difficult problems if I try hard enough.
2. If someone opposes me, I can find 2.92 3.40 .001** means and ways to get what I want.
3. It is easy for me to stick to my aims 3.46 3.63 .019* and accomplish my goals.
4. I am confident that I could deal 3.25 3.46 .011* efficiently with unexpected events.
5. Thanks to my resourcefulness, I know 3.08 3.58 .001** how to handle unforeseen situations.
6. I can solve most problems if I invest 3.69 3.79 .096 the necessary effort.
7. I can remain calm when facing 3.35 3.48 .083 difficulties because I can rely on my
coping abilities.
8. When I am confronted with a problem, 3.29 3.54 .001** I can usually find several solutions.
9. If I am in a bind, I can usually think 3.46 3.6 .019* of something to do.
10. No matter what comes my way, I’m 3.46 3.56 .133 usually able to handle it.
Research question 3. Will self-efficacy to initiate chain-of-command in an
obstetrical setting differ between students who participate in simulation versus those who observe the simulation?
Paired t-test was conducted to determine if statistical significance exists between active participant status and observational status in a high fidelity, student-directed, obstetrical simulation. No significance was found. See Table 4.
Table 4
Comparison of Self-Efficacy Means of Participants(n=25)and Observers(n=23)
________________________________________________________________________
Variable Participants Observers p ________________________________________________________________________
1. I can always manage to solve
difficult problems if I try hard 3.28 3.17 .514* enough.
2. If someone opposes me, I can find 2.96 2.87 .444* means and ways to get what I want.
3. It is easy for me to stick to my aims 3.44 3.48 .811* and accomplish my goals.
4. I am confident that I could deal 3.20 3.30 .528* efficiently with unexpected events.
5. Thanks to my resourcefulness, I know 3.08 3.09 .969* how to handle unforeseen situations.
6. I can solve most problems if I invest 3.76 3.61 .268* the necessary effort.
7. I can remain calm when facing 3.40 3.30 .563* difficulties because I can rely on my
coping abilities.
8. When I am confronted with a problem, 3.20 3.39 .288* I can usually find several solutions.
9. If I am in a bind, I can usually think 3.32 3.61 .086* of something to do.
10. No matter what comes my way, I’m 3.44 3.48 .823* usually able to handle it.
One-way analysis of variance (ANOVA) was conducted to compare pretest and posttest mean scores on the GSES for demographic qualities, such as previous college degree, previously witnessing nursing chain-of-command, or work experience in a health care facility. No significance was found between pretest and posttest scores for
participants with a previous college degree or those who had previously witnessed
nursing chain-of-command. There was no significance at pretest for participants who had health care work experience; however, a statistical significance was noted at posttest [F (1, 46)= 1.872, p,017].
Summary
The data analysis methods used for this capstone project included paired t-tests and one-way ANOVA. The mean self-efficacy score for all participants was 33.2 (SD 3.7). The informational session and simulation did significantly improve self-efficacy scores for all participants at posttest; however, the participants and observers did not score significantly differently from each other.
CHAPTER V Discussion
This study investigated the impact of an informational session and student- directed, high fidelity, obstetrical simulation upon junior baccalaureate nursing students’ self-efficacy related to chain-of-command initiation. The impact of active and
observational roles upon GSES scores was also examined. Project implementation included a chain-of-command informational session, followed by a simulation in which some students actively planned and enacted safety measures, including chain-of-
command, while others observed. Tools included GSES at pretest and posttest, as well as a demographic survey at posttest.
Implications of Findings on Nursing Education
This doctoral capstone project supported the use of high fidelity, student-directed, obstetrical simulation as an effective pedagogy to enhance chain-of-command initiation self-efficacy of junior level baccalaureate nursing students. Because active and
observational participants scored higher self-efficacy scores at posttest, but did not differ significantly from each other, nursing educators can incorporate this finding into their current methods of instruction. This project finding supported the use of simulation observation as an effective pedagogy, as opposed to having all students enact the same scenarios in simulation exercises. In fact, Schunk (2008) asserts that vicarious
experiences accelerate learning compared to traditional teaching in which all students have had to physically enact a given behavior or task. This finding is a tremendous asset for educators who struggle to teach a multitude of skills and concepts, yet often have limited access to clinical simulation laboratories.
