CIN: Computers, Informatics, Nursing
& Vol. 33, No. 7, 278–284 & Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.
F E A T U R E A R T I C L E
Integrating Problem-Based Learning and Simulation Effects on Student Motivation and Life Skills YOUNG SOOK ROH, PhD, RN SANG SUK KIM, PhD, RN
Nurse educators must determine the best possible innovative teaching strategies to support quality and safety education for nurses.1,2 Of these strategies, problem-based learning (PBL) and simulation are increasingly prevalent in health profession education, with close links to the principles of constructivism and collaborative learning.3 A recent meta-analysis demonstrated that PBL is more effective than traditional methods in terms of learning and student satisfaction, and PBL has a moderate to large effect on the development of cognitive, affective, and psychomotor skills.4 A meta-analysis also found that technology-enhanced simulation training, in comparison with other instructional modalities, is associated with better learning outcomes. Differences were significant for satisfaction, knowledge, process skills, and product skills.5 Although PBL and simulation in isolation have educational merit, merging these pedagogies has the scope to link aspects of learning that further enhance and transform knowledge.6 However, some studies have revealed Author Affiliation: Red Cross College of Nursing, Chung-Ang University (CAU) Seoul, Korea. Ethical approval was granted by the institutional review board. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Sang Suk Kim, PhD, RN, 84 Heukseouk-Ro, Dongjak-Gu, Seoul, 156-861, Korea ([email protected]). DOI: 10.1097/CIN.0000000000000161
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Previous research has suggested that a teaching strategy integrating problem-based learning and simulation may be superior to traditional lecture. The purpose of this study was to assess learner motivation and life skills before and after taking a course involving problem-based learning and simulation. The design used repeated measures with a convenience sample of 83 second-year nursing students who completed the integrated course. Data from a self-administered questionnaire measuring learner motivation and life skills were collected at pretest, post–problem-based learning, and post-simulation time points. Repeatedmeasures analysis of variance determined that the mean scores for total learner motivation (F = 6.62, P = .003), communication (F = 8.27, P G .001), problem solving (F = 6.91, P = .001), and selfdirected learning (F = 4.45, P = .016) differed significantly between time points. Post hoc tests using the Bonferroni correction revealed that total learner motivation and total life skills significantly increased both from pretest to postsimulation and from post–problem-based learning test to postsimulation test. Subscales of learner motivation and life skills, intrinsic goal orientation, self-efficacy for learning and performance, problem-solving skills, and self-directed learning skills significantly increased both from pretest to postsimulation test and from post–problem-based learning test to post-simulation test. The results demonstrate that an integrating problem-based learning and simulation course elicits significant improvement in learner motivation and life skills. Simulation plus problem-based learning is more effective than problem-based learning alone at increasing intrinsic goal orientation, task value, self-efficacy for learning and performance, problem solving, and self-directed learning. KEYWORDS Motivation & Patient simulation & Problem-based learning & Problem solving & Self-directed learning
that learning is enhanced with the use of simulation compared with PBL. Steadman et al7 found that simulation led to improved acquisition of assessment and management skills compared with PBL in medical students.
CIN: Computers, Informatics, Nursing & July 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
In other research, pharmacy students in the simulation group showed significantly better improvements in postquiz scores compared with the PBL group. The simulation-based learning group performed at least 15% better in clinical assessment and critical-thinking skills involving problem lists, pharmacotherapy plans, and monitoring plans.8 PharmD students receiving simulation-based learning, compared with those receiving modified PBL and standardized patients, performed better on knowledge-based quizzes and had higher levels of satisfaction.9 A simulation-based learning group showed significantly higher scores on two postintervention scenarios concerning structure and time than a PBL group among 45 fourth-year medical students.10 Integration of simulation exercises into the educational curriculum is an essential feature for their effective use.11 Some studies have demonstrated the beneficial effects of merging PBL and simulation. One study reported the development of a model incorporating PBL in a simulated clinical environment to support the translation of theoretical knowledge into practical skills.12 Incorporation of simulation learning activities into problem-based discussion appears to be an effective educational strategy for teaching nursing students to assess and manage crisis events.3 Nursing students in a 9-week fundamental nursing course integrating PBL and simulation reported significant increases in problem-solving and self-directed learning competency, compared with a traditional curriculum group.13 Nursing students reported favorable perceptions related to competence and small-group learning and had a favorable view of PBL plus simulation, irrespective of their course grade.14 One study demonstrated that assessors’ scores showed a mean improvement in patient assessment, clinical decision making, technical and communication skills, and overall performance after participating in three cycles of PBL and associated simulations.15 After participation in a multifaceted educational session using PBL and simulation, nurses perceived that the education provided an excellent opportunity to increase their knowledge, whereas the simulation experience allowed them to practice their competencies.16 A recent study also reported the positive impact of PBL and a combined learning method among nursing students. The PBL group and the group receiving combined simulation and PBL had higher knowledge and confidence in skill performance scores than did the traditional learning method group. Curricula must not only provide students with the requisite knowledge, skills, and practice, but also foster learner motivation and life skills.17 While research is needed to examine the practicality and feasibility of merging two well-known pedagogies, PBL and simulation, there is relatively little empirical evidence on the motivation and life skills of nursing students taking part in an integrated course of PBL with simulation. Thus, there is a need to further explore whether learner motivation and life skills differ or change with different self-directed learning strategies. Such
findings could provide evidence demonstrating the efficacy of courses integrating PBL and simulation for nursing students.
