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CHAPTER 1 THE PROBLEM RATIONALE 1. 1 Introduction The health care environment has drastically changed over the years with advanced technology. Several disciplines are adjusting to the changes to meet the demands that a diverse society has embraced. Among the several fields of discipline, nursing has greatly evolved especially in terms of educational practice. Traditional methods such as lecture, video presentation, and reporting may be of less significance with the advent of modern technology. The integration of technology in nursing poses a very promising impact among junior nursing students’ learning needs.
It is imperative though that even with advancement; professional nurses must possess clinical competence in order to provide quality health care even with the integration of technology. Decker, Sportsman, Puetz, and Billings (2008) stated that nursing competence involves the acquisition of relevant knowledge, the development of psychomotor skills, and the ability to apply the knowledge and skills appropriately in a given context. According to National Council for State Boards of Nursing (NCSBN, 2005), competence is defined as the application of knowledge nd the interpersonal, decision-making, and psychomotor skills expected for the practice role, within the context of public health. However, there is no standardized definition of clinical competence up to date. Measures, however, to evaluate competence continues to evolve through research in an attempt to objectively measure such. It is inevitable though that clinical competence foreground rest on nursing education and an attempt to enhance such through integration of knowledge and practice early on has a direct impact in providing quality patient care.
Nursing educators are constantly challenged to develop teaching methodologies that would enhance critical thinking, problem solving and decision making skills prior to actual nursing practice with the advent of diverse patients. Several incidents on medication error and violation of protocols in procedures where there was a need to utilize a more in-depth analysis of patient’s problem has proven to be detrimental to client’s care. Nursing students on their linical duties faced with the same dilemma have documented and undocumented cases of clinical errors early on, which could have been avoided if they are equipped with the necessary skills in the prompt delivery of healthcare. The advent of human patient simulators has paved the way to integrating knowledge through presentation of a realistic clinical set-up that would enhance competence without jeopardizing client’s safety. Human patient simulators utilized in nursing education should possess engineering and psychological fidelity depicting a realistic clinical setting (McCallum, 2007).
In human patient simulation, students are exposed to different clinical scenarios, which may not always be readily accessible to a clinical placement. The use of simulation in nursing education enables students to practice and correct mistakes without compromising the health and safety of the patients, thereby, producing no risks when rendering nursing care. However, utilizing human patient simulators as a means to provide a realistic clinical setting alone does not cover all domains of clinical competence.
A more in-depth teaching methodology that would integrate knowledge and technology with human patient simulation should be explored further by nursing institutions. In its effort to provide quality undergraduate nursing education, an educational institution in Valenzuela City, has consistently been focused in developing learning strategies that would address the needs of the students. To enhance the students’ strengths and capabilities, the College of Nursing Virtual laboratory was built in 2007, consisting of eleven cubicles; each simulates a hospital setting with a human patient simulator depicting an actual patient.
With this type of learning environment, students can perform different nursing procedures without compromising the client’s safety, at the same time appropriate feedback will be determined after the simulation. To stimulate students’ competence, a case scenario will be presented to the students on duty simulating the client’s health condition, past and medical history and list of possible doctor’s orders will be identified. The researcher’s concern with the advent of nursing malpractice paved the way to this research.
Students who are on their last year should be accustomed to facing different scenarios specific to patient individualized response to the disease including management. Focus on such would enhance their ability to analyze patients, in turn enhance their clinical competence. In the formative years of a profession, preventive measures and safety should be the focus of management. Integration of theory and practice through scenario-based simulation should be focused on as an alternative teaching strategy.
This positive claim should be supported through research, which would serve as a basis for scenario based simulation as an effective teaching strategy that would enhance clinical competence, hence, this study. 1. 2 Research Impediments The cost of the study may serve as an impediment since it requires financial resources needed to measure the clinical competence of nursing students using an Objective-Structured Clinical Examination (OSCE). However, this weakness can be resolved by seeking sponsorship from the administration and organizations within the institution.
Time constraints can also be a serious impediment due to the fact that the study requires certain amount of time to introduce scenario-based simulation and measure its effect on the clinical competence of the respondents within a controlled environment. Hence, the study should be conducted at the start of the semester to give enough time for the preparation and implementation of the study. The last impediment that can be identified is inconsistencies among OSCE evaluators who will measure the clinical competence of the respondents.
This can be handled by allocating trained faculty members sharing the same expertise and by using a standardized evaluation tool in implementing the study. CHAPTER 2 THE RESEARCH QUESTIONS This chapter deals with the review of related literature and serves as the basis for the study. Previous studies, articles and literatures provide a thorough background for the study. 2. 1 Review of the Literature Competence in Nursing Competence is defined as the ability to do something well, measured against a standard, especially ability acquired through experience or training. Microsoft Encarta, 2007). In nursing however, Patricia Benner defined nursing competency as the ability to perform a task with desirable outcomes under the varied circumstances of the real world. According to EdCaN Competency standards in professional nursing (2008), the holistic definition of competence is not only centered on theoretical knowledge or technical skills it should also involve some inference about a nurse’s attitude and practice. The world of nursing and healthcare is rapidly changing.
The impact of these changes together with an acute nursing shortage puts pressure on nursing education programs to teach a larger number of students a greater amount of information in an efficient manner, toward the goal of graduating an increased number of nursing students adequately prepared to pass state licensure examinations and enter the nursing workforce (Jecklin, 2007). Masual and De Corte (2005) identified that a multidimensional approach is needed to ensure that students achieve competency.
In a review and discussion paper published in 2006, McGrath summarizes a range of views cautioning against the use of generic domains of clinical competence that do not take account of the specific context and skills required to practice in a specialist environment which includes the lack of a systematic approach to incorporating specific competencies into curricula, questions about the methodology used to develop competencies (McGrath, et al, 2006).
Del Bueno (2005) discusses a crisis in nursing education, namely, that new nursing graduates do not meet expectations for entry-level clinical judgment ability. She discusses ways that nursing educators can help to develop this clinical judgment in students using three different exercises, including (1) a written, out-of context series of patient and job events; (2) a visual, out-of context series of patient and job events; and (3) complex, contextual exercises using patient video simulations.