Locally, this project has impacted undergraduate nursing simulation education within the school of nursing where the project was implemented. With finite simulation equipment and technology specialists, course coordinators are challenged to arrange appropriate time and resources in the Simulation Learning Center. This study, however, could potentially decrease the amount of time spent on instruction regarding one skill or concept; thereby allowing for expansion of instruction regarding various safety concepts, such as chain-of-command or interprofessional communication. The course coordinator for the maternal child course has added the educational intervention into end-of-semester simulations to enhance students’ self-efficacy to initiate chain-of-command. As opposed to having each student actively participate in a specific simulation, half of the students will observe the simulation. Afterward, observational students will participate (while others observe) in another simulation to potentially broaden the simulation experience and increase the amount of concepts explored. Based on student feedback and requests for similar simulation experiences, the curriculum committee is exploring implementation throughout all clinical courses.
Research question 1. The first research question explored the level of self-
efficacy perceived by the nursing students. The total mean score for the GSES for all participants was 33.2 (SD 3.7) of out a possible 40 points. The GSES does not establish definitive scores which equate to efficacious behavior; however, this equal to the 83rd percentile.
Clearly, this scoring represents a great opportunity for educators to close the self- efficacy gap for students, especially those who graduate and enter the workforce in specialty, high-risk units, such as labor and delivery. Not only do nurses need to possess
a tremendous amount of skill and knowledge, they also need to be adequately prepared to meet quality and safety measures (Benner et al., 2010; Lutz & Root, 2007). Simulation is a proven pedagogy to help students “take ownership” (Benner et al., 2010, p. 157) while enhancing clinical competence. Transition into professional practice could potentially become less stressful for the new graduate, and safer for patients.
Research question 2. The second research question investigated if students’ self-
efficacy to initiate chain-of-command in an obstetrical setting significantly increased following an informational session and student-directed simulation. The results of a paired-samples t-test of the General Self Efficacy Scale pretest and posttest revealed a significant increase in student’s self-efficacy following the intervention.
Based on these findings, student-directed, high fidelity simulation, combined with didactic instruction regarding nursing chain-of-command, is an effective pedagogy to enhance students’ chain-of-command initiation self-efficacy. This study demonstrated that opportunities exist for nursing educators to proactively enhance self-efficacy of nursing students to advocate for the safety of their patients through chain-of-command. As the national patient safety movement continues to focus on measures to promote patient safety within health care settings, schools of nursing should further explore measures to prepare graduates to enter the workforce with enhanced awareness and self- efficacy related to patient safety.
Research question 3. The third research question evaluated the difference in
self-efficacy scores between students who actively participated in simulation versus those who observed the simulation. Paired t-test was performed to determine if any significant
difference existed between self-efficacy scores of those who were active in the simulation versus those who only observed. No significant difference was noted.
Application to Theoretical/Conceptual Framework
The theoretical and conceptual framework of Bandura’s Social Cognitive Learning Theory was an appropriate guide for measuring self-efficacy in this project. The pretest posttest GSES and posttest demographic survey were consistent with the framework to measure students’ self-efficacy to initiate chain-of-command as a means to promote patient safety. As discussed in the previous chapter, both active and
observational students demonstrated significant increases in self-efficacy at posttest. This finding is consistent with Bandura’s (1986) concept that doing a task, as well as observing a task, can enhance one’s self-efficacy related to accomplishing the same task.
Limitations
These results cannot be generalized to the majority of nursing students due to the limited sample of 48 participants within one school of nursing; however, these findings may inform schools of nursing with a similar size and population characteristics.
Delimitations
Due to time constraints and limited access to participants, the project
administrator allowed the some delimitations. The sample size was small with only baccalaureate junior level students, so this study is not generalizable to all nursing student populations. Holding four individual simulations, as opposed to one simulation
experience, was another planned delimitation so that more students would have the opportunity to actively participate in the chain-of-command process. Although much effort was made to keep simulation guidelines identical, the possibility remains that
variations between simulations affected the results. Obtaining posttests immediately after the intervention was necessary, but no evidence remains that results are sustainable. Eight participants had been in the project administrator’s clinical group during the previous eight weeks. Although final clinical grades were posted prior to the study and students were informed in writing and verbally regarding their ability to decline
participation in the study, the possibility remains that some students participated due to fear of retribution or desire to please the project administrator. Also, the educational session could have verbally encouraged the students in regards to anticipated results; however, these students had never been formally instructed regarding nursing chain-of- command. Instruction was necessary so that the students would understand and be prepared to implement. Finally, students were allowed to self-select in the active participation groups due to the nature of the student-directed simulation. Students with more self-efficacy could have taken the leadership positions, and thus, affected the outcome.
