Nurse Education Today 34 (2014) 1005–1011
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Development and evaluation of simulation-based fever management module for children with febrile convulsion Shin-Jeong Kim a, Jina Oh b,⁎, Kyung-Ah Kang c, SungHee Kim d a
Department of Nursing, Hallym University, Chuncheon, South Korea Department of Nursing, Institute of Health Science, Inje University, Busan, South Korea Department of Nursing, Sahmyook University, Seoul, South Korea d Red Cross College of Nursing, Chung-Ang University, Seoul, South Korea b c
a r t i c l e
i n f o
Article history: Accepted 21 November 2013 Keywords: Patient simulation Child Febrile convulsion Nursing education
s u m m a r y Background: A reliable and valid checklist for the evaluation of simulation learning outcomes has great value in nursing education. This study focuses on simulation-based fever management module including checklist for febrile convulsion in pediatric nursing. Purposes: This study has two aims; (a) to develop a simulation-based fever management module for treating children with febrile convulsion, and (b) to evaluate students' performance and satisfaction. Participants: A convenient sample of 147 senior nursing students from two nursing schools in South Korea participated in this study from April 29 to June 14, 2013. Methods: This study was a three-stage process: developing the simulation-based module including algorithm with scenarios, items in checklist, and contents of debriefing (Stage I), performing simulation and debriefing for nursing students (Stage II), and evaluating the evaluation checklist of simulation performance and satisfaction of nursing students (Stage III). Student satisfaction was measured using the Satisfaction of Simulations Experience [SSE] scale. Debriefing data were analyzed using the Matrix Method. Results: A scenario script was created to treat the patient's health issues. The algorithm proceeded as follows: identification of patient's condition (Step I), nursing interventions (Step II), and outcome evaluation and feedback (Step III). The total mean score of the evaluation checklist was 2.67 (± .32). The debriefing categories were as follows: non-technical skills, self-efficacy, critical thinking, and technical skills. The total mean score of the SSE was 4.48 (±.42). Conclusion: This study provides a blueprint for simulation-based practice for both nursing educators and nursing students. Further studies of checklists used in different contexts would be valuable for expanding upon this research. © 2013 Elsevier Ltd. All rights reserved.
Introduction Background Over the past 10 years, simulation has been rapidly expanded in training for health care professionals; this provides many benefits (Nehring et al., 2001). It provides virtual experiences of situations frequently encountered in a clinical setting (Moule, 2011), affording opportunities for objective, detailed feedback on students' performance, and facilitating decision making (Jeffries and Norton, 2005; Jeffries, 2007; Roh et al., 2013). Also, simulation-based education gives students an opportunity to bridge the gap between academic and clinical settings, and learn core nursing skills through authentic and clinically relevant experiential learning (Cioffi, 2001). Another benefit is that it ⁎ Corresponding author at: Department of Nursing, Inje University, Bokjiro75, Busanjingu, Busan 614-735, South Korea. Tel.: +82 51 890 6833; fax: +82 51 896 9840. E-mail address: [email protected] (J. Oh). 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.11.008
encourages the development of competence of student nurses in a risk-free environment, which leads to improved self-confidence in performance (Cant and Cooper, 2010). Student performance evaluation is a very important step during simulation-based practice (Reed, 2010). Although a module may be well developed, a standardized evaluation checklist is essential for confirming the effectiveness of simulation-based practice. However, evaluation of simulation is not formalized and incorporated with complex theory (Murphy, 2013; Reed, 2010). There is also limited research in the use of simulation in nursing education and the evaluation of student competency (Reed, 2010). To enhance the effectiveness of simulations in nursing education, a reliable and valid evaluation instrument is needed to measure students' performance. Furthermore, a valid instrument is required for the simulation to be considered a formalized implementation and evaluation tool. Fever has been acknowledged as a one of the most common symptoms found in pediatric care units. Unlike adults, children can easily experience febrile convulsions if the fever is not controlled (Hockenberry,
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2005; Potts and Mandleco, 2011). Moreover, Walsh et al. (2006) suggested that nurses may even have “fever phobia,” or a fear of febrile seizures, and therefore provide inadequate fever management. Nursing management of fevers remains static (Poirier et al., 2000; Sarrell et al., 2002), and the incidence of fever-induced febrile convulsions in children supports this notion. Accordingly, simulation modules may help to provide a comprehensive understanding of fever and fever management. Furthermore, students' satisfaction with the simulation is important for meaningful learning and facilitating active participation (Prion, 2008). Finally, simulations provide the experience of nursing practice in a real clinical situation. Studies suggest that students' satisfaction may be correlated with performance (Bremner et al., 2006). Therefore, this study focuses on pediatric nursing education and nursing practice. Kolb (1984) emphasized that the individual learns through personal experiences or simulation to acquire knowledge, and the pondering on students' thoughts related to the experiential activity. This fever management module was developed based on Kolb's experiential learning model. The ability to manage fever of children is critical to the practice of nursing. Experiential learning is considered a strategy that increases to manage fever in students. Therefore, the following research issues were addressed: (a) to develop a simulation-based fever management module for pediatric febrile convulsions, and (b) to evaluate students' performances and satisfaction. IRB Approval Before conducting this study, approval was granted by the Hallym University's Institutional Review Board (HIRB-2013-013) where the primary researcher was affiliated; issues of voluntary participation, anonymity, and confidentiality were addressed. The researchers explained the study protocol to senior nursing students and informed consent was obtained. It explained the purpose of the study, the researchers' credentials, and information regarding confidentiality. It was stated that there would be no negative consequences for nonparticipation and that data would be reported as group data, not as individual. The data will be sealed and kept in the researchers' room and will be shredded after coding. The IRB confirmed that there were no elements to this study that would deprive human rights, and that all contents and processes conform to proper research ethics. Methods The development of the simulation-based fever management module and evaluation checklist for treating children with febrile convulsions was a three-stage process. Stage I: developing the simulationbased module; Stage II: developing programs for nursing students; and Stage III: evaluating the simulation-based module and validating the dimensions (Fig. 1). The module included an algorithm with the scenario, evaluation checklist, and debriefing plan. Process of a Simulation-based Fever Management Module Development For scenario development, we collected information on nursing care from child health nursing textbooks (Hockenberry, 2005; Potts and Mandleco, 2011) and nursing journals (Poirier et al., 2000; Sarrell et al., 2002; Walsh et al., 2006). Issues included signs and symptoms of fever, parents' lack of knowledge, anxiety, and dehydration related to the validity of the simulation evaluation by expert review. The scenario of a fifteen-month-old baby with febrile convulsion was based on a real febrile convulsion case that had occurred in a general hospital. Items and Scoring of the Evaluation Checklist The items were selected, reviewed, and analyzed by an eleven expert panel including two pediatricians, five pediatric nurses, and four child health nursing educators. The evaluation checklist focused on
Fig. 1. The development and evaluation of a simulation-based module.
