Issues in Mental Health Nursing, 34:892–900, 2013 Copyright © 2013 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2013.854543
Fusion of Psychiatric and Medical High Fidelity Patient Simulation Scenarios: Effect on Nursing Student Knowledge, Retention of Knowledge, and Perception Kirstyn M. Kameg, DNP, PMHNP-BC, Nadine Cozzo Englert, PhD, RN, Valerie M. Howard, EdD, RN, and Katherine J. Perozzi, MSN, RN Robert Morris University, College of Nursing and Health Sciences, Pittsburgh, Pennsylvania, USA
High fidelity patient simulation (HFPS) has become an increasingly popular teaching methodology in nursing education. To date, there have not been any published studies investigating HFPS scenarios incorporating medical and psychiatric nursing content. This study utilized a quasi-experimental design to assess if HFPS improved student knowledge and retention of knowledge utilizing three parallel 30-item Elsevier HESITM Custom Exams. A convenience sample of 37 senior level nursing students participated in the study. The results of the study revealed the mean HESI test scores decreased following the simulation intervention although an analysis of variance (ANOVA) determined the difference was not statistically significant (p = .297). Although this study did not reveal improved student knowledge following the HFPS experiences, the findings did provide preliminary evidence that HFPS may improve knowledge in students who are identified as “at-risk.” Additionally, students responded favorably to the simulations and viewed them as a positive learning experience.
Caring for patients experiencing medical and psychiatric comorbidity represents unique challenges for nursing students. Nursing students often demonstrate difficulty integrating holistic care and focus on either the physical care of the patient or the mental health problem. It is becoming increasingly important to educate nursing students to assess and treat the patient holistically. Based on epidemiological data from the 2001–2003 National Comorbidity Survey Replication (Alegria, Jackson, Kessler, & Takeuchi, 2003), 17% of the adult population had comorbid mental and medical conditions within a 12-month period. Alarmingly, suicide is the third leading cause of death among individuals ages 15 to 24 and the second leading cause of death for individuals 25–34 years of age (Centers for Disease Control [CDC], 2010b). Additionally, patients with mental illness are at higher risk for tobacco use, alcohol and/or drug abuse, poor nutrition, and lack of physical activity, which raises their risk of developing chronic illnesses and having poor medical Address correspondence to Kirstyn M. Kameg, Robert Morris University, School of Nursing & Health Sciences, 6001 University Blvd, Moon Township, PA 15108. E-mail: [email protected]
outcomes once the illnesses emerge (CDC, 2010a). The presence of comorbid medical and psychiatric conditions increases health care costs. Melek and Norris (2008) found that the presence of comorbid depression or anxiety significantly increased medical and mental health care expenditures, with over 80% of the increase occurring in medical expenditures. Unfortunately, the structure of nursing curricula can influence the way nursing students assess and provide nursing care to individuals experiencing medical and psychiatric comorbidities. Psychiatric nursing is often a separate course and is placed in the junior or senior year. Other specialty courses generally do not highlight the need for integration of psychiatric care. One way to address the failure of integrating physical and mental health problems in nursing curricula may be through the utilization of high fidelity patient simulation (HFPS). For this study, the researchers developed three scenarios that incorporated skills inherent to the psychiatric nursing specialty into medical HFPS scenarios. The first purpose of the study was to develop and pilot test the three scenarios that incorporated both medical and psychiatric content. The second purpose was to assess if HFPS improved student knowledge and retention of knowledge utilizing Health Education Systems, Inc. (HESITM ) customized examinations, and the third purpose was to evaluate the students’ perceptions of the simulation experiences. REVIEW OF THE LITERATURE Although simulation has been used in the health care domain for the past 15 years, there has been an increase in popularity over the past 5 years, particularly in the field of health care and nursing (McGaghie, Issenberg, Petrusa, & Scalese, 2010). Advances in technology have enabled educators to utilize HFPS to depict patients and clinical scenarios that students are likely to encounter in the clinical setting. Several advantages of utilizing HFPS include learning in a risk-free environment; learning interactively; having enhanced assessment and decision making practice; having an ability to stop interventions during the simulation to replay, provide feedback, or critique performance; and
892
HIGH FIDELITY PATIENT SIMULATION SCENARIOS
having the ability to standardize learning for students (Feingold, Calaluce, & Kallen, 2004; Lapkin, Levett-Jones, Bellchambers, & Fernandez, 2010; McGaghie et al., 2010). In addition to the above noted advantages of HFPS, there have been some recent studies investigating HFPS on student learning outcomes. Sportsman, Schumacker, and Hamilton (2011) conducted a study to determine if participation in scenariobased high fidelity patient simulation for a portion of the clinical experience influenced student outcomes. Simulations were included in seven clinical courses and ranged from 100% of clinical time to 8% of clinical time. Simulations were not included as part of the psychiatric clinical experience. Despite the level of simulation experienced, there were no differences in mean exit examination scores or graduating grade point averages (Sportsman et al., 2011). Results of this study support substitution of traditional clinical experiences with simulation when there is limited availability of clinical sites. Brannan, White, and Bezanson (2008) compared the effectiveness of human patient simulation (HPS) with traditional classroom lecture related to student’s knowledge of acute myocardial infarction. The researchers found that students who received the HPS instructional method achieved significantly higher scores on the post-test compared to the students who received the classroom lecture. Elfrink, Kirkpatrick, Nininger, and Schubert (2010) utilized a pre-/post-test approach with National Council Licensure Examination (NCLEX)-style questions pertaining to the subject matter of the simulation in two prelicensure nursing courses. Eighty-four students participated in the study and completed the questions prior to the simulation, immediately following the simulation, and in their final examination at the end of the term. There was a statistically significant improvement in pre- to posttest scores following the simulation experience (p = 0.000); however, knowledge was not retained on the final examination that was administered at the end of the term (Elfrink et al., 2010). Howard, Ross, Mitchell, and Nelson (2010) compared simulation based educational methodology to case study approach with 50 undergraduate students. A custom HESITM exam was used to measure outcomes related to knowledge and critical thinking. Students in the human patient simulation group scored significantly higher than those in the interactive case study group (p ≤ .05) on the post-test HESI exam, and no significant difference was found in student scores among the three types of nursing programs that participated in the study. Despite the reported advantages of HFPS, results from recent meta-analyses are recommending further research. Yuan, Williams, and Fang (2011) conducted a meta-analysis of 24 studies to review the available evidence about the effects of HFS on students’ confidence and competence within nursing educational programs. The results indicated a mixed contribution of HFS to confidence and competency with a lack of high quality random control trials and large sample sizes. Another weakness identified in the review was a lack of formal measurement tools to evaluate HFS. Shearer (2013) conducted an integrative review of 20 research studies on safety and high fi-
893
delity simulation published in the literature since 2007. Results of this review identified two studies that provide evidence for effectiveness of high fidelity simulation on outcomes of safety, particularly related to patient identification and avoiding medication errors; however, any evidence about perceived improvement in safer communication has not been translated into practice. There also was a recent integrative review of 24 articles on high fidelity patient simulation in nursing education that examined the concepts of confidence, knowledge, knowledge transfer, value, realism, stress, and learner satisfaction (Weaver, 2011). In relation to knowledge gain with HFPS, there were mixed results. Again, weaknesses of the reviewed studies included small sample sizes, lack of valid measures, and convenience sampling (Weaver, 2011). Despite recent integrative reviews of the HFPS literature, there have been limited studies utilizing HFPS in the psychiatric nursing specialty. Kameg, Howard, Clochesy, Mitchell, and Suresky (2010) and Szpak and Kameg (2013) explored the use of HFPS as a means to reduce student anxiety and enhance student self-efficacy regarding communicating with patients experiencing mental illness. Both studies found that simulation resulted in statistically significant findings of improving selfefficacy and decreasing student anxiety prior to communicating with patients experiencing mental illness (Kameg et al., 2010; Szpak & Kameg, 2013). Limitations of both studies were the use of a convenience sample and small sample size. Another recent study investigated the effect of HPS on psychiatric nurses’ knowledge of care for veterans with diabetes. The results of the study revealed a statistically significant improvement between pre- and post-tests scores following the simulation intervention (p = 0.000); however, there was not reliability data provided for the exams nor was there any indication that the exam or the simulation scenario were reviewed for content validity (Wynn, 2011). Another limitation of the study was the small sample size (N = 20). To date, following a search of PubMed, MEDLINE, OVID, and CINAHL, there have been no published studies investigating the use of HFPS on student learning outcomes of caring for patients experiencing both medical and psychiatric problems.
