jurnal buat klmpk 5 & 7

8/4/2019 jurnal buat klmpk 5 & 7

1/5

TEC Ho MG T E C E-I NO L O G Y / L E A R N I N G O U T C O M E S

Using Learning Outcomes to Inform Teaching Practicesin Human Patient SimulationVICTORIA L. ELFRINK, BONNIE KIRKPATRICK, JAM! NININGER, AND CAROLYN SCHUBERT

) .O M D M S H l l M G N U M B E I R S FCLDM l l CA I L SUT ES, f ewercl inical hou rs, and the shortage ofnurse faculty and preceptors areamong various interrelated factors placing students at risk for inade-

quate exposure to requisite cl inical experiences (Simpson &Courtney,2002). Challenged to prepare competent pract i t ioners to meet thehealth care needs of an evolving health care delivery system, nurse fac-ulty are seeking innovative teaching strategies to promote cl inical learn-ing inan efficient and high quality manner.

One strategy gaining increasing use is human-patient simulation.Experts argue that because the use of simulation promotes cl inicallearning v^hile having nonegative effect on patient safety, simulationsshould be increasingly integrated into the curriculum (Jeffries, 2005;Nehr ig , Lashley, & Ellis, 2002). But how do faculty learn to implement andlead simulations?

Implementing simulation requires ahigh cost in technical and humanresources, as well as knowledge of best pedagogical practices. But at th epresent t ime, most faculty development takes place on the job, withinskills labs, and the teachers are often vendors of interactive human sim-ulators. Some educators.con tinue to argue that the focus on simulationsdetracts f rom t ime spent in real-world cl inical sett ings (Nehrig &Lashley, 2004). Factors including the high costs involved and the ongoingresistance among some faculty lead to the understanding that researchis needed to evaluate the effectiveness of teaching practices used inhuman patient simulation.

This exploratory study is a cont inuat ion of work that began inautumn 2005 involving the evaluation ofsimulation use in the curr icu-lum. The study was designed to inform teaching practices through themeasurement of cognit ive learning outcomes associated with humanpatient simulation.

T h r e e q u e s t i o n s g u i d e d the i n v e s t i g a t i o n :1. Is there a difference inthe subject-related knowledge of studentsfrom pre- to postsimulation?2. Is there retent ion of subject-related knowledge?3. How can the f indings from the pre/postmeasurement and reten-t i on of learning outcomes inform teaching pract ices for humanpatient simulation?

The Pedagogical Structure SITUATED LEAR NING S i tuatlearning and mastery learning frameworks provide the pedagogist ructure for the design of this college of nursing simulation experien(see Figure). Situated learning posits that knowledge and skills are beacquired and applied when students experience subject matter incontext of specific, applied, everyday situations (Stein, 1998). In nurseducat ion, situated learning takes many forms, including role-play atask training, as well as high-f idel ity human p atient simulations.Figure I. Framework for Human Patient Simulation

Situated/Mastery Learning Pedagogical Framework for HunrianPatient SimulationContent = ^Developmentofa realworld scenario Assessment ofpre-simulationknowledge

Orientation to simulation settingAssistance inplanning priorityactionsFaciiitation of clinical problem solvingDebriefng simulationRefinem ent in planning priorityactionsFaciiitation of clinical problem solvingDebriefing simulationAssessment o f post-simulationknowledge

^ Product =Measurable student(earning outcomesShare d con structeccl inicalknowledgeCommunity ofpractice

Four elements make up the situated learning event: con tent, con tecomm unity, and part icip ation (Stein, 1998). Each contributes to the sdent's learning in a unique way. Content isexpressed in situated learning as ahigher ordered thiing process rather than simply the acquisit ion of isolated facts. Contprovides ameans forstudents to engage in reflective thinking (Sh1996).The goal of learning in this stage is the application of knowled The contex t of situated learning involves creating scenarios that c osider the variety of comp eting prio rit ie s, values, and pol it ics. Rather thbeing passive, learners dwell and are interactive in theexperience. Communi ty of practice involves sharing meaning and analysis amothe part icipants in the learning experience.

A B S T R A C T This evaluation research focused on m ethods for improving simulation instruction by determining if student.^' knowlabout simulation .subject matter improved and was retained following a simulation experience. Using apretest/posttest approaNCLEX-style questions pertaining to the simulation subject matter content were administered to nursing students from, two prelicennursing courses immediately preceding the simulation, immediately following the simulation, and then ag ain at their final examinations. These findings have helped faculty determine when their simulation instruction is effective an d have provided a guide for revitheir simulation teaching. While this pretest/posttest method offers insight into student learning outcomes, it perhaps more importacreates a systematic approach for evaluating simulation instruction.

