545134 research-article2014
WJNXXX10.1177/0193945914545134Western Journal of Nursing ResearchTubaishat and Tawalbeh
Intervention Studies
Effect of Cardiac Arrhythmia Simulation on Nursing Students’ Knowledge Acquisition and Retention
Western Journal of Nursing Research 2015, Vol. 37(9) 1160–1174 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0193945914545134 wjn.sagepub.com
Ahmad Tubaishat1 and Loai I. Tawalbeh1
Abstract The realistic and practical environment that simulation provides is an extremely useful part of the teaching process. Simulation is widely used in health and nursing education today. This study aims to evaluate the effect of simulation-based teaching on the acquisition and retention of arrhythmiarelated knowledge among nursing students. A randomized controlled design involving a pretest–posttest was used. Nursing students were allocated randomly either to the experimental group (n = 47), who attended simulation scenarios on cardiac arrhythmia, or to the control group (n = 44) who received a traditional lecture on the same topic. A paired t test showed that the mean knowledge score at the posttest was significantly higher than at the pretest for both groups. However, participants in the experimental group demonstrated significantly increased knowledge of cardiac arrhythmia in the first and the second posttest compared with those in the control group. Thus, simulation is superior and significantly improves students’ arrhythmia knowledge. Keywords simulation, teaching, arrhythmia, nursing students, Jordan 1Al
al-Bayt University, Mafraq, Jordan
Corresponding Author: Ahmad Tubaishat, Faculty of Nursing, Al al-Bayt University, P.O. Box 130040, Mafraq 25113, Jordan. Email: [email protected]
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High-quality education in nursing is needed whether it is delivered in the classroom or in clinical settings. However, there are challenges associated with both learning contexts. In the classroom, the main limitations are the large number of enrolled students and the limited time available, whereas in the clinical areas, the major challenges are an occasional lack of patients and a shortage of clinical training sites (Zulkosky, 2012). In effort to minimize the impact of these challenges, and to prepare competent nurses; educators in the field of nursing should incorporate technology to enhance the teaching and learning process (Arnold, Johnson, Tucker, Chesak, & Dierkhising, 2013). One of the latest technological innovations is the use of simulation in learning (Zulkosky, 2012). Simulation involves the use of devices and monitors that have a control on a simulated patient, which can respond accurately to actions taken by the simulation user (Gaba, 2007). It is now widespread in health care and nursing education, and it has proved to be an effective teaching method (DeVita, Schaefer, Lutz, Dongilli, & Wang, 2004; Mayo, Hackney, Mueck, Ribaudo, & Schneider, 2004; Seropian, Brown, Gavilanes, & Driggers, 2004). The use of simulation can offer an interactive learner-focused environment, which can be used to teach cognitive, psychomotor, and affective skills or to convey knowledge (Cumin & Merry, 2007). Moreover, it can be extended to cover a whole range of nursing situations, from simple to complex, in many specialism, such as critical care, pediatrics, obstetrics, mental health, and community (Arnold et al., 2013). One of the available applications of simulation is for improving electrocardiogram (ECG) interpretation skills and the management of ECG arrhythmias (Mueller et al., 2005). In other words, life threatening cardiac arrhythmias can be simulated on a lifelike fully computerized mannequin (Morgan, Cleave-Hogg, Desousa, & Lam-McCulloch, 2006). It has been reported by Salerno, Alguire, and Waxman (2003) that to master the skills of ECG interpretation, a combination of knowledge, skills, and clinical practice are needed. Simulation can provide this experience as students can visually observe accurate pathophysiological changes for certain arrhythmias, and the response to a therapy or intervention (Mueller et al., 2005). Very few studies have been conducted to date to evaluate the effectiveness of simulation on improving knowledge of ECG and arrhythmia. Interestingly, most of those that were located during a literature search were found to have used the descriptive design. In a study by Sumner, Chang, Jones, Burke, and McAdams (2012), a sample of 138 registered nurses were asked to complete a pretest before attending a session on simulated arrhythmia, then they were asked to complete a posttest. The results of this descriptive study showed that there was a significant difference (p < .01) in the pre- and posttest scores (Sumner et al., 2012).
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This positive finding was supported by another study conducted by Brown (2008), which was carried out to investigate critical care nurses and nursing students’ ability to identify ECG arrhythmia and its treatment. Participants were exposed to simulated scenarios that mimicked real patients’ situations, and the participants were asked for quick recognition and response. Subjects were asked to complete a measurement tool to assess their ECG-related knowledge both pre- and post-simulation. It was found that the postsimulation knowledge mean scores were significantly higher than the mean pre-simulation scores (Brown, 2008). The field of simulation education has been explored in regard to a number of specialties other than nursing. The impact of simulation on physiotherapy students’ confidence and ability to interpret ECGs, and to make decisions based on their ECG interpretations, was investigated (Smith, Prybylo, & Conner-Kerr, 2012). A summative practical exam using the simulator was set to evaluate ECG knowledge. The findings revealed that 100% of students correctly identified the ECG rhythms and made correct clinical treatment decisions. Undergraduate medical students were the target of a study conducted to evaluate the use of simulator on a drug therapy course (Mueller et al., 2005). A total of 234 students were randomly allocated into an experimental group, who received simulation education, and a control group, who attended a traditional lecture on antiarrhythmic drugs. The participants in the simulation group considered the simulator to be a helpful and effective teaching tool. At the other extreme, Talwar, Arora, and Tamang (2012) conducted a study in a hospital in India to evaluate the effectiveness of simulation on staff nurses’ (n = 30) knowledge and skills of arrhythmia interpretation using a pretest–posttest design; and proved the opposite. The results showed that there was no significant difference in the nurses’ pre- and posttest knowledge and skills regarding the management of dysrhythmias before and after simulation. However, a small sample size used may distort any obtainable conclusion. Arrhythmias studies are not the only concern in simulation research. Other studies focused on other areas and skills. The impact of simulation on acute care assessment and management skills amide 31 medical students was examined using a randomized controlled trial (Steadman et al., 2006). The findings of this study showed that simulation has a significant effect on acute assessment and management skills and it was superior to problem-based learning in enhancing the assessment and the skills. Furthermore, a quasiexperimental study was conducted to measure the impact of simulation on confidence, knowledge, and satisfaction with physical assessment skills for 29 nursing students (Tiffen, Graf, & Corbridge, 2009). The 15 students in the