THEORETICAL FRAMEWORK The Theory of Experiential Learning was utilized as the framework for this study (Kolb, 1984). The guiding principle of this theory is the ability to transfer theoretical knowledge and apply this in a practice setting leading to acquisition of knowledge. The traditional methods of teaching in a lecture format, with the instructor sharing facts with the students is perhaps not the best teaching method for service learning professions such as nursing (Dewey, 1938; Kolb, 1984). Kolb’s theory has been used many times in the service learning industry to explain the necessity for the incorporation of practice into the curriculum, such as through nursing students’ clinical experiences. According to the theory, learning is enhanced when students are actively
894
K. M. KAMEG ET AL.
involved in gaining knowledge through experience, with problem solving, decision making, and active reflection being integral components of the learning process (Dewey, 1938; Kolb, 1984). The three simulation scenarios and the debriefing questions were developed to support active learning, decision making, and reflection. Additionally, students were able to apply their nursing knowledge to the care of the simulated patients within a safe environment, without concern of harming the patient.
METHODS This study employed a non-random assignment, repeatedmeasures quasi-experimental design to measure the effect of HFPS on student knowledge and retention of knowledge. The researchers developed three HFPS scenarios based upon medical surgical problems and infused psychiatric mental health concerns into them. The scenarios were designed based on the most recent recommendations and standards of best practice that have emerged from simulation based literature (McGaghie et al, 2010; The International Nursing Association for Clinical Simulation and Learning [INACSL] Board of Directors, 2011), and incorporated the following: (1) a standardized framework with clear and measureable objectives; (2) a review by a panel of content experts to establish content validity; (3) current evidence for the development of the scenarios and debriefing questions; (4) reliable and valid outcome measures to evaluate the student’s knowledge gain and satisfaction; and (5) experienced simulation instructors to facilitate the scenarios. Simulation Protocol The three scenarios were developed by the simulation researchers who each had greater than five years teaching experience in the simulation lab. The scenarios focused on: Care of the Patient Experiencing Acute Alcohol Withdrawal; Care of the Patient Experiencing Trauma related to Intimate Partner Violence (IPV); and Care of the Patient Experiencing Postpartum Depression (PPD). Each scenario had detailed learning objectives related to the nursing care of both the physical and mental health needs of the client and was reviewed by two content experts to evaluate content validity. (See Tables 1, 2, and 3 for the learning objectives of each scenario.) Prior to entering the simulation lab, the participants were given pre-briefing activities that consisted of reading journal articles and reviewing textbook content regarding mental health issues corresponding to the scenarios. Upon entering the simulation lab, student participants were provided with the description of the scenario (nursing report), scripts for the family member, and were assigned different roles in each of the scenarios (i.e., primary nurse, secondary nurse, nursing assistant, or family member, if applicable to the scenario). Each scenario lasted approximately 30 minutes, and was followed by a debriefing experience using the Debriefing for Meaningful Learning Model (Dreifuerst, 2012).
The IPV scenario occurred in an emergency department setting and the 3–5 students were assigned the role of primary nurse, secondary nurse, nursing assistant, or observer. A standardized embedded actor played the role of an abusive husband. This embedded actor received training and was given a pre-developed script to guide his interactions with emergency department personnel and the patient. The researchers utilized R computerized mannequin for the simLaerdal’s 3 G SimMan ulation scenarios to play the role of the patient experiencing IPV. Upon entering the room, the student participants had to perform the steps of the nursing process according to the objectives, identify that the patient was indeed a victim of IPV, and provide nursing care to the patient while attempting to remove the abusive spouse. The Alcohol Withdrawal scenario occurred in an acute care setting and the mannequin portrayed the role of the patient experiencing symptoms of withdrawal. An embedded actor portrayed the role of the patient’s spouse in order to enhance realism and communication. The 3–5 students portrayed the role of primary nurse, secondary nurse, nursing assistant, or observer. Upon entering the patient’s room, the student participants had to implement the steps of the nursing process and provide care for the patient experiencing alcohol withdrawal while maintaining safety and addressing the issues of alcohol consumption with the patient and spouse. The PPD scenario occurred in the outpatient clinic, where the patient was presenting for her 6-week postpartum visit. The mannequin portrayed the role of the postpartum patient and an embedded actor portrayed the patient’s mother. In addition, the Laerdal SimBaby © mannequin was used for the 6-week old infant. The 3–5 students participated in the role of primary nurse, secondary nurse, student nurse, or observer. The primary purpose was to perform a postpartum assessment on the mother and identify that she was experiencing signs of postpartum depression.
Instruments The researchers partnered with Elsevier and developed three parallel 30-item Health Education Systems, Inc (HESITM ) Custom Exams to measure knowledge gain related to the simulations. Questions addressed nursing care related to the medical management as well as the psychiatric care involved in each of the simulation scenarios. Schools of nursing are increasingly administering computerized exams developed by HESITM to evaluate student and program outcomes and provide evidencebased rationale for curriculum development and modification. Morrison, Adamson, Nibert, and Hsia (2004) reported that estimated reliability coefficients for HESITM exams ranged from 0.86 to 0.99. The pre-test and post-test examinations used to assess student learning in this particular study were determined to be parallel and reliable based on psychometric measures, including average point biserial correlation coefficient (PBCC), level of difficulty, and reliability (see Table 4).
HIGH FIDELITY PATIENT SIMULATION SCENARIOS
895
TABLE 1 Acute Alcohol Withdrawal Learning Objectives Upon completion of this scenario, the student will be able to: 1. Assess the client who is experiencing signs and symptoms of alcohol withdrawal ◦ Tremors, diaphoresis, hypertension, tachycardia, hallucinations ◦ CAGE questionnaire ◦ CIWA score 2. Utilize therapeutic communication while caring for the client who is experiencing signs and symptoms of alcohol withdrawal ◦ Establish rapport with the patient ◦ Use open-ended questions, empathy, clarification, etc. 3. Utilize appropriate nursing diagnoses to plan care for the client who is experiencing signs and symptoms of alcohol withdrawal ◦ Deficient knowledge ◦ Ineffective individual coping ◦ Ineffective health maintenance 4. Intervene effectively with the client who is experiencing signs and symptoms of alcohol withdrawal ◦ Quiet, well-lit room ◦ IVF ◦ Thiamine ◦ Folate ◦ MVI ◦ CIWA score: 15—Lorazepam 5. Evaluate the effectiveness of interventions for the client who is experiencing signs and symptoms of alcohol withdrawal ◦ Vital signs ◦ Level of agitation/anxiety ◦ Sedation scale ◦ Absence of seizure activity ◦ Absence of hallucinations A Simulation Evaluation Survey was also administered following the HFPS experiences to evaluate student perceptions. This survey was developed by Howard et al. (2010) and consists of nine questions to be answered on a 5-point Likert scale. This instrument has been reviewed by experts in the field of simulation education and has undergone several revisions for content validity. Internal consistency was determined by Cronbach’s alpha (0.87), suggesting that the instrument is reliable (Howard et al., 2010). Procedures The Bachelor of Science in Nursing (BSN) program at this particular institution has two tracks: a traditional four-year track and an accelerated second-degree track. The traditional track is intended for students who begin after high school without a college degree. The second-degree track is intended for students with a non-nursing degree (baccalaureate or higher) and is completed within five semesters. Institutional Review Board approval was received from the university prior to recruiting for the study. The study was initially conducted in the Spring term of 2011 with a group of traditional nursing students enrolled in their final nursing course, Preparation for Professional Practice. All of the students in Group 1 (n = 16) were traditional students
who had already completed a psychiatric nursing course in a previous semester. One of the researchers approached the students in this class and explained the study. At that time, students signed up for a date/time to come in for the simulation experiences. Students who participated in the simulation experience were provided with eight clinical hours that could count towards their clinical requirement for the course. Simulation experiences were conducted on four different days. Prior to the simulation experiences, students took the HESITM Custom Exam 30-item pre-test. Following completion of the simulated scenarios, students underwent a group debriefing and then were given the parallel 30-item customized post-test A. Additionally, following completion of the post-test, students were asked to complete a simulation evaluation survey to evaluate their perceptions of the simulation experiences. Twelve weeks later students were asked to complete a second 30-item customized post-test B to evaluate retention of knowledge. The study protocol was then repeated in the Summer term of 2011 with another group of nursing students (n = 19); Group 2 was comprised of predominantly second-degree students (79%). The same procedures outlined above were followed with the exception of clinical hours. In the second group, the eight clinical hours were offered for the Community Nursing course in place of the Preparation for Professional Practice course.
