Crit Care Nurs Q Vol. 38, No. 1, pp. 81–88 c 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
Forensic Nursing Science Knowledge and Competency The Use of Simulation Stacy A. Drake, PhD, MPH, RN; Rae Langford, EdD, RN; Anne Young, EdD, RN; Constance Ayers, PhD, RN Forensic nursing is a nursing specialty that provides services to a variety of patient populations who have experienced violence, including interpersonal violence, sudden or unexpected death, and motor vehicle collisions. However, many critical care nurses have received the background knowledge or practical skills required to provide the level of care required by many forensic patients. The purpose of this study was to determine whether differences in knowledge or practical competence exist between participants using 2 different learning modalities: medium fidelity simulation versus face-to-face lecture. Participants who were enrolled in an elective online forensic nursing science course were randomly assigned to an intervention or control group. The 18 intervention group participants were given three 2-hour forensic simulation sessions in the laboratory. The 17 control group participants attended 3 face-to-face lectures covering forensic science topics. All study participants also received the same forensic course content via the online Blackboard platform. No significant differences were found between the 2 groups in either knowledge or practical competency. The lack of results may have been heavily influenced by the small sample size, which resulted in insufficient power to detect possible differences. Key words: evaluation, forensic nursing science education, simulation
F
ORENSIC NURSING SCIENCE is a recognized nursing specialty1 that supports practice roles such as sexual assault nurse examiners, clinical forensic nurse examiners, legal nurse consultants, and forensic nurse death investigators. Although practicing critical care nurses often encounter situations that require knowledge of and competency
Author Affiliations: The University of Texas Health Science Center at Houston School of Nursing (Dr Drake); and Nelda C. Stark College of Nursing, Texas Woman’s University, Houston (Drs Langford, Young, and Ayers). The study was financially supported by a grant from John Winston Carter fund. To the authors’ knowledge, no conflict of interest, financial or otherwise, exists. The authors had no sponsors in concept, design, data collection, analysis, or interpretation. Correspondence: Stacy A. Drake, PhD, MPH, RN, The University of Texas Health Science Center at Houston School of Nursing, 6901 Bertner Ave #748, Houston, TX 77030 ([email protected]). DOI: 10.1097/CNQ.0000000000000045
in medicolegal aspects of patient care,2 basic nursing education usually does not include much of the specialty knowledge needed to care for forensic patients. A forensic patient, as defined by Fulton and Assid,3 is any patient who may potentially have criminal or civil liability, specific to the circumstances in which services are sought. Many published articles discuss the advantage of integrating simulation into academia.4,5 However, there is very little published research associated with simulation and forensic patient populations.6,7 Therefore, this project was designed to determine whether the commonly used teaching technique, simulation, is an effective way to enhance participant skills and enable nurses to respond appropriately when encountering forensic patients within the clinical setting. BACKGROUND The use of simulation as a teaching strategy within nursing and other health care 81
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
82
CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2015
professions is well supported in literature.4,5 However, few researchers have investigated the effectiveness of using simulation as a modality in teaching forensic nursing science. To date, the most frequent use of simulated forensic scenarios has occurred with sexual assault nurse examiner training.6-9 Sexual assault victims are not the most common type of forensic patients cared for by critical care nurses. Therefore, critical care nurses may not be familiar with the roles and responsibilities inherent in caring for typical critical care forensic patients and can have difficulty incorporating forensic concepts into patient care.2,9 The use of simulation allows the learner to be immersed in patient situations and then later permits selfreflection and reevaluation of patient care actions and decisions.5 Hoyt10 maintains that nurses