Del Bueno addresses the fact that new nurses cannot identify primary problems their patients are experiencing, nor can they initiate actions to prevent further harm to their patients. She also asserts that new nurses cannot state their rationale for taking appropriate actions. These issues suggest that teaching may be based more on content materials than on the practical application of the knowledge students are receiving. Assessing Clinical Competence
According to Dolan (2003) assessment of competence of practicing nurses has been identified as crucially important in maintaining professional standards, identifying areas for professional development and educational needs and ensuring that nurse competencies are put to the best possible use in patient care. In a 2008 competency assessment literature review, it has been reported that a range of indicators and tools have been developed for competence assessment but empirical evidence regarding their effectiveness in measuring competence is lacking.
A key challenge identified in all articles reporting on methods for competence assessment was ensuring objectivity. The review identified a range of items that may be used as indicators for competence in clinical nursing practice include continuing education, portfolios, examinations, peer review (assessment), direct observation; self-assessment, interview, patient outcomes. It is generally accepted that assessment of competence should use more than one indicator. However, there is limited evidence about the most effective or reliable indicators to use.
Most of the studies identified report on general issues of competence/competence assessment, portfolios and OSCEs. Evidence in relation to peer assessment, direct observation, self-assessment, and continuing education and patient outcomes is more limited. No article was identified relating to interviews. The majority of articles focused on initial competence with only limited investigation of issues of continuing competence. Waldner and Olson (2007) acknowledged the difficulty in measuring clinical performance compared with quantifying knowledge, critical thinking, or self-efficacy on standard measures such as written tests.
Objective Structured Clinical Examination as an Assessment Tool An objective structured clinical examination (OSCE) is a series of stations/exercises through which students rotate individually to demonstrate a range of skills and knowledge. Reported benefits of OSCEs include enhancement of skills acquisition through a hands-on approach, the opportunity for students to practice skills in a safe and controlled environment and the opportunity to combine both teaching and assessment.
OSCEs have been identified as a satisfactory way of assessing communication, clinical skills, knowledge, and intention. According to a literature review by Harden and associates (2002), use of the OSCE has become widespread gaining worldwide recognition and universal acceptance as an exceptionally useful tool in the evaluation of clinical competence since its introduction 26 years ago. It has been referred to as the ‘gold standard’ of assessing clinical competence. However, OSCEs have been reported as costly to run and can be time-consuming.
A number of studies reported the OSCE setting to be stressful or intimidating for participants – although none compared the level of stress to other forms of formal examination. Time constraints at each station can also limit the ability for reflection. Inconsistencies between assessors and actors have been reported as a source of frustration and inconsistency for those being examined. Objective structured clinical examination has been widely recognized as an effective method of assessing clinical skills among health care providers for more than three decades. This was pioneered by the medical profession nd eventually different health care professions increasingly recognize its importance in their undergraduate curriculum. The Objective Structured Clinical Examination was originally developed in the University of Dundee in 1975 to assess the clinical competence of trainee doctors (Harden & Gleeson 1979). This type of assessment is composed of several short exercises, or stations, through which students rotate individually for a given time (Allinier, 2005). The first use of OSCE is in the nursing setting evaluating competence in performing clinical skills (Ross et al. 998). 10 years after, “the Bart’s Nursing OSCE” is developed by Nicol and Freeth (1998) to provide a more meaningful simulation wherein students are rotated in a certain station longer compared to the first study (Mc Callum, 2007). While OSCEs are an effective method of assessing clinical competence (Schoonheim-Klein et al. , 2005), Alinier et al. (2006) and Alinier, Hunt, and Gordon (2004) used an OSCE to test the knowledge and skills mastery of students assigned to either a simulation group or a group that followed the normal curriculum.
Rushforth (2007) examined the potential role of OSCE in nursing education and concluded that this assessment approach may come closest to measuring the ”knows” and ”know hows” that Miller (1990) described in his model of clinical skills acquisition. This type of outcomes assessment may be more reliable and valid than other, more subjective measures, but it can be extremely resource intensive and requires a highly structured environment, carefully developed testing situations, and extensive evaluator training (Brosnan, et. l, 2006; Byrne & Smyth, 2008). The idea of imposing changes into an organization may result to resistance among members. (Schoonheim-Klein et al. , 2005). If the students are not used to being exposed in such changes, like the use of OSCE, there is a possibility, that acceptance may not be gained, leading to undesirable outcomes. Therefore, there is a need to consider careful planning and implementation of such evaluation tool in a curriculum, including preparation of facilitators, participants, and setting.
Similar studies emphasize the importance of implementing a “mock – run” prior to OSCE exposure as this helps in the preparation of both the assessors/facilitators and participants (Major, 2005; Schoonheim-Klein et al, 2005; Rennie & Main, 2006). Trends in Nursing Education As nurse educators are continuously challenged with developing teaching methodologies that would suit the learning needs of the students as well as technological advances, it is essential that evidenced-based teaching must be taken into consideration.
Through the years, the traditional lecture method of instruction takes precedence over other teaching methodologies; it has gained disputes regarding its effectiveness and suitability (Di Leonardi, 2007). Although many nurse educators cite traditional lecture as the most effective teaching methodology in terms of preparation time, class size, efficiency, and personal comfort (Delpier, 2006; Mikol, 2005). As a teaching strategy, the traditional lecture is one to which most students have adapted throughout the educational process to provide them with the necessary information for their classes.
Further, experience indicates that students have an increased comfort level with this traditional teaching methodology partly because they can remain in a passive role. Students report a preference for receiving didactic instruction that provides the information they believe they need to know. Many students indicate a decreased comfort level with nontraditional teaching methods because of a need to be prepared, become an active participant, and change their role from passive to active learner (Delpier, 2006).
However, in a recent study of Meehan-Andrews (2009) regarding teaching mode efficiency and learning preferences of first year nursing students, majority of them prefer kinesthetic modes of information presentation. This kind of learners would choose case study or hands on type of learning rather than the traditional lecture method. That is, to learn by doing. New methodologies, such as problem-based learning, support an active student role in learning and assist students to move from a basic understanding of information at the knowledge and comprehension levels to a higher level of understanding.
