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Japan Journal of Nursing Science (2015) 12, 222–231
doi:10.1111/jjns.12062
ORIGINAL ARTICLE
First experiences of high-fidelity simulation training in junior nursing students in Korea Suk Jeong LEE,1 Sang Suk KIM1 and Young-Mi PARK2 1 Red Cross College of Nursing, Chung-Ang University (CAU), CAU Healthcare System, Seoul and 2Ansan College of Nursing, Ansan, Korea
Abstract Aim: This study was conducted to explore first experiences of high-fidelity simulation training in Korean nursing students, in order to develop and establish more effective guidelines for future simulation training in Korea. Methods: Thirty-three junior nursing students participated in high-fidelity simulation training for the first time. Using both qualitative and quantitative methods, data were collected from reflective journals and questionnaires of simulation effectiveness after simulation training. Descriptive statistics were used to analyze simulation effectiveness and content analysis was performed with the reflective journal data. Results: Five dimensions and 31 domains, both positive and negative experiences, emerged from qualitative analysis: (i) machine–human interaction in a safe environment; (ii) perceived learning capability; (iii) observational learning; (iv) reconciling practice with theory; and (v) follow-up debriefing effect. More than 70% of students scored high on increased ability to identify changes in the patient’s condition, critical thinking, decision-making, effectiveness of peer observation, and debriefing in effectiveness of simulation. Conclusion: This study reported both positive and negative experiences of simulation. The results of this study could be used to set the level of task difficulty in simulation. Future simulation programs can be designed by reinforcing the positive experiences and modifying the negative results. Key words: Korea, nursing education, nursing student, patient simulation.
INTRODUCTION The demands for the protection of patient rights and safety have become a major issue in medical and nursing care systems over the past decade. The protection of patient safety has caused difficulty in finding real patients for students’ clinical training (Cho & Kwon, 2007) and has shifted the direction of clinical training to mere observation and simple skill development (Benner, Sutphen, Leonard, & Day, 2010). The success of clinical training relies on the ability of a student to apply
Correspondence: Sang Suk Kim, Red Cross College of Nursing, Chung-Ang University(CAU), 84 Heukseok-Ro, Dongjak-Gu, Seoul 156-861, Korea. Email: [email protected] Received 6 December 2013; accepted 13 September 2014.
relevant knowledge and theoretical principles to competent nursing problem solving action. However, without enough opportunity of caring for real patients in a clinical setting, nursing students have difficulty in adjusting to complicated nursing situations after they graduate from nursing colleges (Kim & Jang, 2011; Malouf & West, 2011). Such obstacles have facilitated innovative training strategies in nursing and simulation has emerged as one of the viable alternatives. Organized in an environment similar to a real-life clinical setting, simulation training was introduced as an innovative alternative to conventional training in nursing in the early 1990s, in advanced countries (Kim, 2013). However, in Korea, it was not until the early 2000s that nursing colleges started to include simulation-based clinical training (Lee, Eom, & Lee, 2007). Currently, a number of 3 year nursing colleges in
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 222–231
Korea have merged into a 4 year diploma program with modified curriculums, including simulations. Simulation is one of the up-and-coming learning strategies in the nursing curriculum, especially for nursing practice. It is critical to identify the effectiveness and meaning of highfidelity simulation for nursing students, to consider the applicability of simulation to nursing curriculum, and to set the task difficulty level. The types of simulation consist of partial task training, role play, and computer-based simulation (Gaba, 2007). While partial task training is used for simple technical skills, high-fidelity simulation refers to structured student learning experiences with the use of a technologically advanced computerized mannequin, the Human Patient Simulator (Lasater, 2007). The comparative clinical performance between partial task training and high-fidelity simulation revealed that those who had completed high-fidelity simulation were more likely have improved ability to perform nursing intervention and critical thinking (Kim, Lee, Hwang, Kim, & Cha, 2012). High-fidelity simulation was more effective in increasing confidence and communication skills with other nursing care providers, and reinforcing motivation for learning (Fero et al., 2010; Wotton, Davis, Button, & Kelton, 2010). Adamson (2011) emphasized the importance of the suitability of simulation that could produce effective learning outcomes in students. Previous assessments of the suitability of simulation for clinical training were mainly reported on pre- and post-training comparisons using questionnaires, and few have attempted any in-depth understanding of how and why simulation users perceived a given training tool to be effective. The studies that reported effectiveness of simulation had limitations of cultural and ethnic diversity of students (Lasater, 2007; Reilly & Spratt, 2007). Simulation provides opportunity for practice activities prior to clinical practice and provides a special learning experience to nursing students who have never been exposed to simulation. It is a challenge for Korean nursing students who are not familiar with team approach nursing care and do not communicate with patients frequently. A systemic review article identified the importance of providing feedback, repetitive practice, curriculum, range of difficulty level, and multiple learning strategies as important variables of effective simulation education (Issenberg, McGaghie, Petrusa, Gordon, & Scalese, 2005). However, Korean qualitative studies of student experience of high-fidelity simulation either focused on the meaning of the experience, or students were exposed to simulation prior to the study
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(Kim & Suh, 2012; Lee, Kim, Yeo, Cho, & Kim, 2009). Exploring students’ first experiences with high-fidelity simulation provides valuable insight into what is effective and the modifications needed. This study may contribute evidence to support further integration of high-fidelity simulation in nursing programs, valuable information to establish effective strategies, and resources for suitable guidelines based on the levels of task difficulty for simulation training.
METHOD Design Using a mixed research method, this study analyzed students’ reflective journals to explore their first experience of simulation training qualitatively. Additionally, the effectiveness of simulation training was analyzed quantitatively using a questionnaire.
Participants Participants in this study included 33 junior nursing students in Korea, who had no previous experience in simulation. As many as 18 participants agreed to write reflective journals, while 31 students completed questionnaires.
Data collection Reflective journal writing is a valuable method of collecting anecdotal evidence of students’ subjective perceptions of clinical training. This practice leads students to develop critical thinking, self-understanding, and reflection (Billings, 2006). Pedro (2006) also pointed out that journaling served as a valuable tool to keep track of the students approach to problem solving. The following questions were provided to participants: (i) “What kind of experience did you have from the method of high-fidelity simulation training?”; (ii) “What kind of experience have you had from the instructional process for simulation training?”; (iii) “What kind of experience have you had from the interaction with your peers?”; and (iv) “What kind of experience have you had in terms of the applicability of what you have learned in the simulation program to a real-life clinical case?”. The length of the text was 3 pages and the duration of each student’s journaling time was between 20 and 30 min. The reflective journals were collected by mail 10 days after simulation training, and immediately after completing simulation, a questionnaire was administered. The present authors measured the effectiveness of simulation, developed by Elfrink Cordi, Leighton, and
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Ryan-Wenger (2012), and translated into Korean by Shim (2012), which consisted of 13 questions with eight items of learning and five items of confidence areas. It was a 3 point scale ranging from 1 (“strongly disagree”) to 3 (“strongly agree”).