896
K. M. KAMEG ET AL.
TABLE 2 Intimate Partner Violence Learning Objectives Upon completion of this scenario, the student will be able to: 1. Assess the client who is experiencing signs and symptoms of intimate partner violence (IPV) ◦ Client’s medical history and current presenting complaint (wrist injury) ◦ Pain ◦ Mental status ◦ Abuse and safety of the client (utilize intimate partner documentation form) 2. Utilize therapeutic communication while caring for the client who is a victim of IPV ◦ Establish rapport with the client ◦ Establish total privacy to ask screening questions 3. Identify appropriate nursing diagnoses for the client who is a victim of IPV ◦ Risk for injury ◦ Ineffective coping ◦ Deficient knowledge ◦ Self-esteem disturbance 4. Intervene effectively with the client who is experiencing IPV and a wrist injury ◦ Stabilize wrist ◦ Administer medication for pain ◦ Provide client with IPV information including safety planning ◦ Provide client with shelter information/hotline 5. Evaluate the effectiveness of interventions for the client who is experiencing IPV and a wrist injury ◦ Re-evaluate pain following administration of pain medication ◦ Evaluate patient’s understanding of the IPV education and safety plan
DATA ANALYSIS AND RESULTS There were initially 18 students who participated in the study in the Spring term and an additional 19 participants in the Summer term. Of the 37 research participants, 35 (95%) completed the entire study protocol; two participants were excluded from final data analysis because they did not take post-test B three months following the simulation intervention. The sample was predominantly female (91.5%) with a total of three males (8.5%) participating in the study. In this particular program, students can be enrolled in one of two BSN tracks: a traditional four-year track or an accelerated second-degree track intended for those with a previous non-nursing degree. The final study sample was comprised of 20 (57%) traditional students and 15 (43%) second-degree students. As noted previously, the pre-test was administered immediately before the simulation intervention, post-test A was administered immediately following the simulation, and post-test B was administered three months following the simulation intervention. A HESITM test score was reported by Elsevier for each study participant on each of the three HESITM custom exams (see Table 5). In general, a proprietary mathematical model is used to calculate HESI scores, which range from 0 to over 1,000; the score is dependent on the difficulty level of the test items included in the exam (Langford & Young, 2013). Although the mean HESITM test scores unexpectedly decreased following the
simulation intervention, an analysis of variance (ANOVA) determined the difference was not statistically significant (p = .297). To further explore the effect of the teaching strategy on student performance, individual student HESI scores were analyzed based on “at-risk” and “non-risk” categories. Evidence in the literature (Zweighaft, 2012) and institution-specific data assisted the faculty in this BSN program to assign a benchmark HESI score of 850 as a determinant of student success; therefore, students who earn less than 850 on any HESI exam are considered “at-risk.” The purpose of this categorization process is to identify students in need of targeted remediation and additional learning support. Of the 35 study participants, 13 (37%) were categorized as at-risk with a mean pre-test score of 737.79. Immediately following the simulation intervention, ten of those at-risk students (77%) scored at the non-risk level (M = 863.62). A chi-square analysis determined the improvement in scores to be statistically significant (p < .05), supporting the value of simulation as a teaching strategy for this at-risk population. An additional area of interest for the researchers was the students’ perceptions of simulation as an effective teaching and learning strategy. Following the simulation experience, students were directed to complete an online Simulation Evaluation Survey. The results of the survey are presented in Table 6, including both quantitative and qualitative data received from 25 (71.4%)
HIGH FIDELITY PATIENT SIMULATION SCENARIOS
897
TABLE 3 Postpartum Depression Learning Objectives Upon completion of this scenario, the student will be able to: 1. Assess the postpartum woman and differentiate normal vs. abnormal findings ◦ Fundal height—not palpable ◦ Lochia—absent or scant alba ◦ Vital signs—as pre-pregnancy ◦ Perineum—absence of pain; healing complete ◦ Breasts/breastfeeding—nipples intact; absence of pain; infant nursing well ◦ Emotional status 2. Utilize therapeutic communication while caring for the postpartum client who is experiencing signs and symptoms of postpartum depression ◦ Establish rapport with the patient and husband ◦ Use open-ended questions, empathy, clarification, etc. 3. Utilize appropriate nursing diagnoses to plan care for the client who is experiencing signs and symptoms of postpartum depression ◦ Ineffective individual coping ◦ Risk for altered parenting ◦ Potential for self-injury ◦ Potential for injury to newborn 4. Intervene effectively with the client who is experiencing signs and symptoms of postpartum depression ◦ Provide education related to antidepressant treatment ◦ Promote good nutrition ◦ Promote rest ◦ Encourage use of support resources for help with daily responsibilities and infant care ◦ Refer to support group 5. Evaluate the effectiveness of interventions for the client who is experiencing signs and symptoms of postpartum depression ◦ Evaluate patient’s understanding of the antidepressant treatment ◦ Patient expresses willingness to seek treatment ◦ Patient verbalizes understanding of the importance of rest and nutrition ◦ Patient utilizes available support ◦ Infant is safe and well cared for of the study participants regarding their simulation experience. As indicated in Table 6, the students were highly satisfied with the simulation learning experience. Strengths and Limitations of the Study There were several strengths of this study. The researchers adhered to the most recent recommendations and standards emerging from simulation based literature including utilization TABLE 4 HESI Custom Exam Psychometrics Test
PBCC
Difficulty
Reliability
Version A: Pre-test Version B: Immediate post-test Version C: 3-month post-test
0.14 0.14
0.65 0.65
0.99 0.98
0.15
0.62
0.98
of evidence-based information and content experts in the development of the scenarios; application of a standardized structure in developing the scenarios with identified learning objectives; the use of a valid, reliable instrument; and incorporation of a debriefing (McGaghie et al., 2010; The INACSL Board of Directors, 2011). The researchers are experienced in simulation facilitation as well as experts in the content of the scenarios. Lastly, although there was not an overall statistically significant difference in knowledge gained following the simulations, students who were identified as “at-risk” had a statistically significant improvement in test scores following the simulation experiences. Additionally, students responded positively to the simulation experiences, indicating agreement that the HFPS experience “helped them to better understand nursing concepts.” Despite the above identified strengths, there were several limitations of the study. The scenarios were designed to emphasize fusion of psychiatric mental health principles into medically based scenarios. An identified objective in each of the scenarios was to establish rapport with the patient. This objective is
898
K. M. KAMEG ET AL.
TABLE 5 HESI Custom Exam Scores Pre-test
Group 1 (n = 16) Group 2 (n = 19) Total (n = 35)
Post-test A
Post-test B
Mean
SD
Mean
SD
Mean
SD
889.56 949.26 921.97 Range 527–1312
213.19 147.80 184.02
856.94 849.68 853.03 Range 427–1263
227.33 169.04 198.66
851.75 971.26 916.63 Range 414–1399
216.99 212.94 223.18
R difficult to achieve with Laerdal’s 3 G SimMan computerized mannequin due to the simulator’s inability to display a range of nonverbal behavior. Another limitation in the use of HFPS is the inability to maintain a controlled environment secondary to extraneous variables. Each simulation scenario can be slightly different based on how the students ask questions or responds to the high fidelity simulator. A limitation of the sample was that it was a small, convenience sample that resulted in an under-powered study. Lastly, a final limitation included the daily structure of the simulation activities. Students presented to the lab and were given the pre-test. Following the pre-test, students participated in three simulation scenarios and were de-
briefed on all three scenarios. Post-test A was administered at the end of a long day of simulating and debriefing. Factors such as tiredness, lack of any type of external motivators, and/or just wanting to complete the day may have affected student performance on the exam. These factors may be reasons why Kolb’s Theory of Experiential Learning was not supported. Implications for Future Research HFPS has become a popular teaching strategy in health care education. Despite the popularity of this strategy, there is still limited research investigating learning outcomes with this
TABLE 6 Simulation Evaluation Survey Results Results Survey Item
Mean
SD
Overall, I was satisfied with the simulation experience. Valuable learning experience Stimulated critical thinking abilities Helped to better understand the educational concepts Simulation experiences should be included in all aspects of medical field education. Simulation was realistic Knowledge gained through the simulation experiences can be transferred to a real life scenario Because of simulation, I will be less nervous in the clinical setting when providing care for similar patients. I was nervous during the simulation experience. Simulation experiences can substitute for clinical experiences in the health care setting. Student Open-Ended Responses: “I did not realize how much psych nursing can be in every situation a nurse is faced with! Great learning experience.” “I am really glad that I signed up for this simulation. The thing I liked the best was how small the groups were.” “I felt like I learned a lot more than I normally would in a bigger group.” “I loved this simulation. I learned so much during the different scenarios.” “As time goes on, I value simulation more and more. I’m so glad that I participated in the study because it gave me 3 simulations more than I would have had.”