the attainment of nursing goals based on nursing processes rather than outcomes. Finally, 3 items were deleted and 37 items reached by consensus (Table 1). The assessment category was divided into two subcategories: preparation and focus assessment. The preparation subcategory consisted of seven checkpoints, while the focus assessment subcategory consisted of eight checkpoints. Four problems were included in the identification category. The intervention category consisted of fourteen checkpoints, and the evaluation category consisted of four checkpoints (Table 1). The evaluation checklist score was based on a 4point Likert scale (1 = beginning, 2 = developing, 3 = accomplished, 4 = exemplary). The higher the evaluation checklist score, the better the performance. A content validity test was conducted with seventeen nurses who worked in a pediatric unit in one of the three general hospitals sampled; each had at least five years of experience in the unit. According to Lynn (1986), an expert panel ideally includes about ten people. Each expert checked validity using the 4-point Likert scale; 1 = not valid at all, 2 = not valid, 3 = valid, and 4 = very valid. There were 37 items in total; the mean score of each item ranged from 3.06 to 4.00. The results of the Content Validity Index were above 80% (Waltz and Bausell, 1981). Contents of the Debriefing The researchers developed the following debriefing questions: (a) What did you learn? (b) How did you feel? (c) What did you do? (d) What were your strong and weak points? These four questions for debriefing are based on the four steps of clinical judgment model (noticing, interpreting, responding, and reflecting) by Tanner (2006). After the simulation-based practice, students were asked to discuss their experience freely. It took about 20–30 min per group of three students. The nursing students were encouraged to reflect on their problem solving and critical thinking. Satisfaction With the Simulation Experience Students' satisfaction with the clinical simulation was measured just after finishing the debriefing session using the Satisfaction of Simulations Experience [SSE] scale developed by Levett-Jones et al. (2011). This scale consists of 18 items: debrief and reflection (9 items), clinical reasoning (5 items), and clinical learning (4 items). Each item was scored on a 5-point Likert scale. Higher scores indicated higher
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Table 1 Means of evaluation checklist items. N = 147. Category (M ± SD)
Items
M ± SD
Preparation Assessment (2.26 ± .53) Critical thinking (2.35 ± .37)
1. Washing hands 2. Prepare needed materials 3. Introducing self to the patient & his/her parent(s) 4. Identify patient by name card and/or bracelet 5. Support parent(s) 6. Identify medical appliances belonging to patient 7. Identify past history Focus 1. Check the chief complaint assessment 2. Identify symptoms related to chief complaint 1) Inspection: skin color, warmth, perspiration, pallor, chilling (2.43 ± .36) 2) Palpitation: cold extremities 3) Vital signs: temperature, pulse, respiration 4) Other symptoms besides fever 5) Dehydration signs: diminished urine output, skin turgor, level of capillary compensation, activity level, dehydrated lip & mucus of mouth, sunken eye(s), absent tears 6) Febrile convulsion symptoms: consciousness level, drooling saliva, appearance of bubbles around mouth, deviation of eyeball, rigid extremity, bending knees & elbows 7) Check pulse, cardiorespiratory monitoring equipment Nursing problems: Identifies nursing problems Problem identification 1) Potential physical injury related to inability of airway patency Critical thinking 2) Hyperthermia (2.94 ± .46) 3) Fluid & electrolyte imbalance 4) Parent(s)'s anxiety related to lack of knowledge about child's current condition 1. Airway maintenance Interventions 2. Notify doctor & receive treatment order if needed Critical thinking (priority 3. Administration of O2 therapy interventions) (2.89 ± .40) 1) Explain to the parent(s) the purpose and method of O2 therapy 2) Attach the oxymeter, which is filled with sterile water, to the instrument and the connect O2 mask 3) Check that O2 is flowing and administer O2 supply as ordered 4. Preparation of prescribed medications (antipyretics, IV fluids) 5. Nursing care for temperature control 1) Administer prescribed antipyretics 2) Remove the child's clothes and then provide warm bath 3) Educate parent(s) about tepid massage 4) Lower the room temperature 6. Check vital signs repeatedly, SaO2, EKG monitoring, consciousness level, & dehydration signs 7. Provide comfortable resting environment 8. Explain child's present condition & care to the parent(s) 9. Record the nursing implementations 1. Check normal range of body temperature & vital signs Evaluations 2. Check SaO2 & level of consciousness Critical thinking (2.82 ± .56) 3. Check recurrence of febrile convulsion 4. Improve parents' understanding about therapy & anxiety Total
2.07 2.27 1.94 2.13 3.21 2.17 2.01 2.80
± ± ± ± ± ± ± ±
1.26 .99 1.18 1.06 .54 .77 1.17 .65
2.04 1.62 3.61 1.71 1.63
± ± ± ± ±
.60 .58 .46 .72 .50
2.46 ± .81 3.60 ± .54 3.73 2.07 3.27 2.71 2.36 3.62
± ± ± ± ± ±
.75 1.39 1.01 1.30 1.17 .57
2.47 3.22 2.47 3.57
± ± ± ±
.32 .82 .88 .57
3.67 3.48 3.00 1.27 2.66 1.84 3.30 3.58 3.36 3.06 1.97 2.89 1.67
± ± ± ± ± ± ± ± ± ± ± ± ±
.63 .75 1.00 .77 .60 .65 .67 .55 .70 .72 .76 .88 .32
Note: Likert scale ratings as follows: 1 (not implemented), 2 (improperly implemented), 3 (properly implemented—properly, average), and 4 (exemplary).
satisfaction. Cronbach's alpha coefficient was .78 in the original study, and .94 in this study. Population The target population for this study included undergraduate students. One hundred forty-seven nursing students were selected from two universities located in Seoul, South Korea. The inclusion criteria to attain homogeneity included (a) senior nursing students, (b) completion of fundamental and child health nursing courses with the same credits and textbook, and (c) no prior participation in a simulation class focused on febrile convulsion.
Before the simulation, students received an orientation that included how to operate the simulator and the scenario information, including past history, chief complaints, and present conditions related to health status. The simulations were scheduled in simulation rooms in which the high-fidelity patient simulators were used. Three nursing students were engaged in the simulation at the same time. One operator and one instructor observed the simulations from the control room. Each simulation lasted 20–30 min, with both the simulation and simulation class taking about 2 h per group. Their performance was evaluated as a group. The evaluation checklist was handed to an instructor in a sealed envelope. Students were asked to wear uniforms and to treat these as actual professional situations. In addition, an SSE was used to measure student satisfaction with the simulation.
Data Collection Procedure Data Analysis Method Data were collected from April 29, 2013 to June 14, 2013. The study's purpose and its procedures, as well as information regarding confidentiality, were explained to the participants prior to obtaining informed consent. All participants enrolled in this study voluntarily and anonymously. In addition, participants were made aware that there was no disadvantage to nonparticipation, and that data would be reported as a whole and not individually. The ratio of participation was 96.1%.