should not have an option of whether they are involved in forensic patient care, instead, believes that it should be a distinct part of professional practice. SIGNIFICANCE Without knowledge of how to assess, interpret, document, and intervene with forensic issues such as abuse or neglect and recognize sudden, unexpected, or nonnatural death, health care facilities and nurses are at risk for legal repercussions as well as financial and professional sanctions. Providing forensic training to all nurses enables them to implement patient-centered care in a responsive manner. QUESTION ADDRESSED The research question posed was whether 2 groups of nursing participants enrolled in an online forensic nursing science course would demonstrate differences in knowledge and skill proficiency when an experimental group received a simulation-based intervention and a control group received face-to-face lecture material. The hypothesis was that participants taking part in clinical forensic simulation scenarios would be more knowledgeable of their
responsibilities in caring for forensic patients and more proficient in the application of their forensic skills than participants in the control group. METHODS The research participants were randomly assigned into an intervention group or an attention control group. A basic posttest-only design was used to evaluate the effectiveness of a simulation intervention on education outcomes. In this design, the intervention group completed 3 laboratory exercises, 2 hours per session, using 3 different simulation scenarios. The second group served as an attention control group and received an equivalent amount of time listening to face-to-face lectures in a classroom setting. An attention control group method was used to rule out the possibility that attention provided to the simulation group was not an additional contributor to any research outcome.11 Setting and course description The setting was a school of nursing in a large metropolitan area in the southwestern United States. The introductory forensic nursing science course was conducted as an online elective for academic or continuing education credit. The online portion of the course was given in conjunction with an intervention teaching modality (simulation) versus face-to face lectures (attention control). Identical online content was presented to both the intervention and control groups as modules. The online module topics included forensic nursing process, interpersonal violence, evidence principles and techniques, mechanism of injury, public health and epidemiology, medicolegal death investigation, and forensic nursing standards. The online content was provided as a Microsoft PowerPoint presentation and included the following: learning objectives, key terms, and required readings; module-associated questions to guide the participant’s study; individual and team assignments; and additional resources.
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Forensic Nursing Science Knowledge and Competency The principal research investigator (PI) was one of the coinstructors for the online forensic course. This instructor had a background in medicolegal death investigation and was an advanced forensic nurse, boardcertified, by the American Nurses Credentialing Center. The second coinstructor for the online forensic course participated in evaluating the online discussion board postings, grading individual assignments, and served as one of the faculty evaluators for the final research simulation exercises. Five additional faculty members, who also served as evaluators of the final research simulation exercise, had varied experience in forensic sciences. The practice background of the evaluators included 1 forensic pathologist, 1 novice forensic nurse specialist (12/y No response Prior forensic education Yes No
Control (n = 17)
Total Sample (N = 35)
f
%
f
%
F
%
3 15
16.7 83.3
1 16
5.9 94.1
4 31
11.4 88.6
10 1 1 3 3
55.5 5.5 5.5 16.7 16.7
10 1 4 2 0
62.5 5.9 23.5 11.8 0.0
20 2 5 5 3
57.1 5.7 14.3 14.3 8.6
0 2 16 0
0.0 11.1 88.9 0.0
1 1 14 1
5.9 5.9 82.4 5.9
1 3 30 1
2.9 8.6 85.7 2.9
2 16
11.1 88.9
2 15
11.8 88.2
4 31
11.4 88.6
14 4
77.7 22.2
8 8
50 50
22 12
62.8 34.2
7 7 2 2
38.9 38.9 11.1 11.1
10 6 1 0
58.8 35.3 5.9 0.0
17 13 3 2
48.6 37.1 8.6 5.7
3 15
16.7 83.3
0 17
0.0 100.0
3 32
8.6 91.4
Abbreviations: ADN, associate degree in nursing; BSN, bachelor of science in nursing; CE, continuing education; DNP, doctor of nursing practice; ME/C, medical examiner/coroner; LVN, licensed visiting/vocational nursing.