Procedure The half-day training program was centered on a simulated patient, SimMan, calibrated to present symptoms of dyspnea. The simulation scenario was developed in 2009 at the simulation center of a nursing college in Seoul, Korea, where it has been used since. The simulation procedure included four sessions including orientation, briefing, simulation operation, and debriefing. Students were divided into small groups of 2–3; two groups worked as a team and one group performed simulation training, while the other group observed, and took turns. At the end of the simulation, three instructors led a 30 min debriefing session for their participants to reflect on their performances during the scenario. The instructors asked the students to reflect on what happened during the scenario, analyze their actions, and summarize lessons learned from the participation. At the end of the debriefing, each participant was asked to complete a questionnaire on simulation effectiveness. Reflective journals were collected 10 days after simulation training by mail.
Ethical considerations Before this study was conducted, approval was obtained from the institutional review board of the nursing college. Full explanations on the purpose of the study and confidentiality of personal information were given to all the participants in this study. Participants were informed that writing journals did not affect school grades, they could withdraw from the study at anytime, and that they would not be penalized for noninvolvement in the study. Written consent was obtained from all participants.
RESULTS Content analysis of reflective journals The response rate for the reflective journals was 18 out of 33 (55%), two were male nursing students and 16 were female, with an average age of 21.1 years (± standard deviation, 0.64). None had previous experience of high-fidelity simulation. Through the analysis, 31 positive and negative domains of textual responses emerged, which were grouped into five dimensions. Table 1 lists key improvement areas suggested in each dimension.
Table 1 Key improvement areas in each dimension after the simulation
Data analysis A qualitative content analysis was employed to identify the recurring patterns in the texts of participants’ reflective journals. This process highlighted key domains and allowed for taxonomic classification. During the content analysis process, three researchers verified whether the textual responses were pertinent to, and incorporated within, the domains by repeatedly underlining the recurring patterns through a process of comparison, classification, and abstraction. The process was repeated until an acceptable level of inter-rater agreement and reliability was achieved. All discrepancies were discussed in person, and the opinion of an independent expert was obtained in several ambiguous cases to reach agreement on classification. Another nursing educator, specialized in qualitative research method, was involved in evaluating the overall research methodology and provided feedback whenever the analysis and interpretation of the data needed verifying.
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Descriptive statistics were applied to analyze the effectiveness of simulation.
Dimension Machine–human interaction Perceived learning capabilities
Observational learning Reconciling practice with theory
Follow-up effect
Key improvement areas A richer nursing experience without jeopardizing the patient’s condition A sense of reality Motivation toward learning Confidence in clinical nursing A sense of accomplishment A feeling of empathy for patients Learning both desirable and undesirable behavior Realized the importance of fundamental nursing skills Provide effective replies to patients questions Patient education at the level of patient’s understanding Reflect and reinforce clinical training Learning the importance of objectivity in nursing intervention
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Dimension 1: Machine–human interaction Positive domains: Voice interaction and safe environment. Most of the participants mentioned that highfidelity simulation was a very interesting method of learning, and they felt safe with the simulated patient. They suggested they could have a richer nursing experience without jeopardizing a patient’s condition. Moreover, most of the students reported a sense of reality on hearing the simulator-generated voice. The simulated patient issued vocal outputs describing its symptoms of dyspnea and asking the participants questions about nursing interventions for symptom management. Through interaction with the voice-activated simulator, the students experienced greater immersion in the program. For example: The simulation training was quite a lifelike experience, because SimMan complained about his symptoms like a real patient. When he asked me questions, SimMan did it much like a real symptomatic patient who constantly wondered what his problems were. With this simulation, I could actually touch the medical equipment with my hands and communicate with SimMan like a real patient. I have to be more careful and attentive to the patient needs if he or she is a real patient in a hospital. Even worse, when people become nervous about what they have to do for a patient, they tend to make more mistakes than they expect. For that reason, preceptor nurses do not want nursing students to engage in direct nursing care in the hospital. As a result, it is very difficult for me to get experience, but this simulation training program did not impose any risks of accidental wrongdoing. As it turned out, I could try as many different nursing interventions as I wanted and learned a lot from this simulation.
Negative domains: Preset arrangement of time and parameters and lack of realism. Negative reported statements for simulation training were related to the automated timing of the simulated patient’s questions and responses. Participants expressed that the timing was too rapid to follow. The participants stated that they wanted the simulation operation to be slower and better adjusted to fit novice students at simulation. They also preferred the option of repetitive learning for bedside training; they suggested that it would enhance critical thinking and their ability to make effective clinical inferences. For example: We had to hurry when allocating each person’s role because we did not have enough time to prepare and react to what SimMan wanted us to do.
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If we had more time for training, we could answer SimMan’s questions a lot better than we did this time. In order to improve my ability to make inferences and think critically, I need more hands-on experience with this simulated patient.
Another negative response was related to a decreased sense of realism in simulation. Some participants indicated that the reactions made by the simulated patient and the circumstances under which the mechanical patient was suffering were not sufficiently similar to a real-life clinical setting. For example: The simulator was not a human being, but a model, so it was unable to move any part of the body like a real patient. I thought that a real patient would exhibit anxiety or stress resulting from severe symptoms in that situation.
Dimension 2: Perceived learning capabilities Positive domains: Motivation for learning, confidence in nursing care, sense of achievement, and empathy with patient. Another dimension of experiencing simulation training was related to the self-perceived personal traits or attributes contributing to, or hindering, learning. Positive personal traits for learning included improvement in motivation toward learning, confidence in clinical nursing, a sense of accomplishment, and a feeling of empathy for the patient. All of these traits helped the students provide proper nursing interventions to the patient, without confusion. For example: After I had experienced simulation, I felt a lot more confident in coping with real-life situations similar to this, and I feel like I can take care of real patients a lot better than before. Even when I had clinical training in the medical–surgical nursing department for adult patients, I felt that clinical training focused more on theoretical knowledge than practice, so I did not think that that clinical training for adult patients was good enough for practical application. However, after this simulation, I was satisfied because not only had I gained some relevant knowledge but I was also able to take the initiative in performing nursing techniques that might not have been allowed in a real-life clinical setting. Furthermore, I could move on to the next action without interruption. I was able to try every single nursing technique in very little time.
The participants stated the importance of feeling empathy toward the patient. Participants were able to learn how to share feelings and emotions with the simulated patient. By sharing feelings, they also learned how to explain the principles of nursing care to the patient
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from the patient’s point of view, not from the professional point of view. For example: I was surprised to find that some of my basic knowledge was not basic to the patient. I mean, the patient wanted to know a lot about his condition, but did not understand what I considered to be very basic knowledge. So, I realized that I have to explain what the patient really wants to know in more layman terms.
Negative domains: Lack of confidence, poor judgment, lack of communication skills, and lack of basic nursing skills. Throughout the simulation process, participants realized the limits of their capacity and clinical competency. Examples included their inability to explain the intended nursing intervention correctly to the simulator, feeling inferior to, and less competent than, their peers, and having difficulty in establishing priorities in nursing intervention because of a lack of pertinent knowledge. For example: While I gave my answer to SimMan’s question on his breathing difficulty, I tried to think about how I could help him, and became desperate when I could not help SimMan alleviate his symptoms. I came to realize that I did not have enough knowledge for nursing care, and I needed to know how to prioritize nursing care for him.
Many participants realized that they lacked communication and basic nursing skills. The participants experienced these problems when encountering a patient with severe symptoms and when explaining what nursing intervention the patient would receive in a manner grounded in theory and knowledge. For example: If I cannot convey what I know to the patient properly, I think that it will be useless and dead knowledge. I became aware that it is very important for me to explain the condition of the disease and nursing intervention to the patient, but I do not think that I am good enough. I believe I have a lot to learn on how to communicate with the patient more effectively.