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experimental group exhibit significant enhancement in the knowledge of physical assessment skills compared with those in the control group. In Jordan, no study has been located about the effect of simulation on cardiac arrhythmia knowledge. However, one study was identified that examined the effect of simulation on Basic Life Support (BLS) knowledge acquisition and retention among nursing students (Akhu-Zaheya, Gharaibeh, & Alostaz, 2013). A quasi-experimental design was used by allocating students into an experimental group (n = 52) who received traditional teaching on BLS (a standard lecture and demonstration on a static manikin) and simulation, and a control group (n = 58) who received only traditional teaching on BLS (a standard lecture and demonstration on a static manikin). The results showed no significant differences in the knowledge scores between the experimental and the control group. The fact that there has been a lack of such studies in Jordan and worldwide motivated the present work. Also, a systemic review conducted in 2009 stressed the need for more studies to explore the effectiveness of simulation for enhancing students’ learning (Kaakinen & Arwood, 2009). Thus, the current study was conducted in Jordan (a) to examine the effect of a simulationbased teaching program on nursing students’ knowledge about the interpretation and management of cardiac arrhythmias using a well-controlled experimental design, and (b) to assess their knowledge retention over time. Jeffries’ Simulation Model was used to guide the current study (Jeffries, 2005). This model comprises connected relationships between the teacher, student, and educational practices. The latter in this study incorporated into a high-fidelity simulation educational strategy that could affect the students outcomes of learning in term of knowledge, skills, critical thinking, satisfaction, and confidence gained. Thus, two important components are necessary in this model; the simulation as learning strategies and its outcomes on the learner (Jeffries, 2005). According to Jeffries (2005), the well-designed simulation should have a number of characteristics including objectives, fidelity, problem solving, student support, and reflection. The objectives of simulation teaching should be clearly outlined. In this study, the students receive written and oral objectives of this simulation experience to guide their learning. Fidelity of simulation mimics reality to enhance learning outcomes. A programmed high-fidelity simulation doll that mimic physiological responses to certain arrhythmias was used. The problem solving depends on the students’ ability to recognize and manage the presented arrhythmias with appropriate interventions. The students support element occurs through the use of prompts or hints during the scenario to reach the appropriate clinical judgment. The last characteristics is the reflection, which usually occurs at the end of the simulation
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scenario; where in the current work, the instructor give a debriefing session after each scenario for 10 min to encourage students to think in depth on the learning activity and to link theory to practice. The outcome that is the last component of this model may contain knowledge, skills, critical thinking, satisfaction, and confidence (Jeffries, 2005). The aim of using the simulation in this work was to show the greater knowledge was gained from simulation compared with other teaching strategies (i.e., conventional lecture). In summary, Jeffries’s (2005) Simulation Model was a valuable empirically supported model to guide the current research on the design and implementation of simulation in an organized and systematic manner.
Method Design A randomized controlled design was used, where the pretest–posttest experiment was utilized to evaluate the effect of simulation on students’ knowledge of arrhythmia. The students were randomly selected and then randomly allocated either to the experimental or control group.
Setting This study was conducted in the School of Nursing of one public university in Jordan. This School offers the bachelor’s degree of nursing on completion of a 4-year program. It comprised several classrooms equipped with desktop computers, and a data show projector for lecture presentations. There were nine laboratory rooms fitted with the required equipments used to improve the students’ clinical skills. In addition, there were two simulation laboratory rooms supplied with pediatric and adult manikins, monitors, computers, and other important equipment.
Sample and Sampling Procedures A simple random sampling technique was used to select the nursing students who would take part in this study. A list containing all students in the School was obtained from the academic registry. Subsequently, a sample of nursing students was randomly chosen using a computer generated list. The inclusion criteria for the subjects were (a) any nursing student regardless their level in the school as long as did not attend any critical care course previously, and (b) that they agreed to participate.
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The sample size was calculated using G* power software (Faul, Erdfelder, Lang, & Buchner, 2007). For the purpose of this work, a medium effect size was needed, which is 0.50. The sample size was decided based on the power level, which is 0.80, and the use of usual α = 0.05 two-tailed criterion of the significance. Consequently, 70 students were required. An extra 30 students were added to this number to overcome the attrition problem, giving a final sample of 100 students. Those students were randomly allocated either to the experimental group (n = 50) or the control group (n = 50).
Data Collection Procedure After permission was gained from the Institution Review Board, the study commenced. Students were asked to provide brief demographical data before a pretest about cardiac arrhythmia knowledge was set for both groups. After that, students in the control group received a traditional lecture about cardiac arrhythmia interpretation and management. The experimental group observed virtual simulation scenarios, each lasting approximately 20 min, on the same topic. After both sessions ended, a posttest involving the arrhythmia written examination was set for both groups. The pretest, education, and posttest followed one after another, first for the control group on one particular day, and then for the experimental group the following day. In each case, the teaching was delivered by the same instructor; the primary researcher. All data were collected and analyzed by the primary researcher as well. Students who completed the pretest did not know their group assignments, but the researcher knew the groups in which they were included. The students were informed of their groups before the start of teaching, thus students were not aware of each other. Each student in both groups was given an ID number to anonymize their participation and protect the confidentiality of their data. A second posttest was performed 3 months after the first posttest for both the experimental and control group to examine knowledge retention. No sharing between students in the control and experimental group was occurred. Figure 1 simplifies the data collection procedures and phases. The study method and protocol was reviewed and approved by the Institutional Review Board. Verbal and written information about the study’s aims and procedures was given and all participants who agreed to participate granted their informed consent. Furthermore, the completed questionnaires were held in a locked cabinet for the purposes of data privacy. Participation in this study was completely voluntary and students were informed that they had the right to withdraw from the study at any stage without penalty. Students were also informed that data would be collected from them on three occasions; once before the education was delivered, and twice afterward. After the
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Faculty of Nursing (n=650 students)
Random selection n=100 Random assignment
Acquisition phase (same day)
Retention phase (after 3 months)
Control group n= 50 pretest knowledge
Experimental group n= 50 pretest knowledge
Traditional lecture n=50
Simulation scenario n=50
First posttest n=47
First posttest n=44
Second posttest n=43 Retention
Second posttest n=42 Retention
Figure 1. Data collection procedures and phases.
