Nurse Educator Vol. 39, No. 5, pp. 209-211 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nurse Educator
Technology Corner
Use of Multiuser, High-Fidelity Virtual Simulation to Teach Leadership Styles to Nursing Students Cynthia Foronda, PhD, RN, CNE & Chakra Budhathoki, PhD Deborah Salani, DNP, ARNP, CPON, BC-NE
A
ccording to the American Association of Colleges of Nursing’s Essentials of Master’s Education in Nursing, leadership (Essential II) and use of technology (Essential V) are key elements in a master’s nursing curriculum.1 Faculty members may argue it is difficult for students to act in a leadership position when in the role of a student learner in a new clinical environment. To provide students an engaging learning experience as a leader, an innovative approach involves using a virtual clinical environment. Using virtual environments is advantageous so students become comfortable with technology as well as experience challenging clinical experiences from the vantage of a leader. This pedagogy has not been well studied. Evidence regarding the effectiveness of using virtual simulation in the classroom is needed to guide faculty. The purpose of the study was to evaluate the intervention of virtual simulation to teach leadership styles to students in a master’s program in nursing education.
Background Leadership in Nursing Historically in nursing, exceptional clinical nurses are promoted to be leaders, yet excellent practitioners do not always possess strong leadership skills. In today’s challenging healthcare environment, it is essential to have nurse leaders who are dedicated, passionate, and committed to promoting quality patient outcomes. Nurse leadership styles influence staff performance and patient outcomes. Effective nurse leaders must manage conflict and use a variety of leadership styles depending on events. Educating nursing students to understand the various leadership styles and develop leadership skills is fundamental to preparation of future leaders. Author Affiliations: Assistant Professor (Drs Foronda and Budhathoki), School of Nursing, Johns Hopkins University, Baltimore, Maryland; and Assistant Professor of Clinical (Dr Salani), School of Nursing and Health Studies, University of Miami, Coral Gables, Florida. The authors declare no conflicts of interest. Correspondence: Dr Foronda, School of Nursing, Johns Hopkins University, 525N Wolfe St, Ste 414 Baltimore, MD 21205 ([email protected]). DOI: 10.1097/NNE.0000000000000073
Nurse Educator
Virtual Simulation The term virtual simulation has been used in many contexts including exercises offered on a computer, 2-dimensional computerized case studies, virtual communities, and Webbased products.2 For purposes of this article, virtual simulation refers to synchronous, Web-based, multiplayer clinical environments using avatars to practice the art of a specialty. Several studies described use of virtual simulation to teach skills in nursing including safety, decision making, communication, professional behavior, and priority setting.3-7 Most studies in nursing education using avatars have used Second Life (Linden Lab, San Francisco, California) and examined student satisfaction rather than learning outcomes.8 No studies were located using virtual simulation in the classroom to teach leadership styles. Jeffries’9 Simulation Model was the theoretical framework for the study. Jeffries’ framework describes the variables in simulations including teacher, student, and proposed student outcomes. In this study, we evaluated student learning gained from the simulation.
Methods A pretest-posttest design was used to frame the study. The test was a 20-item, 100-point, multiple-choice examination about leadership styles developed by the faculty member. This study met criteria of a quality improvement initiative; thus, institutional review board approval was not required. All 8 master’s-level nursing students completed a computerized pretest on Blackboard (Blackboard, Inc, Washington, DC). A series of multiplayer, virtual simulation exercises were administered using the virtual world of CliniSpace, created by Innovation in Learning, Inc, Los Altos Hills, California (Figure 1). Students logged into the virtual world on their personal laptops and chose avatars. The faculty member also entered the world and displayed her view of the simulated clinical setting with the overhead projector for all students to see. The clinical environment was situated in an acute care hospital having a nurses’ station, waiting room, and a patient in a private room. Students were able to obtain vital signs and give medications by clicking Volume 39 & Number 5 & September/October 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
209
Figure 1. Image from CliniSpacei. Reprinted with permission from Innovation in Learning, Inc, 2014.
on the items within the environment. Dynamic vital signs were displayed on a monitor, and the faculty member manipulated the vital signs in conjunction with the students’ interventions. Students took turns performing in various roles acting as nurse, patient, and administrator to demonstrate various leadership styles in conflict situations. The student learning outcomes of the simulations were to (a) recognize different leadership styles and (b) demonstrate conflict resolution. After each simulation, a mini-debriefing session was led by the instructor to discuss the characteristics of the leader as well as what the leader might say. The series of simulations lasted approximately 12 hours. Immediately following the simulations, students completed the posttest. A Wilcoxon signed rank test was used to compare pretest versus posttest scores.