Participant outcomes Two independent t tests were conducted to discover whether any significant differences existed between the intervention and attention control group knowledge and competency examination scores. All underlying assumptions were met for both t tests. Analysis indicated that there was no significant difference between the intervention (M = 62.89, SD = 4.86) and attention control group (M = 64.71, SD = 6.78; t33 = 0.915, P = .367) knowledge examination scores. The magnitude of the mean difference
was small (η2 = 0.025). In addition, analysis indicated that there was no significance difference between the intervention (M = 2.94, SD = 0.94) and attention control group (M = 2.59, SD = 0.71; t33 = 1.26, P = .217) competency scores. The magnitude of the mean difference was small to moderate (η2 = 0.05). DISCUSSION In this study, scored results from the knowledge-based examination and practical competency results were shown not to
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
86
CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2015
be significantly influenced by the study intervention. The participants performed in a similar manner when the simulation and attention control group outcomes were compared. Several reasons may account for the study results. The primary factor was thought to be the small sample size. The total sample size of 35 participants resulted in power levels of less than 20%, with an α of .025 and effect sizes of 0.31 (knowledge) and 0.42 (competency). The knowledge-based examination also proved to have a very low reliability rating (KR20 = 0.27), which may have influenced results. Knowledge-based posttest results Overall, the mean posttest knowledge scores for all study participants were lower than any of the researchers’ expected. Such surprising results may be partially explained by some of the participant feedback. Participants in this study revealed that the amount of study time they devoted to elective courses, especially those that were not delivered solely online, was generally less than the amount of time devoted to their core courses. Such study practices could account for the research findings, especially since participants also reported to spending less time reviewing the forensic course content. Therefore, as reflected by the participants, such findings may account for the low examination grades. In addition, the low course grades may indicate that the course content may be better received if the content was broken up and implemented into discrete topic courses such as pathology of trauma, foundations of forensic sciences, and victimology. The scores may support the American Nurses Association’s recognition that forensic nursing is a specialized field within nursing.1 As any specialized field within nursing, additional education and practical experience are required. The participants who dropped out of the course, as briefly described previously, were primarily undergraduates, and previous studies have reported that undergraduate nursing participants have little flexibility in their schedules for electives due to
core courses.2,12 The majority of study participants (86%) were master of science in nursing graduate students, and the feedback from them mirrored that of the undergraduate participants who dropped out of the course; core courses were the priority. In addition, the master of science in nursing students thought that the course evaluation requirements (eg, examination and competency evaluation) for an elective were too rigorous. Anecdotal feedback from the participants was that the simulation exercises provided realistic experiences that required them to reprioritize their typical care regimen. For example, in the auto-pedestrian scenario, instead of focusing on cleaning the wounds and applying a dressing, participant priorities were to focus on recognizing and collecting physical evidence. For example, one participant stated, “I actively participated in the labs and learned a lot of new information.” Although the test items had been reviewed by an external panel of 6 forensic experts for content validity and consistency with the course learning objectives, there could have been problems with the level of difficulty or construction format with some of the test items.13 For example, it was determined that several items required revision of distracter options. Furthermore, approximately 10 items were correctly answered by 95% to 100% of the students. Both of these issues impacted the overall reliability of the test. In addition, because forensic nursing is a specialized field, the researchers felt concerned that one course was not sufficient enough time for the students to grasp the clinical complexities that occur with forensic nursing. This suggested that additional coursework and practice may be required before participants could successfully apply the course content. Practical grading rubric results The final competency simulation exercise that the intervention group was involved in focused on an auto-pedestrian incident. In this scenario exercise, the driver failed to stop and render aid. This scenario was selected
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Forensic Nursing Science Knowledge and Competency because, of the 3 exercises described previously, the probability of this type of forensic patient being admitted to a critical care setting was the most likely. The participants were expected to recognize the critical nature of the patient and, after being deemed stable, prioritize the activities of documentation, collection, and preservation of evidence. After review of the participant competency scores, there was no significant difference between the intervention (M = 2.94, SD = 0.94) and attention control groups (M = 2.59, SD = 0.71; t33 = 1.26, P = .217). Although not statistically significant, the mean skill proficiency scores between the intervention and attention control groups did suggest that the simulation activities reinforced objectives and improved outcomes. However, the mean scores could be the result of the intervention group being more familiar with the simulation setup prior to the final participant proficiency examination. In addition, statistical significant differences could potentially occur by incorporating a practical fellowship experience as part of the forensic nursing science curriculum. At an end of the semester faculty debriefing session, the researcher noted that despite providing guidelines and training on how to use the practical grading rubric, the faculty without previous forensic science education or experience differed in how they evaluated participant performance. For example, less experienced faculty tended to overlook details specific to the appropriate recognition, collection, and preservation of evidence and still marked the participants as being proficient. This suggests that faculty involved in a forensic science course should at a minimum have practical training in evaluating participant skill proficiency in a clinical forensic setting. The differences in faculty backgrounds may indicate a need for using only experienced faculty to rate participant skills in the proficiency examination. KentWilkinson14 supports this suggestion and believes that forensic nursing programs do not exist at all levels of nursing education because of lack of adequately prepared faculty.