study was ended, all questionnaires were disposed off. The students were not subject to any physical, psychological, or economic harm, as the data collection procedures depended solely on a non-invasive questionnaire. No credits were awarded for students’ participation. Control group (traditional lecture). Students were presented with a PowerPoint presentation about ECG, starting with basic concepts such as waves, intervals, and heart rate calculation, and then a discussion of the most common arrhythmias suffered by patients in the hospitals. The arrhythmias were displayed onto a projector screen and a discussion about these ECG strips occurred between the students and the primary researcher in an effort to analyze the ECG strips and diagnose them. Then, the appropriate intervention for the presented arrhythmias was discussed, without there being an opportunity
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to apply these interventions directly to a patient, such as in the case of the experimental group (see below). A total of 50 students were enrolled in this session which lasted about 2 hr, was held in one of the School classrooms, and was given by a primary researcher. The contents of the educational lecture were drawn from critical care nursing textbooks (Huff, 2006; Morton, Fontaine, Hudak, & Gallo, 2005). Some Internet resources like the American Heart Association (AHA; 2010) website were consulted as well. The content of the lecture was pilot tested by a team of experts from academic and clinical backgrounds and, as a result, a number of amendments were made to the teaching and assessment methods used. Experimental group (simulation). A high-fidelity simulator (METI Version 6), with many features such as blood pressure measurement, pulse palpation, ECG, chest expansion, and simulator voice, was used. The simulator mannequin responds in a precise way to an induced pharmacological or physiological intervention. In addition, the “patient” has the capability to talk, move his arm, and open and close his eyes. Students were presented with normal ECG rhythms, which were dynamic and displayed on a monitor, and which represented patient conditions. All waves, intervals, and segments were illustrated to students. Subsequently, a group of scenarios that had already been uploaded to the METI software and that demonstrated some cardiac arrhythmias were presented on the machine monitor. Each scenario lasted approximately 20 min. The primary researcher led a discussion with the students in an effort to encourage them to identify the arrhythmias, and suggest appropriate interventions, including drugs or the use of a defibrillator or a pacemaker. Students were advised to click on the appropriate intervention on the simulator computer and the effect was projected live onto the monitor screen, and onto the “patient.” The same arrhythmias that were presented to the control group were also presented for students in the experimental group. The difference was that in the control group, the students could only suggest an appropriate intervention during the discussion with the primary researcher, whereas in the experimental group, students could apply the relevant intervention by giving an order to the simulator computer and the effect could be observed on both the monitor and on the “patient” directly, as the ECG rhythm could change in response to the treatment that the students chose to administer. Thus, students saw the results appear live as they would on a real patient. Fifty students who were involved in the simulation experience were divided into groups of seven to eight students for demonstration purposes. A debriefing session, which lasted about 10 min, was held after each scenario, to discuss and focus on points which may have arisen during the scenario.
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Instrument. A structured questionnaire was used to collect the data. It started with a concise statement about the aim of the study and a formal request for consent, followed by three main sections. Section 1 was designed to gather demographic data, including age, gender, and grade point average (GPA). The second section was the arrhythmia written examination containing 20 multiple-choice questions on interval and heart rate calculation, rhythm identification, and rhythm management. The questions were adapted from several sources such as associated academic literature, textbooks, Internet resources, and the AHA (2010). Four experts in ECG assessed the face validity and indicated that the instrument was valid. The content validity was assessed by another two experts in ECG and two PhD-qualified nurses. The content validity index was 0.89, confirming that the instrument measured what it was supposed to measure. Following this, it was pilot tested on 10 students to assess the clarity of the questions and instructions, and the time required to complete the questionnaire. Some minor modifications were made based on written feedback received from participants. The scale items were tested for internal consistency in the present study, and the Cronbach’s alpha reliability was .84. The same knowledge test was used in the pretest and the two posttests. Arrhythmia knowledge scores were calculated by correct/incorrect responses. As there were 20 questions, the scores would range from 0 to 20, with higher scores indicating a higher level of knowledge. The mean arrhythmia knowledge scores were calculated for analysis, by comparing the difference of the mean between the experimental and control groups.
Data Analysis The Statistical Package for Social Science (SPSS) Version 17 was used to analyze the data. The sample’s characteristics were described using descriptive statistics. To assess the homogeneity of the sample at the baseline, the independent t test was utilized to test whether there were significant differences between the experimental and the control group at the pretest. The same test was used to examine whether there were statistically significant differences between the experimental and control group in the mean scores of arrhythmia knowledge. To assess whether there was a significant difference between the mean pre- and posttest scores of arrhythmia knowledge for the experimental and control group, the paired t test was used.
Results The study sample was distributed almost equally between both genders (female = 56, male = 44). The mean age for the whole sample was 20.4
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Table 1. An Independent t Test to Compare Arrhythmia Knowledge Between Experimental and Control Group at Baseline, First Posttest, and Second Posttest. Variable Pretest of arrhythmia knowledge (baseline) First posttest (knowledge acquisition) Second posttest (knowledge retention) *p
Experimental Group, M (SD)
Control Group, M (SD)
t Test
6.2 (2.78)
5.7 (2.43)
−4.59
13.2 (3.35)
7.6 (2.36)
−7.11**
12.2 (3.81)
7.2 (2.79)
−4.72**
≤ .05 level (two-tailed). **p ≤ .001 level (two-tailed).
(SD = 0.98), and the mean GPA was 67.9 (SD = 5.42) at the baseline. The experimental and control groups were homogeneous. There was no statistically significance difference between the groups regarding age (p = .20), and GPA (p = .63) as indicated by the results of the independent-sample t test. No significant difference was found as well in the pretest knowledge of arrhythmia as shown in Table 1. A total of 91 students completed the first posttest with 47 (51.6%) students in the control group and 44 (48.4%) in the experimental group. The results of the independent t test confirmed that there was a statistically significant difference, t(88) = −7.11, p < .001, between the experimental group (M = 13.2, SD = 3.35) and the control group (M = 7.6, SD = 2.36) on the topic of arrhythmia knowledge (Table 1). Three months later, the retention phase started, in which 85 students completed the second posttest. For a second time, the difference between the experimental group (M = 12.2, SD = 3.81) and the control group (M = 7.2, SD = 2.79) concerning arrhythmia knowledge was significant, as proved by the results of the independent t test, t(84) = −4.72, p < .001 (Table 1). To compare the results of the pre- and posttest for each group, a paired t test was used. The findings demonstrated that mean scores for arrhythmia knowledge at the posttest were significantly higher than those at the pretest for both the experimental and the control groups (Table 2). This suggests that the subjects’ knowledge of cardiac arrhythmia was significantly enhanced after the provision of both types of teaching; the simulation in the experimental group or the traditional training in the control group. However, the results presented in Table 1 confirmed that simulation-based teaching is more effective than the traditional method of education in improving arrhythmia knowledge.
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Table 2. Paired t Test to Compare Arrhythmia Knowledge in the Pre- and Posttest of Both Groups.