Recommendations
This doctoral capstone project supported the use of student-directed, high fidelity simulation as an effective pedagogy to enhance chain-of-command initiation self-efficacy of junior level baccalaureate nursing students. Because active and observational
participants scored higher self-efficacy scores at posttest, but did not differ significantly from each other, nursing educators can incorporate this finding into their current methods of instruction. This project finding supported the use of simulation observation as an effective pedagogy, as opposed to having all students enact the same scenarios in simulation exercises.
For future similar studies, one recommendation is to increase generalizability by utilizing students from multiple schools. This study could be replicated in associate degree nursing (ADN) programs to determine similarities and differences between baccalaureate and ADN nursing students in relation to chain-of-command self-efficacy. Also, studies with mixed methods could further explore qualitative data associated with student’s self-efficacy. Robb (2012) upheld that further studies are needed to identify the generalizability of self-efficacy perceptions, as well as students’ and faculty’s expectation regarding learning outcomes of simulation exercises such as the one presented here. This project should also be repeated (without the educational session) with the same cohort in the senior year of their nursing program to determine if the findings of enhanced self- efficacy to initiate chain-of-command are sustained. A broad-range, generalizable, longitudinal study is suggested to investigate the impact, if any, participation in a high fidelity, student-directed, obstetrical simulation with didactic component as presented here, would have upon patient outcomes and nursing practice following graduation.
Contingent upon further supportive research, chain-of-command initiation in simulation could become a core safety competency within schools of nursing. This transformational simulation component would promote self-efficacy so that students can confidently initiate chain-of-command while still in nursing school, instead of first applying this concept as new graduates caring for patients.
Conclusion
Appropriate and timely implementation of nursing chain-of-command is essential to the promotion of patient safety, yet new graduates are often hesitant to speak up and advocate for patients. Schools of nursing teach chain-of-command conceptually, but students have little authority and almost nonexistent opportunities to actually implement this protocol. Babenko-Mould (2010) asserts nursing students need opportunities to develop “a sense of empowerment” (para. 1) and “to be prepared to practice with confidence (self-efficacy)” (para. 1). High fidelity, student-directed, obstetrical
simulation was identified as a means to provide students with an opportunity to practice chain-of-command initiation and to enhance their self-efficacy to promote patient safety.
References
Aiken, L., Clarke, S., Sloane, D., Sochalski, J., & Silber, J. (2002). Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. Journal of
The American Medical Association, 288 (16), 1987-1993.
doi.org/10.1001/jama.288.16.1987
Association of Women’s Health, Obstetric, and Neonatal Nurses. (2009). Standards for professional nursing practice in the care of women and newborns. Retrieved September 5, 2014, from awohnn.org
Babenko-Mould. (2010). Clinical teachers’ and nursing students’ empowerment in acute care settings (Doctoral Dissertation).
Bambini, D., Washburn, J., & Perkins, R. (2009). Outcomes of clinical simulation for novice nursing students: Communication, confidence, clinical judgment. Nursing
Education Perspectives, 30(2), 79-82. doi.org/10.1043/1536-5026-030.002.0079
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change (Abstract). Psychological Review, 84(2), 191-215.
http://dx.doi.org/10.1037/0033-295x.84.2.191
Bandura, A. (1986). The explanatory and predictive scope of self-efficacy theory.
Journal of Social and Clinical Psychology, 4(3), 359-373.