4.72 4.24 4.24 4.20 4.08 3.84 3.84
0.54 1.09 1.05 1.00 1.12 1.03 1.03
3.52
1.19
3.24 3.20
1.48 1.12
Note: Survey responses are based on 5-point Likert-type scale: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree
HIGH FIDELITY PATIENT SIMULATION SCENARIOS
approach. Although this study did not reveal improved student knowledge following the HFPS experiences, the results support the increase in scores for those students considered “at-risk” and are consistent with the findings from Brannan, White, and Bezanson (2008); Elfrink et al. (2010); and Howard et al. (2010). Future research is warranted to determine the impact of simulation upon students with differing abilities and learning styles. In addition, use of a mannequin limits the ability to integrate psychiatric principles, such as nonverbal communication, into the scenario. Future research is recommended using standardized patients (SPs) to simulate the scenarios so that students will have the opportunity to assess nonverbal behavior and establish rapport with the SP. In relation to this study, future research should include a larger sample size and administration of post-test A on a different day. Another consideration in terms of research and HFPS is comparing this teaching strategy with other teaching strategies, such as the use of case studies or assigned readings. Lastly, in the realm of HFPS research and simulation scenarios, students are often assigned to portray various roles in the simulated scenario. Future research investigating if learning is different based upon the type of role played during the scenario also is warranted.
DISCUSSION Nurses and other health care providers can no longer separate physical from emotional issues when treating patients. Nurses should begin to assess and manage patients from a holistic standpoint realizing that medical issues can exacerbate psychiatric diagnoses and vice versa. Even if nursing students elect to practice in a different specialty area, they are going to encounter patients experiencing mental health problems and need practice in utilizing skills inherent to this specialty, such as establishing rapport, utilizing therapeutic communication, conducting a suicide risk assessment, and screening for violence. Use of alternative teaching strategies, such as HFPS, may be one method to equip nursing students with the necessary skills to manage the holistic health of their patients. Additionally, the literature supports the reliability of the HESITM examinations as a strategy to identify at-risk students. This identification process can assist faculty with determining knowledge gaps in the curriculum and remediation efforts to better support student learning and outcomes. Enhanced teaching and learning strategies will better equip the novice nurse and strengthen the quality of care delivered in the clinical environment. Declaration of interest: The authors would like to acknowledge Elsevier for providing the custom HESITM examinations in addition to the Greater Pittsburgh Research Council for providing $1000.00 funding to pay the content reviewers. Additionally, Dr. Valerie Howard is the President of the International Nursing Association for Clinical Simulation and Learning (INACSL)
899
and also is a member of Elsevier’s Research Advisory Board. Dr. Kirstyn Kameg is a co-author for Elsevier’s Standardized Patient Psychiatric Nursing Scenarios REFERENCES Alegria, M., Jackson, J. S., Kessler, R. C., & Takeuchi, D. (2003). National Comorbidity Survey Replication (NCS-R), 2001–2003. Ann Arbor, MI: InterUniversity Consortium for Political and Social Research. Brannan, J., White, A., & Bezanson, J. (2008). Simulator effects on cognitive skills and confidence levels. Journal of Nursing Education, 47, 495–500. Centers for Disease Control and Prevention. (2010a). Chronic Diseases and Health Promotion. Retrieved from www.cdc.gov/chronicdisease/overview Centers for Disease Control and Prevention. (2010b). National Center for Injury Prevention and Control. Web-Based Injury Statistics Query and Reporting System (WISQARS). Retrieved from www.cdc.gov/injury/ wisqars/index.html Dewey, J. (1938). Experience and education. New York, NY: Macmillan. Dreifuerst K. T. (2012). Using debriefing for meaningful learning to foster development of clinical reasoning in simulation. Journal of Nursing Education, 51(6), 326–333. Elfrink, V. L., Kirkpatrick, B., Nininger, J., & Schubert, C. (2010). Using learning outcomes to inform teaching practices in human patient simulation. Nursing Education Perspectives, 31(2), 97–100. Feingold, C. E., Calaluce, M., & Kallen, M. A. (2004). Computerized patient model and simulated clinical experiences: Evaluation with baccalaureate nursing students. Journal of Nursing Education, 43(4), 156–163. Howard, V. M., Ross, C., Mitchell, A. M., & Nelson, G. M. (2010). Human patient simulators and interactive case studies: A comparative analysis of learning outcomes and student perceptions. CIN: Computers, Nursing, Informatics, 28(1), 42–48. The International Nursing Association for Clinical Simulation and Learning Board of Directors. (2011). Standards of best practice: Simulation. Clinical Simulation in Nursing, 7(4), S1–S20. Kameg, K., Howard V. M., Clochesy, J., Mitchell, A., & Suresky, J. (2010). The impact of high fidelity human simulation on self-efficacy of communication skills. Issues in Mental Health Nursing, 31, 315–323. doi: 10.3109/01612840903420331 Kolb, D. A. (1984). Experiential learning. Englewood Cliffs, NJ: Prentice Hall. Langford, R., & Young, A. (2013). Predicting NCLEX-RN success with the HESI exit exam: The eight validity study. Journal of Professional Nursing, 29(2 Suppl), S5–S9. Lapkin, S., Levett-Jones, T., Bellchambers, H., & Fernandez, R. (2010). Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: A systematic review. Clinical Simulation in Nursing, 6, e207–e222. McGaghie, W., Issenberg, S., Petrusa, E., & Scalese, R. (2010). A critical review of simulation-based medical education research: 2003–2009. Medical Education, 44, 50–63. Melek, S., & Norris, D. (2008). Chronic Conditions and Comorbid Psychological Disorders. Retrieved from http://publications.milliman.com/research/ health-rr/pdfs/chronic-conditions-and-comorbid-RR07-01-08.pdf Morrison, S., Adamson, C., Nibert, A., & Hsia, S. (2004). HESI exams: An overview of reliability and validity. CIN: Computers, Informatics, Nursing, 22(4), 220–226. Shearer, J. (2013). High fidelity simulation and safety: An integrative review. Journal of Nursing Education, 52(1), 39–45. Sportsman, S., Schumacker, R. E., & Hamilton, P. (2011). Evaluating the impact of scenario-based high-fidelity patient simulation on academic metrics of student success. Nursing Education Perspectives, 32(4), 259–265. Szpak, J. L., & Kameg, K. M. (2013). Simulation decreases nursing student anxiety prior to communication with mentally ill patients. Clinical Simulation in Nursing, 9(1), e13–e19.
900
K. M. KAMEG ET AL.
Weaver, A. (2011). High fidelity patient simulation in nursing education: An integrative review. Nursing Education Perspectives, 32(1), 37–40. Wynn, S. D. (2011). Improving the quality of care of veterans with diabetes: A simulation intervention for psychiatric nurses. Journal of Psychosocial Nursing, 49(2), 38–43. Young, A., & Wilson P. (2012). Predicting NCLEX-RN success: The seventh validity study HESI exit exam. CIN: Computers, Informatics, Nursing, 30(1), 55–60.
