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The Effect of Guided Observation on Learning Outcomes in Simulation-Based Learning
Abstract
The purpose of this study was to examine differences in knowledge, self confidence, satisfaction, and collaboration between baccalaureate nursing students (n = 121) using an Observation Guide (n = 62) when observing a simulated clinical experience (SCE) and those observers without an Observation Guide (n = 59). The study design was a
quantitative quasi-experimental pretest-posttest control group design, used to determine differences between the observer groups. A two way mixed ANOVA and independent t- tests were used to identify differences in learning outcomes between the students using the Observation Guide and those without a guide. Although no significant improvement in knowledge, self-confidence, or collaboration was noted between groups, students utilizing an Observation Guide reported significantly higher satisfaction with the
simulated clinical experience. Findings from the research study indicate implications for nursing education and research.
KEYWORDS: Simulated clinical experience, Observer, Observation Guide, Experiential Learning, Nursing Education
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The Effect of Guided Observation on Learning Outcomes in Simulation-Based Learning
Nurse educators are challenged to stimulate students to become critical thinkers who can function in a dynamic and complex health care delivery system (Decker, Sportsman, Puetz, & Billings, 2008), but are limited by a shortage of faculty and lack of appropriate clinical placement sites (Curl, Smity, Chisholm, Hamilton, & McGhee, 2007). The National League for Nursing has called for reform in nursing curricula to better prepare new graduates to practice in an increasingly technological health care environment (NLN, 2008). In addition, the Carnegie Report (Benner, Sutphen, & Leonard & Day, 2010) calls for profound transformation in nursing education that focuses on integration of didactic and clinical knowledge for a sense of salience in clinical practice.
Simulation-based learning (SBL) is an active learning approach that has been increasingly used in nursing education to meet these challenges, providing structured clinical practice for groups of students and ensuring a variety of experiences, efficient use of faculty, and a safe environment for student learning (Alinier, Hunt, Gordon, &
Harwood, 2006; Birch, et al., 2007). There is a lack of understanding regarding how to enhance knowledge, collaboration, satisfaction and self-confidence of observers of simulation experiences. This study determined if learning outcomes can be enhanced for baccalaureate nursing students observing the simulation experience by the use of an Observation Guide. The research question is: When baccalaureate nursing students view a video recorded SCE, is there a difference in knowledge increase, self-confidence, satisfaction, and collaboration between students who use an Observation Guide and those who do not?
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Background & Significance
Nurse educators are challenged to meet the Institute of Medicine (2010) goal that 80% of practicing Registered Nurses have a baccalaureate degree by the year 2020 despite scarce faculty resources. According to the American Association of Colleges of Nursing (AACN, 2010), 52,115 eligible nursing students were denied admission to baccalaureate and graduate nursing programs in 2010. These students were denied entry due to lack of faculty (62.9%), insufficient clinical placement sites (66.8%), classroom size constraints, lack of preceptors, and budget restrictions (AACN, 2010). Murray, Grant, Howarth, and Leigh (2008) suggest that simulation is a useful educational tool that can help meet the challenges faced by nursing academia.
Simulation learning has been applied in aeronautics, military combat, and medicine for many years in order to allow students to practice in high risk situations without risk of harm to self or others (Rosen, 2008). Flight simulators are used to provide practice on specific skills and knowledge needed to safely fly an aircraft (Rheman, 1995). In medicine and nursing some of the earliest simulators were Mrs. Chase, the first doll designed for use in nursing schools in 1911; the first plastic skeleton in 1938, and Resusci Annie in 1960 (Nehring & Lashley, 2010; Rosen, 2008). These simulators were created to help health care professionals practice their skills without causing harm to patients. In medicine, schools of anesthesia pioneered the use of simulation when teaching
resuscitation and intubation. Two of the most widely used forms of task trainers were spinal models (92.5%) and central line models (81.4%) (Turcato, Roberson, & Covert, 2008). Modifications in anesthesia simulation include using high fidelity simulation for Anesthesia Crisis Resource Management (ACRM). The simulated clinical environment
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produces a learning environment that is conducive to teaching crisis intervention without risking the well-being of a human patient (Turcato, et al., 2008). In addition, one of the most significant contributions to simulation was the development of the first moderate- fidelity patient simulator, SimOne ®, the precursor of modern day simulators (Nehring & Lashley, 2010).