March / April ZOIO V o l . 3 1 No.2 9


2/5

W l i T K l T S C I H J M O I . O G Y / L E A R N I N G O U T C O M E S

Par ticipation is the interchange ofideas among learners, which formsa social construction of knowledge. Experts (lacobsen, 1996) suggestthat practit ioners must learn to perceive, interpret, and communicateexperiences with their peers.

The use of human patient simulation as a nursing education inte rven-tion meets the criteria of situated learning by providing the learner withthe opportuni ty to analyze and solve (content) aclinical problem (con-text) within a shared learning environment (community) in which knowl-edge is partial ly constructed and communicated among the learners(part icipation).The use ofNCLEX-style questions helps faculty measurethe higher order thinking progress of their students and evaluate theirinst ruct ion.

M ASTER Y LEAR N I N G Themastery learning approach engagesstudents inmultiple levels ofthinking, including higher order thinking. Itconsists ofseveral steps as fol lows (Ham mon d, 2006): Presenting a cue set that focuses the student on the learning task. Using mu ltiple strategies to conduct a "best sho t" at inst ruct ion. Facil i tat ing guided practice to apply the learning and experiencesuccess. Performing a formative evaluation about the achieved learning. Providing an opp ortu nity for closure that ties togeth er the learning,instructional strategies, and expectations in ameaningful summary.

Through the use ofhuman patient simulations, students are offereda sequence and set of instructional practices that create the condit ionsfor practice in a moc k wo rk w or ld. Students then receive feedbackthrough debriefing about their practice.The experience offers mult ipleopportuni t ies for corrective practice and crit ical reflection. In humanpatient simu lation, educators have the responsibi l ity ofmaking sure th atthe most relevant cue sets are apparent and that the script for the sce-nario is fol lowed to ensure the intended learning transfer.

M e t h o d SUBJECTS Following approval from th e Institut ional ReviewBoard for Human Subjects, volunteers w ere sough t to pa rt icipate in thestudy.The goals of the study were explained and consent was obtained.Subjects consisted of 84 volunteers f rom two prelicensure nursingcourses part icipating inon e or more human patient simulations. Datawere gathered f rom 41 second-year students during the spring(advanced medical-surgical course) and from 43 third-yea r students dur-ing the winter and spring quarters of2007 (high acuity course).

PRO CEDU RE Both situated and mastery learning are used in thebroad design and sequencing of the simulation as follows:1. Students prepare for a scenario using evidence from reliable resources(e.g., textbooks, electronic reference tools) and case-specific informationfound in the college's computerized information system (CIS).2. Students answer a two-question presimulation assessment of thei rknowledge based on the cl inical content of the scenario.3. Faculty orient students to the clinical environment, performanceexpectations, student roles, and the specif ic scenario.4. Students part icipate in agroup session to plan care for the sim-ulated patient.5. Students carry out the simulation.

6. Faculty and students debrief the simulation based on exp ected leaing outcom es and crit ical nursing actions. A revised plan ofaction mbe developed based on the learning needs of the group.7. In cases where thesimulation objectives were not met, studeswitch roles and repeat the simulation implementing the revised plan8. Following the second simulation (ifapplicable), faculty and studeparticipate in a second debriefing to compare outcomes and actions.9. Students comp lete the same two-q ues tion assessment at this t imStudents complete apostsimulation paper-and-pen assignment answing specif ic case-related questions using documen tation and oth er forof data from the simulation.10. Simulation-related questions are included on the students' f iexaminations.

DATA COLLECTION Pr ior to thestart of each term, NCLEX-Rstudy questions were examined for their relevance and selected for uin each simulation. Each set ofquestions was noted on separate sheeof paper; the simulation number, course number, subject matter, adsignation of the pre- orposttest were clearly identif ied. Different cors were used for the pre- and posttests to keep the collection proceorganized.

At the start of the te rm , volun teer subjects we re assigned uniqidentif ication numbers (IDs). Students were told the purpose of thunique IDs and asked to place the number on all data collection instments, including the pretest, posttes t, and f inal examina tion.