Collected data were analyzed using SPSS 18.0 for Windows to calculate descriptive statistics including means and standard deviations for the evaluation checklist and the SSE. Debriefing data were analyzed using the Matrix Method (Garrad, 2007). All papers and other materials were photocopied and organized as a review matrix that, once labeled appropriately, would serve as a structured abstract of all of the
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documents. The 3Cs (i.e., codes, categories, and concepts) of analysis was used to capture key characteristics of interest, thereby summarizing a large amount of textual information into meaningful themes (Lichtman, 2006). Results Algorithm With a Scenario of Simulation-based Fever Management A scenario script was formulated to resolve the patient's health problem. The algorithm proceeded as follows: identification of patients' condition (Step I), nursing intervention (Step II), and outcome evaluation and feedback (Step III) (Fig. 2). Internal Consistency, Reliability, and Correlation Matrix of the Evaluation Checklist Before conducting the simulations, evaluators had an opportunity to practice evaluation. To reach co-incidence between evaluators, we evaluated each of them twice by direct observation and video record screening. To test the internal consistency and reliability of the evaluation checklist and each subscale, Cronbach's alpha coefficient was measured. This process evaluated the items within the checklist and removed repetitive items. Cronbach's alpha for the evaluation checklist was .87; each subcategory ranged from .71 to .81. We examined the correlation matrix of the evaluation checklist for items with higher (greater than 0.9) or lower (less than 0.4) correlations. Examination of the correlation
matrix for the evaluation checklist resulted in no coefficients greater than 0.9 and no coefficients less than 0.4. Evaluation Checklist The evaluation checklist consisted of four categories based on nursing processes: assessment, problem identification, intervention, and evaluations. The mean score of each category is shown in Table 1. The total mean score of the evaluation checklist was 2.67 (±.32). The mean score of each category was as follows: assessment, 2.35 (±.37); problem identification, 2.94 (±.46); intervention, 2.89 (±.40); and evaluation, 2.82 (±.56). Debriefing Students' comments were grouped into thirteen subcategories following content analysis using the Matrix Method (Table 2). The categories were as follows: non-technical skill (30.7%), self-efficacy (29.8%), critical thinking (21.8%), and technical skill (17.8%). The most frequent categories, in order, were teamwork and collaboration (n = 27), reflection (n = 26), situation recognition (n = 21), core nursing skills (n = 21), emotional support (n = 21), and therapeutic communication (n = 21). Satisfaction With Simulation Experience After debriefing, the students evaluated their satisfaction with the simulation using the SSE scale. The total mean score of SSE was 4.48
Fig. 2. Algorithm with scenario of simulation-based fever management. Note: CBT; cognitive behavior therapy, IV; intravenous, D/S; dextrose saline, IM; intermuscular.
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Table 2 Content analysis of debriefing. N = 147. Categories
n (%)
Subcategory
n (%)
Contents
n
Critical thinking [CT]
49 (21.8)
Situation recognition
21 (42.9)
Decision making
16 (32.6)
Evidence searching
12 (24.5)
Core nursing skill
21 (52.5)
Skilled technique
11 (27.5)
▸Accurate assessment is required. ▸Integrative assessment is necessary. ▸The ability to predict situation is needed. ▸Continuous monitoring is required. ▸Critical thinking is important. ▸Nursing priority should be considered. ▸Procedure is needed step by step. ▸Accurate knowledge of the disease is necessary. ▸Theoretical evidence of nursing care is important. ▸Convulsion/fever control was learned. ▸Fundamental nursing skill was learned. ▸Prompt treatment is required. ▸Accurate nursing skill is needed. ▸Competent nursing skill is essential. ▸Drugs for febrile convulsion were learned. ▸Exact medication method was learned. ▸Action of drugs was understood. ▸Opportunity for empathic nursing intervention. ▸Good rapport with child guardian is needed. ▸Understanding patient's emotional status is considered. ▸Therapeutic environment is needed. ▸Considering patient's present condition is needed. ▸Using therapeutic communication with the person is required. ▸Parent education is needed. ▸Collaborative communication between medical personnel is needed. ▸Teamwork is important. ▸It is important to do one's own role faithfully. ▸Accurate notification to doctor is important. ▸There is a gap between theory and reality. ▸It became an indirect experience like real-life. ▸Feedback process was helpful. ▸I knew my weakness. ▸I felt embarrassment and burdened. ▸Self-led learning is needed. ▸Repeated exercise is important. ▸Preview using open-laboratory hours is needed. ▸Independent nursing care is required. ▸Responsibility about nursing care is essential. ▸Leadership is important. ▸It was a chance to become self-confidence. ▸It was a chance to think like a nurse.
6 8 3 4 5 6 5 7 5 8 13 3 6 2 3 3 2 4 8 7 2 3 12 6 6 4 5 12 4 9 7 12 7 3 6 9 2 2 2 3 1
Technical skill [TS]
40 (17.8)
Medication management
Non-technical skill [NTS]
Self-efficacy [SE]
69 (30.7)
67 (29.8)
8 (20.0)
Emotional support
21 (30.4)
Therapeutic communication
21 (30.4)
Teamwork and collaboration
27 (39.1)
Presence
13 (19.4)
Reflection
26 (38.8)
Motivation
18 (26.9)
Professionalism
10 (14.9)
Note: After multiple responses, number of statements is 225.
(±.42). The mean score for debrief and reflection was 4.55 (±.43), clinical reasoning was 4.39 (±.50), and clinical learning was 4.43 (±.48) (Table 3).
Table 3 The degree of Satisfaction with Simulation Experience [SSE]. Items
M ± SD
Debrief and reflection The facilitator provided constructive criticism during the debriefing The facilitator summarized important issues during the debriefing I had the opportunity to reflect on and discuss my performance during the debriefing The debriefing provided an opportunity to ask questions The facilitator provided feedback that helped me to develop my clinical reasoning skills Reflecting on and discussing the simulation enhanced my learning The facilitator's questions helped me to learn I received feedback during the debriefing that helped me to learn The facilitator made me feel comfortable and at ease during the debriefing Clinical reasoning The simulation developed my clinical reasoning skills The simulation developed my clinical decision making ability The simulation enabled me to demonstrate my clinical reasoning skills The simulation helped me to recognize patient deterioration early This was a valuable learning experience Clinical learning The simulation caused me to reflect on my clinical ability The simulation tested my clinical ability The simulation helped me to apply what I learned from the case study The simulation helped me to recognize my clinical strengths and weaknesses Total
4.55 4.58 4.67 4.51
± ± ± ±
.43 .50 .50 .55
4.46 ± .63 4.50 ± .58 4.55 4.58 4.63 4.48
± ± ± ±
.58 .54 .52 .64
4.39 4.37 4.37 4.32 4.27 4.62 4.43 4.45 4.37 4.30 4.61
± ± ± ± ± ± ± ± ± ± ±
.50 .61 .62 .67 .72 .50 .48 .60 .65 .69 .52
4.48 ± .42
Discussion Simulation is recognized as an innovative pedagogic approach to expand teaching and education (Moule, 2011). Nurse educators are interested in the value and effectiveness of the simulation-based nursing module using the human patient simulator (McCaughey and Traynor, 2010). To ensure that nursing students can respond to changing needs in today's complex health care system, nursing education must be guided by standards of competency and the expectations of professional nursing organizations (Oh et al., 2012). The limited time spent in clinical placements poses a challenge to nursing education; this also limits students' opportunity to practice direct nursing care with patients. The increase in new nursing schools and the shortage of clinical settings for nursing practicum combined with the emphasis on human rights and patient safety in Korea expand the need for simulation-based learning (Hyun et al., 2009; Suh et al., 2009). In this study, a simulation-based fever management module was developed and evaluated. Development of the Simulation-based Module Many nursing educators are interested in simulation, but they have access to only a few clinical scenarios with little time to develop more.