The main educational goal of SBL is to create a learning environment that will ultimately result in better outcomes in health care delivery (Decker, Sportsman, Puetz, & Billings, 2008). SBL is increasingly used in nursing education as a remedy for limited clinical experiences and inadequate numbers of faculty. Due to lack of availability of clinical placement sites and high student faculty ratios in traditional clinical settings, clinical learning situations are often inconsistent and insufficient to prepare a safe practitioner. SBL has been used as an adjunct to or substitute for clinical hours and provides students with an opportunity to experience uncommon but high risk clinical events (Alinier, et al., 2006; Parsh, 2010). The student has the opportunity to practice skills in a safe environment (Smith & Roehrs, 2009) which leads to a decrease in performance anxiety and may promote self-confidence and satisfaction (Bremmner, Aduddell , & Amason, 2008; Decker et al., 2008; Medley & Horne, 2005). Incorporation of SBL has also translated into improved clinical judgment and skill performance
(Bambini, Washburn, & Perkins, 2009; Jeffries & Rizzolo, 2006).
The controlled environment of a simulation laboratory has the potential to increase communication skills which can result in safer clinical practice and improve interdisciplinary problem solving (Ironside, Jeffries, & Martin, 2009; Kameg, Clochesy, Mitchell, & Suresky, 2010; Sears, Goldsworthy, & Goodman, 2010). One of the leading
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causes of sentinel events in the clinical setting is a breakdown in communication between health care professionals (Dillon, Noble, & Kaplan, 2009). The Institute of Medicine report To Err is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 1999) recommended the use of SBL to reduce errors in the clinical setting by enhancing communication and safety skills. Interdisciplinary simulation can also contribute to error reduction by improving the communication of health care team members and promoting experiential learning (Dillon, Noble, & Kaplan, 2009).
Student learning has improved when using SBL over other methods of learning (Brannan, White, & Bezanson, 2008; Howard, 2007). Alinier and colleagues (2006) and Brannan and colleagues (2008) demonstrated significant improvements in cognitive knowledge and clinical performance of students participating in SBL in comparison to traditional lecture. In a comparison of traditional and simulation clinical experiences, Schlairet and Pollock (2010) demonstrated small but significant increases in knowledge following both experiences.
Debriefing, a time of reflection following the active learning experience, is a critical component of SBL (Boet, et al., 2011; Heukelom, Begaz, & Treat, 2010; Kardong-Edgren, Starkweather, & Ward, 2008; Nehring & Lashley, 2010). Debriefing enables the student to reflect on and conceptualize learning (Kardong-Edgren, et al., 2008) and allows students to express thoughts and feelings without fear of repercussion (Nehring & Lashley, 2010). Faculty facilitate debriefing using a structured format enhances clinical reasoning and knowledge acquisition. This process enables the student to focus on learning objectives and foster reflective learning while enhancing clinical reasoning that will transfer knowledge into clinical practice (Nehring & Lashley, 2010).
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Gordon and Buckley (2009) reported that practicing nurses demonstrated improved self- confidence following simulation exercises, an improvement that participants credited particularly to the debriefing phase of the simulation. Differing approaches to debriefing may not affect learning outcomes. No significant differences were noted in two studies on debriefing styles of self-versus- instructor debriefing and in-simulation versus post- simulation debriefing (Boet et al., 2011; Heukelom, et al., 2010).
In general, SBL is conducted using a single faculty member with groups of four to eight students who are each assigned a specific role (Jeffries, 2007). Some students are active participants in the role of primary nurse or secondary nurse; others may be
assigned more passive roles as family members, ancillary personnel, or observers. Little is known about the difference in knowledge acquisition among students in the various roles, specifically the role of observer. In a study on end-of life simulation (Fluharty et al., 2011), knowledge, self-confidence, communication skills, and satisfaction with simulation were evaluated in 370 associate degree, baccalaureate, and accelerated baccalaureate nursing students. There was no difference in knowledge gain between students in the primary nurse role as compared to observer role. Jeffries and Rizzolo (2006) explored differences in knowledge, self-confidence, judgment, and learner satisfaction based on simulation role assignment for 403 baccalaureate and associate degree students enrolled in their first medical-surgical nursing course. No significant differences were found in knowledge gain among students who were assigned to static mannequin or high-fidelity patient simulators. Regardless of the type of simulation, students in the observer role rated themselves lower in clinical judgment and
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should provide a means to engage students in the observer role to increase collaboration . Observation forms given to students prior to the experience might fulfill this need
(Nehring & Lashley, 2010) but there is a lack of robust research evidence on the effect of this approach on learning outcomes.
The purpose of the current study was to determine if there were differences in learning outcomes, including knowledge increase, self-confidence, satisfaction, and collaboration between baccalaureate nursing students using an Observation Guide when observing a simulated clinical experience (SCE) and those observers without an
Observation Guide. If learning outcomes could be improved by the use of an observer guide, simulation learning experiences would be more efficient and effective.