Yuan, H. B., Williams, B. A., & Fang, J. B. (2011). The contribution of high-fidelity simulation to nursing students’ confidence and competence: A systematic review. International Nursing Review, 59(1), 26– 33. Zweighaft, E. L. (2012). The ninth E2 validity study for RNs: Impact of HESI specialty exams, HESI exit exam scores and NCLEX-RN outcomes. Retrieved from http://www.elsevieradvantage.com/pdf/9th E2 Validity Study for RNs E-Flyer.pdf
Copyright of Issues in Mental Health Nursing is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Fusion of Psychiatric and Medical High Fidelity Patient Simulation Scenarios: Effect on Nursing Student Knowledge, Retention of Knowledge, and Perception Kirstyn M. Kameg, DNP, PMHNP-BC, Nadine Cozzo Englert, PhD, RN, Valerie M. Howard, EdD, RN, and Katherine J. Perozzi, MSN, RN Robert Morris University, College of Nursing and Health Sciences, Pittsburgh, Pennsylvania, USA
High fidelity patient simulation (HFPS) has become an increasingly popular teaching methodology in nursing education. To date, there have not been any published studies investigating HFPS scenarios incorporating medical and psychiatric nursing content. This study utilized a quasi-experimental design to assess if HFPS improved student knowledge and retention of knowledge utilizing three parallel 30-item Elsevier HESITM Custom Exams. A convenience sample of 37 senior level nursing students participated in the study. The results of the study revealed the mean HESI test scores decreased following the simulation intervention although an analysis of variance (ANOVA) determined the difference was not statistically significant (p = .297). Although this study did not reveal improved student knowledge following the HFPS experiences, the findings did provide preliminary evidence that HFPS may improve knowledge in students who are identified as “at-risk.” Additionally, students responded favorably to the simulations and viewed them as a positive learning experience.
Caring for patients experiencing medical and psychiatric comorbidity represents unique challenges for nursing students. Nursing students often demonstrate difficulty integrating holistic care and focus on either the physical care of the patient or the mental health problem. It is becoming increasingly important to educate nursing students to assess and treat the patient holistically. Based on epidemiological data from the 2001–2003 National Comorbidity Survey Replication (Alegria, Jackson, Kessler, & Takeuchi, 2003), 17% of the adult population had comorbid mental and medical conditions within a 12-month period. Alarmingly, suicide is the third leading cause of death among individuals ages 15 to 24 and the second leading cause of death for individuals 25–34 years of age (Centers for Disease Control [CDC], 2010b). Additionally, patients with mental illness are at higher risk for tobacco use, alcohol and/or drug abuse, poor nutrition, and lack of physical activity, which raises their risk of developing chronic illnesses and having poor medical Address correspondence to Kirstyn M. Kameg, Robert Morris University, School of Nursing & Health Sciences, 6001 University Blvd, Moon Township, PA 15108. E-mail: [email protected]
outcomes once the illnesses emerge (CDC, 2010a). The presence of comorbid medical and psychiatric conditions increases health care costs. Melek and Norris (2008) found that the presence of comorbid depression or anxiety significantly increased medical and mental health care expenditures, with over 80% of the increase occurring in medical expenditures. Unfortunately, the structure of nursing curricula can influence the way nursing students assess and provide nursing care to individuals experiencing medical and psychiatric comorbidities. Psychiatric nursing is often a separate course and is placed in the junior or senior year. Other specialty courses generally do not highlight the need for integration of psychiatric care. One way to address the failure of integrating physical and mental health problems in nursing curricula may be through the utilization of high fidelity patient simulation (HFPS). For this study, the researchers developed three scenarios that incorporated skills inherent to the psychiatric nursing specialty into medical HFPS scenarios. The first purpose of the study was to develop and pilot test the three scenarios that incorporated both medical and psychiatric content. The second purpose was to assess if HFPS improved student knowledge and retention of knowledge utilizing Health Education Systems, Inc. (HESITM ) customized examinations, and the third purpose was to evaluate the students’ perceptions of the simulation experiences. REVIEW OF THE LITERATURE Although simulation has been used in the health care domain for the past 15 years, there has been an increase in popularity over the past 5 years, particularly in the field of health care and nursing (McGaghie, Issenberg, Petrusa, & Scalese, 2010). Advances in technology have enabled educators to utilize HFPS to depict patients and clinical scenarios that students are likely to encounter in the clinical setting. Several advantages of utilizing HFPS include learning in a risk-free environment; learning interactively; having enhanced assessment and decision making practice; having an ability to stop interventions during the simulation to replay, provide feedback, or critique performance; and
892
HIGH FIDELITY PATIENT SIMULATION SCENARIOS
having the ability to standardize learning for students (Feingold, Calaluce, & Kallen, 2004; Lapkin, Levett-Jones, Bellchambers, & Fernandez, 2010; McGaghie et al., 2010). In addition to the above noted advantages of HFPS, there have been some recent studies investigating HFPS on student learning outcomes. Sportsman, Schumacker, and Hamilton (2011) conducted a study to determine if participation in scenariobased high fidelity patient simulation for a portion of the clinical experience influenced student outcomes. Simulations were included in seven clinical courses and ranged from 100% of clinical time to 8% of clinical time. Simulations were not included as part of the psychiatric clinical experience. Despite the level of simulation experienced, there were no differences in mean exit examination scores or graduating grade point averages (Sportsman et al., 2011). Results of this study support substitution of traditional clinical experiences with simulation when there is limited availability of clinical sites. Brannan, White, and Bezanson (2008) compared the effectiveness of human patient simulation (HPS) with traditional classroom lecture related to student’s knowledge of acute myocardial infarction. The researchers found that students who received the HPS instructional method achieved significantly higher scores on the post-test compared to the students who received the classroom lecture. Elfrink, Kirkpatrick, Nininger, and Schubert (2010) utilized a pre-/post-test approach with National Council Licensure Examination (NCLEX)-style questions pertaining to the subject matter of the simulation in two prelicensure nursing courses. Eighty-four students participated in the study and completed the questions prior to the simulation, immediately following the simulation, and in their final examination at the end of the term. There was a statistically significant improvement in pre- to posttest scores following the simulation experience (p = 0.000); however, knowledge was not retained on the final examination that was administered at the end of the term (Elfrink et al., 2010). Howard, Ross, Mitchell, and Nelson (2010) compared simulation based educational methodology to case study approach with 50 undergraduate students. A custom HESITM exam was used to measure outcomes related to knowledge and critical thinking. Students in the human patient simulation group scored significantly higher than those in the interactive case study group (p ≤ .05) on the post-test HESI exam, and no significant difference was found in student scores among the three types of nursing programs that participated in the study. Despite the reported advantages of HFPS, results from recent meta-analyses are recommending further research. Yuan, Williams, and Fang (2011) conducted a meta-analysis of 24 studies to review the available evidence about the effects of HFS on students’ confidence and competence within nursing educational programs. The results indicated a mixed contribution of HFS to confidence and competency with a lack of high quality random control trials and large sample sizes. Another weakness identified in the review was a lack of formal measurement tools to evaluate HFS. Shearer (2013) conducted an integrative review of 20 research studies on safety and high fi-
893
delity simulation published in the literature since 2007. Results of this review identified two studies that provide evidence for effectiveness of high fidelity simulation on outcomes of safety, particularly related to patient identification and avoiding medication errors; however, any evidence about perceived improvement in safer communication has not been translated into practice. There also was a recent integrative review of 24 articles on high fidelity patient simulation in nursing education that examined the concepts of confidence, knowledge, knowledge transfer, value, realism, stress, and learner satisfaction (Weaver, 2011). In relation to knowledge gain with HFPS, there were mixed results. Again, weaknesses of the reviewed studies included small sample sizes, lack of valid measures, and convenience sampling (Weaver, 2011). Despite recent integrative reviews of the HFPS literature, there have been limited studies utilizing HFPS in the psychiatric nursing specialty. Kameg, Howard, Clochesy, Mitchell, and Suresky (2010) and Szpak and Kameg (2013) explored the use of HFPS as a means to reduce student anxiety and enhance student self-efficacy regarding communicating with patients experiencing mental illness. Both studies found that simulation resulted in statistically significant findings of improving selfefficacy and decreasing student anxiety prior to communicating with patients experiencing mental illness (Kameg et al., 2010; Szpak & Kameg, 2013). Limitations of both studies were the use of a convenience sample and small sample size. Another recent study investigated the effect of HPS on psychiatric nurses’ knowledge of care for veterans with diabetes. The results of the study revealed a statistically significant improvement between pre- and post-tests scores following the simulation intervention (p = 0.000); however, there was not reliability data provided for the exams nor was there any indication that the exam or the simulation scenario were reviewed for content validity (Wynn, 2011). Another limitation of the study was the small sample size (N = 20). To date, following a search of PubMed, MEDLINE, OVID, and CINAHL, there have been no published studies investigating the use of HFPS on student learning outcomes of caring for patients experiencing both medical and psychiatric problems.