Although case studies have been used as educational tools for more than 100 years in a variety of disciplines, a dearth of information exists in the research nursing literature regarding their use, construct, and outcomes (Delpier, 2006). The use of all forms of simulation (e. g. , standardized patients, partial task trainers, computer patients) will be an essential element of this change, and the use of high- fidelity patient simulators (fully computerized mannequins) will be the most effective form of simulation in the near future. Simulation in Other Fields of Discipline
Madhavan (2006) stated that “simulation has emerged as the third leg in the stool of science and education. Theory and experiment are the paradigms of the past century”. In the use of simulation for teaching and training, the educationist is more concerned with its use in the study of psychological and social processes. Many knowledge disciplines have used simulations in various forms and for different purposes. These various disciplines include aviation, business, economics, human resource, industrial engineering, medicine, military strategy, political strategy, and traffic management (Mack, 2009).
A 2005 systematic review done by Issenberg et. al has documented that various types of profession had recognized and accepted the use of simulation as a medium of instruction in education. For example, pilots and astronauts can now train in flight simulators, nuclear power plant employees prepare for technical operations using simulated exercises, and military personnel train by playing war games. Bradley (2006) noted that simulation has been existing in health care but the use of manikins as simulators is relatively new.
In this systematic review, nurses, medical students, resident physicians, practicing physicians and multidisciplinary health care teams are among those health professions involved with the utilization of simulation. Simulation and Its Regulation in Nursing Education In 2005, the National Council of State Boards of Nursing (NCSBN), in its publication, Clinical Instruction in Pre-licensure Nursing Programs, examined simulation and stated that “clinical experiences… might also include innovative teaching strategies that complement clinical experiences for entry into practice competency” (NCSBN, 2005, p. ) Simulation as a major teaching methodology is appropriate because today’s learners need active learning processes rather than traditional lectures (Detweiler, 2005; Twigg & Stoll, 2005). Issenberg, McGaghie, Petrusa, Gordon, and Scalese (2005) and Issenberg & Scalese (2008) broadly defined a simulation as a tool for the authentic education and evaluation of problems as they present in various environments and professions. Participants can role-play a variety of cenarios and fulfill different role expectations within the clinical case. Students can practice their technical and communication skills as they solve common or rare clinical problems. In a well-designed simulation, there is opportunity for participants each to review their actions, evaluate their own performance, receive feedback from peers and instructor, ask additional questions about the content, and develop alternate plans of action (Prion, 2008). Simulation was perceived to be an important element in nursing education.
Overall, there was a belief that clinical simulation requires (a) additional support in terms of the time required to engage in teaching using this modality, (b) additional human resources to support its use, and (c) other types of support such as a repository of clinical simulations to reduce the time from development of a scenario to implementation. Few negative voices were heard. It was evident that with correct support (human resources) and training, many faculty members would embrace clinical simulation because it could support and enhance nursing education.
From a practical perspective, simulation offers an opportunity for students to engage in clinical activities that may not be available to them otherwise due to the decreasing number of clinical settings that are open to nursing students and severely limited clinical time (Curl, Smith, Chisholm, Hamilton & McGee, 2007). One of the important aims of nursing education is to ensure that future nurses are equipped with appropriate knowledge and skills including sound clinical judgment.
In doing so, the use of simulation has been suggested to be effective (Jeffries, 2007). Advantages of Simulation in Education Several literatures have shown the benefits of simulation in nursing education. Students see the opportunity to learn new clinical and cognitive skills within the safety of a clinical learning center that houses high-fidelity simulators capable of mimicking real-life clinical symptoms and responding to interventions (Issenberg, McGaghie, Petrusa, Lee Gordon & Scalese, 2005).
They appreciate the opportunity to receive immediate feedback during and following simulations and recognize that simulation is one strategy to prepare them for the “real world” (Childs & Sepples, 2006). Simulation can also decrease attrition from schools of nursing, increase student confidence in their skills, enable them to link theory to practice (Hanberg & Brown, 2006), and ultimately enhance patient care. In a recent study, Hovancsek (2007) emphasized that simulation is a safe environment for educators and students to practice the ”what if” game without resultant harm while developing both psychomotor and critical-thinking skills.
Simulation as a major teaching methodology is appropriate because today’s learners need active learning processes rather than traditional lectures (Detweiler, 2005; Twigg & Stoll, 2005). Although this innovative strategy, the use of human patient simulators has been touted as potentially useful in clinical education and evaluation, it is still unclear how it will be used in identifying the human and system failures that influence errors and adverse events (Gregory et al. , 2007). High Fidelity Human Patient Simulation
Jeffries (2007) stated that low-fidelity simulators are used to learn, practice, and achieve a designated skill; high-fidelity simulators are used to develop critical thinking skills. Low-fidelity simulators are static, without motion, and demonstrate few features with realism. These refer to simple replications of isolated parts. These are particularly helpful in teaching students to perform specific skills such as how to administer an intramuscular injection or start an intravenous (Rothgeb, 2008).
Medium- fidelity simulators provide more realism, including heart or breath sounds. High-fidelity simulators present a realistic depiction of the human body in look, feel, and response to the provided care. The more expensive high-fidelity simulators physiologically respond appropriately to the provided care, medications, and oxygen (Seropian, Brown, Gavilanes, & Driggers, 2004b). One of the predominant technology-based tools being integrated into undergraduate nursing education is high-fidelity human patient simulators ([HPS] Hoffmann et al. 2007; Rhodes and Curran, 2005). High-fidelity HPS is a computer-controlled mannequin that mimics interaction with students in a controlled simulated clinical setting (Bearnson & Wiker, 2005). Bearnson and Wiker state that a high-fidelity HPS will respond to clinical interventions (e. g. , medication administration, oxygen therapy) in a realistic way. The clinical setting is replicated via a simulated hospital room, and the mannequin is the ”patient”. The instructor has ultimate control of the HPS and the ability to guide clinical scenarios (e. g. , cardiac arrest).
Another component critical in high-fidelity manikin-based simulators is the ability to provide feedback (Bradley, 2006). Feedback comes in two forms. First is the simulator’s response to treatment or intervention by the learner. For example, if a medication that can slow heart rate is being administered to the simulator, then the effect on the simulator will be decreased in the pulse rate. A second form of feedback required in high-fidelity manikin-based patient simulators is the ability to provide objective feedback for participant review in the post simulation setting.