87
Limitations of the study The limitations of this study included a small size that generated insufficient power to detect statistical differences. In addition, the knowledge examination demonstrated low reliability. Finally, faculty training was thought to be inadequate for consistent scoring to occur during the simulated proficiencies. Therefore, faculty experience and knowledge of forensic practices may have hampered the ability of the practical grading rubric to evaluate the participants uniformly. Recommendations for research Recommendations for future research that stem from this research are 3-fold. First, more revision and research should be conducted on the knowledge examination items. Further testing and item analysis could improve the reliability of this tool in the future. Second, the use of experienced forensic practitioners with adequate and structured training on the use of the practical grading rubric could improve reliability. Third, an increased sample size is needed. Literature suggests that a sample size of 44 participants per group is required to acquire a power of 0.8 with an α set at .05 for an estimated effect size determined by a literature review3 to be 0.6. CONCLUSION Regardless of the setting, nurses, especially critical care nurses, encounter forensic patients on a regular basis. Ignoring this patient population’s special needs is no longer an option—violence and trauma are of increasing concern for health care systems. To provide competent care to this patient population, nurses can benefit from receiving forensic nursing science education, regardless of teaching modality chosen. Forensic nursing faculty at a university level can respond to this need by developing, implementing, and evaluating curriculum specific to the specialty of forensic nursing science. Implementation of education specific to all forensic populations as foundational to nursing practice ensures that forensic patients are afforded an adequate long-term outcome.2 Thus, nurses in settings
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2015
in which forensic patients are provided care (eg, critical care) should be required to demonstrate that they have knowledge of forensic aspects of care. Without sufficient preparation, a member of forensic specialist team should be consulted. Failure to provide
adequate forensic care such as recognizing a patient who may have forensic issues, recognizing and collecting evidence, and providing comprehensive documentation can potentially adversely affect outcomes beyond the physical needs of forensic patients.
REFERENCES 1. American Nurses Association. Forensic Nursing: Scope and Standards of Practice. 2nd ed. Washington, DC: American Nurses Association; 2009. 2. Henderson E, Harada N, Amar A. Caring for the forensic population: recognizing the educational needs of emergency department nurses and physicians. J Forensic Nurs. 2012;8:170-177. 3. Fulton DR, Assid P. Evidence collection in the emergency department. In: Lynch VA, Duval JB, eds. Forensic Nursing Science. 1st ed. St Louis, MO: Mosby; 2011:chap 53. 4. Cook DA, Hatala R, Brydges R, et al. Technologyenhanced simulation for health professionals: a systematic review and meta-analysis. JAMA. 2011; 306(9):978-988. 5. Jefferies P. Simulation in Nursing Education: From Conceptualization to Evaluation. New York, NY: National League for Nursing; 2007. 6. Ferguson C, Faugno D. The SAFE CARE model: maintaining competency in sexual assault examinations utilizing patient simulation methods. J Forensic Nurs. 2009;5:109-114. 7. Fitzpatrick M, Ta A, Lenchus J, Arheart KL, Rosen LF, Birnbach DJ. Sexual assault forensic examiners’
8. 9.