Theoretical framework
Kolb’s Theory of Experiential Learning (1984) was used as the theoretical basis for the study. Kolb states that “learning is the process whereby knowledge is created through the transformation of experience” (1984, p. 38). Kolb (Figure 1) proposed that experiential learning requires concrete experience, reflective observation, abstract conceptualization/analysis and active experimentation. All of these experiences are provided in SBL; therefore, experiential learning provides a theoretical framework for the process of embedding SBL within nursing curricula (Waldner & Olson, 2007).
According to Kolb (1984), learning is considered to be a continuous process in which knowledge is created by transforming experience into existing cognitive
frameworks, changing the way a person thinks and behaves. Experiences are grasped through either apprehension (participating in actual experiences) or comprehension (abstract conceptualization). A significant aspect of learning in experiential learning
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theory is the transformation of experiences. Transformation occurs through either an internal process of reflection on an experience (intention) or an external process through active experimentation (extension). Learning can occur at any of the four points in the cyclic process.
Experiential learning directly relates to the role of observer in which students participate during SBL. In this study, the learner was the BSN student who had previous knowledge gained from the lecture component and skills laboratory and observed the SCE. The concrete experience encompassed the simulated experience in which students observe a pre-recorded video simulation. Reflective observation was utilized as the observer and guided observer students learn through active observation of the students in the role of nurse throughout the simulation. Students achieved abstract conceptualization by using critical reasoning and reflection to evaluate the performance of the students in the role of the nurse. Guided observers utilized a written Observation Guide to assist in reflection and integration of their observations into a cognitive framework and the observers reflected and integrated without the assistance of an Observation Guide. The students referred to these observations during simulation debriefing to enhance abstract conceptualization. Active experimentation encompassed the debriefing phase of the SCE where guided observers and observers used the learning gained from observing the video recorded SCE to solve problems related to the SCE. This phase can be extended as the students apply learning to clinical practice.
The use of an Observation Guide aids in the internal process of transformation (intention) of a cognitive framework which occurs when the experience is integrated into the pre-existing cognitive framework through observation, conceptualization, and
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experimentation. Kolb’s theory postulates that the essence of learning is in the way the learning experience is processed. Learning begins with the experience and is processed through reflection, then is applied through action. The Observation Guide was designed to enhance reflective observation and abstract conceptualization.
Method
A quantitative quasi-experimental pretest-posttest control group design was used to determine differences between the observer groups and guided observer groups of baccalaureate nursing students after watching a video recorded Simulated Clinical Experience. Approval of the multi-site study was provided by all participating institutions. A convenience sample of 121 baccalaureate nursing students from four universities participated in the research study. Students enrolled in the fundamentals of nursing course at each university were eligible to participate. Universities were chosen based on similarities in program design and mission. In addition, clinical practicum experiences did not occur until after the research intervention had been implemented. Although each university had a simulation laboratory, a video recorded SCE and debriefing led by the primary investigator (PI) was implemented for consistency and control of the research intervention
Data Collection Procedures
Prior to viewing the SCE, students completed the Elsevier/HESI pretest exam followed by viewing a pre simulation briefing. Pre-simulation briefing included a 10-15 minute introduction of the simulated clinical scenario and discussion of the Observation Guide for the intervention group. Students were encouraged to make written comments on a blank sheet of paper or on the Observation Guide throughout the simulated scenario. Each group then viewed a pre-recorded video SCE (20 minutes) run by an experienced
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simulation coordinator depicting two students, one in the role of primary nurse and one in the role of secondary nurse. This recording was shown to both groups, and provided consistency in the simulated experience. After the SCE each student participated in the debriefing component (30- 40 minutes) of the SCE. Debriefing was facilitated by the PI and consisted of nine open ended questions to encourage student reflection and abstract conceptualization. Following debriefing, each student completed the EPSS and Student Satisfaction and Self-Confidence in Learning Scales and the posttest Elsevier/HESI exam.
Instruments/Measures
A custom 30 item HESI™ parallel pretest and posttest was used to assess student competency. The exams measured the constructs essential for entry level practice, customized to test specific content related to the simulation scenario and matching the test blueprint. Content included medication administration/dosage calculation, safety, infection control, vital sign assessment, basic health assessment skills, and
communication. The content validity for the Elsevier/HESI was established by expert nurse educators and clinicians for each test item. Reliability for the custom 30 item parallel pretest/posttest exam was established by item analysis and measurement of pretest (KR20 = 0.48) and posttest (KR20 = 0.63).
