself is important but presenting an effective way of operating and developing scenarios, and having a competent instructor, are important aspects to help increase acceptance of SBL. The attributes of factor II were consistent with a designation of ‘constructive criticism’. Consensus Views of Perceptions toward SBL of Participants The common important factors regarding the attitude toward SBL among nursing students are summarized in Table 4. The following quotes summed up the feeling of the majority: being able to share the nursing practice and fill in for each others' weaknesses, being able to depend on each other psychologically gives stability, and by giving direct and indirect opportunity to nursing students rather than nurses who have a lot field experience, simulation is a very important learning method. Discussion SBL using a Human Patient Simulator is an effective tool to reinforce technical and nontechnical skills without patient harm in a safe health care environment, and can improve collaboration, critical thinking, as well as communication skills in patient care decision-making processes. In this study, the outcome was the discovery of two factors of participants, which we named the ‘adventurous immersion’ (factor I), and the ‘constructive criticism’ (factor II).
Please cite this article as: Yeun, E.J., et al., Attitudes toward simulation-based learning in nursing students: An application of Q methodology, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.008
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Table 2 Q-statements and typal array of Z-scores. Item
Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q 10 Q 11 Q 12 Q 13 Q 14 Q 15 Q 16 Q 17 Q 18 Q 19 Q 20 Q 21 Q 22 Q 23 Q 24 Q 25 Q 26 Q 27 Q 28 Q 29 Q 30 Q 31 Q 32 Q 33 Q 34 Q 35 Q 36 Q 37 Q 38 Q 39 Q 40 Q 41 Q 42 Q 43 Q 44 Q 45
Q-statements
Z-score
Since it is a virtual reality experience, artificial control is possible. By knowing the exact learning object, can increase the learning achievement. It is a learning method that applies theory to practice. Can learn responsibility and teamwork from efficient division of roles. By increasing the ability to cope, I can quickly adapt to the clinical setting. Simulation feels so much like reality that I tend to concentrate without even realizing. It is embarrassing and burdensome when the standardized patient acts too sensitive. It helps in improving circumstantial judgment and critical thinking. Debriefing helps with self-reflection, which makes up for my fault. By experiencing the clinical setting beforehand, it relieves anxiety due to the actual practicum. Makes me feel as though I am a nurse. Helps with understanding the role of a nurse. Gives the opportunity to become close with friends. Do mind to catch the intention of the professor than patient care during simulation. Since it is such a costly mannequin, I take careful precautions not to break it. It creates anxiety because it feels as though I'm on a stage. It is more pressure working as a team than working alone. I worry about revealing my weaknesses to the standardized patient. Since I can learn more diverse clinical techniques, I am more confident. Simulation and the actual clinical setting are very different in reality. Preliminary studying is important for an effective simulation and it takes extracurricular time and effort. It prompts learning motive because it is more fun and interesting than a lecture. I am afraid that the same situation might happen in the actual clinical setting. It gives a positive pressure to perform accurate nursing practice. It is a waste of time compared to lectures and since it is not a direct nursing experience, it is not of much help. The restrictions on time, place, and equipment for simulation decrease learning effect. Asks too much of the students in a short period of time. It is questionable whether or not simulation-based learning is really needed. Simulation-based learning is needed more for the nurse than for the student. Effective debriefing enables self-reflection and increases learning satisfaction. By working in a given scenario, it makes me fall into mannerisms and decreases the effects of learning. The method of learning is related to the prevention of medical accidents and patient safety. It makes me learn and grow from mistakes. It is important to develop scenarios that are accurate and trustworthy which take into account the clinical setting. By interacting with the standardized patient, I can solve the problem, and increase communication skills and interpersonal relationships. It enables interaction between the professor and student. The student themselves can assess the patient according to the situation. Since it is not real situation, not serious and no sense of reality. Can find out learner's strengths and weaknesses. The professor must be familiar with the simulators, must be quick about the clinical setting, and must be an expert in clinical practice. The professor can also indirectly experience the clinical setting through simulation. It fills the limitations that cannot experience directly in clinical practice. It decreases the gaps between school education and the clinical setting. I tend to focus more on running the whole scenario rather than on the simulation. Simulation cannot replace the clinical practicum.