Purpose The purpose of this study was to assess learner motivation and life skills in second-year nursing students taking a course with integrated PBL and simulation.
METHODS Design This study was a repeated-measures design with data collected from nursing students via questionnaires administered at baseline (pretest), after PBL (post-PBL), and after simulation (post-simulation) (Figure 1).
Participants Regarding sample size, we used G*Power 3 (Heinrich Heine Universitat, Dusseldorf, Germany) to determine that 60 participants were required for a suitable effect size (d = 0.6) with 95% power and a significance level of .05, using one-way repeated-measures analysis of variance (ANOVA).18 This effect size estimate was based on a pooled effect size of 0.62 for multiple learning strategies as reported in a systematic review and meta-analysis of the comparative effectiveness of instructional design features in simulationbased education.19 A nonrandom convenience sample of second-year nursing students enrolled in an adult health nursing course in the second semester of 2012 (n = 90) were invited to participate in the study. After the exclusion of seven questionnaires because of incomplete data, 83 questionnaires (92%) were used in the final analysis. Of the 83 participants, approximately 90% were women. They ranged in age from 19 to 40 years with a mean age of 22.1 (SD, 4.13) years.
Measures Learners’ motivation was measured using the Korean version of the Motivated Strategies for Learning Questionnaire (MSLQ), a self-report instrument designed to assess college students’ motivational orientations toward a college course.20,21 A total of 31 questions, each using a 7-point scale (1 = not true, 7 = very true), make up the six motivation subscales: self-efficacy (eight items), task value beliefs (six items), test anxiety (five items), intrinsic goal orientation (four items), extrinsic goal orientation (four items), and control of learning beliefs (four items). In the development and validation studies of the MSLQ,21,22 Cronbach’s ! for the total and domain scores ranged from .92 to .97. In the current study, Cronbach’s ! for the MSLQ total and domain scores ranged from .90 to .97.
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FIGURE 1. Research design.
Life skills were measured using the Life Skills Questionnaire for Korean college students and adults.23 It consists of three subscales: communication skills (49 items), problem-solving skills (45 items), and self-directed learning skills (45 items). Each item is scored on a 5-point Likerttype scale, from 1 (very uncommon) to 5 (very frequent), with higher scores indicating a higher level of life skills. Alpha coefficients reported for the Life-Skills subscales are .80 for the communication skills subscale, .94 for the problem-solving skills subscale, and .93 for the self-directed learning skills subscale.23 In the current study, ! coefficients for the Life-Skills subscales ranged from .84 to .91 for the communication skills subscale, from .93 to .96 for the problem-solving skills subscale, and from .92 to .95 for the self-directed learning skills subscale.
Procedure An integrated circulorespiratory course was designed based on the framework of PBL combined with simulation.24 This course aimed to improve core nursing competence in the circulorespiratory (ie, cardiovascular and hematologic care in respiratory system) nursing care area through integration of PBL and simulation. The three-credit course consisted of two credits of lectures (30 hours) and one credit of small-group sessions (15 hours), based on the credit regulation of the school of nursing. The course was delivered as a 4-hour lecture and a 2-hour small-group tutorial each week. The nursing students were assigned to three teams of 30 students each. Each team had five groups with five or six students each. Nursing students were assigned to a team based on random selection by choosing a number, and they were informed that their team assignments would remain the same throughout the course. Two faculty members acted as tutors for the three teams. 280
Problem-based learning. Four PBL sessions (2 hours per session per week) were held for students to gain core competence in nursing care of patients with chest pain and dysrhythmia. Problem-based learning scenarios were developed using actual patient situations at a cardiovascular intensive care unit of a university hospital in Korea. The PBL scenario was evaluated by two experienced clinical nurses who served as subject matter experts. The scenarios included a 65-year-old male patient with chest pain and a diagnosis of acute myocardial infarction. Simulation-based learning. After the PBL session, six simulation sessions (2 hours per session per week) were led by two faculty members to help the students acquire cardiopulmonary resuscitation (CPR) skills. Participants had a 4-hour ‘‘hands-on’’ session of instructor-led CPR skills training before a weeklong session of simulation testing in November 2012. Instructor-led CPR skills training was defined in the study as simulation-based resuscitation training in patient assessment, chest compressions, ventilations, defibrillation, medication, and other actions necessary to treat a patient with cardiac arrest due to ventricular fibrillation. Participants were given time to practice protocols and procedures and received structured education from two experienced instructors. All sessions took place in a nursing simulation center at a college of nursing. The 2-hour testing session was followed by a three-step simulation process consisting of briefing, simulation, and debriefing. A team of four nursing students was tested at each session. While one student directed resuscitation efforts, another student performed CPR or other tasks on the human patient simulator, SimMan (Laerdal, Stavanger, Norway). As described in the Advanced Cardiovascular Life Support guidelines, nursing students were expected to (1) obtain a history, (2) perform a physical examination, (3) attach noninvasive monitoring, (4) administer medications, (5) perform procedures
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and tests, and (6) direct the resuscitative efforts of other participants. Institutional review board approval was obtained. Participants provided informed consent prior to the baseline assessment. Students were also informed that they could refuse to participate or withdraw from participation in the survey at any time without penalty to them or their course grade. Nursing students who consented completed the self-administered questionnaire at baseline, post-PBL, and postsimulation.