Results Students’ pretest scores ranged from 45 to 85, with a mean score of 64.4 (SD 14.88). The median score was 62.5. Posttest scores ranged from 65 to 100, with a mean score of 84 (SD 11.11). Students demonstrated a statistically significant improvement of 19.3 points, a 30% improvement over the baseline measure (P = .012). The students demonstrated an improvement in cognitive knowledge after the virtual simulation exercise.
Discussion The findings of this study are similar to previous studies indicating that use of virtual simulation improved student performance.3-7 This study contributed to the literature by examining student learning outcomes, specifically cognitive knowledge attainment about leadership styles resulting from virtual simulation exercises. The results suggested that virtual simulation was an effective method to improve master’s degree students’ cognitive knowledge of leadership styles. Educators may choose to use this innovative technique in the classroom to enhance lecture, as in this study, or perform virtual simulations from a distance as the virtual platform is Web based. Comparative studies are recommended examining learning outcomes including student satisfaction and cognitive knowledge result210
Volume 39 & Number 5 & September/October 2014
ing from virtual simulation compared with other teaching methods such as lecture or reading alone. Furthermore, it would be beneficial to determine if the knowledge resulting from simulation is retained over time. It is possible virtual simulations are more engaging and leave a longer impression and retention than other methods. A cost-benefit analysis of virtual simulation compared with mannequin-based simulation is warranted. This study had limitations. The sample size was small, and demographic information was not obtained; thus, generalizability is limited. In addition, the pretest and posttest were the same. Students may have memorized portions of the pretest and paid closer attention to these concepts during the simulation. However, to avoid this limitation, students were not informed the posttest would be composed of the same questions.
Conclusion Leadership is a core course in many nursing curricula. In higher education, nurse faculty members are challenged to teach in meaningful ways to produce future leaders in the profession. Virtual simulation is an engaging, innovative use of technology that has been supported as an effective method to teach leadership concepts to nursing students. As the uses of virtual simulation expand, so must educational research efforts. Acknowledgments The authors thank the University of Miami for providing financial support of this project and support of innovation in teaching through the Faculty Learning Community. The authors express gratitude to Innovation in Learning, Inc, developers of CliniSpace.
References 1. American Association of Colleges of Nursing. The Essentials of Master’s Education in Nursing. Available at http://www.aacn .nche.edu/education-resources/MastersEssentials11.pdf. Published 2011. Accessed May 29, 2014. 2. Foronda C, Godsall L, Trybulski J. Virtual clinical simulation in nursing: a state of the science. Clin Simulat Nurs. 2012;9(8):e1-e8. 3. Aebersold M, Tschannen D, Stephens M, Anderson P, Lei X. Second Life: a new strategy in educating nursing students. Clin Simulat Nurs. 2011;7(5):e1-e7. Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
4. Aebersold M, Tschannen D, Bathish M. Innovative simulation strategies in education. Nurs Res Pract. 2012;2012:e1-e7. 5. Cook MJ. Design and initial evaluation of a virtual pediatric primary care clinic in Second Life. J Am Acad Nurse Pract. 2012;24:521-527. 6. Foronda C, Gattamorta K, Snowden K, Bauman E. Use of virtual clinical simulation to improve communication skills of baccalaureate nursing students: a pilot study. Nurse Educ Today. 2013; 34(6):e53-e57.
Nurse Educator
7. McCallum J, Ness V, Price T. Exploring nursing students’ decisionmaking skills whilst in a second life clinical simulation laboratory. Nurse Educ Today. 2011;31(7):699-704. 8. Miller M, Jensen R. Avatars in nursing: an integrative review. Nurse Educ. 2014;39(1):38-41. 9. Jeffries PR. A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nurs Educ Perspect. 2005;26(2):96-103.