THEORETICAL FRAMEWORK The Theory of Experiential Learning was utilized as the framework for this study (Kolb, 1984). The guiding principle of this theory is the ability to transfer theoretical knowledge and apply this in a practice setting leading to acquisition of knowledge. The traditional methods of teaching in a lecture format, with the instructor sharing facts with the students is perhaps not the best teaching method for service learning professions such as nursing (Dewey, 1938; Kolb, 1984). Kolb’s theory has been used many times in the service learning industry to explain the necessity for the incorporation of practice into the curriculum, such as through nursing students’ clinical experiences. According to the theory, learning is enhanced when students are actively
894
K. M. KAMEG ET AL.
involved in gaining knowledge through experience, with problem solving, decision making, and active reflection being integral components of the learning process (Dewey, 1938; Kolb, 1984). The three simulation scenarios and the debriefing questions were developed to support active learning, decision making, and reflection. Additionally, students were able to apply their nursing knowledge to the care of the simulated patients within a safe environment, without concern of harming the patient.
METHODS This study employed a non-random assignment, repeatedmeasures quasi-experimental design to measure the effect of HFPS on student knowledge and retention of knowledge. The researchers developed three HFPS scenarios based upon medical surgical problems and infused psychiatric mental health concerns into them. The scenarios were designed based on the most recent recommendations and standards of best practice that have emerged from simulation based literature (McGaghie et al, 2010; The International Nursing Association for Clinical Simulation and Learning [INACSL] Board of Directors, 2011), and incorporated the following: (1) a standardized framework with clear and measureable objectives; (2) a review by a panel of content experts to establish content validity; (3) current evidence for the development of the scenarios and debriefing questions; (4) reliable and valid outcome measures to evaluate the student’s knowledge gain and satisfaction; and (5) experienced simulation instructors to facilitate the scenarios. Simulation Protocol The three scenarios were developed by the simulation researchers who each had greater than five years teaching experience in the simulation lab. The scenarios focused on: Care of the Patient Experiencing Acute Alcohol Withdrawal; Care of the Patient Experiencing Trauma related to Intimate Partner Violence (IPV); and Care of the Patient Experiencing Postpartum Depression (PPD). Each scenario had detailed learning objectives related to the nursing care of both the physical and mental health needs of the client and was reviewed by two content experts to evaluate content validity. (See Tables 1, 2, and 3 for the learning objectives of each scenario.) Prior to entering the simulation lab, the participants were given pre-briefing activities that consisted of reading journal articles and reviewing textbook content regarding mental health issues corresponding to the scenarios. Upon entering the simulation lab, student participants were provided with the description of the scenario (nursing report), scripts for the family member, and were assigned different roles in each of the scenarios (i.e., primary nurse, secondary nurse, nursing assistant, or family member, if applicable to the scenario). Each scenario lasted approximately 30 minutes, and was followed by a debriefing experience using the Debriefing for Meaningful Learning Model (Dreifuerst, 2012).
The IPV scenario occurred in an emergency department setting and the 3–5 students were assigned the role of primary nurse, secondary nurse, nursing assistant, or observer. A standardized embedded actor played the role of an abusive husband. This embedded actor received training and was given a pre-developed script to guide his interactions with emergency department personnel and the patient. The researchers utilized R computerized mannequin for the simLaerdal’s 3 G SimMan ulation scenarios to play the role of the patient experiencing IPV. Upon entering the room, the student participants had to perform the steps of the nursing process according to the objectives, identify that the patient was indeed a victim of IPV, and provide nursing care to the patient while attempting to remove the abusive spouse. The Alcohol Withdrawal scenario occurred in an acute care setting and the mannequin portrayed the role of the patient experiencing symptoms of withdrawal. An embedded actor portrayed the role of the patient’s spouse in order to enhance realism and communication. The 3–5 students portrayed the role of primary nurse, secondary nurse, nursing assistant, or observer. Upon entering the patient’s room, the student participants had to implement the steps of the nursing process and provide care for the patient experiencing alcohol withdrawal while maintaining safety and addressing the issues of alcohol consumption with the patient and spouse. The PPD scenario occurred in the outpatient clinic, where the patient was presenting for her 6-week postpartum visit. The mannequin portrayed the role of the postpartum patient and an embedded actor portrayed the patient’s mother. In addition, the Laerdal SimBaby © mannequin was used for the 6-week old infant. The 3–5 students participated in the role of primary nurse, secondary nurse, student nurse, or observer. The primary purpose was to perform a postpartum assessment on the mother and identify that she was experiencing signs of postpartum depression.
Instruments The researchers partnered with Elsevier and developed three parallel 30-item Health Education Systems, Inc (HESITM ) Custom Exams to measure knowledge gain related to the simulations. Questions addressed nursing care related to the medical management as well as the psychiatric care involved in each of the simulation scenarios. Schools of nursing are increasingly administering computerized exams developed by HESITM to evaluate student and program outcomes and provide evidencebased rationale for curriculum development and modification. Morrison, Adamson, Nibert, and Hsia (2004) reported that estimated reliability coefficients for HESITM exams ranged from 0.86 to 0.99. The pre-test and post-test examinations used to assess student learning in this particular study were determined to be parallel and reliable based on psychometric measures, including average point biserial correlation coefficient (PBCC), level of difficulty, and reliability (see Table 4).
HIGH FIDELITY PATIENT SIMULATION SCENARIOS
895
TABLE 1 Acute Alcohol Withdrawal Learning Objectives Upon completion of this scenario, the student will be able to: 1. Assess the client who is experiencing signs and symptoms of alcohol withdrawal ◦ Tremors, diaphoresis, hypertension, tachycardia, hallucinations ◦ CAGE questionnaire ◦ CIWA score 2. Utilize therapeutic communication while caring for the client who is experiencing signs and symptoms of alcohol withdrawal ◦ Establish rapport with the patient ◦ Use open-ended questions, empathy, clarification, etc. 3. Utilize appropriate nursing diagnoses to plan care for the client who is experiencing signs and symptoms of alcohol withdrawal ◦ Deficient knowledge ◦ Ineffective individual coping ◦ Ineffective health maintenance 4. Intervene effectively with the client who is experiencing signs and symptoms of alcohol withdrawal ◦ Quiet, well-lit room ◦ IVF ◦ Thiamine ◦ Folate ◦ MVI ◦ CIWA score: 15—Lorazepam 5. Evaluate the effectiveness of interventions for the client who is experiencing signs and symptoms of alcohol withdrawal ◦ Vital signs ◦ Level of agitation/anxiety ◦ Sedation scale ◦ Absence of seizure activity ◦ Absence of hallucinations A Simulation Evaluation Survey was also administered following the HFPS experiences to evaluate student perceptions. This survey was developed by Howard et al. (2010) and consists of nine questions to be answered on a 5-point Likert scale. This instrument has been reviewed by experts in the field of simulation education and has undergone several revisions for content validity. Internal consistency was determined by Cronbach’s alpha (0.87), suggesting that the instrument is reliable (Howard et al., 2010). Procedures The Bachelor of Science in Nursing (BSN) program at this particular institution has two tracks: a traditional four-year track and an accelerated second-degree track. The traditional track is intended for students who begin after high school without a college degree. The second-degree track is intended for students with a non-nursing degree (baccalaureate or higher) and is completed within five semesters. Institutional Review Board approval was received from the university prior to recruiting for the study. The study was initially conducted in the Spring term of 2011 with a group of traditional nursing students enrolled in their final nursing course, Preparation for Professional Practice. All of the students in Group 1 (n = 16) were traditional students
who had already completed a psychiatric nursing course in a previous semester. One of the researchers approached the students in this class and explained the study. At that time, students signed up for a date/time to come in for the simulation experiences. Students who participated in the simulation experience were provided with eight clinical hours that could count towards their clinical requirement for the course. Simulation experiences were conducted on four different days. Prior to the simulation experiences, students took the HESITM Custom Exam 30-item pre-test. Following completion of the simulated scenarios, students underwent a group debriefing and then were given the parallel 30-item customized post-test A. Additionally, following completion of the post-test, students were asked to complete a simulation evaluation survey to evaluate their perceptions of the simulation experiences. Twelve weeks later students were asked to complete a second 30-item customized post-test B to evaluate retention of knowledge. The study protocol was then repeated in the Summer term of 2011 with another group of nursing students (n = 19); Group 2 was comprised of predominantly second-degree students (79%). The same procedures outlined above were followed with the exception of clinical hours. In the second group, the eight clinical hours were offered for the Community Nursing course in place of the Preparation for Professional Practice course.