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Murphy (2013) reported that only approximately 20% of the faculties were well trained in simulation instruction. In this study, the development of the simulation-based module was the first step toward solving the nursing problems associated with caring for febrile convulsions in pediatric patients. The module included clinical scenarios that provided vivid, realistic situations without risk to the patient. The evaluation checklist was validated by expert panels and consisted of four nursing processes: assessment, problem identification, intervention, and evaluation. Moule (2011) reported that simulation improves students' competencies in preparation for clinical settings. Fever management is an integral aspect of pediatric nursing practice. Walsh et al. (2006) reported that a lack of knowledge about fever and fever management might result in inadequate treatment in children. Fever management requires a thorough knowledge of fever and the febrile response, based on a thorough assessment of the patient. Among the evaluation categories, problem identification ranked first, with a mean score of 2.94 (± .46). Based on this result, students identified the nursing problems that patients have experienced. The intervention category examined students' critical thinking, as well as their knowledge and skills in proper nursing care. Costello (2011) also reported that simulation-based learning is an excellent instruction method that allows students to practice their drug dosage calculation skills in a safe manner, without fear of injury to the patients. The evaluation category, which fully implements high-fidelity simulations, offers information to nursing educators about students' learning outcomes. The use of simulations to evaluate clinical ability provides a more direct correlation to actual clinical settings than other commonly used forms of evaluation. The evaluation indicated that the focus was on performance rather than learning. The study's evaluation checklist would also be a useful and established guide for nursing educators evaluating student performance through simulations. This checklist describes the overall evaluation process and clarifies the evaluation's target subject and procedure. This encourages students to repeat checkpoint reviews, leading to the correction of earlier mistakes. The effect of reviewing past checkpoints creates an integrative, rather than a static learning experience (Reed, 2010). The previous literature regarding simulation evaluation tools did not report reliability or validity. In this study, a reliable and valid instrument was developed, and internal consistency was measured with Cronbach's alpha coefficient.
Evaluation of the Simulation-based Module Debriefing after clinical simulation is an integral component of the simulation experience, as it promotes critical thinking and reflection in students (Murphy, 2013). Debriefing sessions give students the opportunity to discuss various aspects of care provided during the simulations, and requires them to actively participate in patient care, decision-making, skilled techniques, and patient-care responsibility (Hockenberry, 2005). During debriefing sessions, nursing educators should provide constructive, non-judgmental feedback to the students in order to facilitate therapeutic communication and affirm students' emotions and feelings (Jeffries, 2007). Content analysis results from students' open-ended comments during the debriefing session were meaningful. Students in this study acknowledged the importance of effective communication in teamwork and collaboration, reflected on their experiences and valuable feedback, recognized and accurately assessed the situation, grasped core nursing skills with a hands-on learning approach, formulated a rapport with emotional support, and promoted therapeutic communication between patients and their parents. Students realized that the “team approach” should be included in every clinical practice experience. Exposure to simulation-based nursing care using human patient simulators can provide students with experiential learning that may be absent in diminishing traditional clinical placements (Gillan et al., 2012). Both
our study and previous studies have highlighted the importance of applying simulation-based practice in nursing education. Many studies have reported high satisfaction with simulation experiences (Abdo and Ravert, 2006; Bremner et al., 2006; Levett-Jones et al., 2011; Schoening et al., 2006). Roh et al. (2013) also reported that nurses who participated in simulation-based resuscitation training showed favorable, positive self-efficacy and satisfaction. The total mean SSE score (4.8 ± .42) in this study was slightly higher than that found by LevettJones and colleagues (4.47 ± .36) (2011). Comparing the mean scores of our subcategories with those of Levett-Jones and colleagues, our results (debriefing and reflection: 4.55 ± .43; clinical learning: 4.43 ± .48; and clinical reasoning: 4.39 ± .50) and theirs (clinical learning: 4.53 ± .16; debrief and reflection: 4.46 ± .08; and clinical reasoning: 4.35 ± .09) were similar (Levett-Jones et al., 2011). These students learned to manage a pediatric health issue in a safe learning environment, and these results demonstrate the need for simulations in nursing education (Berragan, 2011). They promote powerful teaching and learning strategies, active and experiential learning, creative thinking, and high-level problem solving (Bland et al., 2011). This module provided a strong connection between the learners and the clinical scenario of a febrile convulsion, helping the students clarify their experiences and reflection according to Kolb's (1984) experiential learning model. The simulation module allowed students to better understand the experiences of the febrile infant caring they may encounter during their clinical practice. In the next step we will be able to better understand what patients and their families might have experienced, and further increase their level of empathy with a standard patient. Moreover, the next step is also to research and develop modules related to varying health problems in order to meet educational needs. The simulation-based fever management module can promote innovative nursing care and improve students' fever management practice. This simulation-based learning enabled students to communicate with and care for children experiencing febrile convulsions and provide better clinical care. Conclusion Simulation-based learning is expected to increase in nursing education because it is an educational tool that accurately recreates real clinical settings. Simulation-based educational modules for nursing students should target students' needs and focus on clinical relevant situations that students may frequently encounter. This study was able to develop more reliable algorithms and evaluation tools for fever management in nursing care. This study identified a nursing care module for children with febrile convulsions. The implications for nursing education include determining how nursing students care for patients using critical thinking and nursing skills. This study also provides a blueprint for simulationbased practice for both nursing educators and nursing students. Furthermore, this study recommends developing an evaluation checklist for other nursing education programs. A large sample size in more than one geographic location will provide valid and reliable data for this module and the evaluation checklist. In addition, this study highlights the need for the full integration of simulations into nursing curricula. Financial support None. Conflict of interest Neither of the authors has any actual or potential of interest including any financial, personal, or other relationships with other people or organization that could inappropriately influence or be perceived to influence this work.