Factor I participants believed that, distinct from the traditional oneway listening form of lecture, SBL allows direct participation and nursing intervention through the presented situations, which allows the student to experience the dynamic clinical environment and experience motivation to learn voluntarily. Robinson et al. (2011) conducted a study in which 82 second-year student pharmacists evaluated their
Factor I (n = 12)
Factor II (n = 10)
−0.45 0.62 0.84 0.70 1.03 0.27 −0.49 1.38 1.40 1.20 0.95 0.87 0.09 −1.18 −1.72 −1.53 −1.20 −0.98 0.85 −0.57 0.19 1.27 −1.66 −0.06 −1.55 −1.01 −1.23 −1.89 −1.30 1.23 −1.03 −0.15 1.19 0.28 0.74
−0.34 0.66 0.69 0.86 0.13 −0.47 1.75 0.43 1.41 −0.54 −0.15 0.30 −0.36 −0.19 −1.65 0.66 −1.94 −0.84 −0.04 0.75 −0.38 0.52 −0.68 0.34 −1.96 −1.24 0.81 −1.62 −1.43 0.43 −0.25 −0.92 1.69 1.88 0.10
0.35 0.74 −0.67 0.98 0.42
−0.23 −0.98 −1.47 1.51 1.51
−0.12 1.03 1.22 −0.34 −0.74
−0.12 0.35 −0.35 0.00 1.35
cognitive skills and drug arbitration in a virtual emergency situation. Ninety three percent of the students accurately recognized the presented situations and 83% considered the SBL to be very similar to the actual situation and a very effective learning tool. Factor I believed that hands-on practice facilitated a more enjoyable learning experience, and regarded SBL as a more lively and effective
Table 3 Differences between factors I and II. Item
Q-statements
Q 10 Q 37 Q 43 Q 11 Q 40
By experiencing the clinical setting beforehand, it relieves anxiety due to the actual practicum. The student themselves can assess the patient according to the situation. It decreases the gaps between school education and the clinical setting. Makes me feel as though I am a nurse. The professor must be familiar with the simulators, must be quick about the clinical setting, and must be an expert in clinical practice. Simulation and the actual clinical setting are very different in reality. It is important to develop scenarios that are accurate and trustworthy which take into account the clinical setting. Asks too much of the students in a short period of time. Simulation cannot replace the clinical practicum. It creates anxiety because it feels as though I'm on a stage It is embarrassing and burdensome when the standardized patient acts too sensitive.
Q 20 Q 34 Q 27 Q 45 Q 16 Q7
Z-score factor I
Z-score factor II
Difference
1.20 0.74 1.21 0.94 0.42
−0.53 −0.98 −0.35 −0.15 1.50
1.74 1.72 1.56 1.09 −1.08
−0.57 0.28 −1.23 −0.74 −1.52 −0.48
0.75 1.88 0.81 1.35 0.65 1.74
−1.32 −1.59 −2.04 −2.09 −2.18 −2.23
Please cite this article as: Yeun, E.J., et al., Attitudes toward simulation-based learning in nursing students: An application of Q methodology, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.008
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E.J. Yeun et al. / Nurse Education Today xxx (2014) xxx–xxx
learning tool than traditional lecture-based learning. A study conducted by Fernandez et al. (2007) reported that the majority of student enjoyed the simulator. Over 90% would like to participate in simulation in the future if given the choice. Wotton et al. (2010) reported that more than 90% of students thought SBL is extremely enjoyable and even felt enthusiasm, and almost 95% of students were absorbed in simulation. This group, in particular, delineated the importance of debriefing through statements such as ‘Debriefing helps with self-reflection and helps overcome one's weaknesses’, and ‘Effective debriefing enables self-reflection and increases learning satisfaction’. Debriefing especially can evaluate nursing roles played out by individuals and as a team. Going over the learning objectives and having a lively debate about the core of nursing practice enable adjustments and continuous education. A study conducted by Cantrell (2008) reported that debriefing facilitates that students integrate the clinical practice and nursing knowledge learned in the class when debriefing is immediately implemented after simulation. Furthermore, students preferred debriefing to be held as soon as simulation is completed and they believed immediate debriefing enhanced their learning. Another study conducted by Savoldelli et al. (2006) reported that using recorded videotapes for debriefing can improve nontechnical skills. However, Fanning and Gaba (2007) insisted that debriefing carefully contemplated students' learning style is more important to boost learning effect. Consequently, the time for debriefing, the use of tools for debriefing, and students' learning style should be considered to increase students' positive learning outcomes when planning a debriefing. Over all, the type I participants constituted a group of students who recognized simulation as a new learning method, and who experienced a motivation to self-develop through their active engagement in this learning and self-reflection concerning their performance, and who highlighted the importance of debriefing. Therefore, the teaching and learning strategies for factor I are to promote