The high-fidelity manikin-based patient simulators currently available all have proprietary software designed to log student actions and simulator responses for playback in the post-simulation debriefing. Instructors or facilitators utilize this data to review the event with students as a means of encouraging student reflection on action and as a stimulus for students to consider how to change their actions to improve patient (simulator) response (Rodgers, 2007). The use of high-fidelity simulators provide n opportunity to enable students to engage in clinical activities without fear of harming a patient or themselves (Curl et al. , 2007; Issenberg et al. , 2005). Baillie and Curzio (2008) supported this in a study wherein high percentage of students and facilitators identified that simulation enabled learning from mistakes without harming patients. In the clinical setting errors must be prevented or stopped immediately to prevent harm. In simulation, they can be allowed to progress and then reviewed, thus error management is learned without risk to patients (Hogg et al. , 2006).
Related Studies on Simulation Most of the studies have focused on the measurement outcomes of self-confidence, knowledge attainment, satisfaction, or skill acquisition (Childs & Seeples, 2006). Some studies suggest that simulation improves nursing students’ confidence in their clinical skills (Goldenberg, Andrusyszyn, & Iwasiw, 2005,). Based on the study conducted by Bremmer et. al (2006) regarding simulation, students considered that the simulation programmes assisted their confidence development. In addition to this, simulation apparently has reduced placement-associated anxiety (Bremner et al. 2006; Childs and Sepples, 2006). Waldner and Olson (2007) stated that ”the purpose of simulation education is really to improve performance or clinical competency”. Development of clinical knowledge, judgment, and decision making occurs in the context of reflection on action, in which actions and outcomes are reviewed (Tanner, 2006). Several qualitative studies focusing on the perceptions of faculty members with the use of simulation in nursing education were also conducted. The results reported that faculty members are in favor of utilizing simulation to support learning in nursing education. Decker, Galvan, & Sridaromont, 2005) They also feel that it is a valuable teaching strategy to fill learning gaps. It is one that can be used to support learning but cannot be used to replace “real-life” clinical learning (Akhtar-Danesh, 2009). In a study by Bearnson & Wiker (2005), simulation was perceived to be valuable in the learning experience of the students. A satisfaction survey was done by Abdo and Ravert (2006) which revealed that responses were very positive regarding the transferability, realism and value of the simulation experience.
It also demonstrated that the human patient simulator appears to benefit students in their decision-making skills, technical skills, level of confidence, preparation for ”real life” settings and in reinforcing the learning occurring in class. Fountain & Alfred (2009) conducted a study, which reported positive results on students’ satisfaction in simulation. Additionally, they explore how learning styles correlate with students’ satisfaction. In addition to this, related studies revealed no improvement in the performance of the participants after simulation or between simulation and another teaching methodology (Dobbs et al. 006; Jeffries and Rizzolo 2006; and Gordon, Brown, & Armstrong, 2006, Chronister & Brown, 2009). Implications to Nursing Education Despite the increasing body of literature regarding the use of simulation in nursing education, there is still lack of evidence regarding its effectiveness as compared to the traditional methods of teaching. In regard to this, the researcher seeks to explore if there will be a difference in the clinical competence of nursing students who will be exposed to scenario – based simulation. The dearth of nursing research on the use of patient simulation indicates that there is a need for further study.
Researchers may further explore on the success and effectiveness of scenario based simulation in the nursing curriculum. Considering the cost of acquiring human patient simulators in nursing education, there is a need to examine other possible teaching methodologies that may also address the challenges that the nursing education is facing at present. 2. 2 Theoretical Framework According to Brooks (2007), all simulations must have theoretical grounding in order to illuminate the conflict between theory and practice.
This study is anchored primarily on Benner’s theory of the development of nursing skills (1984) and Kolb’s experiential learning theory. Both are used as frameworks to examine the use of simulation in the context of nursing education. Waldner and Olson (2007) integrated these theories in analyzing simulation in nursing education. This combined simulation theory describes the transformation from novice to competent nurse through experiential opportunities that build the existing knowledge base and offer conceptualization, involvement in the experience, and active reflection.
At the novice level, simulation should be simple and straightforward, with exposure to simple abnormal findings like and include an ”opportunity to discuss their findings and anchor their experience to the cognitive frameworks they already possess” (Waldner & Olson, 2007). For students at the advanced beginner level, simulations should include consequences of student actions, algorithms and protocols to guide actions, and a positive atmosphere for simulation debriefing. At the competent level, simulations should be complex and full scales, proceed ithout interruptions, and are followed by structured debriefing, which includes in-depth discussion of any misconceptions, correction of any errors, and, most important, emphasis on what was correct, appropriate, and safe during the experience (Jeffries, 2005; Willford & Doyle, 2006; Rothgeb, 2008). Benner’s (1984) theory of nurses’ stages of learning, from novice to expert, fits well with simulation learning because simulations assist student nurses in advancing from novice to beginning stages of competency within the safety of a laboratory setting utilizing scenario – based simulation.
Skills acquired during a simulated scenario can help nursing students begin to perceive clinically meaningful patterns and predictable outcomes, which build their clinical competence and their clinical self-confidence without jeopardizing client’s safety. Through scenario-based simulation, undergraduate nurses will move to a higher level of competence as they apply the knowledge and perform the skills necessary in patient care after repeated exposure to such during the teaching – learning process. 2. Research Questions This study aims to determine if scenario – based simulation will enhance clinical competence of junior nursing students enrolled during the first semester of the school year 2011-2012 in an educational institution in Valenzuela City in performing male catheterization in a patient with urolithiasis. Specifically, it also aims to answer the following questions: 1) What is the demographic profile of the respondents when grouped according to the following variables: 1. Age 2. Gender ) What is the clinical competence of nursing students in the control group in performing male catheterization in a patient with urolithiasis before and after the traditional method of teaching in terms of: 1. Knowledge 2. Skills 3. Attitude 3) What is the clinical competence of the nursing students in the experimental group in performing male catheterization in a patient with urolithiasis before and after exposure to scenario-based simulation in terms of : 1. Knowledge 2. Skills 3. Attitude ) Is there a significant difference in the clinical competence of the nursing students in the control group in performing male catheterization in a patient with urolithiasis before and after the traditional method of teaching in terms of: 1. Knowledge 2. Skills 3. Attitude 5) Is there a significant difference in the clinical competence of the nursing students in the experimental group in performing male catheterization in a patient with urolithiasis before and after exposure to scenario-based simulation in terms of: . Knowledge 2. Skills 3. Attitude 6) Is there a significant difference in the clinical competence of junior nursing students between the experimental and control group in performing male catheterization in a patient with urolithiasis in terms of: 1. Knowledge 2. Skills 3. Attitude 2. 4 Research Paradigm Figure 1: The Research Paradigm Figure 1 illustrates the paradigm of the study wherein the research samples include junior nursing students enrolled in an educational institution in Valenzuela City.