Dimension 3: Observational learning Positive domains: Learning by observing others, group dynamics, efficiency in tasks, and teachable moments. Observational learning refers to learning that occurs by observing others’ behavior (Bandura, 1989). In this study, participants stated they learned the following when they took on the role of observers: effectiveness of learning by observing their peers, understanding of group dynamics, efficiency of
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performing tasks in teams, and teachable moments. The participants indicated that they learned by observing what and how other team members performed nursing interventions. The participants learned both desirable and undesirable behavior through observational learning. For example: I think I learned what to do and what not to do for patient care while I observed other students. Not only did I learn the dos and don’ts from my friends, but I also learned that I could make the same mistakes as they did even after watching them make those mistakes.
The participants stated that they were able to work effectively in teams although they had never experienced it before in conventional clinical training. They suggested that cooperative work was more efficient than individually provided nursing care. The participants also pointed out the importance of interpersonal solidarity among team members, who could help each other and break down tasks into simpler actions. For example: If I was put in such a situation alone, I would be at a loss for an answer to my patient’s questions and could not possibly do anything at all on my own. However, our team members helped and cooperated with each other, so we were able to come up with a better solution than I could alone.
Not only observing, but also sharing others’ experiences facilitated and reinforced the learning process. It served as one of the most appropriate “teachable moments”. For example: When I observed other students doing what I was curious about and what I had failed to do during my turn, it was a very special moment of learning to me.
Negative domains: Lack of interaction with peers, time constraints, hindering personal attributes, and decrease in realism. Despite the importance and effectiveness of good teamwork, participants in this study felt that there were negative experiences of teamwork, as well. Specifically, they highlighted an overall lack of active interaction among group members due to the lack of time for clearly defining roles among team members. Additionally, participants indicated that group members’ personal traits and attributes hindered group dynamics, resulting in individual members doing only their own tasks and paying no attention to others. As a result, participants stated that they could not remember what their peers had done in teamwork. For example:
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During simulation, I could hardly pay attention to what the other students were doing because I was so preoccupied with my own job and nervous about doing it correctly. I could not remember what my team members had done. That was something that I regretted. I think I learned by observing my friends commit errors in very basic nursing care, and thought that I would never make such mistakes while I was watching. However, when it came to my turn, I found myself making the same mistakes as my friends. I learned the lesson that fundamental nursing skills are apt to be forgotten, so that I have to make every effort to keep them alive to provide good nursing care.
The participants stated that working in teams was also very different from the conventional one-on-one clinical training. None of the participants had experienced a team environment before simulation. For example: In a real clinical situation, we do not observe a single patient with many nursing students together, so the team approach did not feel like a real situation to me.
Dimension 4: Reconciling practice with theory Positive domains: Utilization of knowledge, cope with emergency, patient education, readiness for real-life cases. When participants were asked to apply what they had learned from simulation to real-life nursing situations, many stated that they realized the importance of fundamental nursing skills that could be applied to nursing interventions to best suit the particular needs of a patient. They could also act as effective replies to patients’ abrupt and unexpected questions, as well as a method of patient education at the patient’s level of understanding. The participants described simulation training as enrichment experience in reconciling theory with practice. For example: Today’s simulation required us to cope with an emergency situation, and I could learn how to manage and choose the most appropriate nursing intervention tailored for the needs of SimMan, which were changing at every single moment of the situation. Inasmuch as an experienced and skillful nurse in a clinical setting can become an expert, I will get accustomed to any clinical situation and cultivate the ability to adapt to new clinical environments if I gain experience through this simulation. I hope I will have more such opportunities to practice.
In addition, through hands-on experiences with the simulated patient, the participants stated that they could integrate disparate fragments of knowledge in making clinical inferences. They also expressed that they learned
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how to establish priorities depending on the rationale for the intervention. For example: Rather than just using the techniques and skills required for clinical training, I could actually take the theoretical principles from my head and apply them to the actual scene of the nursing intervention. At the hospital clinical training, it was limited to observation, instead of doing something really helpful for the patient. But through this hands-on clinical training, I was able to apply a particular nursing intervention to a patient with a particular condition.
Negative domains: Inability to answer questions, difficulty in setting priorities, and insufficient time allocation. However, participants reported some negative responses about narrowing down the gap between theory and practice, including their inability to answer questions asked by the simulator, the difficulty of setting priorities during interventions, and insufficient time allocation for nursing care. For example: I did not know how to answer when SimMan asked about the medication I had given to him, and when he kept complaining about chest pain even after I connected him to the oxygen tank. On the other hand, whenever I encountered difficult situations and patients threw questions at me like that, I realized that I had to study harder. Although I think I have learned a lot from SimMan, it was not good enough for me to learn how to deal with patients whom I might encounter in a real hospital. I need more time to practice.
Dimension 5: Follow-up effect Positive domains: Debriefing backup system, reinforcing effect, reflective effect, and gaining objectivity. Participants expressed that the debriefing session right after simulation training helped to reflect and reinforce clinical training. Through presentations made by each group and in-depth discussion following the presentations, the participants learned the importance of objectivity in nursing interventions. For example: During the debriefing session after simulation training was all over, I was able to reflect on my weaknesses in terms of the lack of knowledge and skills. I learned a lot from the feedback of other students in the debriefing section. During the debriefing session, it was very helpful to watch other teams making presentations, and from them, I found the answers to the questions that I had not figured out during simulation training. There is lack of negative domains related to dimension of follow-up effect.
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Table 2 Results of simulation effectiveness Strongly disagree, N (%) Agree, N (%) Strongly agree, N (%) The instructor’s questions helped me to think critically I feel better prepared to care for real patients I developed a better understanding of the pathophysiology of the conditions in the SCE I developed a better understanding of the medications that were administrated in the SCE I feel more confident in my decision-making skills I am more confident in determining what to tell the healthcare provider My assessment skills improved I feel more confident that I will be able to recognize changes in my real patient’s condition I am able to better predict what changes may occur with my real patients Completing the SCE helped me understand classroom information better I was challenged in my thinking and decision-making skills I learned as much from observing my peers as I did when I was actively involved in caring for the simulated patient Debriefing and group discussion were valuable
0 2 (6.5) 1 (3.2)
7 (22.6) 13 (41.9) 16 (51.6)
24 (77.4) 16 (51.6) 14 (45.2)
1 (3.1)
18 (58.1)
12 (38.7)
1 (3.2) 3 (9.7)
14 (45.2) 16 (51.6)
16 (51.6) 12 (38.7)
1 (3.2) 0
10 (32.3) 14 (45.2)
20 (64.5) 17 (54.8)
2 (6.5)
6 (19.4)
23 (74.2)
1 (3.2)
6 (19.4)
24 (77.4)
0 0
8 (25.8) 2 (6.5)
23 (74.2) 29 (93.5)
0
5 (16.1)
26 (83.9)
SCE, simulated clinical experience.
Effectiveness of high-fidelity simulation training Out of 31 participants who completed the questionnaires, more than 70% of the participants scored strongly agree on “I am able to better predict what changes may occur in my real patients”, “Completing the simulated clinical experience helped me understand classroom information better”, and “I was challenged in my thinking and decision-making skills”. Further, 29 students (93.5%) scored strongly agree on “I learned as much from observing my peers as I did when I was actively involved in caring for the simulated patient”, which indicated that observing peers was found to be a very effective learning process. As many as 26 students (83.9%) also scored strongly agree on debriefing and group discussion. On the other hand, only 12 students (38.7%) scored strongly agree on gaining confidence in communication with other nursing care providers, and 12 students (38.7%) on understanding medications that were administrated during simulation (see Table 2).