Variable
Pretest, M (SD)
Experimental 6.2 (2.78) group Control 5.7 (2.43) group *p
First Posttest, M (SD)
Second Posttest, M (SD)
13.2 (3.35)
12.2 (3.81)
−5.94**
−5.14**
7.6 (2.36)
7.2 (2.79)
−5.03**
−4.93**
t(39) (Pretest t(41) (Pretest and First and Second Posttest) Posttest)
≤ .05 level (two-tailed). **p ≤ .001 level (two-tailed).
Discussion This experimental study aimed to examine the effect of simulation-based teaching on cardiac arrhythmia knowledge acquisition and retention. The results demonstrated that students in the experimental group who were subject to simulation-based teaching showed significant improvement in their arrhythmia knowledge score in both the first and second posttests, compared with those in the control group who were taught by means of a traditional lecture. These findings are in harmony with other studies (Brown, 2008; Smith et al., 2012; Sumner et al., 2012), which showed that simulation has a positive effect on improving knowledge of arrhythmia. However, Talwar et al. (2012) showed that there was no significant difference between the two methods of teaching but the involvement of only 30 staff nurses working in the cardiac units could distort any inferences made from this study. Significant variations were noted in the above-mentioned studies. In Sumner et al. (2012), the posttest was held 4-weeks after the arrhythmia program, which gave the participants a chance for additional reading or study about the topic, and this in turn may have helped improve their knowledge score. In the current study, however, the first posttest was held immediately after the simulation session on the same day. Moreover, in the same study, some of the participants had had clinical experience with arrhythmia identification before completing the study because of their placement in the clinical areas (Sumner et al., 2012). In the current work, it was ensured that the students had no prior knowledge of the topic investigated. Anyone who had undertaken a previous course was excluded from the study. The small sample size used in some studies could constitute a threat to the external validity of the studies (Sumner et al., 2012; Talwar et al., 2012). In the present research, the sample size was calculated based on power analysis to obtain an adequate sample in order that the findings could be generalized.
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The significant difference between the experimental and control group observed in the current work could be due to the use of a practical, realistic patient environment. The use of simulation provides a safe environment and mimics real patient situations (Smith et al., 2012; Sumner et al., 2012). Students in the experimental group noted the arrhythmia on the monitor and observed the live response to any management applied to the simulated patient. This interactive, realistic, and practical environment provided by the simulation is superior to a superficial response obtained from traditional lectures in the classroom (Schoening, Sittner, & Todd, 2006; Smith et al., 2012). In research such as this, knowledge retention should be measured over time (Sumner et al., 2012). Smith et al. (2012) recommended that a longitudinal approach is preferable in such cases to judge whether the obtained results remain consistent over time. Although the students’ knowledge of arrhythmia in the current work declined over time, where the mean score decreased from 13.2 ± 3.35 (Posttest 1) to 12.2 ± 3.81 (Posttest 2), students in the experimental group had significantly better knowledge of arrhythmia compared with those in the control group at the second posttest (retention phase) that held 3 months after the simulation. Interestingly, these findings are not uncommon. Although Hamilton (2005) found in an integrative literature review that skills and knowledge after cardiopulmonary resuscitation (CPR) training declined over time, Ackermann (2009) reported a positive effect of simulation on knowledge retention of CPR. It is frequently reported that there is a dearth of nursing research which compares the effectiveness of simulation with other teaching modalities that measure cognitive growth (Cant & Cooper, 2009; Kardong-Edgren & Adamson, 2009; Rush, Dyches, Waldrop, & Davis, 2008). Jordan is no exception, where no previous studies were found that had dealt with the phenomena of interest. Akhu-Zaheya et al. (2013) dealt with a different topic, the effect of simulation on BLS knowledge acquisition and retention, and also differs from the current study in terms of the design, sample, setting, and data collection procedures. Therefore, the current work can be said to provide a unique contribution to the body of knowledge, and expands the Jordanian and Arab literature on the topic investigated. There are many opportunities for future research to be conducted to evaluate other learning outcomes using simulation. The effect of simulation on arrhythmia has been explored in this study. A variety of critical care, emergency, and community skills can be taught using simulation. Furthermore, the positive findings of the current study may mean that it is used as a guide for nursing educators to enhance the education of arrhythmia specifically and of nursing in general. The integration of simulation into nursing education provides a new learning experience, which offers students the opportunity to
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train in a controlled and safe environment that is associated with lower levels of stress and which could help them in new clinical situations. This in turn could enhance practice and ensure the provision of high-quality care (Sumner et al., 2012). Nursing administrators should benefit from the current results as they may encourage funding and support for the development and establishment of simulation centers in their universities. As in any work, some limitations exist. Despite being randomly selected, the sample was drawn from a single site in Jordan. This could limit the generalizability to only this research site. Although it would be difficult to conduct such a study on a larger scale as not all nursing faculties in Jordan have such specialized laboratories, it is necessary to able to generalize the findings to a larger community. Knowledge retention was measured over a period of 3 months. However, it would have been better if it had been measured over a longer period, to see whether the same results could be sustained over time. Moreover, the study measured only cognitive knowledge rather than actual performance. In summary, both simulation and traditional lectures have a positive effect on improving students’ arrhythmia knowledge acquisition and retention. However, the use of simulation-based teaching may have a stronger impact than the traditional lecture in improving arrhythmia knowledge. These findings can add to the rising body of knowledge in this field and can promote the benefits of the integration of simulation into nursing education. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Rush, K. L., Dyches, C. E., Waldrop, S., & Davis, A. (2008). Critical thinking among RN-to-BSN distance students participating in human patient simulation. The Journal of Nursing Education, 47(11), 501-507. Salerno, S. M., Alguire, P. C., & Waxman, H. S. (2003). Training and competency evaluation for interpretation of 12-lead electrocardiograms: Recommendations from the American College of Physicians. Annals of Internal Medicine, 138, 747750. Schoening, A. M., Sittner, B. J., & Todd, M. J. (2006). Simulated clinical experience: Nursing students’ perceptions and the educators’ role. Nurse Educator, 31, 253258. Seropian, M. A., Brown, K., Gavilanes, J. S., & Driggers, B. (2004). Simulation: Not just a manikin. The Journal of Nursing Education, 43(4), 164-169. Smith, N., Prybylo, S., & Conner-Kerr, T. (2012). Using simulation and patient role play to teach electrocardiographic rhythms to physical therapy students. Cardiopulmonary Physical Therapy Journal, 23(1), 36-42. Steadman, R. H., Coates, W. C., Huang, Y. M., Matevosian, R., Larmon, B. R., McCullough, L., & Ariel, D. (2006). Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills. Critical Care Medicine, 34, 151-157. Sumner, L., Chang, L.-T., Jones, D., Burke, S., & McAdams, M. (2012). Evaluation of basic arrhythmia knowledge retention and clinical application by registered nurses. Journal for Nurses in Staff Development, 28(2), e5-e9. Talwar, S. R., Arora, S., & Tamang, E. L. (2012). Effectiveness of a simulation based teaching program on dysrhythmias: A pre-experimental study. International Journal of Nursing Education, 4, 83-86. Tiffen, J., Graf, N., & Corbridge, S. (2009). Effectiveness of a low-fidelity simulation experience in building confidence among advanced practice nursing graduate students. Clinical Simulation in Nursing, 5, e113-e117. Zulkosky, K. D. (2012). Simulation use in the classroom: Impact on knowledge acquisition, satisfaction, and self-confidence. Clinical Simulation in Nursing, 8, e25-e33.