Demographic variables as to age, gender and educational background will be determined. This study includes two groups, which will be randomly assigned as to control, and experimental groups using probability sampling method. The experimental group will be subjected to scenario-based simulation, while the control group will be subjected to traditional lecture method of teaching regarding a patient with urolithiasis. 2. 5 Hypotheses: The purpose of this study is to test the following hypotheses: H1: Younger nursing students are more clinically competent in performing ale catheterization in a patient with urolithiasis than older nursing students. H2: Female nursing students are more clinically competent in performing male catheterization in a patient with urolithiasis than male nursing students. H3: There is a significant difference in the clinical competence of the nursing students in the control group in performing male catheterization in a patient with urolithiasis before and after the traditional method of teaching in terms of knowledge, skills, and attitude.
H4: There is a significant difference in the clinical competence of the nursing students in performing male catheterization in a patient with urolithiasis before and after exposure to scenario-based simulation in terms of knowledge, skills, and attitude. H5: There is a significant difference in the clinical competence of the nursing students in performing male catheterization in a patient with urolithiasis between the experimental and control groups in terms of knowledge, skills and attitude. CHAPTER 3 THE RESEARCH METHODS 3. 1 The Research Design
This quantitative study will use a true experimental research utilizing pretest- posttest design. A true experiment is considered by many as the gold standard for yielding reliable evidence about cause and effect (Polit & Beck, 2008). According to Salustiano (2009), this design involves two groups, the control group and experimental group. Furthermore, a true experiment possesses four properties: manipulation, control, randomization and validity. Random selection and assignment as to control and experimental groups will be employed in the study using a table of random numbers.
In this study, two distinct groups are formed: the control group, which will be subjected to traditional method of teaching while the experimental group which will be subjected to scenario-based simulation. A pre-test post – test design will be employed in the study utilizing the Objective Structured Clinical Examination (OSCE) method which will measure the clinical competence of the respondents in performing male catheterization in a patient with urolithiasis. This will be administered to both groups before and after their respective teaching methodologies. 3. . Selection/Subjects and Study Site The target population for this study will be the junior nursing students enrolled during the first semester of the school year 2011-2012 in an educational institution in Valenzuela City. With a population of 200 junior nursing students, the researcher will arrive at a sample size of 134 using the Slovin’s formula. The probability sampling using simple random technique will be used by the researcher in selecting the respondents of the study. The sample size will be determined using the Slovin’s formula (n= ___N___ ) +N (e) Where: n = the size of the sample N = the size of the population; e = the margin of error The total population of the junior nursing students is 200. Using a 0. 05 margin of error, the computed sample size will be n=134 for the actual study. This study will be piloted using 20 participants who will not be included during the actual study. All of the respondents will be required to meet the inclusion criteria and exclusion criteria before assigning them using simple random method into two groups: the control group and the experimental group.
The inclusion criteria will include: 1) Must be a regular junior nursing student presently enrolled during the first semester of the school year 2011-2012; 2) Must have no prior exposure to the virtual laboratory before the intervention; The exclusion criteria will include: 1) Junior nursing students who are second coursers; 2) Junior nursing students with clinical exposure to special areas, such as critical care unit, emergency room, intensive care unit and medical-surgical ward. The study will be conducted in an educational institution in Valenzuela City.
This university was chosen based on its existing virtual laboratory operational since 2007. Specifically, the setting will be at the Virtual laboratory of the university. This state-of-the-art virtual laboratory is equipped with life-sized, computer-controlled human patient simulators capable of depicting clinical scenarios. It consists of cubicles; each is equipped with a high fidelity human patient simulator, which can mimic patient’s problems in a controlled environment without compromising patients’ safety. 3. 3 Data Measure
To obtain the needed data in the study, the researcher will implement the teaching methodology, scenario-based simulation. This will become the basis of assessing the clinical competence of the participants from the experimental group in performing male catheterization in a patient with urolithiasis. A self-structured scenario will be presented to the experimental group focusing on a patient with urolithiasis. The contents were adapted from Medical-Surgical Nursing books. The topic was chosen based on the course content of the college.
After the presentation of the scenario, discussion will follow based on the signs and symptoms specific to the patient, including its nursing management. The control group, however, will be given a traditional lecture method with the same topic, urolithiasis and its nursing management. The male catheterization procedure will be demonstrated by a virtual laboratory instructor. The flow of the discussion will be patterned from the course syllabus of the college. Both the control and experimental groups will utilize high fidelity human patient simulator in the demonstration of the skill male catheterization.
The research instrument will be submitted to her adviser for correction and revision before it will be given to a statistician to determine correctness of options. The tool will be forwarded to three expert validators for its content validity 1)the clinical coordinator of the College of Nursing; 2) virtual laboratory instructor of the College of Nursing with MAN degree; 3) virtual laboratory coordinator of the College of Nursing 4) urologist. The pre testing of research instruments will be conducted with the supervision of three selected virtual laboratory instructors.
To generate data for the study, the researcher will utilize the following research tools to assess clinical competence of the respondents for both the experimental and control groups in performing male catheterization in a patient with urolithiasis: The Objective Structured Clinical Skills Examination (OSCE), which consists of three stations that the respondents will have to undergo to determine their clinical competence as to knowledge, skills, and attitude. A copy of this can be found in Appendix VI. The OSCE will utilize the following research tools:
Nursing performance checklist, which will measure the skill acquisition of the participants in performing the procedure. Specifically, a checklist on male catheterization procedure will be employed in the study. This is the existing checklist that the chosen university is currently utilizing based on its course syllabus. Written examination which will measure the knowledge of the participants based on their understanding on the scenario that will be presented, consists of 10-item multiple-choice type of questions specific to a patient with urolithiasis.