DISCUSSION This study was conducted to explore Korean junior nursing students’ first experience of a high-fidelity simulation training program. For this study, quantitative
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analysis of 33 students’ responses to the questionnaire and qualitative analysis of 18 students’ reflective journals were completed. As a result of the qualitative analysis, five dimensions in 31 domains emerged. The domains consisted of 18 positive and 13 negative areas reflecting the students’ first experiences with mixed feelings about simulation training. In the absence of students’ accessibility to real-life patients in a clinical setting, one of the most positive outcomes of simulation training is that the students are able to acquire a viable learning experience and develop nursing skills without any risks to the condition of the patient. Students learned not only technical nursing skills but also the entire nursing process, from patient assessment to nursing intervention and evaluation. It represented a broader spectrum of nursing process compared to partial task training. High-fidelity simulation is effective for improving learning motivation as described in the students’ eagerness for harder study on patient care after using the simulation (Kim et al., 2012). However, students reported lack of realism because of limitations in expressing patient signs and symptoms, as would be in real patients. It is critical to graft other strategies onto simulation to increase better reproducibility of clinical settings.
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Other advantages of the simulation training were characterized by a two prong approach: team performance and observational learning. Students reported a positive experience regarding the group dynamics. As a group, they could provide the patient with quicker and more efficient nursing care, through appropriate role allocation and good teamwork, than an individual nursing student could do. On the other hand, because this was their first exposure to this psychologically intense simulation environment, students reported being unable to pay attention to what their peers were doing. In order to solve such problems, further simulation should be organized with sufficient amounts of presimulation process focused on understanding the simulated patient and relieving stress. Although simulation training was reinforcing and interesting enough to attract students’ attention, students reported several negative experiences in the training, including insufficient preset timeline, lack of confidence and communication skills, interaction problems with peers, and difficulty in setting priority. The students also reported negative feelings of embarrassment and confusion during the simulation, not only in the qualitative analysis, but also in the quantitative analysis. Only 38.7% of the students scored strongly agree on the improvement in communication skills with other nursing care providers, and a little over half of the students (54.8%) scored strongly high on the acquisition of confidence in identifying changes in real patients’ conditions in a real clinical setting. These findings were consistent with other studies indicating that the participants in simulation had mixed feelings of increased interest, confidence, and achievement with anxiety and stupidity (Cant & Cooper, 2009; Lasater, 2007). Another study showed confidence and a sense of accomplishment coupled with negative experiences of anxiety and decreased satisfaction (Kim & Suh, 2012). In order to be more effective, the educational direction, the level of difficulty, and the stages of skill development should be clearly articulated (Suh, 2012) based on the students’ prerequisite learning (Lee & Kim, 2011). Accordingly, negative experiences that emerged in this study would play a critical role in setting up the level of task difficulty and the steps of simulation. Therefore, future simulation training programs should take steps to reorganize the structure and contents of simulation, in order to develop a more effective simulation scenario that can make up for the negative experiences found in this study and maximize the confidence in students (Suh, 2012). While performing nursing care,
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nursing students are apt to feel an enormous sense of burden that will only increase as the patient’s condition develops into an emergency (Hofmann, 2009; Park & Sun, 2003); thus, simulation training that is similar to a real-life situation is a valuable training tool, which can facilitate spontaneous thinking and improve clinical judgment and confidence in nursing care for the nursing students. Some students found themselves repeating the same mistakes as their peers even after they had observed their peers making the mistakes. In accordance with Bandura’s (1989) four stages of observational learning, attention, retention, initiation, and motivation, a number of the participants reported difficulty in even remembering what they had paid attention to during simulation. This might have occurred because the combination of different individual knowledge levels and the rapid automated simulation timeline made it difficult for the students to remember or structure the information in an easy-to-access form. Thus, it is necessary to adjust the whole process of simulation to fit students’ individual paces and to provide the students with more opportunities to acquire skills for reproducing appropriate actions. Finally, debriefing, a process of gaining reflective insight into an experience and strengthening the learning process by receiving feedback after certain activities are accomplished, is one of the most important parts of simulation (Issenberg, McGaghie, Petrusa, Lee Gordon, & Scalese, 2005; Reilly & Spratt, 2007). By thinking back on what happened in simulation, the participants in this study expressed that they had a very meaningful opportunity to reflect on the tasks through the debriefing session. Quantitative analysis also showed the importance of debriefing, indicating that it would be worthwhile to strengthen the debriefing process. The limitation of this study was that the number of participants was small and response rate of journaling was low. Finally, further study is needed to verify the difference between the first experience and multiple experiences of simulation practice.
CONCLUSION Korean nursing students who participated in highfidelity simulation training for the first time had positive experiences of machine–human interaction in a safer environment, perceived learning capability, observational learning, reconciling practice with theory, and follow-up debriefing effect. Future simulation developed on the basis of negative experiences, such as time
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allotment in simulation, will allow students to improve cooperativeness and interaction with their peers, as well as communication skills, resulting in improved confidence.
CONFLICT OF INTEREST The authors declare that there is no conflict of interest. Funding sources had no role in this study.
AUTHOR CONTRIBUTION All authors contributed to the conception and design of this study, the collection and analyses of the data, the preparation of the manuscript, the interpretation of the results, and drafting of the manuscript.
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Hofmann, B. (2009). Why simulation can be efficient: on the preconditions of efficient learning in complex technology based practices. BMC Medical Education, 9, 48. Issenberg, S. B., McGaghie, W. C., Petrusa, E. R., Lee Gordon, D. & Scalese, R. J. (2005). Features and uses of highfidelity medical simulations that lead to effective learning: A BEME systematic review. Medical Teacher, 27, 10–28. Kim, D. H., Lee, Y. J., Hwang, M. S., Kim, H. S. & Cha, H. G. (2012). Effects of a Simulation-based Integrated Clinical Practice Program (SICPP) on the Problem Solving Process, Clinical Competence and Critical Thinking in a Nursing Student. The Journal of Korean Academic Society of Nursing Education, 18, 499–509 (in Korean). Kim, H. W. (2013). Development and application of phased nursing simulation modules: Based on a conceptual framework of 3-D nursing simulation education. Unpublished dissertation. Seoul National University. Korea (in Korean). Kim, H. W. & Suh, E. Y. (2012). Nursing Students’ Immersion Experience in a Comprehensive Simulation Scenario Using High-Fidelity Human Patient Simulator among Nursing Students: A Phenomenological Study. Journal of Military Nursing Research, 30, 89–99 (in Korean). Kim, Y. H. & Jang, K. S. (2011). Effect of a Simulation-based Education on Cardio-pulmonary Emergency Care Knowledge, Clinical Performance Ability and Problem Solving Process in New Nurses. Journal of Korean Academy of Nursing, 41, 245–255 (in Korean). Lasater, K. (2007). High fidelity simulation and the development of clinical judgment: students’ experiences. Journal Nursing Education, 46, 269–275. Lee, J. H., Kim, S. S., Yeo, K. S., Cho, S. J. & Kim, H. L. (2009). Experiences among undergraduate nursing students on high-fidelity simulation education: a focus group study. The Journal of Korean Academic Society of Nursing Education, 15, 183–193 (in Korean). Lee, S. O., Eom, M. R. & Lee, J. H. (2007). Use of simulation in nrsing education. The Journal of Korean Academic Society of Nursing Education, 13, 90–94 (in Korean). Lee, W. S. & Kim, M. (2011). Effects and adequacy of highfidelity simulation-based training for obstetrical nursing. Journal of Korean Academy Nursing, 41, 433–443. http:// dx.doi.org/10.4040/jkan.2011.41.4.433 (in Korean). Malouf, N. & West, S. (2011). Fitting in: a pervasive new graduate nurse need. Nurse Education Today, 31, 488– 493. Park, J. W. & Sun, H. N. (2003). Nursing students’ clinical experiences. Journal of Korean Academic Psychiatric Mental Health Nursing, 12, 27–35 (in Korean). Pedro, J. (2006). Taking reflection into the real world of teaching. Kappa Delta Pi Record, 42, 129–136. Reilly, A. & Spratt, C. (2007). The perceptions of undergraduate student nurses of high-fidelity simulation-based learning: A case report from the University of Tasmania. Nurse Education Today, 27, 542–550.