Volume 39 & Number 5 & September/October 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
211
Nurse Educator
Technology Corner
Use of Multiuser, High-Fidelity Virtual Simulation to Teach Leadership Styles to Nursing Students Cynthia Foronda, PhD, RN, CNE & Chakra Budhathoki, PhD Deborah Salani, DNP, ARNP, CPON, BC-NE
A
ccording to the American Association of Colleges of Nursing’s Essentials of Master’s Education in Nursing, leadership (Essential II) and use of technology (Essential V) are key elements in a master’s nursing curriculum.1 Faculty members may argue it is difficult for students to act in a leadership position when in the role of a student learner in a new clinical environment. To provide students an engaging learning experience as a leader, an innovative approach involves using a virtual clinical environment. Using virtual environments is advantageous so students become comfortable with technology as well as experience challenging clinical experiences from the vantage of a leader. This pedagogy has not been well studied. Evidence regarding the effectiveness of using virtual simulation in the classroom is needed to guide faculty. The purpose of the study was to evaluate the intervention of virtual simulation to teach leadership styles to students in a master’s program in nursing education.
Background Leadership in Nursing Historically in nursing, exceptional clinical nurses are promoted to be leaders, yet excellent practitioners do not always possess strong leadership skills. In today’s challenging healthcare environment, it is essential to have nurse leaders who are dedicated, passionate, and committed to promoting quality patient outcomes. Nurse leadership styles influence staff performance and patient outcomes. Effective nurse leaders must manage conflict and use a variety of leadership styles depending on events. Educating nursing students to understand the various leadership styles and develop leadership skills is fundamental to preparation of future leaders. Author Affiliations: Assistant Professor (Drs Foronda and Budhathoki), School of Nursing, Johns Hopkins University, Baltimore, Maryland; and Assistant Professor of Clinical (Dr Salani), School of Nursing and Health Studies, University of Miami, Coral Gables, Florida. The authors declare no conflicts of interest. Correspondence: Dr Foronda, School of Nursing, Johns Hopkins University, 525N Wolfe St, Ste 414 Baltimore, MD 21205 ([email protected]). DOI: 10.1097/NNE.0000000000000073
Nurse Educator
Virtual Simulation The term virtual simulation has been used in many contexts including exercises offered on a computer, 2-dimensional computerized case studies, virtual communities, and Webbased products.2 For purposes of this article, virtual simulation refers to synchronous, Web-based, multiplayer clinical environments using avatars to practice the art of a specialty. Several studies described use of virtual simulation to teach skills in nursing including safety, decision making, communication, professional behavior, and priority setting.3-7 Most studies in nursing education using avatars have used Second Life (Linden Lab, San Francisco, California) and examined student satisfaction rather than learning outcomes.8 No studies were located using virtual simulation in the classroom to teach leadership styles. Jeffries’9 Simulation Model was the theoretical framework for the study. Jeffries’ framework describes the variables in simulations including teacher, student, and proposed student outcomes. In this study, we evaluated student learning gained from the simulation.
Methods A pretest-posttest design was used to frame the study. The test was a 20-item, 100-point, multiple-choice examination about leadership styles developed by the faculty member. This study met criteria of a quality improvement initiative; thus, institutional review board approval was not required. All 8 master’s-level nursing students completed a computerized pretest on Blackboard (Blackboard, Inc, Washington, DC). A series of multiplayer, virtual simulation exercises were administered using the virtual world of CliniSpace, created by Innovation in Learning, Inc, Los Altos Hills, California (Figure 1). Students logged into the virtual world on their personal laptops and chose avatars. The faculty member also entered the world and displayed her view of the simulated clinical setting with the overhead projector for all students to see. The clinical environment was situated in an acute care hospital having a nurses’ station, waiting room, and a patient in a private room. Students were able to obtain vital signs and give medications by clicking Volume 39 & Number 5 & September/October 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
209
Figure 1. Image from CliniSpacei. Reprinted with permission from Innovation in Learning, Inc, 2014.
on the items within the environment. Dynamic vital signs were displayed on a monitor, and the faculty member manipulated the vital signs in conjunction with the students’ interventions. Students took turns performing in various roles acting as nurse, patient, and administrator to demonstrate various leadership styles in conflict situations. The student learning outcomes of the simulations were to (a) recognize different leadership styles and (b) demonstrate conflict resolution. After each simulation, a mini-debriefing session was led by the instructor to discuss the characteristics of the leader as well as what the leader might say. The series of simulations lasted approximately 12 hours. Immediately following the simulations, students completed the posttest. A Wilcoxon signed rank test was used to compare pretest versus posttest scores.