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WJNXXX10.1177/0193945914545134Western Journal of Nursing ResearchTubaishat and Tawalbeh
Intervention Studies
Effect of Cardiac Arrhythmia Simulation on Nursing Students’ Knowledge Acquisition and Retention
Western Journal of Nursing Research 2015, Vol. 37(9) 1160–1174 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0193945914545134 wjn.sagepub.com
Ahmad Tubaishat1 and Loai I. Tawalbeh1
Abstract The realistic and practical environment that simulation provides is an extremely useful part of the teaching process. Simulation is widely used in health and nursing education today. This study aims to evaluate the effect of simulation-based teaching on the acquisition and retention of arrhythmiarelated knowledge among nursing students. A randomized controlled design involving a pretest–posttest was used. Nursing students were allocated randomly either to the experimental group (n = 47), who attended simulation scenarios on cardiac arrhythmia, or to the control group (n = 44) who received a traditional lecture on the same topic. A paired t test showed that the mean knowledge score at the posttest was significantly higher than at the pretest for both groups. However, participants in the experimental group demonstrated significantly increased knowledge of cardiac arrhythmia in the first and the second posttest compared with those in the control group. Thus, simulation is superior and significantly improves students’ arrhythmia knowledge. Keywords simulation, teaching, arrhythmia, nursing students, Jordan 1Al
al-Bayt University, Mafraq, Jordan
Corresponding Author: Ahmad Tubaishat, Faculty of Nursing, Al al-Bayt University, P.O. Box 130040, Mafraq 25113, Jordan. Email: [email protected]
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High-quality education in nursing is needed whether it is delivered in the classroom or in clinical settings. However, there are challenges associated with both learning contexts. In the classroom, the main limitations are the large number of enrolled students and the limited time available, whereas in the clinical areas, the major challenges are an occasional lack of patients and a shortage of clinical training sites (Zulkosky, 2012). In effort to minimize the impact of these challenges, and to prepare competent nurses; educators in the field of nursing should incorporate technology to enhance the teaching and learning process (Arnold, Johnson, Tucker, Chesak, & Dierkhising, 2013). One of the latest technological innovations is the use of simulation in learning (Zulkosky, 2012). Simulation involves the use of devices and monitors that have a control on a simulated patient, which can respond accurately to actions taken by the simulation user (Gaba, 2007). It is now widespread in health care and nursing education, and it has proved to be an effective teaching method (DeVita, Schaefer, Lutz, Dongilli, & Wang, 2004; Mayo, Hackney, Mueck, Ribaudo, & Schneider, 2004; Seropian, Brown, Gavilanes, & Driggers, 2004). The use of simulation can offer an interactive learner-focused environment, which can be used to teach cognitive, psychomotor, and affective skills or to convey knowledge (Cumin & Merry, 2007). Moreover, it can be extended to cover a whole range of nursing situations, from simple to complex, in many specialism, such as critical care, pediatrics, obstetrics, mental health, and community (Arnold et al., 2013). One of the available applications of simulation is for improving electrocardiogram (ECG) interpretation skills and the management of ECG arrhythmias (Mueller et al., 2005). In other words, life threatening cardiac arrhythmias can be simulated on a lifelike fully computerized mannequin (Morgan, Cleave-Hogg, Desousa, & Lam-McCulloch, 2006). It has been reported by Salerno, Alguire, and Waxman (2003) that to master the skills of ECG interpretation, a combination of knowledge, skills, and clinical practice are needed. Simulation can provide this experience as students can visually observe accurate pathophysiological changes for certain arrhythmias, and the response to a therapy or intervention (Mueller et al., 2005). Very few studies have been conducted to date to evaluate the effectiveness of simulation on improving knowledge of ECG and arrhythmia. Interestingly, most of those that were located during a literature search were found to have used the descriptive design. In a study by Sumner, Chang, Jones, Burke, and McAdams (2012), a sample of 138 registered nurses were asked to complete a pretest before attending a session on simulated arrhythmia, then they were asked to complete a posttest. The results of this descriptive study showed that there was a significant difference (p < .01) in the pre- and posttest scores (Sumner et al., 2012).