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Development and evaluation of simulation-based fever management module for children with febrile convulsion Shin-Jeong Kim a, Jina Oh b,⁎, Kyung-Ah Kang c, SungHee Kim d a
Department of Nursing, Hallym University, Chuncheon, South Korea Department of Nursing, Institute of Health Science, Inje University, Busan, South Korea Department of Nursing, Sahmyook University, Seoul, South Korea d Red Cross College of Nursing, Chung-Ang University, Seoul, South Korea b c
a r t i c l e
i n f o
Article history: Accepted 21 November 2013 Keywords: Patient simulation Child Febrile convulsion Nursing education
s u m m a r y Background: A reliable and valid checklist for the evaluation of simulation learning outcomes has great value in nursing education. This study focuses on simulation-based fever management module including checklist for febrile convulsion in pediatric nursing. Purposes: This study has two aims; (a) to develop a simulation-based fever management module for treating children with febrile convulsion, and (b) to evaluate students' performance and satisfaction. Participants: A convenient sample of 147 senior nursing students from two nursing schools in South Korea participated in this study from April 29 to June 14, 2013. Methods: This study was a three-stage process: developing the simulation-based module including algorithm with scenarios, items in checklist, and contents of debriefing (Stage I), performing simulation and debriefing for nursing students (Stage II), and evaluating the evaluation checklist of simulation performance and satisfaction of nursing students (Stage III). Student satisfaction was measured using the Satisfaction of Simulations Experience [SSE] scale. Debriefing data were analyzed using the Matrix Method. Results: A scenario script was created to treat the patient's health issues. The algorithm proceeded as follows: identification of patient's condition (Step I), nursing interventions (Step II), and outcome evaluation and feedback (Step III). The total mean score of the evaluation checklist was 2.67 (± .32). The debriefing categories were as follows: non-technical skills, self-efficacy, critical thinking, and technical skills. The total mean score of the SSE was 4.48 (±.42). Conclusion: This study provides a blueprint for simulation-based practice for both nursing educators and nursing students. Further studies of checklists used in different contexts would be valuable for expanding upon this research. © 2013 Elsevier Ltd. All rights reserved.
Introduction Background Over the past 10 years, simulation has been rapidly expanded in training for health care professionals; this provides many benefits (Nehring et al., 2001). It provides virtual experiences of situations frequently encountered in a clinical setting (Moule, 2011), affording opportunities for objective, detailed feedback on students' performance, and facilitating decision making (Jeffries and Norton, 2005; Jeffries, 2007; Roh et al., 2013). Also, simulation-based education gives students an opportunity to bridge the gap between academic and clinical settings, and learn core nursing skills through authentic and clinically relevant experiential learning (Cioffi, 2001). Another benefit is that it ⁎ Corresponding author at: Department of Nursing, Inje University, Bokjiro75, Busanjingu, Busan 614-735, South Korea. Tel.: +82 51 890 6833; fax: +82 51 896 9840. E-mail address: [email protected] (J. Oh). 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.11.008
encourages the development of competence of student nurses in a risk-free environment, which leads to improved self-confidence in performance (Cant and Cooper, 2010). Student performance evaluation is a very important step during simulation-based practice (Reed, 2010). Although a module may be well developed, a standardized evaluation checklist is essential for confirming the effectiveness of simulation-based practice. However, evaluation of simulation is not formalized and incorporated with complex theory (Murphy, 2013; Reed, 2010). There is also limited research in the use of simulation in nursing education and the evaluation of student competency (Reed, 2010). To enhance the effectiveness of simulations in nursing education, a reliable and valid evaluation instrument is needed to measure students' performance. Furthermore, a valid instrument is required for the simulation to be considered a formalized implementation and evaluation tool. Fever has been acknowledged as a one of the most common symptoms found in pediatric care units. Unlike adults, children can easily experience febrile convulsions if the fever is not controlled (Hockenberry,
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2005; Potts and Mandleco, 2011). Moreover, Walsh et al. (2006) suggested that nurses may even have “fever phobia,” or a fear of febrile seizures, and therefore provide inadequate fever management. Nursing management of fevers remains static (Poirier et al., 2000; Sarrell et al., 2002), and the incidence of fever-induced febrile convulsions in children supports this notion. Accordingly, simulation modules may help to provide a comprehensive understanding of fever and fever management. Furthermore, students' satisfaction with the simulation is important for meaningful learning and facilitating active participation (Prion, 2008). Finally, simulations provide the experience of nursing practice in a real clinical situation. Studies suggest that students' satisfaction may be correlated with performance (Bremner et al., 2006). Therefore, this study focuses on pediatric nursing education and nursing practice. Kolb (1984) emphasized that the individual learns through personal experiences or simulation to acquire knowledge, and the pondering on students' thoughts related to the experiential activity. This fever management module was developed based on Kolb's experiential learning model. The ability to manage fever of children is critical to the practice of nursing. Experiential learning is considered a strategy that increases to manage fever in students. Therefore, the following research issues were addressed: (a) to develop a simulation-based fever management module for pediatric febrile convulsions, and (b) to evaluate students' performances and satisfaction. IRB Approval Before conducting this study, approval was granted by the Hallym University's Institutional Review Board (HIRB-2013-013) where the primary researcher was affiliated; issues of voluntary participation, anonymity, and confidentiality were addressed. The researchers explained the study protocol to senior nursing students and informed consent was obtained. It explained the purpose of the study, the researchers' credentials, and information regarding confidentiality. It was stated that there would be no negative consequences for nonparticipation and that data would be reported as group data, not as individual. The data will be sealed and kept in the researchers' room and will be shredded after coding. The IRB confirmed that there were no elements to this study that would deprive human rights, and that all contents and processes conform to proper research ethics. Methods The development of the simulation-based fever management module and evaluation checklist for treating children with febrile convulsions was a three-stage process. Stage I: developing the simulationbased module; Stage II: developing programs for nursing students; and Stage III: evaluating the simulation-based module and validating the dimensions (Fig. 1). The module included an algorithm with the scenario, evaluation checklist, and debriefing plan. Process of a Simulation-based Fever Management Module Development For scenario development, we collected information on nursing care from child health nursing textbooks (Hockenberry, 2005; Potts and Mandleco, 2011) and nursing journals (Poirier et al., 2000; Sarrell et al., 2002; Walsh et al., 2006). Issues included signs and symptoms of fever, parents' lack of knowledge, anxiety, and dehydration related to the validity of the simulation evaluation by expert review. The scenario of a fifteen-month-old baby with febrile convulsion was based on a real febrile convulsion case that had occurred in a general hospital. Items and Scoring of the Evaluation Checklist The items were selected, reviewed, and analyzed by an eleven expert panel including two pediatricians, five pediatric nurses, and four child health nursing educators. The evaluation checklist focused on
Fig. 1. The development and evaluation of a simulation-based module.