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Shim, K. K. (2012). The reliability and validity of the Lasater clinical judgement rubric in Korean nursing students. (Doctoral dissertation). Kyung Hee University, Seoul, Korea. Suh, E. E. (2012). Development of a conceptual framework for nursing simulation education utilizing human patient simulators and standardized patients. Journal of Korean
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Academy Society Nursing Education, 18, 206–219 (in Korean). Wotton, K., Davis, J., Button, D. & Kelton, M. (2010). Thirdyear undergraduate nursing students’ perceptions of high fidelity simulation. The Journal of Nursing Education, 49, 632–639.
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doi:10.1111/jjns.12062
ORIGINAL ARTICLE
First experiences of high-fidelity simulation training in junior nursing students in Korea Suk Jeong LEE,1 Sang Suk KIM1 and Young-Mi PARK2 1 Red Cross College of Nursing, Chung-Ang University (CAU), CAU Healthcare System, Seoul and 2Ansan College of Nursing, Ansan, Korea
Abstract Aim: This study was conducted to explore first experiences of high-fidelity simulation training in Korean nursing students, in order to develop and establish more effective guidelines for future simulation training in Korea. Methods: Thirty-three junior nursing students participated in high-fidelity simulation training for the first time. Using both qualitative and quantitative methods, data were collected from reflective journals and questionnaires of simulation effectiveness after simulation training. Descriptive statistics were used to analyze simulation effectiveness and content analysis was performed with the reflective journal data. Results: Five dimensions and 31 domains, both positive and negative experiences, emerged from qualitative analysis: (i) machine–human interaction in a safe environment; (ii) perceived learning capability; (iii) observational learning; (iv) reconciling practice with theory; and (v) follow-up debriefing effect. More than 70% of students scored high on increased ability to identify changes in the patient’s condition, critical thinking, decision-making, effectiveness of peer observation, and debriefing in effectiveness of simulation. Conclusion: This study reported both positive and negative experiences of simulation. The results of this study could be used to set the level of task difficulty in simulation. Future simulation programs can be designed by reinforcing the positive experiences and modifying the negative results. Key words: Korea, nursing education, nursing student, patient simulation.
INTRODUCTION The demands for the protection of patient rights and safety have become a major issue in medical and nursing care systems over the past decade. The protection of patient safety has caused difficulty in finding real patients for students’ clinical training (Cho & Kwon, 2007) and has shifted the direction of clinical training to mere observation and simple skill development (Benner, Sutphen, Leonard, & Day, 2010). The success of clinical training relies on the ability of a student to apply
Correspondence: Sang Suk Kim, Red Cross College of Nursing, Chung-Ang University(CAU), 84 Heukseok-Ro, Dongjak-Gu, Seoul 156-861, Korea. Email: [email protected] Received 6 December 2013; accepted 13 September 2014.
relevant knowledge and theoretical principles to competent nursing problem solving action. However, without enough opportunity of caring for real patients in a clinical setting, nursing students have difficulty in adjusting to complicated nursing situations after they graduate from nursing colleges (Kim & Jang, 2011; Malouf & West, 2011). Such obstacles have facilitated innovative training strategies in nursing and simulation has emerged as one of the viable alternatives. Organized in an environment similar to a real-life clinical setting, simulation training was introduced as an innovative alternative to conventional training in nursing in the early 1990s, in advanced countries (Kim, 2013). However, in Korea, it was not until the early 2000s that nursing colleges started to include simulation-based clinical training (Lee, Eom, & Lee, 2007). Currently, a number of 3 year nursing colleges in
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Korea have merged into a 4 year diploma program with modified curriculums, including simulations. Simulation is one of the up-and-coming learning strategies in the nursing curriculum, especially for nursing practice. It is critical to identify the effectiveness and meaning of highfidelity simulation for nursing students, to consider the applicability of simulation to nursing curriculum, and to set the task difficulty level. The types of simulation consist of partial task training, role play, and computer-based simulation (Gaba, 2007). While partial task training is used for simple technical skills, high-fidelity simulation refers to structured student learning experiences with the use of a technologically advanced computerized mannequin, the Human Patient Simulator (Lasater, 2007). The comparative clinical performance between partial task training and high-fidelity simulation revealed that those who had completed high-fidelity simulation were more likely have improved ability to perform nursing intervention and critical thinking (Kim, Lee, Hwang, Kim, & Cha, 2012). High-fidelity simulation was more effective in increasing confidence and communication skills with other nursing care providers, and reinforcing motivation for learning (Fero et al., 2010; Wotton, Davis, Button, & Kelton, 2010). Adamson (2011) emphasized the importance of the suitability of simulation that could produce effective learning outcomes in students. Previous assessments of the suitability of simulation for clinical training were mainly reported on pre- and post-training comparisons using questionnaires, and few have attempted any in-depth understanding of how and why simulation users perceived a given training tool to be effective. The studies that reported effectiveness of simulation had limitations of cultural and ethnic diversity of students (Lasater, 2007; Reilly & Spratt, 2007). Simulation provides opportunity for practice activities prior to clinical practice and provides a special learning experience to nursing students who have never been exposed to simulation. It is a challenge for Korean nursing students who are not familiar with team approach nursing care and do not communicate with patients frequently. A systemic review article identified the importance of providing feedback, repetitive practice, curriculum, range of difficulty level, and multiple learning strategies as important variables of effective simulation education (Issenberg, McGaghie, Petrusa, Gordon, & Scalese, 2005). However, Korean qualitative studies of student experience of high-fidelity simulation either focused on the meaning of the experience, or students were exposed to simulation prior to the study
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(Kim & Suh, 2012; Lee, Kim, Yeo, Cho, & Kim, 2009). Exploring students’ first experiences with high-fidelity simulation provides valuable insight into what is effective and the modifications needed. This study may contribute evidence to support further integration of high-fidelity simulation in nursing programs, valuable information to establish effective strategies, and resources for suitable guidelines based on the levels of task difficulty for simulation training.
METHOD Design Using a mixed research method, this study analyzed students’ reflective journals to explore their first experience of simulation training qualitatively. Additionally, the effectiveness of simulation training was analyzed quantitatively using a questionnaire.