self-learning motivation through the application and development of diverse and advanced SBL methods. Using diverse methods of briefing based on students' learning style are also a stratagem for this group. Factor II participants were categorized as the ‘constructive criticism’. They recognized a primary problem in the SBL. For the right settlement of SBL, they preferred a realistic scripted scenario that was close to the actual clinical setting developed by instructors with abundant clinical experience and academic competency. In reality, students can apply the theory and knowledge learned in classrooms for clinical decision-making through realistic scenarios. According to research by Tokunaga et al. (2010) to quickly identify drug treatment effects and adverse effects, patient simulators that considered student competency were used for pharmacology students. A patient simulator for this should be able to increase the ability to assess clinical settings, critical thinking, recognition of change in the patient condition, setting nursing priority and problem solving skills, and monitor responses for nursing by students (Rosen et al., 2008; Seybert et al., 2008). By monitoring their nursing practice it could be decided whether it was adequate or inadequate, could be used to evaluate personal or
team strengths and weaknesses, and provide some reflection for the future. By looking at these details, the factor II responses suggest a precondition for the right outcome of SBL and provide productive pathway directions for instructors. Also, SBL is a great catalyst that helps clinical practice, although it cannot be used as a substitute for actual clinical setting. Therefore, the teaching and learning strategies for factor II individuals should not focus on the perceived imposing barriers of the SBL, but should involve a sharing of the learning preparations and curriculum. This group, in particular, highlights the importance of simulated scenarios and proficient instructors in SBL. To achieve this, development of diverse scenarios which are associated with actual clinical setting and hire of well-trained instructors are necessary. Implications for Nursing Education The improvement in undergraduate nursing students' technical and nontechnical skills including psychomotor skills without patients harm in a safe environment is the biggest benefit of SBL. Although the benefits of SBL are abundant, students' feelings and attitudes regarding SBL are not identical. Two factors revealed in this study showed how SBL is important, how SBL affects nursing students, how SBL must be going to, and what instructors should be done for successful SBL. Nursing educators particularly involved in SBL should reflect nursing students' attitudes in order to encourage and inspire students to be more engaged in SBL with willingness. Strengths and Limitation There were several strengths of this study. Teaching and learning strategies based on factors I and II can be used to refine an alternative learning approach that supports and complements clinical practice. Also, the identified thoughts and views of the students can promote a constructive instructor–student dialogue that centers on SBL. In spite of these strengths, attitudes toward SBL between nursing students and educators or instructors could be different. Although the subjectivity of nursing college students toward SBL is important, knowledge of the views and the attitudes of the instructor who takes the lead in the students learning is needed to help guide the desired outcome of SBL. Conclusion The major finding of this study is noteworthy for its findings of students' subjective attitude toward SBL for successful simulation. Nursing educators should understand and approach what have had a students' subjectivity toward SBL. Nursing educators particularly involved in SBL should endeavor to develop realistic scenarios. Inviting clinical nurses or consulting clinical specialists to reflect actual clinical setting would be helpful to develop diverse and realistic scenarios. Debriefing session
Table 4 Consensus items and average Z-scores between two factors. Item
Q-statements
Average Z-score
Q 33 Q9 Q 39 Q 38 Q 26 Q 23 Q 29 Q 17 Q 15 Q 25 Q 28
It makes me learn and grow from mistakes. Debriefing helps with self-reflection, which makes up for my fault. Can find out learner's strengths and weaknesses. Since it is not real situation, not serious and no sense of reality. The restrictions on time, place, and equipment for simulation decrease learning effect. I am afraid that the same situation might happen in the actual clinical setting. Simulation-based learning is needed more for the nurse than for the student. It is more pressure working as a team than working alone. Since it is such a costly mannequin, I take careful precautions not to break it. It is a waste of time compared to lectures and since it is not a direct nursing experience, it is not of much help. It is questionable whether or not simulation-based learning is really needed.