the attainment of nursing goals based on nursing processes rather than outcomes. Finally, 3 items were deleted and 37 items reached by consensus (Table 1). The assessment category was divided into two subcategories: preparation and focus assessment. The preparation subcategory consisted of seven checkpoints, while the focus assessment subcategory consisted of eight checkpoints. Four problems were included in the identification category. The intervention category consisted of fourteen checkpoints, and the evaluation category consisted of four checkpoints (Table 1). The evaluation checklist score was based on a 4point Likert scale (1 = beginning, 2 = developing, 3 = accomplished, 4 = exemplary). The higher the evaluation checklist score, the better the performance. A content validity test was conducted with seventeen nurses who worked in a pediatric unit in one of the three general hospitals sampled; each had at least five years of experience in the unit. According to Lynn (1986), an expert panel ideally includes about ten people. Each expert checked validity using the 4-point Likert scale; 1 = not valid at all, 2 = not valid, 3 = valid, and 4 = very valid. There were 37 items in total; the mean score of each item ranged from 3.06 to 4.00. The results of the Content Validity Index were above 80% (Waltz and Bausell, 1981). Contents of the Debriefing The researchers developed the following debriefing questions: (a) What did you learn? (b) How did you feel? (c) What did you do? (d) What were your strong and weak points? These four questions for debriefing are based on the four steps of clinical judgment model (noticing, interpreting, responding, and reflecting) by Tanner (2006). After the simulation-based practice, students were asked to discuss their experience freely. It took about 20–30 min per group of three students. The nursing students were encouraged to reflect on their problem solving and critical thinking. Satisfaction With the Simulation Experience Students' satisfaction with the clinical simulation was measured just after finishing the debriefing session using the Satisfaction of Simulations Experience [SSE] scale developed by Levett-Jones et al. (2011). This scale consists of 18 items: debrief and reflection (9 items), clinical reasoning (5 items), and clinical learning (4 items). Each item was scored on a 5-point Likert scale. Higher scores indicated higher
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Table 1 Means of evaluation checklist items. N = 147. Category (M ± SD)
Items
M ± SD
Preparation Assessment (2.26 ± .53) Critical thinking (2.35 ± .37)
1. Washing hands 2. Prepare needed materials 3. Introducing self to the patient & his/her parent(s) 4. Identify patient by name card and/or bracelet 5. Support parent(s) 6. Identify medical appliances belonging to patient 7. Identify past history Focus 1. Check the chief complaint assessment 2. Identify symptoms related to chief complaint 1) Inspection: skin color, warmth, perspiration, pallor, chilling (2.43 ± .36) 2) Palpitation: cold extremities 3) Vital signs: temperature, pulse, respiration 4) Other symptoms besides fever 5) Dehydration signs: diminished urine output, skin turgor, level of capillary compensation, activity level, dehydrated lip & mucus of mouth, sunken eye(s), absent tears 6) Febrile convulsion symptoms: consciousness level, drooling saliva, appearance of bubbles around mouth, deviation of eyeball, rigid extremity, bending knees & elbows 7) Check pulse, cardiorespiratory monitoring equipment Nursing problems: Identifies nursing problems Problem identification 1) Potential physical injury related to inability of airway patency Critical thinking 2) Hyperthermia (2.94 ± .46) 3) Fluid & electrolyte imbalance 4) Parent(s)'s anxiety related to lack of knowledge about child's current condition 1. Airway maintenance Interventions 2. Notify doctor & receive treatment order if needed Critical thinking (priority 3. Administration of O2 therapy interventions) (2.89 ± .40) 1) Explain to the parent(s) the purpose and method of O2 therapy 2) Attach the oxymeter, which is filled with sterile water, to the instrument and the connect O2 mask 3) Check that O2 is flowing and administer O2 supply as ordered 4. Preparation of prescribed medications (antipyretics, IV fluids) 5. Nursing care for temperature control 1) Administer prescribed antipyretics 2) Remove the child's clothes and then provide warm bath 3) Educate parent(s) about tepid massage 4) Lower the room temperature 6. Check vital signs repeatedly, SaO2, EKG monitoring, consciousness level, & dehydration signs 7. Provide comfortable resting environment 8. Explain child's present condition & care to the parent(s) 9. Record the nursing implementations 1. Check normal range of body temperature & vital signs Evaluations 2. Check SaO2 & level of consciousness Critical thinking (2.82 ± .56) 3. Check recurrence of febrile convulsion 4. Improve parents' understanding about therapy & anxiety Total
2.07 2.27 1.94 2.13 3.21 2.17 2.01 2.80
± ± ± ± ± ± ± ±
1.26 .99 1.18 1.06 .54 .77 1.17 .65
2.04 1.62 3.61 1.71 1.63
± ± ± ± ±
.60 .58 .46 .72 .50
2.46 ± .81 3.60 ± .54 3.73 2.07 3.27 2.71 2.36 3.62
± ± ± ± ± ±
.75 1.39 1.01 1.30 1.17 .57
2.47 3.22 2.47 3.57
± ± ± ±
.32 .82 .88 .57
3.67 3.48 3.00 1.27 2.66 1.84 3.30 3.58 3.36 3.06 1.97 2.89 1.67
± ± ± ± ± ± ± ± ± ± ± ± ±
.63 .75 1.00 .77 .60 .65 .67 .55 .70 .72 .76 .88 .32
Note: Likert scale ratings as follows: 1 (not implemented), 2 (improperly implemented), 3 (properly implemented—properly, average), and 4 (exemplary).
satisfaction. Cronbach's alpha coefficient was .78 in the original study, and .94 in this study. Population The target population for this study included undergraduate students. One hundred forty-seven nursing students were selected from two universities located in Seoul, South Korea. The inclusion criteria to attain homogeneity included (a) senior nursing students, (b) completion of fundamental and child health nursing courses with the same credits and textbook, and (c) no prior participation in a simulation class focused on febrile convulsion.
Before the simulation, students received an orientation that included how to operate the simulator and the scenario information, including past history, chief complaints, and present conditions related to health status. The simulations were scheduled in simulation rooms in which the high-fidelity patient simulators were used. Three nursing students were engaged in the simulation at the same time. One operator and one instructor observed the simulations from the control room. Each simulation lasted 20–30 min, with both the simulation and simulation class taking about 2 h per group. Their performance was evaluated as a group. The evaluation checklist was handed to an instructor in a sealed envelope. Students were asked to wear uniforms and to treat these as actual professional situations. In addition, an SSE was used to measure student satisfaction with the simulation.
Data Collection Procedure Data Analysis Method Data were collected from April 29, 2013 to June 14, 2013. The study's purpose and its procedures, as well as information regarding confidentiality, were explained to the participants prior to obtaining informed consent. All participants enrolled in this study voluntarily and anonymously. In addition, participants were made aware that there was no disadvantage to nonparticipation, and that data would be reported as a whole and not individually. The ratio of participation was 96.1%.