Participants Participants in this study included 33 junior nursing students in Korea, who had no previous experience in simulation. As many as 18 participants agreed to write reflective journals, while 31 students completed questionnaires.
Data collection Reflective journal writing is a valuable method of collecting anecdotal evidence of students’ subjective perceptions of clinical training. This practice leads students to develop critical thinking, self-understanding, and reflection (Billings, 2006). Pedro (2006) also pointed out that journaling served as a valuable tool to keep track of the students approach to problem solving. The following questions were provided to participants: (i) “What kind of experience did you have from the method of high-fidelity simulation training?”; (ii) “What kind of experience have you had from the instructional process for simulation training?”; (iii) “What kind of experience have you had from the interaction with your peers?”; and (iv) “What kind of experience have you had in terms of the applicability of what you have learned in the simulation program to a real-life clinical case?”. The length of the text was 3 pages and the duration of each student’s journaling time was between 20 and 30 min. The reflective journals were collected by mail 10 days after simulation training, and immediately after completing simulation, a questionnaire was administered. The present authors measured the effectiveness of simulation, developed by Elfrink Cordi, Leighton, and
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Ryan-Wenger (2012), and translated into Korean by Shim (2012), which consisted of 13 questions with eight items of learning and five items of confidence areas. It was a 3 point scale ranging from 1 (“strongly disagree”) to 3 (“strongly agree”).
Procedure The half-day training program was centered on a simulated patient, SimMan, calibrated to present symptoms of dyspnea. The simulation scenario was developed in 2009 at the simulation center of a nursing college in Seoul, Korea, where it has been used since. The simulation procedure included four sessions including orientation, briefing, simulation operation, and debriefing. Students were divided into small groups of 2–3; two groups worked as a team and one group performed simulation training, while the other group observed, and took turns. At the end of the simulation, three instructors led a 30 min debriefing session for their participants to reflect on their performances during the scenario. The instructors asked the students to reflect on what happened during the scenario, analyze their actions, and summarize lessons learned from the participation. At the end of the debriefing, each participant was asked to complete a questionnaire on simulation effectiveness. Reflective journals were collected 10 days after simulation training by mail.
Ethical considerations Before this study was conducted, approval was obtained from the institutional review board of the nursing college. Full explanations on the purpose of the study and confidentiality of personal information were given to all the participants in this study. Participants were informed that writing journals did not affect school grades, they could withdraw from the study at anytime, and that they would not be penalized for noninvolvement in the study. Written consent was obtained from all participants.
RESULTS Content analysis of reflective journals The response rate for the reflective journals was 18 out of 33 (55%), two were male nursing students and 16 were female, with an average age of 21.1 years (± standard deviation, 0.64). None had previous experience of high-fidelity simulation. Through the analysis, 31 positive and negative domains of textual responses emerged, which were grouped into five dimensions. Table 1 lists key improvement areas suggested in each dimension.
Table 1 Key improvement areas in each dimension after the simulation
Data analysis A qualitative content analysis was employed to identify the recurring patterns in the texts of participants’ reflective journals. This process highlighted key domains and allowed for taxonomic classification. During the content analysis process, three researchers verified whether the textual responses were pertinent to, and incorporated within, the domains by repeatedly underlining the recurring patterns through a process of comparison, classification, and abstraction. The process was repeated until an acceptable level of inter-rater agreement and reliability was achieved. All discrepancies were discussed in person, and the opinion of an independent expert was obtained in several ambiguous cases to reach agreement on classification. Another nursing educator, specialized in qualitative research method, was involved in evaluating the overall research methodology and provided feedback whenever the analysis and interpretation of the data needed verifying.
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Descriptive statistics were applied to analyze the effectiveness of simulation.
Dimension Machine–human interaction Perceived learning capabilities
Observational learning Reconciling practice with theory
Follow-up effect
Key improvement areas A richer nursing experience without jeopardizing the patient’s condition A sense of reality Motivation toward learning Confidence in clinical nursing A sense of accomplishment A feeling of empathy for patients Learning both desirable and undesirable behavior Realized the importance of fundamental nursing skills Provide effective replies to patients questions Patient education at the level of patient’s understanding Reflect and reinforce clinical training Learning the importance of objectivity in nursing intervention
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Dimension 1: Machine–human interaction Positive domains: Voice interaction and safe environment. Most of the participants mentioned that highfidelity simulation was a very interesting method of learning, and they felt safe with the simulated patient. They suggested they could have a richer nursing experience without jeopardizing a patient’s condition. Moreover, most of the students reported a sense of reality on hearing the simulator-generated voice. The simulated patient issued vocal outputs describing its symptoms of dyspnea and asking the participants questions about nursing interventions for symptom management. Through interaction with the voice-activated simulator, the students experienced greater immersion in the program. For example: The simulation training was quite a lifelike experience, because SimMan complained about his symptoms like a real patient. When he asked me questions, SimMan did it much like a real symptomatic patient who constantly wondered what his problems were. With this simulation, I could actually touch the medical equipment with my hands and communicate with SimMan like a real patient. I have to be more careful and attentive to the patient needs if he or she is a real patient in a hospital. Even worse, when people become nervous about what they have to do for a patient, they tend to make more mistakes than they expect. For that reason, preceptor nurses do not want nursing students to engage in direct nursing care in the hospital. As a result, it is very difficult for me to get experience, but this simulation training program did not impose any risks of accidental wrongdoing. As it turned out, I could try as many different nursing interventions as I wanted and learned a lot from this simulation.
Negative domains: Preset arrangement of time and parameters and lack of realism. Negative reported statements for simulation training were related to the automated timing of the simulated patient’s questions and responses. Participants expressed that the timing was too rapid to follow. The participants stated that they wanted the simulation operation to be slower and better adjusted to fit novice students at simulation. They also preferred the option of repetitive learning for bedside training; they suggested that it would enhance critical thinking and their ability to make effective clinical inferences. For example: We had to hurry when allocating each person’s role because we did not have enough time to prepare and react to what SimMan wanted us to do.
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If we had more time for training, we could answer SimMan’s questions a lot better than we did this time. In order to improve my ability to make inferences and think critically, I need more hands-on experience with this simulated patient.
Another negative response was related to a decreased sense of realism in simulation. Some participants indicated that the reactions made by the simulated patient and the circumstances under which the mechanical patient was suffering were not sufficiently similar to a real-life clinical setting. For example: The simulator was not a human being, but a model, so it was unable to move any part of the body like a real patient. I thought that a real patient would exhibit anxiety or stress resulting from severe symptoms in that situation.
Dimension 2: Perceived learning capabilities Positive domains: Motivation for learning, confidence in nursing care, sense of achievement, and empathy with patient. Another dimension of experiencing simulation training was related to the self-perceived personal traits or attributes contributing to, or hindering, learning. Positive personal traits for learning included improvement in motivation toward learning, confidence in clinical nursing, a sense of accomplishment, and a feeling of empathy for the patient. All of these traits helped the students provide proper nursing interventions to the patient, without confusion. For example: After I had experienced simulation, I felt a lot more confident in coping with real-life situations similar to this, and I feel like I can take care of real patients a lot better than before. Even when I had clinical training in the medical–surgical nursing department for adult patients, I felt that clinical training focused more on theoretical knowledge than practice, so I did not think that that clinical training for adult patients was good enough for practical application. However, after this simulation, I was satisfied because not only had I gained some relevant knowledge but I was also able to take the initiative in performing nursing techniques that might not have been allowed in a real-life clinical setting. Furthermore, I could move on to the next action without interruption. I was able to try every single nursing technique in very little time.