1.44 1.40 1.25 −1.07 −1.12 −1.17 −1.36 −1.57 −1.69 −1.75 −1.75
Please cite this article as: Yeun, E.J., et al., Attitudes toward simulation-based learning in nursing students: An application of Q methodology, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.008
E.J. Yeun et al. / Nurse Education Today xxx (2014) xxx–xxx
by skilled instructor is essential to promote students' self-reflection. Nursing schools should encourage instructors to complete continuing education for debriefing, but also share new information about SBL with others. Recommendations for Further Research Based on the findings, the study would be developing the customized program for teaching and learning strategies on SBL. Consideration of students' learning style and its application to SBL will be a good strategy for improving the students' learning outcomes. Attitudes toward SBL between nursing students and educators or instructors could be different. Hence, further studies using the co-orientation approach which is a methodology to investigate communal meanings, consensus or conflict, and estimates of others' perceptions to identify the subjective attitudes toward SBL of nursing educators and students could help ease these limitations. Acknowledgment The authors wish to thank the subjects who participated in the study. This study was supported by Konkuk University. References Akhtar-Danesh, N., Baumann, A., Cordingley, L., 2008. Q-methodology in nursing research: a promising method for the study of subjectivity. West. J. Nurs. Res. 30 (6), 759–773. http://dx.doi.org/10.1177/0193945907312979. Bremner, M.N., Aduddell, K., Bennett, D.N., VanGeest, J.B., 2006. The use of human patient simulators: best practices with novice nursing students. Nurse Educ. 31 (4), 170–174. Brown, S.R., 1980. Political Subjectivity: Application of Q Methodology in Political Science. Yale University Press, New Haven, CT. Cantrell, M.A., 2008. The importance of debriefing in clinical simulations. Clin. Simul. Nurs. 4 (2), 19–23. http://dx.doi.org/10.1016/j.ecns.2008.06.006. Chinnis, A.S., Summers, D.E., Doerr, C., Paulson, D.J., Davis, S.M., 2001. Q methodology—a new way of assessing employee satisfaction. J. Nurs. Adm. 31 (5), 252–259. Cook, D.A., Brydges, R., Zendejas, B., Hamstra, S.J., Hatala, R., 2013. Mastery Learning for Health Professionals Using Technology-Enhanced Simulation: A Systematic Review and Meta-Analysis. Acad. Med. http://dx.doi.org/10.1097/ACM.0b013e31829a365d (Epub ahead of print). Crea, K.A., 2011. Practice skill development through the use of human patient simulation. Am. J. Pharm. Educ. 75 (9), 188. http://dx.doi.org/10.5688/ajpe759188. Fanning, R.M., Gaba, D.M., 2007. The role of debriefing in simulation-based learning. J. Soc. Simul. Healthc. 2 (2), 115–125. http://dx.doi.org/10.1097/SIH.0b013e3180315539.
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Please cite this article as: Yeun, E.J., et al., Attitudes toward simulation-based learning in nursing students: An application of Q methodology, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.02.008