Data Analysis Descriptive statistics were obtained, and one-way repeatedmeasures ANOVAs with post hoc tests (Bonferroni correction) were conducted on each of the subscales and total scales using the SPSS version 21.0 program (SPSS Inc, Chicago, IL). The level of significance was set at .05 for all tests. In preparation for the single-group analyses, the data were examined for violations of the statistical assumptions (independence, normality, sphericity) underlying repeatedmeasures ANOVA. A Kolmogorov-Smirnov test revealed that the distribution of the sample was normal. Mauchly’s tests indicated that the assumption of sphericity was met only in the extrinsic goal orientation subscale (# 22 = 2.66, P = .265), test anxiety subscale (# 22 = 1.13, P = .569), total life skills scale (# 22 = 5.66, P = .059), communication skills subscale (# 22 = 1.19, P = .552), and the problem-solving skills subscale (# 22 = 5.15, P = .076). The Huynh-Feldt correction was used when the variables violated the assumption of sphericity.
RESULTS A repeated-measures ANOVA determined that the mean scores for total learner motivation scale (F = 6.62, P = .003)
and total life skills scale (F = 8.89, P G .001) differed significantly between time points. Subscale analysis of learner motivation scale showed that intrinsic goal orientation (F = 6.90, P = .002), task value (F = 5.20, P = .009), control of learning beliefs (F = 7.41, P = .001), and selfefficacy for learning and performance (F = 5.08, P = .010) differed significantly between time points. Subscale analysis of life skills scale showed that communication skills (F = 8.27, P G .001), problem-solving skills (F = 6.91, P = .001), and self-directed learning skills (F = 4.45, P = .016) differed significantly between time points (Table 1). Post hoc tests using the Bonferroni correction revealed that total learner motivation (P = .009), intrinsic goal orientation (P = .008), task value (P = .042), self-efficacy for learning and performance (P = .004), total life skills (P G .001), communication skills (P G .001), problem-solving skills (P G .001), and self-directed learning skills (P = .001) significantly increased from pretest to postsimulation test. Total learner motivation (P = .001), intrinsic goal orientation (P = .001), task value (P = .002), control of learning beliefs (P = .001), self-efficacy for learning and performance (P = .003), total life skills (P = .005), problem-solving skills (P = .003), and self-directed learning skills (P = .029) also increased significantly from post-PBL test to postsimulation test.
DISCUSSION The present study assessed the effects of a teaching strategy integrating PBL with simulation on learner motivation and life skills among second-year nursing students in Korea. The integrated nursing course resulted in a significant improvement in learner motivation and life skills. To our knowledge, this is the first report examining the effects of integrating PBL with simulation on learner motivation and life skills in a nursing course.
T a b l e 1 Effects of PBL With Simulation on Learner Motivation and Life Skills (n = 83) Variable
Baseline (A) Post-PBL (B) Post-simulation (C)
Learner motivation Intrinsic goal orientation Extrinsic goal orientation Task value Control of learning beliefs Self-efficacy for learning and performance Test anxiety Life skills Communication skills Problem-solving skills Self-directed learning skills a
5.03 4.94 5.25 5.28 5.18 5.06 4.48 3.43 3.42 3.44 3.44
T T T T T T T T T T T
0.63 0.97 0.99 0.85 0.70 0.89 1.04 0.32 0.29 0.42 0.45
4.88 4.83 5.05 5.11 4.87 4.97 4.42 3.46 3.50 3.45 3.45
T T T T T T T T T T T
0.96 1.06 1.00 1.11 1.14 1.16 1.07 0.41 0.36 0.52 0.52
5.21 5.27 5.29 5.45 5.26 5.30 4.59 3.57 3.57 3.61 3.55
T T T T T T T T T T T
0.77 0.92 1.01 0.90 0.82 0.98 0.96 0.40 0.39 0.45 0.48
F
P
6.62a .003 6.90a .002 2.53b .079 5.20a .009 7.41a .001 5.08a .010 1.23b .294 8.89b G.001 8.27b G.001 6.91b .001 4.45a .016
Bonferroni Correction A, B G C A, B G C A, B G C BGC A, B G C A, B A A, B A, B
G G G G
C C C C
When the sphericity assumption for the variance was not satisfied, the corrected F test (Huynh-Feldt) was applied. When sphericity assumption for the variance was satisfied, the F test was used.