896
K. M. KAMEG ET AL.
TABLE 2 Intimate Partner Violence Learning Objectives Upon completion of this scenario, the student will be able to: 1. Assess the client who is experiencing signs and symptoms of intimate partner violence (IPV) ◦ Client’s medical history and current presenting complaint (wrist injury) ◦ Pain ◦ Mental status ◦ Abuse and safety of the client (utilize intimate partner documentation form) 2. Utilize therapeutic communication while caring for the client who is a victim of IPV ◦ Establish rapport with the client ◦ Establish total privacy to ask screening questions 3. Identify appropriate nursing diagnoses for the client who is a victim of IPV ◦ Risk for injury ◦ Ineffective coping ◦ Deficient knowledge ◦ Self-esteem disturbance 4. Intervene effectively with the client who is experiencing IPV and a wrist injury ◦ Stabilize wrist ◦ Administer medication for pain ◦ Provide client with IPV information including safety planning ◦ Provide client with shelter information/hotline 5. Evaluate the effectiveness of interventions for the client who is experiencing IPV and a wrist injury ◦ Re-evaluate pain following administration of pain medication ◦ Evaluate patient’s understanding of the IPV education and safety plan
DATA ANALYSIS AND RESULTS There were initially 18 students who participated in the study in the Spring term and an additional 19 participants in the Summer term. Of the 37 research participants, 35 (95%) completed the entire study protocol; two participants were excluded from final data analysis because they did not take post-test B three months following the simulation intervention. The sample was predominantly female (91.5%) with a total of three males (8.5%) participating in the study. In this particular program, students can be enrolled in one of two BSN tracks: a traditional four-year track or an accelerated second-degree track intended for those with a previous non-nursing degree. The final study sample was comprised of 20 (57%) traditional students and 15 (43%) second-degree students. As noted previously, the pre-test was administered immediately before the simulation intervention, post-test A was administered immediately following the simulation, and post-test B was administered three months following the simulation intervention. A HESITM test score was reported by Elsevier for each study participant on each of the three HESITM custom exams (see Table 5). In general, a proprietary mathematical model is used to calculate HESI scores, which range from 0 to over 1,000; the score is dependent on the difficulty level of the test items included in the exam (Langford & Young, 2013). Although the mean HESITM test scores unexpectedly decreased following the
simulation intervention, an analysis of variance (ANOVA) determined the difference was not statistically significant (p = .297). To further explore the effect of the teaching strategy on student performance, individual student HESI scores were analyzed based on “at-risk” and “non-risk” categories. Evidence in the literature (Zweighaft, 2012) and institution-specific data assisted the faculty in this BSN program to assign a benchmark HESI score of 850 as a determinant of student success; therefore, students who earn less than 850 on any HESI exam are considered “at-risk.” The purpose of this categorization process is to identify students in need of targeted remediation and additional learning support. Of the 35 study participants, 13 (37%) were categorized as at-risk with a mean pre-test score of 737.79. Immediately following the simulation intervention, ten of those at-risk students (77%) scored at the non-risk level (M = 863.62). A chi-square analysis determined the improvement in scores to be statistically significant (p < .05), supporting the value of simulation as a teaching strategy for this at-risk population. An additional area of interest for the researchers was the students’ perceptions of simulation as an effective teaching and learning strategy. Following the simulation experience, students were directed to complete an online Simulation Evaluation Survey. The results of the survey are presented in Table 6, including both quantitative and qualitative data received from 25 (71.4%)
HIGH FIDELITY PATIENT SIMULATION SCENARIOS
897
TABLE 3 Postpartum Depression Learning Objectives Upon completion of this scenario, the student will be able to: 1. Assess the postpartum woman and differentiate normal vs. abnormal findings ◦ Fundal height—not palpable ◦ Lochia—absent or scant alba ◦ Vital signs—as pre-pregnancy ◦ Perineum—absence of pain; healing complete ◦ Breasts/breastfeeding—nipples intact; absence of pain; infant nursing well ◦ Emotional status 2. Utilize therapeutic communication while caring for the postpartum client who is experiencing signs and symptoms of postpartum depression ◦ Establish rapport with the patient and husband ◦ Use open-ended questions, empathy, clarification, etc. 3. Utilize appropriate nursing diagnoses to plan care for the client who is experiencing signs and symptoms of postpartum depression ◦ Ineffective individual coping ◦ Risk for altered parenting ◦ Potential for self-injury ◦ Potential for injury to newborn 4. Intervene effectively with the client who is experiencing signs and symptoms of postpartum depression ◦ Provide education related to antidepressant treatment ◦ Promote good nutrition ◦ Promote rest ◦ Encourage use of support resources for help with daily responsibilities and infant care ◦ Refer to support group 5. Evaluate the effectiveness of interventions for the client who is experiencing signs and symptoms of postpartum depression ◦ Evaluate patient’s understanding of the antidepressant treatment ◦ Patient expresses willingness to seek treatment ◦ Patient verbalizes understanding of the importance of rest and nutrition ◦ Patient utilizes available support ◦ Infant is safe and well cared for of the study participants regarding their simulation experience. As indicated in Table 6, the students were highly satisfied with the simulation learning experience. Strengths and Limitations of the Study There were several strengths of this study. The researchers adhered to the most recent recommendations and standards emerging from simulation based literature including utilization TABLE 4 HESI Custom Exam Psychometrics Test
PBCC
Difficulty
Reliability
Version A: Pre-test Version B: Immediate post-test Version C: 3-month post-test
0.14 0.14
0.65 0.65
0.99 0.98
0.15
0.62
0.98
of evidence-based information and content experts in the development of the scenarios; application of a standardized structure in developing the scenarios with identified learning objectives; the use of a valid, reliable instrument; and incorporation of a debriefing (McGaghie et al., 2010; The INACSL Board of Directors, 2011). The researchers are experienced in simulation facilitation as well as experts in the content of the scenarios. Lastly, although there was not an overall statistically significant difference in knowledge gained following the simulations, students who were identified as “at-risk” had a statistically significant improvement in test scores following the simulation experiences. Additionally, students responded positively to the simulation experiences, indicating agreement that the HFPS experience “helped them to better understand nursing concepts.” Despite the above identified strengths, there were several limitations of the study. The scenarios were designed to emphasize fusion of psychiatric mental health principles into medically based scenarios. An identified objective in each of the scenarios was to establish rapport with the patient. This objective is
898
K. M. KAMEG ET AL.
TABLE 5 HESI Custom Exam Scores Pre-test
Group 1 (n = 16) Group 2 (n = 19) Total (n = 35)
Post-test A
Post-test B
Mean
SD
Mean
SD
Mean
SD
889.56 949.26 921.97 Range 527–1312
213.19 147.80 184.02
856.94 849.68 853.03 Range 427–1263
227.33 169.04 198.66
851.75 971.26 916.63 Range 414–1399
216.99 212.94 223.18
R difficult to achieve with Laerdal’s 3 G SimMan computerized mannequin due to the simulator’s inability to display a range of nonverbal behavior. Another limitation in the use of HFPS is the inability to maintain a controlled environment secondary to extraneous variables. Each simulation scenario can be slightly different based on how the students ask questions or responds to the high fidelity simulator. A limitation of the sample was that it was a small, convenience sample that resulted in an under-powered study. Lastly, a final limitation included the daily structure of the simulation activities. Students presented to the lab and were given the pre-test. Following the pre-test, students participated in three simulation scenarios and were de-
briefed on all three scenarios. Post-test A was administered at the end of a long day of simulating and debriefing. Factors such as tiredness, lack of any type of external motivators, and/or just wanting to complete the day may have affected student performance on the exam. These factors may be reasons why Kolb’s Theory of Experiential Learning was not supported. Implications for Future Research HFPS has become a popular teaching strategy in health care education. Despite the popularity of this strategy, there is still limited research investigating learning outcomes with this
TABLE 6 Simulation Evaluation Survey Results Results Survey Item
Mean
SD
Overall, I was satisfied with the simulation experience. Valuable learning experience Stimulated critical thinking abilities Helped to better understand the educational concepts Simulation experiences should be included in all aspects of medical field education. Simulation was realistic Knowledge gained through the simulation experiences can be transferred to a real life scenario Because of simulation, I will be less nervous in the clinical setting when providing care for similar patients. I was nervous during the simulation experience. Simulation experiences can substitute for clinical experiences in the health care setting. Student Open-Ended Responses: “I did not realize how much psych nursing can be in every situation a nurse is faced with! Great learning experience.” “I am really glad that I signed up for this simulation. The thing I liked the best was how small the groups were.” “I felt like I learned a lot more than I normally would in a bigger group.” “I loved this simulation. I learned so much during the different scenarios.” “As time goes on, I value simulation more and more. I’m so glad that I participated in the study because it gave me 3 simulations more than I would have had.”