The National League for Nursing Educational Practices in Simulation Scale (EPSS) measures four educational practices; active learning (items 1-10), collaboration (items 11 & 12), diverse ways of learning (items 13 & 14), and high expectations (items 15 & 16). This 16-item instrument is scored on a five-point Likert Scale. Factor analysis on the instrument was used to classify the seven principles of best practices into four
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categories. The instrument is used to determine if specific educational practices were present in the simulation and the importance of each to the student learner. Jeffries (2007) reports reliability for the instrument was 0.86 Cronbach’s alpha. The reliability for this study was Cronbach alpha 0.92.
The Student Satisfaction and Self-Confidence in Learning Scale is a 13-item instrument on a five-point Likert Scale. Five items on the scale (1-5) measure student satisfaction with simulated learning and the remaining eight items on the scale (6-13) measure student feelings of confidence in knowledge and skills of patient care. Content validity was established by nine experts (Jeffries & Rizzolo, 2006). Reliability for the instruments ranged from 0.87- 0.94 Cronbach’s alpha. The reliability in this study for the Satisfaction Scale was 0.93 and for Self-Confidence it was 0.87.
The Observation Guide was developed by the researcher to direct student attention to six specific aspects of the simulation. The components of the guide (assessment, clinical judgment, nursing interventions, communication, safety, and teamwork) are based on the learning objectives for the experience and the nursing process. Students used the Observation Guide to direct critical reasoning and reflection during the SCE.
Results Sample
Demographic characteristics for the sample are outlined in Table 1. The sample consisted of a total of 121undergraduate nursing students from four universities of which 119 completed the demographic information. Of 119 students, the age range was 18 to 46 years of age, with a mean age of 22.64 years. The total sample included 92 (77.3%)
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Caucasian, 14 (11.8%) Black, 6 (5%) Asian, 3 (2.5%) Hispanic, 3 (2.5%) other, and 1 (0.8%) multiracial students. Of the total, 84.9% (n = 101) were female and 15.1% (n =18) were male. The majority of the students had no previous medical or nursing experience (77.3%) and the highest level of education was a high school diploma (63%). The
sample was randomized into two groups; the experimental group (n = 62), which received an Observation Guide and the control group (n = 59), which did not receive an
Observation Guide. Data Analysis
A two-way mixed ANOVA was used with pretest vs. posttest as a within subject variable and guided vs. non-guided observation as a between subject variable to
determine the change scores in knowledge on the Elsevier/HESI pretest posttest
examination. Statistical analysis was performed using SPSS 17.0 statistical software. A total of 121 students participated in the pretest and posttest HESI examination. The pretest mean HESI score for the students with an Observation Guide (n = 62) was 814.01 (SD = 156.26) and 787.55 (SD = 152.88) for students without an Observation Guide (n = 59). The posttest mean score for the students with an Observation Guide was 719.95 (SD = 171.68) and 666.14 (SD = 169.53) for students without an Observation Guide. Both groups’ overall mean posttest scores were lower than the pretest mean scores. The results of the interaction effect indicate that knowledge change was not significantly affected by the type of observation in simulation, F (1,119) = .705, p = .403 (table 2).
Differences in Satisfaction, Self-Confidence, and Collaboration
Independent t tests were used to determine the differences of satisfaction, self- confidence, and collaboration between students with an Observation Guide and the
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student without an Observation Guide. Overall, students were satisfied with their current learning during the simulation activity. With a potential range of 5 to 25, students with an Observation Guide were more satisfied (M = 22.11, SE .34) than students without an Observation Guide (M = 20.51, SE = .55). There was a significant difference between the groups (t (117) = 2.518, p = .013), although effect size was small (r = .05). There was no significant difference in self confidence in learning between the groups (t (117) = 1.507, p = .134). With a potential range of 8 to 40, the students with an Observation Guide had a mean score of 33.93 (SE = .49) and the students without an Observation Guide had a mean score of 32.59 (SE = .75). On average, for the Educational Practices in Simulation Scale students with an Observation Guide had a mean score of 1.46 (SE = 1.07) and students without an Observation Guide had a mean score of 68.21 (SE = 1.71). This difference was not significant (t (117) = 1.640, p = .104) (Table 3).
Discussion
The findings from the study revealed that students with an Observation Guide were more satisfied with learning than students without a Guide. Satisfaction with
learning is an important aspect of SBL and has been associated with student performance (Bremner, et al., 2006). Students who are satisfied with their learning are more likely to