b
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In this study, learner motivation significantly increased from pretest to postsimulation and from post-PBL to postsimulation. One previous study has demonstrated that, compared with baseline, intrinsic goal orientation, control of learning beliefs, and self-efficacy for learning and performance improved after a learner-centered pharmacology course.25 The reason for the improvement of learning motivation associated with simulation was thought to be the experiential learning afforded in the simulation method compared with PBL alone. In our course, a blended approach integrating PBL and simulation was applied. Experiential learning provides a useful model for simulation training. Experience provides the main motivation for learning, and new knowledge is established from reflection on experience. The model of learning from experience includes concrete experience with abstract conceptualization as a means of perceiving the experience, as well as critical reflection and active experimentation as a means of transforming the experience.26 Engaging nursing students in CPR skills training using simulation provides both the realism and the time with which to analyze and interpret scenarios and their outcomes. The experiential learning process using simulation techniques allows learners to reflect critically on how they felt during the simulation. They could then begin to formulate concepts and hypotheses concerning the experience through discussion and reflection. Further experimentation with newly formed concepts and experiences could then lead to further reflection on experimentation.26 Learner motivation is essential for enhancing students’ academic achievement. Studies have shown associations between motivation measures and course grades,27,28 persistence, and self-directedness.28 Among medical residents, total MSLQ scores have shown significant positive associations with posttest knowledge scores, and the strongest domain-specific relationships were between self-efficacy and control of learning belief scores and knowledge scores.29 Thus, our results provide nursing educators with evidence demonstrating the usefulness of integrating PBL and simulation to improve learner motivation. Regarding the effects on life skills, post hoc tests using the Bonferroni correction revealed that communication and self-directed learning scores significantly increased from pretest to postsimulation. Problem-solving scores significantly increased from pretest to postsimulation and from post-PBL to postsimulation. The finding that students with simulation-based learning demonstrated higher competencies than observed with PBL alone is certainly consistent with many reports.7–10 This result supports the finding that nursing students in a 9-week fundamental nursing course with integrated PBL and simulation reported significant increases in problem solving and self-directed learning, compared with a traditional curriculum group.13Self-directed learning is a method of instruction that can be defined in terms of the amount of responsibility the learner accepts 282
for his/her own learning.30 Evidence suggests that selfdirected learning in education for health professionals is more effective than lectures in the acquisition of knowledge31 and that simulation is a good way to introduce active learning. Our study demonstrates that simulation plus PBL is more effective than PBL alone at increasing learner motivation, problem solving, and self-directed learning. A possible explanation for this result is the greater feedback and learning time, group work, and lesser extraneous cognitive load associated with simulation versus the comparison intervention.5 Williams and Beattie32 contended that PBL provides a practical clinical teaching approach to guide students in the acquisition of critical reasoning and practical skills. However, this approach alone does not replicate the realworld environment, whereas simulation is the vehicle for translating classroom knowledge into practice in a safe learning environment.33 Integrating PBL and simulation enables students to think aloud and generate knowledge related to a patient problem in tutorial groups (PBL) and then practice how they would manage that problem in a controlled environment (simulation).6 Integrative approaches that encourage discussion, problem solving, and performancebased assessment require a commitment to small-group work, expert facilitation, and a move away from the delivery of content to the development of integrative competencies.15 Through training that merges PBL and simulation, nursing students may be able to more efficiently and effectively develop the necessary competencies for the quality and safety of patient care. Instructional design should be based on conceptions of how students learn and what it means to learn. To comply with these principles, we designed and implemented a course merging PBL and simulation based on several educational principles and models, including adult learning theory, constructivism, and reflective practice. Regarding adult learning principles, adult learners have a readiness to learn what they perceive to be beneficial for coping effectively in real-life situations. Students can use high-level activities appropriate for achieving the intended outcomes, resulting in a deep approach to learning.34 It is crucial for educators to structure and sequence the PBL and simulation so that the learners’ confidence, critical thinking, and problem-solving skills can evolve in a coordinated, supported context.6 Cardiopulmonary resuscitation skills are an essential nursing competency as nurses are frequently first responders in hospital emergency situations. During orientation, teachers can address the importance of CPR skills by noting the association between early initiation of resuscitation and positive patient outcome and, in this way, motivate students who understand that participating in the training session may help them cope effectively as nurses in real emergency situations. This study has a number of limitations worthy of discussion. Repeated-measures designs are widely used because they have advantages over cross-sectional designs. For
CIN: Computers, Informatics, Nursing & July 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
instance, collecting repeated measurements of key variables can provide a more definitive evaluation of withinperson change across time. Moreover, collecting repeated measurements can simultaneously increase statistical power for detecting changes while reducing the costs of conducting a study.35 However, despite the advantages over crosssectional designs, repeated-measures designs complicate the crucial process of selecting a sample size. Furthermore, the extent of improvement demonstrated is all that could result from a single semester of an adult health nursing course, and intrinsic self-rating scales may affect the validity of the findings.
10.
11.
12. 13.
14.
CONCLUSION
15.
Curricula must not only provide students with knowledge, skills, and practice, but also foster learner motivation and life skills. In this study, a nursing course with integrated PBL and simulation elicited a significant improvement in learner motivation and life skills. Simulation plus PBL is a more effective teaching strategy than PBL alone at increasing intrinsic goal orientation, task value, self-efficacy for learning and performance, problem solving, and selfdirected learning. This evidence is valuable in helping nurse educators consider the best possible innovative teaching strategies to support the quality and safety education of nurses.