The participants stated the importance of feeling empathy toward the patient. Participants were able to learn how to share feelings and emotions with the simulated patient. By sharing feelings, they also learned how to explain the principles of nursing care to the patient
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from the patient’s point of view, not from the professional point of view. For example: I was surprised to find that some of my basic knowledge was not basic to the patient. I mean, the patient wanted to know a lot about his condition, but did not understand what I considered to be very basic knowledge. So, I realized that I have to explain what the patient really wants to know in more layman terms.
Negative domains: Lack of confidence, poor judgment, lack of communication skills, and lack of basic nursing skills. Throughout the simulation process, participants realized the limits of their capacity and clinical competency. Examples included their inability to explain the intended nursing intervention correctly to the simulator, feeling inferior to, and less competent than, their peers, and having difficulty in establishing priorities in nursing intervention because of a lack of pertinent knowledge. For example: While I gave my answer to SimMan’s question on his breathing difficulty, I tried to think about how I could help him, and became desperate when I could not help SimMan alleviate his symptoms. I came to realize that I did not have enough knowledge for nursing care, and I needed to know how to prioritize nursing care for him.
Many participants realized that they lacked communication and basic nursing skills. The participants experienced these problems when encountering a patient with severe symptoms and when explaining what nursing intervention the patient would receive in a manner grounded in theory and knowledge. For example: If I cannot convey what I know to the patient properly, I think that it will be useless and dead knowledge. I became aware that it is very important for me to explain the condition of the disease and nursing intervention to the patient, but I do not think that I am good enough. I believe I have a lot to learn on how to communicate with the patient more effectively.
Dimension 3: Observational learning Positive domains: Learning by observing others, group dynamics, efficiency in tasks, and teachable moments. Observational learning refers to learning that occurs by observing others’ behavior (Bandura, 1989). In this study, participants stated they learned the following when they took on the role of observers: effectiveness of learning by observing their peers, understanding of group dynamics, efficiency of
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performing tasks in teams, and teachable moments. The participants indicated that they learned by observing what and how other team members performed nursing interventions. The participants learned both desirable and undesirable behavior through observational learning. For example: I think I learned what to do and what not to do for patient care while I observed other students. Not only did I learn the dos and don’ts from my friends, but I also learned that I could make the same mistakes as they did even after watching them make those mistakes.
The participants stated that they were able to work effectively in teams although they had never experienced it before in conventional clinical training. They suggested that cooperative work was more efficient than individually provided nursing care. The participants also pointed out the importance of interpersonal solidarity among team members, who could help each other and break down tasks into simpler actions. For example: If I was put in such a situation alone, I would be at a loss for an answer to my patient’s questions and could not possibly do anything at all on my own. However, our team members helped and cooperated with each other, so we were able to come up with a better solution than I could alone.
Not only observing, but also sharing others’ experiences facilitated and reinforced the learning process. It served as one of the most appropriate “teachable moments”. For example: When I observed other students doing what I was curious about and what I had failed to do during my turn, it was a very special moment of learning to me.
Negative domains: Lack of interaction with peers, time constraints, hindering personal attributes, and decrease in realism. Despite the importance and effectiveness of good teamwork, participants in this study felt that there were negative experiences of teamwork, as well. Specifically, they highlighted an overall lack of active interaction among group members due to the lack of time for clearly defining roles among team members. Additionally, participants indicated that group members’ personal traits and attributes hindered group dynamics, resulting in individual members doing only their own tasks and paying no attention to others. As a result, participants stated that they could not remember what their peers had done in teamwork. For example:
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During simulation, I could hardly pay attention to what the other students were doing because I was so preoccupied with my own job and nervous about doing it correctly. I could not remember what my team members had done. That was something that I regretted. I think I learned by observing my friends commit errors in very basic nursing care, and thought that I would never make such mistakes while I was watching. However, when it came to my turn, I found myself making the same mistakes as my friends. I learned the lesson that fundamental nursing skills are apt to be forgotten, so that I have to make every effort to keep them alive to provide good nursing care.
The participants stated that working in teams was also very different from the conventional one-on-one clinical training. None of the participants had experienced a team environment before simulation. For example: In a real clinical situation, we do not observe a single patient with many nursing students together, so the team approach did not feel like a real situation to me.
Dimension 4: Reconciling practice with theory Positive domains: Utilization of knowledge, cope with emergency, patient education, readiness for real-life cases. When participants were asked to apply what they had learned from simulation to real-life nursing situations, many stated that they realized the importance of fundamental nursing skills that could be applied to nursing interventions to best suit the particular needs of a patient. They could also act as effective replies to patients’ abrupt and unexpected questions, as well as a method of patient education at the patient’s level of understanding. The participants described simulation training as enrichment experience in reconciling theory with practice. For example: Today’s simulation required us to cope with an emergency situation, and I could learn how to manage and choose the most appropriate nursing intervention tailored for the needs of SimMan, which were changing at every single moment of the situation. Inasmuch as an experienced and skillful nurse in a clinical setting can become an expert, I will get accustomed to any clinical situation and cultivate the ability to adapt to new clinical environments if I gain experience through this simulation. I hope I will have more such opportunities to practice.
In addition, through hands-on experiences with the simulated patient, the participants stated that they could integrate disparate fragments of knowledge in making clinical inferences. They also expressed that they learned
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how to establish priorities depending on the rationale for the intervention. For example: Rather than just using the techniques and skills required for clinical training, I could actually take the theoretical principles from my head and apply them to the actual scene of the nursing intervention. At the hospital clinical training, it was limited to observation, instead of doing something really helpful for the patient. But through this hands-on clinical training, I was able to apply a particular nursing intervention to a patient with a particular condition.
Negative domains: Inability to answer questions, difficulty in setting priorities, and insufficient time allocation. However, participants reported some negative responses about narrowing down the gap between theory and practice, including their inability to answer questions asked by the simulator, the difficulty of setting priorities during interventions, and insufficient time allocation for nursing care. For example: I did not know how to answer when SimMan asked about the medication I had given to him, and when he kept complaining about chest pain even after I connected him to the oxygen tank. On the other hand, whenever I encountered difficult situations and patients threw questions at me like that, I realized that I had to study harder. Although I think I have learned a lot from SimMan, it was not good enough for me to learn how to deal with patients whom I might encounter in a real hospital. I need more time to practice.
Dimension 5: Follow-up effect Positive domains: Debriefing backup system, reinforcing effect, reflective effect, and gaining objectivity. Participants expressed that the debriefing session right after simulation training helped to reflect and reinforce clinical training. Through presentations made by each group and in-depth discussion following the presentations, the participants learned the importance of objectivity in nursing interventions. For example: During the debriefing session after simulation training was all over, I was able to reflect on my weaknesses in terms of the lack of knowledge and skills. I learned a lot from the feedback of other students in the debriefing section. During the debriefing session, it was very helpful to watch other teams making presentations, and from them, I found the answers to the questions that I had not figured out during simulation training. There is lack of negative domains related to dimension of follow-up effect.