4.72 4.24 4.24 4.20 4.08 3.84 3.84
0.54 1.09 1.05 1.00 1.12 1.03 1.03
3.52
1.19
3.24 3.20
1.48 1.12
Note: Survey responses are based on 5-point Likert-type scale: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree
HIGH FIDELITY PATIENT SIMULATION SCENARIOS
approach. Although this study did not reveal improved student knowledge following the HFPS experiences, the results support the increase in scores for those students considered “at-risk” and are consistent with the findings from Brannan, White, and Bezanson (2008); Elfrink et al. (2010); and Howard et al. (2010). Future research is warranted to determine the impact of simulation upon students with differing abilities and learning styles. In addition, use of a mannequin limits the ability to integrate psychiatric principles, such as nonverbal communication, into the scenario. Future research is recommended using standardized patients (SPs) to simulate the scenarios so that students will have the opportunity to assess nonverbal behavior and establish rapport with the SP. In relation to this study, future research should include a larger sample size and administration of post-test A on a different day. Another consideration in terms of research and HFPS is comparing this teaching strategy with other teaching strategies, such as the use of case studies or assigned readings. Lastly, in the realm of HFPS research and simulation scenarios, students are often assigned to portray various roles in the simulated scenario. Future research investigating if learning is different based upon the type of role played during the scenario also is warranted.
DISCUSSION Nurses and other health care providers can no longer separate physical from emotional issues when treating patients. Nurses should begin to assess and manage patients from a holistic standpoint realizing that medical issues can exacerbate psychiatric diagnoses and vice versa. Even if nursing students elect to practice in a different specialty area, they are going to encounter patients experiencing mental health problems and need practice in utilizing skills inherent to this specialty, such as establishing rapport, utilizing therapeutic communication, conducting a suicide risk assessment, and screening for violence. Use of alternative teaching strategies, such as HFPS, may be one method to equip nursing students with the necessary skills to manage the holistic health of their patients. Additionally, the literature supports the reliability of the HESITM examinations as a strategy to identify at-risk students. This identification process can assist faculty with determining knowledge gaps in the curriculum and remediation efforts to better support student learning and outcomes. Enhanced teaching and learning strategies will better equip the novice nurse and strengthen the quality of care delivered in the clinical environment. Declaration of interest: The authors would like to acknowledge Elsevier for providing the custom HESITM examinations in addition to the Greater Pittsburgh Research Council for providing $1000.00 funding to pay the content reviewers. Additionally, Dr. Valerie Howard is the President of the International Nursing Association for Clinical Simulation and Learning (INACSL)
899
and also is a member of Elsevier’s Research Advisory Board. Dr. Kirstyn Kameg is a co-author for Elsevier’s Standardized Patient Psychiatric Nursing Scenarios REFERENCES Alegria, M., Jackson, J. S., Kessler, R. C., & Takeuchi, D. (2003). National Comorbidity Survey Replication (NCS-R), 2001–2003. Ann Arbor, MI: InterUniversity Consortium for Political and Social Research. Brannan, J., White, A., & Bezanson, J. (2008). Simulator effects on cognitive skills and confidence levels. Journal of Nursing Education, 47, 495–500. Centers for Disease Control and Prevention. (2010a). Chronic Diseases and Health Promotion. Retrieved from www.cdc.gov/chronicdisease/overview Centers for Disease Control and Prevention. (2010b). National Center for Injury Prevention and Control. Web-Based Injury Statistics Query and Reporting System (WISQARS). Retrieved from www.cdc.gov/injury/ wisqars/index.html Dewey, J. (1938). Experience and education. New York, NY: Macmillan. Dreifuerst K. T. (2012). Using debriefing for meaningful learning to foster development of clinical reasoning in simulation. Journal of Nursing Education, 51(6), 326–333. Elfrink, V. L., Kirkpatrick, B., Nininger, J., & Schubert, C. (2010). Using learning outcomes to inform teaching practices in human patient simulation. Nursing Education Perspectives, 31(2), 97–100. Feingold, C. E., Calaluce, M., & Kallen, M. A. (2004). Computerized patient model and simulated clinical experiences: Evaluation with baccalaureate nursing students. Journal of Nursing Education, 43(4), 156–163. Howard, V. M., Ross, C., Mitchell, A. M., & Nelson, G. M. (2010). Human patient simulators and interactive case studies: A comparative analysis of learning outcomes and student perceptions. CIN: Computers, Nursing, Informatics, 28(1), 42–48. The International Nursing Association for Clinical Simulation and Learning Board of Directors. (2011). Standards of best practice: Simulation. Clinical Simulation in Nursing, 7(4), S1–S20. Kameg, K., Howard V. M., Clochesy, J., Mitchell, A., & Suresky, J. (2010). The impact of high fidelity human simulation on self-efficacy of communication skills. Issues in Mental Health Nursing, 31, 315–323. doi: 10.3109/01612840903420331 Kolb, D. A. (1984). Experiential learning. Englewood Cliffs, NJ: Prentice Hall. Langford, R., & Young, A. (2013). Predicting NCLEX-RN success with the HESI exit exam: The eight validity study. Journal of Professional Nursing, 29(2 Suppl), S5–S9. Lapkin, S., Levett-Jones, T., Bellchambers, H., & Fernandez, R. (2010). Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: A systematic review. Clinical Simulation in Nursing, 6, e207–e222. McGaghie, W., Issenberg, S., Petrusa, E., & Scalese, R. (2010). A critical review of simulation-based medical education research: 2003–2009. Medical Education, 44, 50–63. Melek, S., & Norris, D. (2008). Chronic Conditions and Comorbid Psychological Disorders. Retrieved from http://publications.milliman.com/research/ health-rr/pdfs/chronic-conditions-and-comorbid-RR07-01-08.pdf Morrison, S., Adamson, C., Nibert, A., & Hsia, S. (2004). HESI exams: An overview of reliability and validity. CIN: Computers, Informatics, Nursing, 22(4), 220–226. Shearer, J. (2013). High fidelity simulation and safety: An integrative review. Journal of Nursing Education, 52(1), 39–45. Sportsman, S., Schumacker, R. E., & Hamilton, P. (2011). Evaluating the impact of scenario-based high-fidelity patient simulation on academic metrics of student success. Nursing Education Perspectives, 32(4), 259–265. Szpak, J. L., & Kameg, K. M. (2013). Simulation decreases nursing student anxiety prior to communication with mentally ill patients. Clinical Simulation in Nursing, 9(1), e13–e19.
900
K. M. KAMEG ET AL.
Weaver, A. (2011). High fidelity patient simulation in nursing education: An integrative review. Nursing Education Perspectives, 32(1), 37–40. Wynn, S. D. (2011). Improving the quality of care of veterans with diabetes: A simulation intervention for psychiatric nurses. Journal of Psychosocial Nursing, 49(2), 38–43. Young, A., & Wilson P. (2012). Predicting NCLEX-RN success: The seventh validity study HESI exit exam. CIN: Computers, Informatics, Nursing, 30(1), 55–60.
Yuan, H. B., Williams, B. A., & Fang, J. B. (2011). The contribution of high-fidelity simulation to nursing students’ confidence and competence: A systematic review. International Nursing Review, 59(1), 26– 33. Zweighaft, E. L. (2012). The ninth E2 validity study for RNs: Impact of HESI specialty exams, HESI exit exam scores and NCLEX-RN outcomes. Retrieved from http://www.elsevieradvantage.com/pdf/9th E2 Validity Study for RNs E-Flyer.pdf
Copyright of Issues in Mental Health Nursing is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