Results Students’ pretest scores ranged from 45 to 85, with a mean score of 64.4 (SD 14.88). The median score was 62.5. Posttest scores ranged from 65 to 100, with a mean score of 84 (SD 11.11). Students demonstrated a statistically significant improvement of 19.3 points, a 30% improvement over the baseline measure (P = .012). The students demonstrated an improvement in cognitive knowledge after the virtual simulation exercise.
Discussion The findings of this study are similar to previous studies indicating that use of virtual simulation improved student performance.3-7 This study contributed to the literature by examining student learning outcomes, specifically cognitive knowledge attainment about leadership styles resulting from virtual simulation exercises. The results suggested that virtual simulation was an effective method to improve master’s degree students’ cognitive knowledge of leadership styles. Educators may choose to use this innovative technique in the classroom to enhance lecture, as in this study, or perform virtual simulations from a distance as the virtual platform is Web based. Comparative studies are recommended examining learning outcomes including student satisfaction and cognitive knowledge result210
Volume 39 & Number 5 & September/October 2014
ing from virtual simulation compared with other teaching methods such as lecture or reading alone. Furthermore, it would be beneficial to determine if the knowledge resulting from simulation is retained over time. It is possible virtual simulations are more engaging and leave a longer impression and retention than other methods. A cost-benefit analysis of virtual simulation compared with mannequin-based simulation is warranted. This study had limitations. The sample size was small, and demographic information was not obtained; thus, generalizability is limited. In addition, the pretest and posttest were the same. Students may have memorized portions of the pretest and paid closer attention to these concepts during the simulation. However, to avoid this limitation, students were not informed the posttest would be composed of the same questions.
Conclusion Leadership is a core course in many nursing curricula. In higher education, nurse faculty members are challenged to teach in meaningful ways to produce future leaders in the profession. Virtual simulation is an engaging, innovative use of technology that has been supported as an effective method to teach leadership concepts to nursing students. As the uses of virtual simulation expand, so must educational research efforts. Acknowledgments The authors thank the University of Miami for providing financial support of this project and support of innovation in teaching through the Faculty Learning Community. The authors express gratitude to Innovation in Learning, Inc, developers of CliniSpace.
References 1. American Association of Colleges of Nursing. The Essentials of Master’s Education in Nursing. Available at http://www.aacn .nche.edu/education-resources/MastersEssentials11.pdf. Published 2011. Accessed May 29, 2014. 2. Foronda C, Godsall L, Trybulski J. Virtual clinical simulation in nursing: a state of the science. Clin Simulat Nurs. 2012;9(8):e1-e8. 3. Aebersold M, Tschannen D, Stephens M, Anderson P, Lei X. Second Life: a new strategy in educating nursing students. Clin Simulat Nurs. 2011;7(5):e1-e7. Nurse Educator
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
4. Aebersold M, Tschannen D, Bathish M. Innovative simulation strategies in education. Nurs Res Pract. 2012;2012:e1-e7. 5. Cook MJ. Design and initial evaluation of a virtual pediatric primary care clinic in Second Life. J Am Acad Nurse Pract. 2012;24:521-527. 6. Foronda C, Gattamorta K, Snowden K, Bauman E. Use of virtual clinical simulation to improve communication skills of baccalaureate nursing students: a pilot study. Nurse Educ Today. 2013; 34(6):e53-e57.
Nurse Educator
7. McCallum J, Ness V, Price T. Exploring nursing students’ decisionmaking skills whilst in a second life clinical simulation laboratory. Nurse Educ Today. 2011;31(7):699-704. 8. Miller M, Jensen R. Avatars in nursing: an integrative review. Nurse Educ. 2014;39(1):38-41. 9. Jeffries PR. A framework for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nurs Educ Perspect. 2005;26(2):96-103.
Volume 39 & Number 5 & September/October 2014
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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