10.
11.
12. 13.
14.
training and assessment using simulation technology. Nurse Educator. 2012;38(1):85-90.e6. Lawson L, Rowe S. The scientific foundations of SANE education. J Forensic Nurs. 2009;5:115-118. Eisert PJ, Eldredge K, Hartlaub T, et al. CSI: New York development of forensic evidence collection guidelines for the emergency department. Crit Care Nurs Q. 2010;33(2):190-199. Hoyt C. Integrating forensic science into nursing processes in the ICU. Crit Care Nurs Q. 2006;29(3):259270. Polit DF, Beck CT. Nursing Research: Generating and Assessing Evidence for Nursing Practice. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012. Crane PA, Muscari M. Survey explores forensic content in nursing programs. On the Edge. 2005;11(4):3. Drake SA. The Impact of an Educational Intervention on Knowledge and Competency Levels for Student Enrolled in a Forensic Nursing Science Course [doctoral dissertation]. TX: Texas Woman’s University. Proquest UMI No. 3623945. Kent-Wilkinson A. Forensic nursing education. In: Lynch VA, Duval JB, eds. Forensic Nursing Science. 2nd ed. St Louis, MO: Mosby; 2011:chap 3.
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Forensic Nursing Science Knowledge and Competency The Use of Simulation Stacy A. Drake, PhD, MPH, RN; Rae Langford, EdD, RN; Anne Young, EdD, RN; Constance Ayers, PhD, RN Forensic nursing is a nursing specialty that provides services to a variety of patient populations who have experienced violence, including interpersonal violence, sudden or unexpected death, and motor vehicle collisions. However, many critical care nurses have received the background knowledge or practical skills required to provide the level of care required by many forensic patients. The purpose of this study was to determine whether differences in knowledge or practical competence exist between participants using 2 different learning modalities: medium fidelity simulation versus face-to-face lecture. Participants who were enrolled in an elective online forensic nursing science course were randomly assigned to an intervention or control group. The 18 intervention group participants were given three 2-hour forensic simulation sessions in the laboratory. The 17 control group participants attended 3 face-to-face lectures covering forensic science topics. All study participants also received the same forensic course content via the online Blackboard platform. No significant differences were found between the 2 groups in either knowledge or practical competency. The lack of results may have been heavily influenced by the small sample size, which resulted in insufficient power to detect possible differences. Key words: evaluation, forensic nursing science education, simulation
F
ORENSIC NURSING SCIENCE is a recognized nursing specialty1 that supports practice roles such as sexual assault nurse examiners, clinical forensic nurse examiners, legal nurse consultants, and forensic nurse death investigators. Although practicing critical care nurses often encounter situations that require knowledge of and competency
Author Affiliations: The University of Texas Health Science Center at Houston School of Nursing (Dr Drake); and Nelda C. Stark College of Nursing, Texas Woman’s University, Houston (Drs Langford, Young, and Ayers). The study was financially supported by a grant from John Winston Carter fund. To the authors’ knowledge, no conflict of interest, financial or otherwise, exists. The authors had no sponsors in concept, design, data collection, analysis, or interpretation. Correspondence: Stacy A. Drake, PhD, MPH, RN, The University of Texas Health Science Center at Houston School of Nursing, 6901 Bertner Ave #748, Houston, TX 77030 ([email protected]). DOI: 10.1097/CNQ.0000000000000045
in medicolegal aspects of patient care,2 basic nursing education usually does not include much of the specialty knowledge needed to care for forensic patients. A forensic patient, as defined by Fulton and Assid,3 is any patient who may potentially have criminal or civil liability, specific to the circumstances in which services are sought. Many published articles discuss the advantage of integrating simulation into academia.4,5 However, there is very little published research associated with simulation and forensic patient populations.6,7 Therefore, this project was designed to determine whether the commonly used teaching technique, simulation, is an effective way to enhance participant skills and enable nurses to respond appropriately when encountering forensic patients within the clinical setting. BACKGROUND The use of simulation as a teaching strategy within nursing and other health care 81
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
82
CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2015