16.
17.
18.
19.
20.
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& Vol. 33, No. 7, 278–284 & Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.
F E A T U R E A R T I C L E
Integrating Problem-Based Learning and Simulation Effects on Student Motivation and Life Skills YOUNG SOOK ROH, PhD, RN SANG SUK KIM, PhD, RN
Nurse educators must determine the best possible innovative teaching strategies to support quality and safety education for nurses.1,2 Of these strategies, problem-based learning (PBL) and simulation are increasingly prevalent in health profession education, with close links to the principles of constructivism and collaborative learning.3 A recent meta-analysis demonstrated that PBL is more effective than traditional methods in terms of learning and student satisfaction, and PBL has a moderate to large effect on the development of cognitive, affective, and psychomotor skills.4 A meta-analysis also found that technology-enhanced simulation training, in comparison with other instructional modalities, is associated with better learning outcomes. Differences were significant for satisfaction, knowledge, process skills, and product skills.5 Although PBL and simulation in isolation have educational merit, merging these pedagogies has the scope to link aspects of learning that further enhance and transform knowledge.6 However, some studies have revealed Author Affiliation: Red Cross College of Nursing, Chung-Ang University (CAU) Seoul, Korea. Ethical approval was granted by the institutional review board. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Sang Suk Kim, PhD, RN, 84 Heukseouk-Ro, Dongjak-Gu, Seoul, 156-861, Korea ([email protected]). DOI: 10.1097/CIN.0000000000000161
278
Previous research has suggested that a teaching strategy integrating problem-based learning and simulation may be superior to traditional lecture. The purpose of this study was to assess learner motivation and life skills before and after taking a course involving problem-based learning and simulation. The design used repeated measures with a convenience sample of 83 second-year nursing students who completed the integrated course. Data from a self-administered questionnaire measuring learner motivation and life skills were collected at pretest, post–problem-based learning, and post-simulation time points. Repeatedmeasures analysis of variance determined that the mean scores for total learner motivation (F = 6.62, P = .003), communication (F = 8.27, P G .001), problem solving (F = 6.91, P = .001), and selfdirected learning (F = 4.45, P = .016) differed significantly between time points. Post hoc tests using the Bonferroni correction revealed that total learner motivation and total life skills significantly increased both from pretest to postsimulation and from post–problem-based learning test to postsimulation test. Subscales of learner motivation and life skills, intrinsic goal orientation, self-efficacy for learning and performance, problem-solving skills, and self-directed learning skills significantly increased both from pretest to postsimulation test and from post–problem-based learning test to post-simulation test. The results demonstrate that an integrating problem-based learning and simulation course elicits significant improvement in learner motivation and life skills. Simulation plus problem-based learning is more effective than problem-based learning alone at increasing intrinsic goal orientation, task value, self-efficacy for learning and performance, problem solving, and self-directed learning. KEYWORDS Motivation & Patient simulation & Problem-based learning & Problem solving & Self-directed learning
that learning is enhanced with the use of simulation compared with PBL. Steadman et al7 found that simulation led to improved acquisition of assessment and management skills compared with PBL in medical students.
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In other research, pharmacy students in the simulation group showed significantly better improvements in postquiz scores compared with the PBL group. The simulation-based learning group performed at least 15% better in clinical assessment and critical-thinking skills involving problem lists, pharmacotherapy plans, and monitoring plans.8 PharmD students receiving simulation-based learning, compared with those receiving modified PBL and standardized patients, performed better on knowledge-based quizzes and had higher levels of satisfaction.9 A simulation-based learning group showed significantly higher scores on two postintervention scenarios concerning structure and time than a PBL group among 45 fourth-year medical students.10 Integration of simulation exercises into the educational curriculum is an essential feature for their effective use.11 Some studies have demonstrated the beneficial effects of merging PBL and simulation. One study reported the development of a model incorporating PBL in a simulated clinical environment to support the translation of theoretical knowledge into practical skills.12 Incorporation of simulation learning activities into problem-based discussion appears to be an effective educational strategy for teaching nursing students to assess and manage crisis events.3 Nursing students in a 9-week fundamental nursing course integrating PBL and simulation reported significant increases in problem-solving and self-directed learning competency, compared with a traditional curriculum group.13 Nursing students reported favorable perceptions related to competence and small-group learning and had a favorable view of PBL plus simulation, irrespective of their course grade.14 One study demonstrated that assessors’ scores showed a mean improvement in patient assessment, clinical decision making, technical and communication skills, and overall performance after participating in three cycles of PBL and associated simulations.15 After participation in a multifaceted educational session using PBL and simulation, nurses perceived that the education provided an excellent opportunity to increase their knowledge, whereas the simulation experience allowed them to practice their competencies.16 A recent study also reported the positive impact of PBL and a combined learning method among nursing students. The PBL group and the group receiving combined simulation and PBL had higher knowledge and confidence in skill performance scores than did the traditional learning method group. Curricula must not only provide students with the requisite knowledge, skills, and practice, but also foster learner motivation and life skills.17 While research is needed to examine the practicality and feasibility of merging two well-known pedagogies, PBL and simulation, there is relatively little empirical evidence on the motivation and life skills of nursing students taking part in an integrated course of PBL with simulation. Thus, there is a need to further explore whether learner motivation and life skills differ or change with different self-directed learning strategies. Such
findings could provide evidence demonstrating the efficacy of courses integrating PBL and simulation for nursing students.