Benner, P., Stuphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for
Berarducci, A., & Lengacher, C.A. (1998). Self-efficacy: An essential component of advanced-practice nursing. [Abstract]. Nursing Connections, 11(1), 55-67. http://eds.a.ebscohost.com.ezproxy.gardner-
webb.edu/ehost/detail/detail?vid=13&sid=9b2f0650-22b6-40f9-9f40-
a5b2313613b3%40sessionmgr4003&hid=4113&bdata=JnNpdGU9ZWhvc3QtbGl 2ZQ%3d%3d#db=rzh&AN=1998049487
Brenmer, M., Bennett, D., & VanGeest, J. (2006). The use of human patient simulators: Best practices with novice nursing students. Nurse Educator, 31, 170-174. Brydges, R., Nair, P., Ma, I., Shanks, D., & Hatala, R. (2012). Directed self-regulated
learning versus instructor-regulated learning in simulation training. Medical
Education, 46(7), 648-656. doi.org/10.1111/j.1365-2923.2012.04268.x
Cannon-Diehl, M. (2009). Simulation in healthcare and nursing: State of the science. [Abstract]. Critical Care Nursing Quarterly, 32(2), 128-136.
doi:10.1097/CNQ.0b013e3181a27e0f
Casualty of North America Healthpro & Nurses Services Organization, (2011).
Understanding nurse liability, 2006-2010: A three-part approach. Retrieved May 13, 2013 from http://www.nso.com/pdfs/db/RN-2010-CNA-Claims-
Study.pdf?fileName=RN-2010-CNA-Claims- Study.pdf&folder=pdfs/db&isLiveStr=Y
Chang, Y. (2011). Psychometric validity of the problem-focused style of coping scale: In relation to self-efficacy and life satisfaction among nursing staff in Taiwan.
Journal of Advanced Nursing, 67(7), 1625-1631. doi.org/10.1111/j.1365-
Chang, Y., & Levin, R. (2014). Tactics for teaching evidence-based practice: Improving self-efficacy in finding and appraising evidence in a master’s evidence-based practice unit. Worldviews on Evidence-Based Nursing, 11(4), 266-269. Como, J. (2007). Care and caring: A look at history, ethics, and theory. International
Journal for Human Caring, 11(4), 37-45. Retrieved from
http://eds.a.ebscohost.com.ezproxy.gardner-
webb.edu/ehost/detail/detail?vid=3&sid=6047698c-cc99-4b4b-a601-
7f9c4f4cbaea%40sessionmgr4003&hid=4202&bdata=JnNpdGU9ZWhvc3QtbGl2 ZQ%3d%3d#db=rzh&AN=2009754502
Dolansky, M. A., & Moore, S. M. (2013). Quality and safety education for nurses
(QSEN): The key is systems thinking. Online Journal Of Issues In Nursing, 18(3), 1-12. doi:10.3912/OJIN.Vol18No03Man01
Etheridge, S. (2007). Learning to think like a nurse: stories from new nurse graduates.
Journal Of Continuing Education In Nursing, 38(1), 24-30.
Fabro, K., Schaffer, M., & Scharton, J. (2014). The development, implementation, and evaluation of an end-of-life simulation experience for baccalaureate nursing students. Nursing Education Perspectives, 35(1), 19-25.
Fong, W. (2013). Nursing students’ satisfaction and self-confidence towards high-
fidelity simulation and its relationship with the development of critical thinking in Hong Kong (Doctoral dissertation). Retrieved from
http://eds.a.ebscohost.com.ezproxy.gardner-
webb.edu/ehost/resultsadvanced?sid=6de15324-8ed5-453e-9a78-
b431b7544f2d%40sessionmgr4005&vid=12&hid=4105&bquery=(high+fidelity+ simulation)+AND+(clinical+experience)+AND+(nursing+education)&bdata=Jm RiPXJ6aCZ0eXBlPTEmc2l0ZT1laG9zdC1saXZl
Gaberson & Oermann, (2010). Clinical Teaching Strategies in Nursing. Springer: New York: NY.
Ginter, N. (2014). Promoting RN satisfaction with a program for novice nurses (Doctoral Dissertation). Retrieved from http://eds.a.ebscohost.com.ezproxy.gardner-
webb.edu/ehost/detail/detail?vid=7&sid=ee58ee07-7c79-46d0-be47-
1973c15a21e7%40sessionmgr4003&hid=4102&bdata=JnNpdGU9ZWhvc3QtbGl 2ZQ%3d%3d#db=rzh&AN=2012566531
Glenn, A., Stocker-Schnieder, J., McCune, R., McClelland, M., & King, D. (2014). Caring nurse practice in the intrapartum setting: Nurses’ perspectives on
complexity, relationships and safety. Journal of Advanced Nursing, 70(9), 2019- 2030. doi: 10.1111/jan.12356
Gloudemans, H. A., Schalk, R. M., & Reynaert, W. (2013). The relationship between critical thinking skills and self-efficacy beliefs in mental health nurses. Nurse
Goldsztejn, N. (2009). Registered nurse perception of communication in labor and delivery (Doctoral dissertation).