professions is well supported in literature.4,5 However, few researchers have investigated the effectiveness of using simulation as a modality in teaching forensic nursing science. To date, the most frequent use of simulated forensic scenarios has occurred with sexual assault nurse examiner training.6-9 Sexual assault victims are not the most common type of forensic patients cared for by critical care nurses. Therefore, critical care nurses may not be familiar with the roles and responsibilities inherent in caring for typical critical care forensic patients and can have difficulty incorporating forensic concepts into patient care.2,9 The use of simulation allows the learner to be immersed in patient situations and then later permits selfreflection and reevaluation of patient care actions and decisions.5 Hoyt10 maintains that nurses should not have an option of whether they are involved in forensic patient care, instead, believes that it should be a distinct part of professional practice. SIGNIFICANCE Without knowledge of how to assess, interpret, document, and intervene with forensic issues such as abuse or neglect and recognize sudden, unexpected, or nonnatural death, health care facilities and nurses are at risk for legal repercussions as well as financial and professional sanctions. Providing forensic training to all nurses enables them to implement patient-centered care in a responsive manner. QUESTION ADDRESSED The research question posed was whether 2 groups of nursing participants enrolled in an online forensic nursing science course would demonstrate differences in knowledge and skill proficiency when an experimental group received a simulation-based intervention and a control group received face-to-face lecture material. The hypothesis was that participants taking part in clinical forensic simulation scenarios would be more knowledgeable of their
responsibilities in caring for forensic patients and more proficient in the application of their forensic skills than participants in the control group. METHODS The research participants were randomly assigned into an intervention group or an attention control group. A basic posttest-only design was used to evaluate the effectiveness of a simulation intervention on education outcomes. In this design, the intervention group completed 3 laboratory exercises, 2 hours per session, using 3 different simulation scenarios. The second group served as an attention control group and received an equivalent amount of time listening to face-to-face lectures in a classroom setting. An attention control group method was used to rule out the possibility that attention provided to the simulation group was not an additional contributor to any research outcome.11 Setting and course description The setting was a school of nursing in a large metropolitan area in the southwestern United States. The introductory forensic nursing science course was conducted as an online elective for academic or continuing education credit. The online portion of the course was given in conjunction with an intervention teaching modality (simulation) versus face-to face lectures (attention control). Identical online content was presented to both the intervention and control groups as modules. The online module topics included forensic nursing process, interpersonal violence, evidence principles and techniques, mechanism of injury, public health and epidemiology, medicolegal death investigation, and forensic nursing standards. The online content was provided as a Microsoft PowerPoint presentation and included the following: learning objectives, key terms, and required readings; module-associated questions to guide the participant’s study; individual and team assignments; and additional resources.
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Forensic Nursing Science Knowledge and Competency The principal research investigator (PI) was one of the coinstructors for the online forensic course. This instructor had a background in medicolegal death investigation and was an advanced forensic nurse, boardcertified, by the American Nurses Credentialing Center. The second coinstructor for the online forensic course participated in evaluating the online discussion board postings, grading individual assignments, and served as one of the faculty evaluators for the final research simulation exercises. Five additional faculty members, who also served as evaluators of the final research simulation exercise, had varied experience in forensic sciences. The practice background of the evaluators included 1 forensic pathologist, 1 novice forensic nurse specialist (12/y No response Prior forensic education Yes No
Control (n = 17)
Total Sample (N = 35)
f
%
f
%
F
%
3 15
16.7 83.3
1 16
5.9 94.1
4 31
11.4 88.6
10 1 1 3 3
55.5 5.5 5.5 16.7 16.7
10 1 4 2 0
62.5 5.9 23.5 11.8 0.0
20 2 5 5 3
57.1 5.7 14.3 14.3 8.6
0 2 16 0
0.0 11.1 88.9 0.0
1 1 14 1
5.9 5.9 82.4 5.9
1 3 30 1
2.9 8.6 85.7 2.9
2 16
11.1 88.9
2 15
11.8 88.2
4 31
11.4 88.6
14 4
77.7 22.2
8 8
50 50
22 12
62.8 34.2
7 7 2 2
38.9 38.9 11.1 11.1
10 6 1 0
58.8 35.3 5.9 0.0
17 13 3 2
48.6 37.1 8.6 5.7
3 15
16.7 83.3
0 17
0.0 100.0
3 32
8.6 91.4
Abbreviations: ADN, associate degree in nursing; BSN, bachelor of science in nursing; CE, continuing education; DNP, doctor of nursing practice; ME/C, medical examiner/coroner; LVN, licensed visiting/vocational nursing.