Purpose The purpose of this study was to assess learner motivation and life skills in second-year nursing students taking a course with integrated PBL and simulation.
METHODS Design This study was a repeated-measures design with data collected from nursing students via questionnaires administered at baseline (pretest), after PBL (post-PBL), and after simulation (post-simulation) (Figure 1).
Participants Regarding sample size, we used G*Power 3 (Heinrich Heine Universitat, Dusseldorf, Germany) to determine that 60 participants were required for a suitable effect size (d = 0.6) with 95% power and a significance level of .05, using one-way repeated-measures analysis of variance (ANOVA).18 This effect size estimate was based on a pooled effect size of 0.62 for multiple learning strategies as reported in a systematic review and meta-analysis of the comparative effectiveness of instructional design features in simulationbased education.19 A nonrandom convenience sample of second-year nursing students enrolled in an adult health nursing course in the second semester of 2012 (n = 90) were invited to participate in the study. After the exclusion of seven questionnaires because of incomplete data, 83 questionnaires (92%) were used in the final analysis. Of the 83 participants, approximately 90% were women. They ranged in age from 19 to 40 years with a mean age of 22.1 (SD, 4.13) years.
Measures Learners’ motivation was measured using the Korean version of the Motivated Strategies for Learning Questionnaire (MSLQ), a self-report instrument designed to assess college students’ motivational orientations toward a college course.20,21 A total of 31 questions, each using a 7-point scale (1 = not true, 7 = very true), make up the six motivation subscales: self-efficacy (eight items), task value beliefs (six items), test anxiety (five items), intrinsic goal orientation (four items), extrinsic goal orientation (four items), and control of learning beliefs (four items). In the development and validation studies of the MSLQ,21,22 Cronbach’s ! for the total and domain scores ranged from .92 to .97. In the current study, Cronbach’s ! for the MSLQ total and domain scores ranged from .90 to .97.
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FIGURE 1. Research design.
Life skills were measured using the Life Skills Questionnaire for Korean college students and adults.23 It consists of three subscales: communication skills (49 items), problem-solving skills (45 items), and self-directed learning skills (45 items). Each item is scored on a 5-point Likerttype scale, from 1 (very uncommon) to 5 (very frequent), with higher scores indicating a higher level of life skills. Alpha coefficients reported for the Life-Skills subscales are .80 for the communication skills subscale, .94 for the problem-solving skills subscale, and .93 for the self-directed learning skills subscale.23 In the current study, ! coefficients for the Life-Skills subscales ranged from .84 to .91 for the communication skills subscale, from .93 to .96 for the problem-solving skills subscale, and from .92 to .95 for the self-directed learning skills subscale.
Procedure An integrated circulorespiratory course was designed based on the framework of PBL combined with simulation.24 This course aimed to improve core nursing competence in the circulorespiratory (ie, cardiovascular and hematologic care in respiratory system) nursing care area through integration of PBL and simulation. The three-credit course consisted of two credits of lectures (30 hours) and one credit of small-group sessions (15 hours), based on the credit regulation of the school of nursing. The course was delivered as a 4-hour lecture and a 2-hour small-group tutorial each week. The nursing students were assigned to three teams of 30 students each. Each team had five groups with five or six students each. Nursing students were assigned to a team based on random selection by choosing a number, and they were informed that their team assignments would remain the same throughout the course. Two faculty members acted as tutors for the three teams. 280
Problem-based learning. Four PBL sessions (2 hours per session per week) were held for students to gain core competence in nursing care of patients with chest pain and dysrhythmia. Problem-based learning scenarios were developed using actual patient situations at a cardiovascular intensive care unit of a university hospital in Korea. The PBL scenario was evaluated by two experienced clinical nurses who served as subject matter experts. The scenarios included a 65-year-old male patient with chest pain and a diagnosis of acute myocardial infarction. Simulation-based learning. After the PBL session, six simulation sessions (2 hours per session per week) were led by two faculty members to help the students acquire cardiopulmonary resuscitation (CPR) skills. Participants had a 4-hour ‘‘hands-on’’ session of instructor-led CPR skills training before a weeklong session of simulation testing in November 2012. Instructor-led CPR skills training was defined in the study as simulation-based resuscitation training in patient assessment, chest compressions, ventilations, defibrillation, medication, and other actions necessary to treat a patient with cardiac arrest due to ventricular fibrillation. Participants were given time to practice protocols and procedures and received structured education from two experienced instructors. All sessions took place in a nursing simulation center at a college of nursing. The 2-hour testing session was followed by a three-step simulation process consisting of briefing, simulation, and debriefing. A team of four nursing students was tested at each session. While one student directed resuscitation efforts, another student performed CPR or other tasks on the human patient simulator, SimMan (Laerdal, Stavanger, Norway). As described in the Advanced Cardiovascular Life Support guidelines, nursing students were expected to (1) obtain a history, (2) perform a physical examination, (3) attach noninvasive monitoring, (4) administer medications, (5) perform procedures
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and tests, and (6) direct the resuscitative efforts of other participants. Institutional review board approval was obtained. Participants provided informed consent prior to the baseline assessment. Students were also informed that they could refuse to participate or withdraw from participation in the survey at any time without penalty to them or their course grade. Nursing students who consented completed the self-administered questionnaire at baseline, post-PBL, and postsimulation.