This was adapted from Medical-Surgical Nursing Books and Comprehensive Review Books for Nursing. A copy of the questionnaire can be found in Appendix V. Attitude checklist, which will measure the attitude of the respondents including communication skills. In order to ensure the research instruments for its reliability, a dry-run utilizing research instruments will be conducted before the actual study. Pre – testing of the tool will be done at the Virtual Laboratory of the College of Nursing a month prior to the actual study with 20 junior nursing students who will not be included in the actual study.
Selected virtual laboratory instructors as properly endorsed by the Virtual laboratory coordinator will facilitate the pre testing of the research instrument. Results will be forwarded to the statistician for reliability test. The tool will be subjected to item analysis determination. 3. 1. 4 Data Gathering Procedure 1) The researcher will personally request a letter of permission from the Dean’s office of the College of Nursing. This is to obtain permission to distribute the research instruments and to explain the purpose of the study. A copy of the request to conduct the study can be found in Appendix I. ) An approval from the university research committee will be requested to ensure that the respondents’ rights will not be violated. 3) Informed consent will be obtained from the respondents who will agree to participate on a voluntary basis. A copy of the consent form can be found in Appendix III. 4) With the approval of the respondents, demographic profile will be gathered during this session. A copy of a letter to the respondents to gather pertinent data can be found in Appendix II. 5) Pre simulation briefing of the respondents will be conducted three days prior to the actual study.
This will include discussion on the use of OSCE wherein the respondents will have to undergo three different stations that will measure their clinical competence. According to Jeffries (2005), knowing how to debrief students is of the same importance with that of knowing how to create scenarios and using the equipment to represent human physiological responses to care when conducting simulation. Post simulation debriefing will be conducted immediately after the assessment of clinical competence using OSCE.
All of the respondents will be gathered at the multipurpose hall near the virtual laboratory for the post simulation debriefing. A. Pre-Simulation briefing – During this time, respondents will be given instructions regarding their proper conduct inside the virtual laboratory; they will also be oriented to the simulators and the learning environment. Pre -simulation briefing will be conducted by the researcher. Pretest examination will also be administered during this period using the Objective Structured Clinical Evaluation (OSCE). B. Post Simulation Debriefing – This is one of the most important aspects of simulation.
It is imperative that it is done well in order to help students have the best possible synthesis experience. Respondents will be moved to the multipurpose hall and will be given handouts with key points related to the activities they were able to perform inside the virtual laboratory. This will be facilitated by a virtual laboratory instructor. Prior to preparation of the scenario, the researcher will have to undergo thorough review on different literatures and studies from scholarly journals and articles, including medical surgical nursing textbooks.
A self – structured scenario regarding urolithiasis will be prepared to stimulate the learning of the respondents (experimental group). Signs, symptoms, and written doctor’s orders will be incorporated to elicit certain nursing intervention that should be performed by the students. This will be subjected for content validity by four experts. A copy of the request for content validation can be found in Appendix VII. One faculty member will conduct the lecture – discussion of both control and experimental groups to minimize possible bias resulting from differences in teaching methodology or strategy by another faculty member.
Virtual laboratory instructors who have undergone specialized training for each respective human patient simulator will facilitate the respondents in each station. These assessors need to be precisely oriented about their role and informed of their possible interaction with the respondents. To ensure consistency in their learning approach, the assessors will have to coordinate with one another. This helps to ensure that they are not influenced by their own values and beliefs, thereby promoting inter-observer reliability. (Jones, 2010). The researcher will employ the following research interventions specific to their group assignment:
Control Group: 1) A traditional lecture method will be conducted to this group a day prior to measuring their clinical competence using the Objective Structure Clinical Examination (OSCE). The topic that will be discussed will include urolithiasis and and its nursing management. 2) After the lecture discussion, on the second day of the study, the respondents will undergo a three station – OSCE that will measure their clinical competence. Experimental Group: 1) A scenario-based simulation will be employed for this group a day prior to measuring their clinical competence using the Objective Structured Clinical Examination (OSCE).
The self – structured scenario that has gone through content validity from a panel of experts will be presented to this group. The discussion will be based on the signs and symptoms, including the nursing management applicable to the patient’s problems as stated in the scenario. A copy of a case scenario can be found in Appendix IV. 2) After the scenario-based simulation, on the second day, the respondents will undergo a three station – OSCE that will measure their clinical competence.
Both groups (control and experimental groups) will be assessed in terms of their clinical competence using the OSCE tool (Objective Structured Clinical Examination), comprising of three stations that will measure different aspects (Knowledge, Skills and Attitude). Respondents will be given five minutes to accomplish each station. Each station should last 5 minutes: one minute is set aside for reading the question and instructions and there are 4 minutes allowed for answering the question or performing the required task.
Participants must stay in the station for the full 5 minutes even if they complete the task before the time allotment. A bell will ring when it is time to move on. To ensure that optimum learning will be achieved, the respective instructors assigned on each station will conduct appropriate feedback after the evaluation of the respondents. (Allinier, 2006; Lasater, 2007; Cantrell, 2008). The Objective Structured Clinical Examination Stations: Station 1 Identification and assessment of patient’s problems Clinical competence of the respondents as to assessment will be measured in this station.
A high fidelity human patient simulator that could simulate body activities such as vital signs, oxygen saturation, heart sounds, and lung sounds will be utilized to assess patient’s condition. This will also measure the respondents’ attitude in dealing with the patient’s presenting problems. A virtual laboratory instructor who has undergone physical assessment training will serve as the facilitator in this area. Station 2 Assessment of Skill Clinical competence of the participants as to skill acquisition will be assessed using a high fidelity human patient simulator that will simulate a client with urolithiasis.
This simulator can also depict different cardiac rhythms depending on the scenario that will be presented to the respondents. In this station, the respondents should perform proper nursing management to the patient. Station 3 Assessment of Attitude Clinical competence of the participants will be measured on how they perform evaluation of the patient’s condition. This will necessitate the use of proper communication skills and right attitude in dealing with the client’s problems. Written Examination After conducting the OSCE, both groups will be subjected to a written examination in a classroom setting.
Clinical competence of the respondents as to knowledge of the pre-identified topic covered during the first day of the study will be measured through a 10-item written examination. This will be used as a pretest and posttest for measuring the clinical competence of the respondents in performing catheterization in a patient with urolithiasis. Respondents will be allotted 30 minutes to accomplish the 10-item multiple choice type examination. A faculty member of the college of nursing will serve as the facilitator during the examination period.