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Table 2 Results of simulation effectiveness Strongly disagree, N (%) Agree, N (%) Strongly agree, N (%) The instructor’s questions helped me to think critically I feel better prepared to care for real patients I developed a better understanding of the pathophysiology of the conditions in the SCE I developed a better understanding of the medications that were administrated in the SCE I feel more confident in my decision-making skills I am more confident in determining what to tell the healthcare provider My assessment skills improved I feel more confident that I will be able to recognize changes in my real patient’s condition I am able to better predict what changes may occur with my real patients Completing the SCE helped me understand classroom information better I was challenged in my thinking and decision-making skills I learned as much from observing my peers as I did when I was actively involved in caring for the simulated patient Debriefing and group discussion were valuable
0 2 (6.5) 1 (3.2)
7 (22.6) 13 (41.9) 16 (51.6)
24 (77.4) 16 (51.6) 14 (45.2)
1 (3.1)
18 (58.1)
12 (38.7)
1 (3.2) 3 (9.7)
14 (45.2) 16 (51.6)
16 (51.6) 12 (38.7)
1 (3.2) 0
10 (32.3) 14 (45.2)
20 (64.5) 17 (54.8)
2 (6.5)
6 (19.4)
23 (74.2)
1 (3.2)
6 (19.4)
24 (77.4)
0 0
8 (25.8) 2 (6.5)
23 (74.2) 29 (93.5)
0
5 (16.1)
26 (83.9)
SCE, simulated clinical experience.
Effectiveness of high-fidelity simulation training Out of 31 participants who completed the questionnaires, more than 70% of the participants scored strongly agree on “I am able to better predict what changes may occur in my real patients”, “Completing the simulated clinical experience helped me understand classroom information better”, and “I was challenged in my thinking and decision-making skills”. Further, 29 students (93.5%) scored strongly agree on “I learned as much from observing my peers as I did when I was actively involved in caring for the simulated patient”, which indicated that observing peers was found to be a very effective learning process. As many as 26 students (83.9%) also scored strongly agree on debriefing and group discussion. On the other hand, only 12 students (38.7%) scored strongly agree on gaining confidence in communication with other nursing care providers, and 12 students (38.7%) on understanding medications that were administrated during simulation (see Table 2).
DISCUSSION This study was conducted to explore Korean junior nursing students’ first experience of a high-fidelity simulation training program. For this study, quantitative
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analysis of 33 students’ responses to the questionnaire and qualitative analysis of 18 students’ reflective journals were completed. As a result of the qualitative analysis, five dimensions in 31 domains emerged. The domains consisted of 18 positive and 13 negative areas reflecting the students’ first experiences with mixed feelings about simulation training. In the absence of students’ accessibility to real-life patients in a clinical setting, one of the most positive outcomes of simulation training is that the students are able to acquire a viable learning experience and develop nursing skills without any risks to the condition of the patient. Students learned not only technical nursing skills but also the entire nursing process, from patient assessment to nursing intervention and evaluation. It represented a broader spectrum of nursing process compared to partial task training. High-fidelity simulation is effective for improving learning motivation as described in the students’ eagerness for harder study on patient care after using the simulation (Kim et al., 2012). However, students reported lack of realism because of limitations in expressing patient signs and symptoms, as would be in real patients. It is critical to graft other strategies onto simulation to increase better reproducibility of clinical settings.
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Other advantages of the simulation training were characterized by a two prong approach: team performance and observational learning. Students reported a positive experience regarding the group dynamics. As a group, they could provide the patient with quicker and more efficient nursing care, through appropriate role allocation and good teamwork, than an individual nursing student could do. On the other hand, because this was their first exposure to this psychologically intense simulation environment, students reported being unable to pay attention to what their peers were doing. In order to solve such problems, further simulation should be organized with sufficient amounts of presimulation process focused on understanding the simulated patient and relieving stress. Although simulation training was reinforcing and interesting enough to attract students’ attention, students reported several negative experiences in the training, including insufficient preset timeline, lack of confidence and communication skills, interaction problems with peers, and difficulty in setting priority. The students also reported negative feelings of embarrassment and confusion during the simulation, not only in the qualitative analysis, but also in the quantitative analysis. Only 38.7% of the students scored strongly agree on the improvement in communication skills with other nursing care providers, and a little over half of the students (54.8%) scored strongly high on the acquisition of confidence in identifying changes in real patients’ conditions in a real clinical setting. These findings were consistent with other studies indicating that the participants in simulation had mixed feelings of increased interest, confidence, and achievement with anxiety and stupidity (Cant & Cooper, 2009; Lasater, 2007). Another study showed confidence and a sense of accomplishment coupled with negative experiences of anxiety and decreased satisfaction (Kim & Suh, 2012). In order to be more effective, the educational direction, the level of difficulty, and the stages of skill development should be clearly articulated (Suh, 2012) based on the students’ prerequisite learning (Lee & Kim, 2011). Accordingly, negative experiences that emerged in this study would play a critical role in setting up the level of task difficulty and the steps of simulation. Therefore, future simulation training programs should take steps to reorganize the structure and contents of simulation, in order to develop a more effective simulation scenario that can make up for the negative experiences found in this study and maximize the confidence in students (Suh, 2012). While performing nursing care,
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nursing students are apt to feel an enormous sense of burden that will only increase as the patient’s condition develops into an emergency (Hofmann, 2009; Park & Sun, 2003); thus, simulation training that is similar to a real-life situation is a valuable training tool, which can facilitate spontaneous thinking and improve clinical judgment and confidence in nursing care for the nursing students. Some students found themselves repeating the same mistakes as their peers even after they had observed their peers making the mistakes. In accordance with Bandura’s (1989) four stages of observational learning, attention, retention, initiation, and motivation, a number of the participants reported difficulty in even remembering what they had paid attention to during simulation. This might have occurred because the combination of different individual knowledge levels and the rapid automated simulation timeline made it difficult for the students to remember or structure the information in an easy-to-access form. Thus, it is necessary to adjust the whole process of simulation to fit students’ individual paces and to provide the students with more opportunities to acquire skills for reproducing appropriate actions. Finally, debriefing, a process of gaining reflective insight into an experience and strengthening the learning process by receiving feedback after certain activities are accomplished, is one of the most important parts of simulation (Issenberg, McGaghie, Petrusa, Lee Gordon, & Scalese, 2005; Reilly & Spratt, 2007). By thinking back on what happened in simulation, the participants in this study expressed that they had a very meaningful opportunity to reflect on the tasks through the debriefing session. Quantitative analysis also showed the importance of debriefing, indicating that it would be worthwhile to strengthen the debriefing process. The limitation of this study was that the number of participants was small and response rate of journaling was low. Finally, further study is needed to verify the difference between the first experience and multiple experiences of simulation practice.
CONCLUSION Korean nursing students who participated in highfidelity simulation training for the first time had positive experiences of machine–human interaction in a safer environment, perceived learning capability, observational learning, reconciling practice with theory, and follow-up debriefing effect. Future simulation developed on the basis of negative experiences, such as time
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allotment in simulation, will allow students to improve cooperativeness and interaction with their peers, as well as communication skills, resulting in improved confidence.
CONFLICT OF INTEREST The authors declare that there is no conflict of interest. Funding sources had no role in this study.
AUTHOR CONTRIBUTION All authors contributed to the conception and design of this study, the collection and analyses of the data, the preparation of the manuscript, the interpretation of the results, and drafting of the manuscript.
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