Participant outcomes Two independent t tests were conducted to discover whether any significant differences existed between the intervention and attention control group knowledge and competency examination scores. All underlying assumptions were met for both t tests. Analysis indicated that there was no significant difference between the intervention (M = 62.89, SD = 4.86) and attention control group (M = 64.71, SD = 6.78; t33 = 0.915, P = .367) knowledge examination scores. The magnitude of the mean difference
was small (η2 = 0.025). In addition, analysis indicated that there was no significance difference between the intervention (M = 2.94, SD = 0.94) and attention control group (M = 2.59, SD = 0.71; t33 = 1.26, P = .217) competency scores. The magnitude of the mean difference was small to moderate (η2 = 0.05). DISCUSSION In this study, scored results from the knowledge-based examination and practical competency results were shown not to
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
86
CRITICAL CARE NURSING QUARTERLY/JANUARY–MARCH 2015
be significantly influenced by the study intervention. The participants performed in a similar manner when the simulation and attention control group outcomes were compared. Several reasons may account for the study results. The primary factor was thought to be the small sample size. The total sample size of 35 participants resulted in power levels of less than 20%, with an α of .025 and effect sizes of 0.31 (knowledge) and 0.42 (competency). The knowledge-based examination also proved to have a very low reliability rating (KR20 = 0.27), which may have influenced results. Knowledge-based posttest results Overall, the mean posttest knowledge scores for all study participants were lower than any of the researchers’ expected. Such surprising results may be partially explained by some of the participant feedback. Participants in this study revealed that the amount of study time they devoted to elective courses, especially those that were not delivered solely online, was generally less than the amount of time devoted to their core courses. Such study practices could account for the research findings, especially since participants also reported to spending less time reviewing the forensic course content. Therefore, as reflected by the participants, such findings may account for the low examination grades. In addition, the low course grades may indicate that the course content may be better received if the content was broken up and implemented into discrete topic courses such as pathology of trauma, foundations of forensic sciences, and victimology. The scores may support the American Nurses Association’s recognition that forensic nursing is a specialized field within nursing.1 As any specialized field within nursing, additional education and practical experience are required. The participants who dropped out of the course, as briefly described previously, were primarily undergraduates, and previous studies have reported that undergraduate nursing participants have little flexibility in their schedules for electives due to
core courses.2,12 The majority of study participants (86%) were master of science in nursing graduate students, and the feedback from them mirrored that of the undergraduate participants who dropped out of the course; core courses were the priority. In addition, the master of science in nursing students thought that the course evaluation requirements (eg, examination and competency evaluation) for an elective were too rigorous. Anecdotal feedback from the participants was that the simulation exercises provided realistic experiences that required them to reprioritize their typical care regimen. For example, in the auto-pedestrian scenario, instead of focusing on cleaning the wounds and applying a dressing, participant priorities were to focus on recognizing and collecting physical evidence. For example, one participant stated, “I actively participated in the labs and learned a lot of new information.” Although the test items had been reviewed by an external panel of 6 forensic experts for content validity and consistency with the course learning objectives, there could have been problems with the level of difficulty or construction format with some of the test items.13 For example, it was determined that several items required revision of distracter options. Furthermore, approximately 10 items were correctly answered by 95% to 100% of the students. Both of these issues impacted the overall reliability of the test. In addition, because forensic nursing is a specialized field, the researchers felt concerned that one course was not sufficient enough time for the students to grasp the clinical complexities that occur with forensic nursing. This suggested that additional coursework and practice may be required before participants could successfully apply the course content. Practical grading rubric results The final competency simulation exercise that the intervention group was involved in focused on an auto-pedestrian incident. In this scenario exercise, the driver failed to stop and render aid. This scenario was selected