All data gathered will be tallied, organized into tables, charts or graphs, and will be interpreted and analyzed by the researcher with the assistance of a competent statistician. 3. 1. 5 Ethical Consideration To ensure that the respondents’ rights will not be violated, ethical approval to undertake this study will be obtained from the University Ethics Committee and Dean of the College of Nursing. A written informed consent will be obtained for those who will participate on a voluntary basis. The respondents will be provided a copy of the consent for their personal records.
They will be subjected to a debriefing session wherein they will be oriented to the study design, purpose and activities that will be undertaken and that all questions related to the study will be entertained. This is to ensure everyone receives consistent information related to the study. Moreover, the questionnaire for the demographic profile will also be distributed during this session. The respondents will be assured of anonymity and confidentiality of information and that they can choose to withdraw at anytime during the study without risking penalty (Polit & Beck, 2004).
A student identification code will be assigned to each respondent , in which only the data collectors have knowledge of. The respondents will be selected randomly and that fair treatment to both groups will be guaranteed. The study will be conducted in a familiar setting, which is safe and conducive to learning among respondents. 3. 1. 6 Data Analysis The following statistical methods will be applied to analyze and interpret the data that will be gathered by the researcher: Frequency and Percentage Distribution to describe the demographic rofile of the participants in terms of age, gender, educational background; this is expressed as: [pic][pic] ; Where:P is the percentage; f is the frequency of respondents and N is the total number of the respondents. Mean and weighted mean to determine the overall average of the participants’ scores. T – test to compare the scores of the participants of both groups in the study. This is computed using the formula: Processing of the raw data will be done using the Statistical Package for Social Sciences (SPSS) Version 17. BIBLIOGRAPHY Alinier, G. , Hunt, B. , Gordon, R. , & Harwood, C. (2006). Effectiveness f intermediate-fidelity simulation training technology in undergraduate nursing education. Journal of Advanced Nursing, 54(3), 359-369. Bradley, P. (2006). The history of simulation in medical education and possible future directions. Medical Education, 40, 254-262. Brosnan, M. , Evans, W. , Brosnan, E. , & Brown, G. (2006). Nurse Education Today, 26, 115-122. Brosnan, M. , Evans, W. , Brosnan, E. , Brown, G. , 2006. Implementing objective structured skills evaluation (OSCE) in nurse registration programmes in a centre in Ireland: A utilization focused evaluation. Nurse Education Today 26, 115–122. Byrne, E. & Smyth S. 2007). Lecturers’ experiences and perspectives of Using an objective structured clinical examination. School of Nursing and Midwifery, National University of Ireland, Galway, Ireland Curl, E. D. , Smith, S. , Chisholm, L. , Hamilton, J. , & McGee, L. A. (2007). Multidimensional approaches to extending nurse faculty resources without testing faculty’s patience. Journal of Nursing Education, 46, 193-195. Decker, S. , Sportsman, S. , Puetz, L. , & Billings, L. (2008). The evolution of simulation and its contribution to competency. Journal of Continuing Education in Nursing, 39, 74-80. Del Bueno D. A crisis in critical thinking.
Nurs Educ Perspect 2005;26:278- 282. Delpier, T. (2006). Cases 101: Learning to teach with cases. Nursing Education Perspectives, 27, 204? 299. Detweiler, R. (2005, 9 December). The rewards of the digital age. The Chronicle of Higher Education. pp. B8. Harden, R. , Gleeson, F. , 1979. Assessment of clinical competence using an objective structured clinical examination (O. S. C. E. ). Medicine Education 31, 41–54. Hoffman, R. , O’Donnel, J. , & Kim, Y. (2007). The effects of human patient simulators on basic knowledge in critical care nursing students. Journal of the Society for Simulation in Healthcare, 2(2),110-114. Issenberg, S.
B. , McGaghie, W. C. , Petrusa, E. R. , Lee Gordon, D. , & Scalese, R. J. (2005). Features and uses of high-fidelity medical simulations that lead to effective learning: A BEME systematic review. Medical Teacher, 27, 10-28. Jeffries, P. J. (2007). Simulation in nursing education: From conceptualization to evaluation. New York: Nation League of Nursing. Madhavan, K. P. C. (2006, June). Cyber indicators are high. Campus Technology, 64 Major, D. , 2005. OSCEs – seven years on the bandwagon: The progress of an objective structured clinical evaluation programme. Nurse Education Today 25, 442–454. Masual, C. , De Corte, E. , 2005.
Learning to reflect and to attribute constructively as basic components of self-redulated learning. British Journal of Educational Psychology 75, 351–372. Mc Callum, J. (2007). The debate in favour of using simulation education in pre-registration adult nursing. United Kingdom. Nurse Education Today (2007) 27, 825–831 McGrath P, Fox Young S, Moxham L, Anastasi J, Gorman D, Tollefson J. Collaborative voices: ongoing reflections on nursing competencies. Contemporary Nurse 2006;22:46-58. Meehan-Andrews, T. (2009). Teaching mode efficiency and learning preferences of first year nursing students. Nurse Education Today (2009) 29, 24–32
Microsoft® Encarta® 2007. © 1993-2006 Microsoft Corporation. All rights reserved. EdCaN Competency standards in professional nursing: a summary of literature published since 2000 Mikol, C. (2005). Teaching nursing without lecturing: Critical pedagogy as communicative dialogue. Nursing Education Perspectives, 26, 86? 89. National Colleges of State Boards of Nursing. (2006, July). Evidence- Based nursing education for regulation (EBNER). Chicago: Author. Retrieved December 7, 2008, from https://wwww. ncsbn. org/Final_06_EBNER_Report. pdf Prion, S. K. (2008). Evaluating simulations [Online faculty development module].
New York: National League for Nursing. http://sirc. nln. org/mod/resource/view. php. Rennie, A. , Main, M. , 2006. Student midwives’ views of the objective structured clinical examination. British Journal of Midwifery 14 (10), 602–607. Rhodes, M. , & Curran, C. (2005). Use of the human patient simulator to teach clinical judgment skills in a baccalaureate nursing program. CIN: Computers, Informatics, Nursing, September/October 256-262. Rushforth, H. E. (2007). Objective structured clinical examination: Review of the literature and implications for nursing education. Nurse Education Today, 27, 481-490.