Data Analysis Descriptive statistics were obtained, and one-way repeatedmeasures ANOVAs with post hoc tests (Bonferroni correction) were conducted on each of the subscales and total scales using the SPSS version 21.0 program (SPSS Inc, Chicago, IL). The level of significance was set at .05 for all tests. In preparation for the single-group analyses, the data were examined for violations of the statistical assumptions (independence, normality, sphericity) underlying repeatedmeasures ANOVA. A Kolmogorov-Smirnov test revealed that the distribution of the sample was normal. Mauchly’s tests indicated that the assumption of sphericity was met only in the extrinsic goal orientation subscale (# 22 = 2.66, P = .265), test anxiety subscale (# 22 = 1.13, P = .569), total life skills scale (# 22 = 5.66, P = .059), communication skills subscale (# 22 = 1.19, P = .552), and the problem-solving skills subscale (# 22 = 5.15, P = .076). The Huynh-Feldt correction was used when the variables violated the assumption of sphericity.
RESULTS A repeated-measures ANOVA determined that the mean scores for total learner motivation scale (F = 6.62, P = .003)
and total life skills scale (F = 8.89, P G .001) differed significantly between time points. Subscale analysis of learner motivation scale showed that intrinsic goal orientation (F = 6.90, P = .002), task value (F = 5.20, P = .009), control of learning beliefs (F = 7.41, P = .001), and selfefficacy for learning and performance (F = 5.08, P = .010) differed significantly between time points. Subscale analysis of life skills scale showed that communication skills (F = 8.27, P G .001), problem-solving skills (F = 6.91, P = .001), and self-directed learning skills (F = 4.45, P = .016) differed significantly between time points (Table 1). Post hoc tests using the Bonferroni correction revealed that total learner motivation (P = .009), intrinsic goal orientation (P = .008), task value (P = .042), self-efficacy for learning and performance (P = .004), total life skills (P G .001), communication skills (P G .001), problem-solving skills (P G .001), and self-directed learning skills (P = .001) significantly increased from pretest to postsimulation test. Total learner motivation (P = .001), intrinsic goal orientation (P = .001), task value (P = .002), control of learning beliefs (P = .001), self-efficacy for learning and performance (P = .003), total life skills (P = .005), problem-solving skills (P = .003), and self-directed learning skills (P = .029) also increased significantly from post-PBL test to postsimulation test.
DISCUSSION The present study assessed the effects of a teaching strategy integrating PBL with simulation on learner motivation and life skills among second-year nursing students in Korea. The integrated nursing course resulted in a significant improvement in learner motivation and life skills. To our knowledge, this is the first report examining the effects of integrating PBL with simulation on learner motivation and life skills in a nursing course.
T a b l e 1 Effects of PBL With Simulation on Learner Motivation and Life Skills (n = 83) Variable
Baseline (A) Post-PBL (B) Post-simulation (C)
Learner motivation Intrinsic goal orientation Extrinsic goal orientation Task value Control of learning beliefs Self-efficacy for learning and performance Test anxiety Life skills Communication skills Problem-solving skills Self-directed learning skills a
5.03 4.94 5.25 5.28 5.18 5.06 4.48 3.43 3.42 3.44 3.44
T T T T T T T T T T T
0.63 0.97 0.99 0.85 0.70 0.89 1.04 0.32 0.29 0.42 0.45
4.88 4.83 5.05 5.11 4.87 4.97 4.42 3.46 3.50 3.45 3.45
T T T T T T T T T T T
0.96 1.06 1.00 1.11 1.14 1.16 1.07 0.41 0.36 0.52 0.52
5.21 5.27 5.29 5.45 5.26 5.30 4.59 3.57 3.57 3.61 3.55
T T T T T T T T T T T
0.77 0.92 1.01 0.90 0.82 0.98 0.96 0.40 0.39 0.45 0.48
F
P
6.62a .003 6.90a .002 2.53b .079 5.20a .009 7.41a .001 5.08a .010 1.23b .294 8.89b G.001 8.27b G.001 6.91b .001 4.45a .016
Bonferroni Correction A, B G C A, B G C A, B G C BGC A, B G C A, B A A, B A, B
G G G G
C C C C
When the sphericity assumption for the variance was not satisfied, the corrected F test (Huynh-Feldt) was applied. When sphericity assumption for the variance was satisfied, the F test was used.