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Forensic Nursing Science Knowledge and Competency because, of the 3 exercises described previously, the probability of this type of forensic patient being admitted to a critical care setting was the most likely. The participants were expected to recognize the critical nature of the patient and, after being deemed stable, prioritize the activities of documentation, collection, and preservation of evidence. After review of the participant competency scores, there was no significant difference between the intervention (M = 2.94, SD = 0.94) and attention control groups (M = 2.59, SD = 0.71; t33 = 1.26, P = .217). Although not statistically significant, the mean skill proficiency scores between the intervention and attention control groups did suggest that the simulation activities reinforced objectives and improved outcomes. However, the mean scores could be the result of the intervention group being more familiar with the simulation setup prior to the final participant proficiency examination. In addition, statistical significant differences could potentially occur by incorporating a practical fellowship experience as part of the forensic nursing science curriculum. At an end of the semester faculty debriefing session, the researcher noted that despite providing guidelines and training on how to use the practical grading rubric, the faculty without previous forensic science education or experience differed in how they evaluated participant performance. For example, less experienced faculty tended to overlook details specific to the appropriate recognition, collection, and preservation of evidence and still marked the participants as being proficient. This suggests that faculty involved in a forensic science course should at a minimum have practical training in evaluating participant skill proficiency in a clinical forensic setting. The differences in faculty backgrounds may indicate a need for using only experienced faculty to rate participant skills in the proficiency examination. KentWilkinson14 supports this suggestion and believes that forensic nursing programs do not exist at all levels of nursing education because of lack of adequately prepared faculty.
87
Limitations of the study The limitations of this study included a small size that generated insufficient power to detect statistical differences. In addition, the knowledge examination demonstrated low reliability. Finally, faculty training was thought to be inadequate for consistent scoring to occur during the simulated proficiencies. Therefore, faculty experience and knowledge of forensic practices may have hampered the ability of the practical grading rubric to evaluate the participants uniformly. Recommendations for research Recommendations for future research that stem from this research are 3-fold. First, more revision and research should be conducted on the knowledge examination items. Further testing and item analysis could improve the reliability of this tool in the future. Second, the use of experienced forensic practitioners with adequate and structured training on the use of the practical grading rubric could improve reliability. Third, an increased sample size is needed. Literature suggests that a sample size of 44 participants per group is required to acquire a power of 0.8 with an α set at .05 for an estimated effect size determined by a literature review3 to be 0.6. CONCLUSION Regardless of the setting, nurses, especially critical care nurses, encounter forensic patients on a regular basis. Ignoring this patient population’s special needs is no longer an option—violence and trauma are of increasing concern for health care systems. To provide competent care to this patient population, nurses can benefit from receiving forensic nursing science education, regardless of teaching modality chosen. Forensic nursing faculty at a university level can respond to this need by developing, implementing, and evaluating curriculum specific to the specialty of forensic nursing science. Implementation of education specific to all forensic populations as foundational to nursing practice ensures that forensic patients are afforded an adequate long-term outcome.2 Thus, nurses in settings
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in which forensic patients are provided care (eg, critical care) should be required to demonstrate that they have knowledge of forensic aspects of care. Without sufficient preparation, a member of forensic specialist team should be consulted. Failure to provide
adequate forensic care such as recognizing a patient who may have forensic issues, recognizing and collecting evidence, and providing comprehensive documentation can potentially adversely affect outcomes beyond the physical needs of forensic patients.
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