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This positive finding was supported by another study conducted by Brown (2008), which was carried out to investigate critical care nurses and nursing students’ ability to identify ECG arrhythmia and its treatment. Participants were exposed to simulated scenarios that mimicked real patients’ situations, and the participants were asked for quick recognition and response. Subjects were asked to complete a measurement tool to assess their ECG-related knowledge both pre- and post-simulation. It was found that the postsimulation knowledge mean scores were significantly higher than the mean pre-simulation scores (Brown, 2008). The field of simulation education has been explored in regard to a number of specialties other than nursing. The impact of simulation on physiotherapy students’ confidence and ability to interpret ECGs, and to make decisions based on their ECG interpretations, was investigated (Smith, Prybylo, & Conner-Kerr, 2012). A summative practical exam using the simulator was set to evaluate ECG knowledge. The findings revealed that 100% of students correctly identified the ECG rhythms and made correct clinical treatment decisions. Undergraduate medical students were the target of a study conducted to evaluate the use of simulator on a drug therapy course (Mueller et al., 2005). A total of 234 students were randomly allocated into an experimental group, who received simulation education, and a control group, who attended a traditional lecture on antiarrhythmic drugs. The participants in the simulation group considered the simulator to be a helpful and effective teaching tool. At the other extreme, Talwar, Arora, and Tamang (2012) conducted a study in a hospital in India to evaluate the effectiveness of simulation on staff nurses’ (n = 30) knowledge and skills of arrhythmia interpretation using a pretest–posttest design; and proved the opposite. The results showed that there was no significant difference in the nurses’ pre- and posttest knowledge and skills regarding the management of dysrhythmias before and after simulation. However, a small sample size used may distort any obtainable conclusion. Arrhythmias studies are not the only concern in simulation research. Other studies focused on other areas and skills. The impact of simulation on acute care assessment and management skills amide 31 medical students was examined using a randomized controlled trial (Steadman et al., 2006). The findings of this study showed that simulation has a significant effect on acute assessment and management skills and it was superior to problem-based learning in enhancing the assessment and the skills. Furthermore, a quasiexperimental study was conducted to measure the impact of simulation on confidence, knowledge, and satisfaction with physical assessment skills for 29 nursing students (Tiffen, Graf, & Corbridge, 2009). The 15 students in the
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experimental group exhibit significant enhancement in the knowledge of physical assessment skills compared with those in the control group. In Jordan, no study has been located about the effect of simulation on cardiac arrhythmia knowledge. However, one study was identified that examined the effect of simulation on Basic Life Support (BLS) knowledge acquisition and retention among nursing students (Akhu-Zaheya, Gharaibeh, & Alostaz, 2013). A quasi-experimental design was used by allocating students into an experimental group (n = 52) who received traditional teaching on BLS (a standard lecture and demonstration on a static manikin) and simulation, and a control group (n = 58) who received only traditional teaching on BLS (a standard lecture and demonstration on a static manikin). The results showed no significant differences in the knowledge scores between the experimental and the control group. The fact that there has been a lack of such studies in Jordan and worldwide motivated the present work. Also, a systemic review conducted in 2009 stressed the need for more studies to explore the effectiveness of simulation for enhancing students’ learning (Kaakinen & Arwood, 2009). Thus, the current study was conducted in Jordan (a) to examine the effect of a simulationbased teaching program on nursing students’ knowledge about the interpretation and management of cardiac arrhythmias using a well-controlled experimental design, and (b) to assess their knowledge retention over time. Jeffries’ Simulation Model was used to guide the current study (Jeffries, 2005). This model comprises connected relationships between the teacher, student, and educational practices. The latter in this study incorporated into a high-fidelity simulation educational strategy that could affect the students outcomes of learning in term of knowledge, skills, critical thinking, satisfaction, and confidence gained. Thus, two important components are necessary in this model; the simulation as learning strategies and its outcomes on the learner (Jeffries, 2005). According to Jeffries (2005), the well-designed simulation should have a number of characteristics including objectives, fidelity, problem solving, student support, and reflection. The objectives of simulation teaching should be clearly outlined. In this study, the students receive written and oral objectives of this simulation experience to guide their learning. Fidelity of simulation mimics reality to enhance learning outcomes. A programmed high-fidelity simulation doll that mimic physiological responses to certain arrhythmias was used. The problem solving depends on the students’ ability to recognize and manage the presented arrhythmias with appropriate interventions. The students support element occurs through the use of prompts or hints during the scenario to reach the appropriate clinical judgment. The last characteristics is the reflection, which usually occurs at the end of the simulation
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scenario; where in the current work, the instructor give a debriefing session after each scenario for 10 min to encourage students to think in depth on the learning activity and to link theory to practice. The outcome that is the last component of this model may contain knowledge, skills, critical thinking, satisfaction, and confidence (Jeffries, 2005). The aim of using the simulation in this work was to show the greater knowledge was gained from simulation compared with other teaching strategies (i.e., conventional lecture). In summary, Jeffries’s (2005) Simulation Model was a valuable empirically supported model to guide the current research on the design and implementation of simulation in an organized and systematic manner.
Method Design A randomized controlled design was used, where the pretest–posttest experiment was utilized to evaluate the effect of simulation on students’ knowledge of arrhythmia. The students were randomly selected and then randomly allocated either to the experimental or control group.
Setting This study was conducted in the School of Nursing of one public university in Jordan. This School offers the bachelor’s degree of nursing on completion of a 4-year program. It comprised several classrooms equipped with desktop computers, and a data show projector for lecture presentations. There were nine laboratory rooms fitted with the required equipments used to improve the students’ clinical skills. In addition, there were two simulation laboratory rooms supplied with pediatric and adult manikins, monitors, computers, and other important equipment.
Sample and Sampling Procedures A simple random sampling technique was used to select the nursing students who would take part in this study. A list containing all students in the School was obtained from the academic registry. Subsequently, a sample of nursing students was randomly chosen using a computer generated list. The inclusion criteria for the subjects were (a) any nursing student regardless their level in the school as long as did not attend any critical care course previously, and (b) that they agreed to participate.
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The sample size was calculated using G* power software (Faul, Erdfelder, Lang, & Buchner, 2007). For the purpose of this work, a medium effect size was needed, which is 0.50. The sample size was decided based on the power level, which is 0.80, and the use of usual α = 0.05 two-tailed criterion of the significance. Consequently, 70 students were required. An extra 30 students were added to this number to overcome the attrition problem, giving a final sample of 100 students. Those students were randomly allocated either to the experimental group (n = 50) or the control group (n = 50).
Data Collection Procedure After permission was gained from the Institution Review Board, the study commenced. Students were asked to provide brief demographical data before a pretest about cardiac arrhythmia knowledge was set for both groups. After that, students in the control group received a traditional lecture about cardiac arrhythmia interpretation and management. The experimental group observed virtual simulation scenarios, each lasting approximately 20 min, on the same topic. After both sessions ended, a posttest involving the arrhythmia written examination was set for both groups. The pretest, education, and posttest followed one after another, first for the control group on one particular day, and then for the experimental group the following day. In each case, the teaching was delivered by the same instructor; the primary researcher. All data were collected and analyzed by the primary researcher as well. Students who completed the pretest did not know their group assignments, but the researcher knew the groups in which they were included. The students were informed of their groups before the start of teaching, thus students were not aware of each other. Each student in both groups was given an ID number to anonymize their participation and protect the confidentiality of their data. A second posttest was performed 3 months after the first posttest for both the experimental and control group to examine knowledge retention. No sharing between students in the control and experimental group was occurred. Figure 1 simplifies the data collection procedures and phases. The study method and protocol was reviewed and approved by the Institutional Review Board. Verbal and written information about the study’s aims and procedures was given and all participants who agreed to participate granted their informed consent. Furthermore, the completed questionnaires were held in a locked cabinet for the purposes of data privacy. Participation in this study was completely voluntary and students were informed that they had the right to withdraw from the study at any stage without penalty. Students were also informed that data would be collected from them on three occasions; once before the education was delivered, and twice afterward. After the
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Faculty of Nursing (n=650 students)
Random selection n=100 Random assignment
Acquisition phase (same day)
Retention phase (after 3 months)
Control group n= 50 pretest knowledge
Experimental group n= 50 pretest knowledge
Traditional lecture n=50
Simulation scenario n=50
First posttest n=47
First posttest n=44
Second posttest n=43 Retention
Second posttest n=42 Retention
Figure 1. Data collection procedures and phases.