Hensel, D. (2014). Typologies of professional identity among graduating baccalaureate- prepared nurses. Journal of Nursing Scholarship, 46(2), 125-133. doi:
10.1111/jnu.12052
Henrisksen, K., & Dayton, E. (2006). Organizational silence and hidden threats to patient safety. Health Services Research, 41(4), 1539-1554.
doi.org/10.1111/j.1475-6773.2006.00564.x
Institute of Medicine (IOM) (2000). To err is human: Building a safer health system. Retrieved from http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A- Safer-Health-System.aspx
Institute of Medicine (IOM) (2001). Crossing the quality chasm: A new health system for
the 21st century. Retrieved from http://www.nap.edu/catalog/10027.html
Institute of Medicine (IOM) (2004). Keeping patients safe: Transforming the work
environment of nurses. National Academies Press: Washington, D.C.
Institute of Medicine (IOM) (2010). The future of nursing: Leading change, advancing
health. Retrieved from
http://www.thefutureofnursing.org/sites/default/files/Future%20of%20Nursing%2 0Report_0.pdf
Interprofessional Education Collaborative Expert Panel (Ed.). (2011). Core competencies
for interprofessional collaborative practice: Report of an expert panel.
http://www.aacp.org/resources/education/Documents/10- 242IPECFullReportfinal.pdf
Jones, K. J., Skinner, A. M., High, R., & Palmon, R. R. (2013). A theory-driven,
longitudinal evaluation of the impact of team training on safety culture in 24
hospitals. BMJ Quality & Safety, 22(5), 394-404. doi:10.1136/bmjqs-2012-
000939
Joy, J. (2009). Nurses: The patient’s first-and perhaps last-line of defense. AORN
Journal, 89 (6), 1133-1136. doi.org/10.1016/j.aorn.2009.05.013
Kameg, K., Howard, V., 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(5), 315-323. doi.org/10.3109/01612840903420331
Kane, R. L., Shamliyan, T.A., Mueller, C., Duval, S., & Wilt, T.J. (2007). The
association of registered nurse staffing levels and patient outcomes: Systematic review and meta-analysis. Med Care 45(12), 1195-1204.
Kim, S., Lee, S., & Chae, H. J. (2012). Effects of clinical practice and simulation-based practice for obstetrical nursing. Korean Journal of Women Health Nursing, 18(3), 180-189. http://dx.doi.org/10.4069/kjwhn.2012.18.3.180
Kuiper, R., Murdock, N., & Grant, N. (2010). Thinking strategies of baccalaureate nursing students prompted by self-regulating learning strategies. Journal of
Nursing Education, 49(8), 429-436. doi.org/10.3928/01484834-20100430-01
Kurtzman, E.T., & Buerhaus, P.I. (2008). New Medicare payment rules: Danger or opportunity for nursing? American Journal of Nursing 108(6):30-35.
Lacey, S. R., & Cox, K.S. (2009). Nursing: Key to quality improvement. Pediatric
Clinics of North America 56(4):975-985.
Landon, B. E., Normand, S.L., Lessler, A., O'Malley, A. J., Schmaltz, S., Loeb, J.M., & McNeil. B.J. (2006). Quality of care for the treatment of acute medical conditions in U.S. hospitals. Archives of Internal Medicine 166(22), 2511-2517.
Lutz, S., & Root, D. (2007). Nurses, consumer satisfaction, and pay for performance. Healthcare Financial Management, 61(10), 56-63.
Lyndon, A., Zlatnik, M., & Wachter, R. (2011). Effective physician-nurse
communication: A patient safety essential for labor and delivery. American
Journal Of Obstetrics & Gynecology, 205(2), 91-96.
http://dx.doi.org/10.1016/j.ajog.2011.04.021
Manojlovich, M. (2003). Environmental and personal predictors of professional nursing
practice behaviors in hospital settings (Doctoral dissertation). Retrieved from
http://eds.a.ebscohost.com.ezproxy.gardner-
webb.edu/ehost/detail/detail?vid=3&sid=e36a6c51-087d-4708-8ad9-
6038713cbe00%40sessionmgr4004&hid=4202&bdata=JnNpdGU9ZWhvc3QtbGl