Collected data were analyzed using SPSS 18.0 for Windows to calculate descriptive statistics including means and standard deviations for the evaluation checklist and the SSE. Debriefing data were analyzed using the Matrix Method (Garrad, 2007). All papers and other materials were photocopied and organized as a review matrix that, once labeled appropriately, would serve as a structured abstract of all of the
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documents. The 3Cs (i.e., codes, categories, and concepts) of analysis was used to capture key characteristics of interest, thereby summarizing a large amount of textual information into meaningful themes (Lichtman, 2006). Results Algorithm With a Scenario of Simulation-based Fever Management A scenario script was formulated to resolve the patient's health problem. The algorithm proceeded as follows: identification of patients' condition (Step I), nursing intervention (Step II), and outcome evaluation and feedback (Step III) (Fig. 2). Internal Consistency, Reliability, and Correlation Matrix of the Evaluation Checklist Before conducting the simulations, evaluators had an opportunity to practice evaluation. To reach co-incidence between evaluators, we evaluated each of them twice by direct observation and video record screening. To test the internal consistency and reliability of the evaluation checklist and each subscale, Cronbach's alpha coefficient was measured. This process evaluated the items within the checklist and removed repetitive items. Cronbach's alpha for the evaluation checklist was .87; each subcategory ranged from .71 to .81. We examined the correlation matrix of the evaluation checklist for items with higher (greater than 0.9) or lower (less than 0.4) correlations. Examination of the correlation
matrix for the evaluation checklist resulted in no coefficients greater than 0.9 and no coefficients less than 0.4. Evaluation Checklist The evaluation checklist consisted of four categories based on nursing processes: assessment, problem identification, intervention, and evaluations. The mean score of each category is shown in Table 1. The total mean score of the evaluation checklist was 2.67 (±.32). The mean score of each category was as follows: assessment, 2.35 (±.37); problem identification, 2.94 (±.46); intervention, 2.89 (±.40); and evaluation, 2.82 (±.56). Debriefing Students' comments were grouped into thirteen subcategories following content analysis using the Matrix Method (Table 2). The categories were as follows: non-technical skill (30.7%), self-efficacy (29.8%), critical thinking (21.8%), and technical skill (17.8%). The most frequent categories, in order, were teamwork and collaboration (n = 27), reflection (n = 26), situation recognition (n = 21), core nursing skills (n = 21), emotional support (n = 21), and therapeutic communication (n = 21). Satisfaction With Simulation Experience After debriefing, the students evaluated their satisfaction with the simulation using the SSE scale. The total mean score of SSE was 4.48
Fig. 2. Algorithm with scenario of simulation-based fever management. Note: CBT; cognitive behavior therapy, IV; intravenous, D/S; dextrose saline, IM; intermuscular.
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Table 2 Content analysis of debriefing. N = 147. Categories
n (%)
Subcategory
n (%)
Contents
n
Critical thinking [CT]
49 (21.8)
Situation recognition
21 (42.9)
Decision making
16 (32.6)
Evidence searching
12 (24.5)
Core nursing skill
21 (52.5)
Skilled technique
11 (27.5)
▸Accurate assessment is required. ▸Integrative assessment is necessary. ▸The ability to predict situation is needed. ▸Continuous monitoring is required. ▸Critical thinking is important. ▸Nursing priority should be considered. ▸Procedure is needed step by step. ▸Accurate knowledge of the disease is necessary. ▸Theoretical evidence of nursing care is important. ▸Convulsion/fever control was learned. ▸Fundamental nursing skill was learned. ▸Prompt treatment is required. ▸Accurate nursing skill is needed. ▸Competent nursing skill is essential. ▸Drugs for febrile convulsion were learned. ▸Exact medication method was learned. ▸Action of drugs was understood. ▸Opportunity for empathic nursing intervention. ▸Good rapport with child guardian is needed. ▸Understanding patient's emotional status is considered. ▸Therapeutic environment is needed. ▸Considering patient's present condition is needed. ▸Using therapeutic communication with the person is required. ▸Parent education is needed. ▸Collaborative communication between medical personnel is needed. ▸Teamwork is important. ▸It is important to do one's own role faithfully. ▸Accurate notification to doctor is important. ▸There is a gap between theory and reality. ▸It became an indirect experience like real-life. ▸Feedback process was helpful. ▸I knew my weakness. ▸I felt embarrassment and burdened. ▸Self-led learning is needed. ▸Repeated exercise is important. ▸Preview using open-laboratory hours is needed. ▸Independent nursing care is required. ▸Responsibility about nursing care is essential. ▸Leadership is important. ▸It was a chance to become self-confidence. ▸It was a chance to think like a nurse.
6 8 3 4 5 6 5 7 5 8 13 3 6 2 3 3 2 4 8 7 2 3 12 6 6 4 5 12 4 9 7 12 7 3 6 9 2 2 2 3 1
Technical skill [TS]
40 (17.8)
Medication management
Non-technical skill [NTS]
Self-efficacy [SE]
69 (30.7)
67 (29.8)
8 (20.0)
Emotional support
21 (30.4)
Therapeutic communication
21 (30.4)
Teamwork and collaboration
27 (39.1)
Presence
13 (19.4)
Reflection
26 (38.8)
Motivation
18 (26.9)
Professionalism
10 (14.9)
Note: After multiple responses, number of statements is 225.
(±.42). The mean score for debrief and reflection was 4.55 (±.43), clinical reasoning was 4.39 (±.50), and clinical learning was 4.43 (±.48) (Table 3).
Table 3 The degree of Satisfaction with Simulation Experience [SSE]. Items
M ± SD
Debrief and reflection The facilitator provided constructive criticism during the debriefing The facilitator summarized important issues during the debriefing I had the opportunity to reflect on and discuss my performance during the debriefing The debriefing provided an opportunity to ask questions The facilitator provided feedback that helped me to develop my clinical reasoning skills Reflecting on and discussing the simulation enhanced my learning The facilitator's questions helped me to learn I received feedback during the debriefing that helped me to learn The facilitator made me feel comfortable and at ease during the debriefing Clinical reasoning The simulation developed my clinical reasoning skills The simulation developed my clinical decision making ability The simulation enabled me to demonstrate my clinical reasoning skills The simulation helped me to recognize patient deterioration early This was a valuable learning experience Clinical learning The simulation caused me to reflect on my clinical ability The simulation tested my clinical ability The simulation helped me to apply what I learned from the case study The simulation helped me to recognize my clinical strengths and weaknesses Total
4.55 4.58 4.67 4.51
± ± ± ±
.43 .50 .50 .55
4.46 ± .63 4.50 ± .58 4.55 4.58 4.63 4.48
± ± ± ±
.58 .54 .52 .64
4.39 4.37 4.37 4.32 4.27 4.62 4.43 4.45 4.37 4.30 4.61
± ± ± ± ± ± ± ± ± ± ±
.50 .61 .62 .67 .72 .50 .48 .60 .65 .69 .52
4.48 ± .42
Discussion Simulation is recognized as an innovative pedagogic approach to expand teaching and education (Moule, 2011). Nurse educators are interested in the value and effectiveness of the simulation-based nursing module using the human patient simulator (McCaughey and Traynor, 2010). To ensure that nursing students can respond to changing needs in today's complex health care system, nursing education must be guided by standards of competency and the expectations of professional nursing organizations (Oh et al., 2012). The limited time spent in clinical placements poses a challenge to nursing education; this also limits students' opportunity to practice direct nursing care with patients. The increase in new nursing schools and the shortage of clinical settings for nursing practicum combined with the emphasis on human rights and patient safety in Korea expand the need for simulation-based learning (Hyun et al., 2009; Suh et al., 2009). In this study, a simulation-based fever management module was developed and evaluated. Development of the Simulation-based Module Many nursing educators are interested in simulation, but they have access to only a few clinical scenarios with little time to develop more.