study was ended, all questionnaires were disposed off. The students were not subject to any physical, psychological, or economic harm, as the data collection procedures depended solely on a non-invasive questionnaire. No credits were awarded for students’ participation. Control group (traditional lecture). Students were presented with a PowerPoint presentation about ECG, starting with basic concepts such as waves, intervals, and heart rate calculation, and then a discussion of the most common arrhythmias suffered by patients in the hospitals. The arrhythmias were displayed onto a projector screen and a discussion about these ECG strips occurred between the students and the primary researcher in an effort to analyze the ECG strips and diagnose them. Then, the appropriate intervention for the presented arrhythmias was discussed, without there being an opportunity
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to apply these interventions directly to a patient, such as in the case of the experimental group (see below). A total of 50 students were enrolled in this session which lasted about 2 hr, was held in one of the School classrooms, and was given by a primary researcher. The contents of the educational lecture were drawn from critical care nursing textbooks (Huff, 2006; Morton, Fontaine, Hudak, & Gallo, 2005). Some Internet resources like the American Heart Association (AHA; 2010) website were consulted as well. The content of the lecture was pilot tested by a team of experts from academic and clinical backgrounds and, as a result, a number of amendments were made to the teaching and assessment methods used. Experimental group (simulation). A high-fidelity simulator (METI Version 6), with many features such as blood pressure measurement, pulse palpation, ECG, chest expansion, and simulator voice, was used. The simulator mannequin responds in a precise way to an induced pharmacological or physiological intervention. In addition, the “patient” has the capability to talk, move his arm, and open and close his eyes. Students were presented with normal ECG rhythms, which were dynamic and displayed on a monitor, and which represented patient conditions. All waves, intervals, and segments were illustrated to students. Subsequently, a group of scenarios that had already been uploaded to the METI software and that demonstrated some cardiac arrhythmias were presented on the machine monitor. Each scenario lasted approximately 20 min. The primary researcher led a discussion with the students in an effort to encourage them to identify the arrhythmias, and suggest appropriate interventions, including drugs or the use of a defibrillator or a pacemaker. Students were advised to click on the appropriate intervention on the simulator computer and the effect was projected live onto the monitor screen, and onto the “patient.” The same arrhythmias that were presented to the control group were also presented for students in the experimental group. The difference was that in the control group, the students could only suggest an appropriate intervention during the discussion with the primary researcher, whereas in the experimental group, students could apply the relevant intervention by giving an order to the simulator computer and the effect could be observed on both the monitor and on the “patient” directly, as the ECG rhythm could change in response to the treatment that the students chose to administer. Thus, students saw the results appear live as they would on a real patient. Fifty students who were involved in the simulation experience were divided into groups of seven to eight students for demonstration purposes. A debriefing session, which lasted about 10 min, was held after each scenario, to discuss and focus on points which may have arisen during the scenario.
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Instrument. A structured questionnaire was used to collect the data. It started with a concise statement about the aim of the study and a formal request for consent, followed by three main sections. Section 1 was designed to gather demographic data, including age, gender, and grade point average (GPA). The second section was the arrhythmia written examination containing 20 multiple-choice questions on interval and heart rate calculation, rhythm identification, and rhythm management. The questions were adapted from several sources such as associated academic literature, textbooks, Internet resources, and the AHA (2010). Four experts in ECG assessed the face validity and indicated that the instrument was valid. The content validity was assessed by another two experts in ECG and two PhD-qualified nurses. The content validity index was 0.89, confirming that the instrument measured what it was supposed to measure. Following this, it was pilot tested on 10 students to assess the clarity of the questions and instructions, and the time required to complete the questionnaire. Some minor modifications were made based on written feedback received from participants. The scale items were tested for internal consistency in the present study, and the Cronbach’s alpha reliability was .84. The same knowledge test was used in the pretest and the two posttests. Arrhythmia knowledge scores were calculated by correct/incorrect responses. As there were 20 questions, the scores would range from 0 to 20, with higher scores indicating a higher level of knowledge. The mean arrhythmia knowledge scores were calculated for analysis, by comparing the difference of the mean between the experimental and control groups.
Data Analysis The Statistical Package for Social Science (SPSS) Version 17 was used to analyze the data. The sample’s characteristics were described using descriptive statistics. To assess the homogeneity of the sample at the baseline, the independent t test was utilized to test whether there were significant differences between the experimental and the control group at the pretest. The same test was used to examine whether there were statistically significant differences between the experimental and control group in the mean scores of arrhythmia knowledge. To assess whether there was a significant difference between the mean pre- and posttest scores of arrhythmia knowledge for the experimental and control group, the paired t test was used.
Results The study sample was distributed almost equally between both genders (female = 56, male = 44). The mean age for the whole sample was 20.4
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Table 1. An Independent t Test to Compare Arrhythmia Knowledge Between Experimental and Control Group at Baseline, First Posttest, and Second Posttest. Variable Pretest of arrhythmia knowledge (baseline) First posttest (knowledge acquisition) Second posttest (knowledge retention) *p
Experimental Group, M (SD)
Control Group, M (SD)
t Test
6.2 (2.78)
5.7 (2.43)
−4.59
13.2 (3.35)
7.6 (2.36)
−7.11**
12.2 (3.81)
7.2 (2.79)
−4.72**
≤ .05 level (two-tailed). **p ≤ .001 level (two-tailed).
(SD = 0.98), and the mean GPA was 67.9 (SD = 5.42) at the baseline. The experimental and control groups were homogeneous. There was no statistically significance difference between the groups regarding age (p = .20), and GPA (p = .63) as indicated by the results of the independent-sample t test. No significant difference was found as well in the pretest knowledge of arrhythmia as shown in Table 1. A total of 91 students completed the first posttest with 47 (51.6%) students in the control group and 44 (48.4%) in the experimental group. The results of the independent t test confirmed that there was a statistically significant difference, t(88) = −7.11, p < .001, between the experimental group (M = 13.2, SD = 3.35) and the control group (M = 7.6, SD = 2.36) on the topic of arrhythmia knowledge (Table 1). Three months later, the retention phase started, in which 85 students completed the second posttest. For a second time, the difference between the experimental group (M = 12.2, SD = 3.81) and the control group (M = 7.2, SD = 2.79) concerning arrhythmia knowledge was significant, as proved by the results of the independent t test, t(84) = −4.72, p < .001 (Table 1). To compare the results of the pre- and posttest for each group, a paired t test was used. The findings demonstrated that mean scores for arrhythmia knowledge at the posttest were significantly higher than those at the pretest for both the experimental and the control groups (Table 2). This suggests that the subjects’ knowledge of cardiac arrhythmia was significantly enhanced after the provision of both types of teaching; the simulation in the experimental group or the traditional training in the control group. However, the results presented in Table 1 confirmed that simulation-based teaching is more effective than the traditional method of education in improving arrhythmia knowledge.