Schoonheim-Klein, M. , Walmsley, A. D. , Habets, L. , van der Velden, U. , Manogue, M. , 2005. An implementation strategy for introducing an OSCE into a dental school. European Journal of Dental Education 9, 143–149. Twigg, C. & Stoll, C. (2005, December 9). Face off: Technology as teacher. The Chronicle of Higher Education, pp. B12-14 APPENDIX I: PERMIT TO CONDUCT THE STUDY Date Lurceli L. Santos, RN MAN Dean, College of Nursing Our Lady of Fatima University Marulas, Valenzuela City Dear Madam; Greetings of Peace! In line with the institution’s requirements for its employees, I am currently orking on my research proposal entitled, Scenario – Based Simulation and Its Effect on the Clinical Competence Of Junior Nursing Students In An Educational Institution In Valenzuela City I am humbly asking your good office for a permission to conduct the study in our institution. With your approval, I am planning to include junior nursing students as my respondents. The respondents shall be subjected to a pretest and posttest measurement that will assess their clinical competence after subjecting them to respective teaching methodologies. I am hoping for your favorable response regarding this matter. Thank you so much.
Respectfully yours, Ma. Ronela L. Paglinawan, RN UST Graduate Student – MA in Nursing Noted by: Prof. Rosalinda P. Salustiano, PhD Research Supervisor APPENDIX II: REQUEST FOR PERTINENT DATA ADDRESSED TO THE RESPONDENTS (ENGLISH) Date Dear Respondents: Greetings of Peace! I, MA. RONELA L. PAGLINAWAN, a registered nurse and a student of the University of Santo Tomas Graduate School taking up Master of Arts in Nursing. I am currently conducting a research study entitled: Scenario – Based Simulation and Its Effect on the Clinical Competence of Junior Nursing Students In An Educational Institution In Valenzuela City “
This study can help develop future recommendations for the improvement of nursing education. The results of the study may provide basis for the formulation of new teaching methodology that would enhance clinical competence of nursing students. In relation to this, I would like to ask for your cooperation in this research. Be assured that confidentiality of your personal information will be kept and maintained. Only the results of the study will be utilized for the presentation and in the final thesis paper. I am hoping for your favorable response regarding this matter. Thank you. Respectfully yours,
Ma. Ronela L. Paglinawan, RN Graduate Student Noted by: Prof. Rosalinda P. Salustiano, Phd Research Supervisor University of Santo Tomas APPENDIX III: INFORMED CONSENT FOR RESEARCH PARTICIPANTS Project Title: “Scenario – Based Simulation and Its Effect on the Clinical Competence of Junior Nursing Students In An Educational Institution In Valenzuela City” I agree to take part in the above UST Graduate School research project. I have had the project explained to me, and I have read the explanatory statement, which I keep for my records. I understand that agreeing to take part means that I am willing to: accomplish the personal information sheet and the researcher’s questionnaire that will be provided to me • participate in the class activities • answer the test examination that will be administered I understand that the information and results that will be collected by the researcher will be maintained confidential and that no information that could lead to the identification of any individual will be disclosed in any reports on the study. However, this information and results will be utilized by the researcher for her presentation and for the final thesis paper.
I also understand that my participation is voluntary, that I can choose not to participate in part or all of the project, and that I can withdraw at any stage of the project without being penalized or disadvantaged in any way. Name (optional)_________________________________ Signature:_________________________________ APPENDIX IV AN EXAMPLE: CASE SCENARIO OF A PATIENT WITH UROLITHIASIS (Experimental Group) A male patient, Mr. Lawrence Fuentes, 46 year old was brought to the Emergency department due to severe right flank pain. 5 days PTA, patient had burning sensation upon urination. hours PTA, he had episodes of vomiting accompanied by a feeling of bloated stomach. The flank pain started from moderate to severe thus, prompted him to consult medical attention. He appears pale, restless and anxious. Vital signs taken and recorded as follows: BP – 130/90; Temp – 38 C; PR – 104 bpm; RR – 26/min. During history taking, the nurse found out that the patient was diagnosed with urolithiasis a year ago. At the ED, the physician orders D5NM 1L to run for 8 hours. Laboratory exams such as CBC, BUN, Creatinine, Serum K, Calcium, Uric Acid and Phosphate were ordered.
The client is for urinalysis and urine culture and sensitivity. Ultrasound of the Kidneys and Bladder is also requested to be performed. He was diagnosed as Urolithiasis to rule out Urinary Tract Infection. APPENDIX V QUESTIONAIRE ON KNOWLEDGE Student Identification Number: _____ Choose the best answer. 1) A nurse is inserting an indwelling foley catheter into the urethra of a male client. As the nurse inflates the balloon, the client complains of discomfort. The appropriate nursing action is to: a. Aspirate the fluid, remove the catheter and insert a new catheter b.
Aspirate the fluid, advance the catheter farther, and reinflate the balloon c. Remove the syringe from the balloon, discomfort is normal and temporary d. Aspirate the fluid, withdraw the catheter slightly, and reinflate the balloon 2) At the ER, the nurse on duty assesses the client for any abnormal findings. Which of the following should be reported to the doctor? a. Tea-colored urine b. Urine output of 40cc/hr c. Specific gravity of 1. 010 d. Urine ph of 6 3) A nurse is inserting an indwelling catheter into a male client, as the catheter is inserted into the urethra, urine begins to flow into the tubing, t this point the nurse begins to: a. Immediately inflates the balloon b. Inserts the catheter 2. 5 cm to 5 cm and inflates the balloon c. Withdraws the catheter 1 cm and inflates the balloon d. Inserts the catheter until resistance is met then inflates the balloon 4) The client with urolithiasis has a history of chronic urinary tract infections. The nurse plans teaching the client to avoid which of the following: a. Long term use of antibiotics b. Wearing synthetic underwear and pantyhose c. High-phosphate foods such as dairy products d. Foods that make the urine more acidic, such as cranberries ) The client who has a history of gout is diagnosed with urolithiasis and the stones are determined to be of uric acid type. The nurse teaches the client to limit which of these foods: a. Milk b. Liver c. Apple d. Carrots 6) The client is admitted with a history of urolithiasis. Which of the following diet should be instructed to the client? a. High sodium b. High potassium c. Low cholesterol d. Low purine 7) A male client has an indwelling foley c