b
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281
In this study, learner motivation significantly increased from pretest to postsimulation and from post-PBL to postsimulation. One previous study has demonstrated that, compared with baseline, intrinsic goal orientation, control of learning beliefs, and self-efficacy for learning and performance improved after a learner-centered pharmacology course.25 The reason for the improvement of learning motivation associated with simulation was thought to be the experiential learning afforded in the simulation method compared with PBL alone. In our course, a blended approach integrating PBL and simulation was applied. Experiential learning provides a useful model for simulation training. Experience provides the main motivation for learning, and new knowledge is established from reflection on experience. The model of learning from experience includes concrete experience with abstract conceptualization as a means of perceiving the experience, as well as critical reflection and active experimentation as a means of transforming the experience.26 Engaging nursing students in CPR skills training using simulation provides both the realism and the time with which to analyze and interpret scenarios and their outcomes. The experiential learning process using simulation techniques allows learners to reflect critically on how they felt during the simulation. They could then begin to formulate concepts and hypotheses concerning the experience through discussion and reflection. Further experimentation with newly formed concepts and experiences could then lead to further reflection on experimentation.26 Learner motivation is essential for enhancing students’ academic achievement. Studies have shown associations between motivation measures and course grades,27,28 persistence, and self-directedness.28 Among medical residents, total MSLQ scores have shown significant positive associations with posttest knowledge scores, and the strongest domain-specific relationships were between self-efficacy and control of learning belief scores and knowledge scores.29 Thus, our results provide nursing educators with evidence demonstrating the usefulness of integrating PBL and simulation to improve learner motivation. Regarding the effects on life skills, post hoc tests using the Bonferroni correction revealed that communication and self-directed learning scores significantly increased from pretest to postsimulation. Problem-solving scores significantly increased from pretest to postsimulation and from post-PBL to postsimulation. The finding that students with simulation-based learning demonstrated higher competencies than observed with PBL alone is certainly consistent with many reports.7–10 This result supports the finding that nursing students in a 9-week fundamental nursing course with integrated PBL and simulation reported significant increases in problem solving and self-directed learning, compared with a traditional curriculum group.13Self-directed learning is a method of instruction that can be defined in terms of the amount of responsibility the learner accepts 282
for his/her own learning.30 Evidence suggests that selfdirected learning in education for health professionals is more effective than lectures in the acquisition of knowledge31 and that simulation is a good way to introduce active learning. Our study demonstrates that simulation plus PBL is more effective than PBL alone at increasing learner motivation, problem solving, and self-directed learning. A possible explanation for this result is the greater feedback and learning time, group work, and lesser extraneous cognitive load associated with simulation versus the comparison intervention.5 Williams and Beattie32 contended that PBL provides a practical clinical teaching approach to guide students in the acquisition of critical reasoning and practical skills. However, this approach alone does not replicate the realworld environment, whereas simulation is the vehicle for translating classroom knowledge into practice in a safe learning environment.33 Integrating PBL and simulation enables students to think aloud and generate knowledge related to a patient problem in tutorial groups (PBL) and then practice how they would manage that problem in a controlled environment (simulation).6 Integrative approaches that encourage discussion, problem solving, and performancebased assessment require a commitment to small-group work, expert facilitation, and a move away from the delivery of content to the development of integrative competencies.15 Through training that merges PBL and simulation, nursing students may be able to more efficiently and effectively develop the necessary competencies for the quality and safety of patient care. Instructional design should be based on conceptions of how students learn and what it means to learn. To comply with these principles, we designed and implemented a course merging PBL and simulation based on several educational principles and models, including adult learning theory, constructivism, and reflective practice. Regarding adult learning principles, adult learners have a readiness to learn what they perceive to be beneficial for coping effectively in real-life situations. Students can use high-level activities appropriate for achieving the intended outcomes, resulting in a deep approach to learning.34 It is crucial for educators to structure and sequence the PBL and simulation so that the learners’ confidence, critical thinking, and problem-solving skills can evolve in a coordinated, supported context.6 Cardiopulmonary resuscitation skills are an essential nursing competency as nurses are frequently first responders in hospital emergency situations. During orientation, teachers can address the importance of CPR skills by noting the association between early initiation of resuscitation and positive patient outcome and, in this way, motivate students who understand that participating in the training session may help them cope effectively as nurses in real emergency situations. This study has a number of limitations worthy of discussion. Repeated-measures designs are widely used because they have advantages over cross-sectional designs. For
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instance, collecting repeated measurements of key variables can provide a more definitive evaluation of withinperson change across time. Moreover, collecting repeated measurements can simultaneously increase statistical power for detecting changes while reducing the costs of conducting a study.35 However, despite the advantages over crosssectional designs, repeated-measures designs complicate the crucial process of selecting a sample size. Furthermore, the extent of improvement demonstrated is all that could result from a single semester of an adult health nursing course, and intrinsic self-rating scales may affect the validity of the findings.
10.
11.
12. 13.
14.
CONCLUSION
15.
Curricula must not only provide students with knowledge, skills, and practice, but also foster learner motivation and life skills. In this study, a nursing course with integrated PBL and simulation elicited a significant improvement in learner motivation and life skills. Simulation plus PBL is a more effective teaching strategy than PBL alone at increasing intrinsic goal orientation, task value, self-efficacy for learning and performance, problem solving, and selfdirected learning. This evidence is valuable in helping nurse educators consider the best possible innovative teaching strategies to support the quality and safety education of nurses.
16.
17.
18.
19.
20.
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