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Table 2. Paired t Test to Compare Arrhythmia Knowledge in the Pre- and Posttest of Both Groups.
Variable
Pretest, M (SD)
Experimental 6.2 (2.78) group Control 5.7 (2.43) group *p
First Posttest, M (SD)
Second Posttest, M (SD)
13.2 (3.35)
12.2 (3.81)
−5.94**
−5.14**
7.6 (2.36)
7.2 (2.79)
−5.03**
−4.93**
t(39) (Pretest t(41) (Pretest and First and Second Posttest) Posttest)
≤ .05 level (two-tailed). **p ≤ .001 level (two-tailed).
Discussion This experimental study aimed to examine the effect of simulation-based teaching on cardiac arrhythmia knowledge acquisition and retention. The results demonstrated that students in the experimental group who were subject to simulation-based teaching showed significant improvement in their arrhythmia knowledge score in both the first and second posttests, compared with those in the control group who were taught by means of a traditional lecture. These findings are in harmony with other studies (Brown, 2008; Smith et al., 2012; Sumner et al., 2012), which showed that simulation has a positive effect on improving knowledge of arrhythmia. However, Talwar et al. (2012) showed that there was no significant difference between the two methods of teaching but the involvement of only 30 staff nurses working in the cardiac units could distort any inferences made from this study. Significant variations were noted in the above-mentioned studies. In Sumner et al. (2012), the posttest was held 4-weeks after the arrhythmia program, which gave the participants a chance for additional reading or study about the topic, and this in turn may have helped improve their knowledge score. In the current study, however, the first posttest was held immediately after the simulation session on the same day. Moreover, in the same study, some of the participants had had clinical experience with arrhythmia identification before completing the study because of their placement in the clinical areas (Sumner et al., 2012). In the current work, it was ensured that the students had no prior knowledge of the topic investigated. Anyone who had undertaken a previous course was excluded from the study. The small sample size used in some studies could constitute a threat to the external validity of the studies (Sumner et al., 2012; Talwar et al., 2012). In the present research, the sample size was calculated based on power analysis to obtain an adequate sample in order that the findings could be generalized.
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The significant difference between the experimental and control group observed in the current work could be due to the use of a practical, realistic patient environment. The use of simulation provides a safe environment and mimics real patient situations (Smith et al., 2012; Sumner et al., 2012). Students in the experimental group noted the arrhythmia on the monitor and observed the live response to any management applied to the simulated patient. This interactive, realistic, and practical environment provided by the simulation is superior to a superficial response obtained from traditional lectures in the classroom (Schoening, Sittner, & Todd, 2006; Smith et al., 2012). In research such as this, knowledge retention should be measured over time (Sumner et al., 2012). Smith et al. (2012) recommended that a longitudinal approach is preferable in such cases to judge whether the obtained results remain consistent over time. Although the students’ knowledge of arrhythmia in the current work declined over time, where the mean score decreased from 13.2 ± 3.35 (Posttest 1) to 12.2 ± 3.81 (Posttest 2), students in the experimental group had significantly better knowledge of arrhythmia compared with those in the control group at the second posttest (retention phase) that held 3 months after the simulation. Interestingly, these findings are not uncommon. Although Hamilton (2005) found in an integrative literature review that skills and knowledge after cardiopulmonary resuscitation (CPR) training declined over time, Ackermann (2009) reported a positive effect of simulation on knowledge retention of CPR. It is frequently reported that there is a dearth of nursing research which compares the effectiveness of simulation with other teaching modalities that measure cognitive growth (Cant & Cooper, 2009; Kardong-Edgren & Adamson, 2009; Rush, Dyches, Waldrop, & Davis, 2008). Jordan is no exception, where no previous studies were found that had dealt with the phenomena of interest. Akhu-Zaheya et al. (2013) dealt with a different topic, the effect of simulation on BLS knowledge acquisition and retention, and also differs from the current study in terms of the design, sample, setting, and data collection procedures. Therefore, the current work can be said to provide a unique contribution to the body of knowledge, and expands the Jordanian and Arab literature on the topic investigated. There are many opportunities for future research to be conducted to evaluate other learning outcomes using simulation. The effect of simulation on arrhythmia has been explored in this study. A variety of critical care, emergency, and community skills can be taught using simulation. Furthermore, the positive findings of the current study may mean that it is used as a guide for nursing educators to enhance the education of arrhythmia specifically and of nursing in general. The integration of simulation into nursing education provides a new learning experience, which offers students the opportunity to
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train in a controlled and safe environment that is associated with lower levels of stress and which could help them in new clinical situations. This in turn could enhance practice and ensure the provision of high-quality care (Sumner et al., 2012). Nursing administrators should benefit from the current results as they may encourage funding and support for the development and establishment of simulation centers in their universities. As in any work, some limitations exist. Despite being randomly selected, the sample was drawn from a single site in Jordan. This could limit the generalizability to only this research site. Although it would be difficult to conduct such a study on a larger scale as not all nursing faculties in Jordan have such specialized laboratories, it is necessary to able to generalize the findings to a larger community. Knowledge retention was measured over a period of 3 months. However, it would have been better if it had been measured over a longer period, to see whether the same results could be sustained over time. Moreover, the study measured only cognitive knowledge rather than actual performance. In summary, both simulation and traditional lectures have a positive effect on improving students’ arrhythmia knowledge acquisition and retention. However, the use of simulation-based teaching may have a stronger impact than the traditional lecture in improving arrhythmia knowledge. These findings can add to the rising body of knowledge in this field and can promote the benefits of the integration of simulation into nursing education. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
References Ackermann, A. D. (2009). Investigation of learning outcomes for the acquisition and retention of CPR knowledge and skills learned with the use of high-fidelity simulation. Clinical Simulation in Nursing, 5, e213-e222. Akhu-Zaheya, L. M., Gharaibeh, M. K., & Alostaz, Z. M. (2013). Effectiveness of simulation on knowledge acquisition, knowledge retention, and self-efficacy of nursing students in Jordan. Clinical Simulation in Nursing, 9, e335-e342. American Heart Association. (2010). The 2010 American Heart Association guidelines for CPR and ECC. Retrieved from http://circ.ahajournals.org/content/122/18_suppl_3.toc
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