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Murphy (2013) reported that only approximately 20% of the faculties were well trained in simulation instruction. In this study, the development of the simulation-based module was the first step toward solving the nursing problems associated with caring for febrile convulsions in pediatric patients. The module included clinical scenarios that provided vivid, realistic situations without risk to the patient. The evaluation checklist was validated by expert panels and consisted of four nursing processes: assessment, problem identification, intervention, and evaluation. Moule (2011) reported that simulation improves students' competencies in preparation for clinical settings. Fever management is an integral aspect of pediatric nursing practice. Walsh et al. (2006) reported that a lack of knowledge about fever and fever management might result in inadequate treatment in children. Fever management requires a thorough knowledge of fever and the febrile response, based on a thorough assessment of the patient. Among the evaluation categories, problem identification ranked first, with a mean score of 2.94 (± .46). Based on this result, students identified the nursing problems that patients have experienced. The intervention category examined students' critical thinking, as well as their knowledge and skills in proper nursing care. Costello (2011) also reported that simulation-based learning is an excellent instruction method that allows students to practice their drug dosage calculation skills in a safe manner, without fear of injury to the patients. The evaluation category, which fully implements high-fidelity simulations, offers information to nursing educators about students' learning outcomes. The use of simulations to evaluate clinical ability provides a more direct correlation to actual clinical settings than other commonly used forms of evaluation. The evaluation indicated that the focus was on performance rather than learning. The study's evaluation checklist would also be a useful and established guide for nursing educators evaluating student performance through simulations. This checklist describes the overall evaluation process and clarifies the evaluation's target subject and procedure. This encourages students to repeat checkpoint reviews, leading to the correction of earlier mistakes. The effect of reviewing past checkpoints creates an integrative, rather than a static learning experience (Reed, 2010). The previous literature regarding simulation evaluation tools did not report reliability or validity. In this study, a reliable and valid instrument was developed, and internal consistency was measured with Cronbach's alpha coefficient.
Evaluation of the Simulation-based Module Debriefing after clinical simulation is an integral component of the simulation experience, as it promotes critical thinking and reflection in students (Murphy, 2013). Debriefing sessions give students the opportunity to discuss various aspects of care provided during the simulations, and requires them to actively participate in patient care, decision-making, skilled techniques, and patient-care responsibility (Hockenberry, 2005). During debriefing sessions, nursing educators should provide constructive, non-judgmental feedback to the students in order to facilitate therapeutic communication and affirm students' emotions and feelings (Jeffries, 2007). Content analysis results from students' open-ended comments during the debriefing session were meaningful. Students in this study acknowledged the importance of effective communication in teamwork and collaboration, reflected on their experiences and valuable feedback, recognized and accurately assessed the situation, grasped core nursing skills with a hands-on learning approach, formulated a rapport with emotional support, and promoted therapeutic communication between patients and their parents. Students realized that the “team approach” should be included in every clinical practice experience. Exposure to simulation-based nursing care using human patient simulators can provide students with experiential learning that may be absent in diminishing traditional clinical placements (Gillan et al., 2012). Both
our study and previous studies have highlighted the importance of applying simulation-based practice in nursing education. Many studies have reported high satisfaction with simulation experiences (Abdo and Ravert, 2006; Bremner et al., 2006; Levett-Jones et al., 2011; Schoening et al., 2006). Roh et al. (2013) also reported that nurses who participated in simulation-based resuscitation training showed favorable, positive self-efficacy and satisfaction. The total mean SSE score (4.8 ± .42) in this study was slightly higher than that found by LevettJones and colleagues (4.47 ± .36) (2011). Comparing the mean scores of our subcategories with those of Levett-Jones and colleagues, our results (debriefing and reflection: 4.55 ± .43; clinical learning: 4.43 ± .48; and clinical reasoning: 4.39 ± .50) and theirs (clinical learning: 4.53 ± .16; debrief and reflection: 4.46 ± .08; and clinical reasoning: 4.35 ± .09) were similar (Levett-Jones et al., 2011). These students learned to manage a pediatric health issue in a safe learning environment, and these results demonstrate the need for simulations in nursing education (Berragan, 2011). They promote powerful teaching and learning strategies, active and experiential learning, creative thinking, and high-level problem solving (Bland et al., 2011). This module provided a strong connection between the learners and the clinical scenario of a febrile convulsion, helping the students clarify their experiences and reflection according to Kolb's (1984) experiential learning model. The simulation module allowed students to better understand the experiences of the febrile infant caring they may encounter during their clinical practice. In the next step we will be able to better understand what patients and their families might have experienced, and further increase their level of empathy with a standard patient. Moreover, the next step is also to research and develop modules related to varying health problems in order to meet educational needs. The simulation-based fever management module can promote innovative nursing care and improve students' fever management practice. This simulation-based learning enabled students to communicate with and care for children experiencing febrile convulsions and provide better clinical care. Conclusion Simulation-based learning is expected to increase in nursing education because it is an educational tool that accurately recreates real clinical settings. Simulation-based educational modules for nursing students should target students' needs and focus on clinical relevant situations that students may frequently encounter. This study was able to develop more reliable algorithms and evaluation tools for fever management in nursing care. This study identified a nursing care module for children with febrile convulsions. The implications for nursing education include determining how nursing students care for patients using critical thinking and nursing skills. This study also provides a blueprint for simulationbased practice for both nursing educators and nursing students. Furthermore, this study recommends developing an evaluation checklist for other nursing education programs. A large sample size in more than one geographic location will provide valid and reliable data for this module and the evaluation checklist. In addition, this study highlights the need for the full integration of simulations into nursing curricula. Financial support None. Conflict of interest Neither of the authors has any actual or potential of interest including any financial, personal, or other relationships with other people or organization that could inappropriately influence or be perceived to influence this work.
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