Prior to the start ofeach simulation, al l students were requiredanswer tw o non graded wri tte n know ledge assessment questions. Thwere also encouraged to provide rationales for their answers on pre- and postassessments. They were no t given the answers to thequestions.Although all students were required tocomplete these quetions, only those wh o voluntee red for the study were given unique Iand only their answers were included inthe data analysis.

Following the simulation, students were asked to answer the samquestions. Again, they were not given the answers. Finally, one to twquestions related to , but n ot exactly the same as, the pre- and posttequestions were added to the f inal examination that students completat the end of the ter m.

DATA AN ALY SIS The data analysis consisted of mult iple sequentquantitative measures as follows: a) A descriptive before-and-after frquencies table was con structed toshow the effectiveness of the simult ion learning, b) Average improve men t pre - to p ostsimulation was calclated using a paired t-test.c) Gauging learning pre- t o postsimulation wdetermined by using only the scores from those who had an incorreanswer before the simulation and performing a one-sample t-test to seif subjects did better than random guessing (mean score < 1.75) aftthe simulation, d) Gauging retention from postsimulation to the finexam was estimated using only those who had acorrect answer aftthe simulation and performing a one-sample t-test to see if students dbetter than guessing on the f inal exam (mean score < 1.75).

F i n d i n g s To i l lustrate the consistency of the evaluation methodused in this study, the findings for a question associated with eac

9 8 Nursing Education Perspectives


3/5

T E A C H I N G W I T M T E C H N O L O G Y / L E A R N I N G O U T C O M E S

course are presented.To fur ther exempl ify the meth od, detailed tablesreporting the f indings are presented forone quest ion.

MAS T EC T O M Y Q U ES T IO N EX A MP L E U p o n a dm is sio n to the surgi-cal unit, a simple ma stectomy patient has vital signs ofBP 100/60, HR 100,and RR 16. In add ition, the Jackson Pra tt drain is three fourths ful l withsanguinous fluid, and the mastectomy dressing is saturated with bright redblood. W ha t is the nurse's priority action?a. Reinforce and apply pressure to mastectomy dressingb. Em pty Jackson Pra tt drainc. Perform pulse oxim etryd. Increase IV fluids

D E T A I L E D A N A L Y SI S1 . D e s c r i p t iv e b e f o r e - a n d - a f t e r ta b l e As s h o wn in Ta b le 1 , 1 0 s t u -dents answered both thepre- and postSimulator questions correctly.Among those students who answered incorrectly before the simulation,17 answered correc tly afterw ard; 11 answered incorre ctly bo th beforeand after the simulation experience.Three students answered correctlybefore the simulation but answered incorrectly afterward.

T a b l e I . N u r s i n g 4 0 2 Mastectomy Content ,P r e - and Postquest ion Frequencies

Mastectomy questionpost-act answer

correct incorrectMastectomy quest ion corre ct 10 3pre-act answer incor rect 17 II2. Estimating average improvement pre/post A paired t-test wasperformed to determine whether people improved on average (seeTable 2).

INTERI'HETATION Th e posi t ive mean value (0.375) indicates that ,on average, studen t scores improve d be tween the pretest andposttest.The p-value of 0.000 indicates that this improvement was sta-t ist ically signif icant.3. Gauging iearning pre- topostsimuiat ion Using only those whohad an inc orre ct answer before the simulation, a one-sample t-test wasperformed to see if they did better than guessing after the simulation.

INTERPRETATION The mean is lower than the score expected byran dom guessing (1.75), and this difference issignificant with a p-value

of 0.001. It was concluded that students who answered incorrectly othe pretest did significantly be tter than guessing on the posttest, indicaing that some learning did occur using the simulator.4. Descriptive post to f inal examinat ion table As shown in Tab3, 23 students gotboth theposttest question and thematched f inaexamination quest ion co rrect . On ly three students were corre ct beforthe simulation but answered the f inal examination incorrectly.T a b l e 3.C o m p a r i s o n of S c o r e s , P o s t t e s t to FinalExam, /Mastectomy

Massmatchfinal0 correct incorre

Mastectomy quest ion corre ct I 23 3post answer incorrect 11 25. Gauging retent ion from postsimuiat ion to f inai exam Usinonly those w ho had a correc t answer after the simulation, a one-sampt-test was perform ed to see if they did better than guessing on the f inexam.

INTERPRETATION The mean score was lower than the scoexpected by random guessing (1.75), and this difference is significawith a f)-value of 0.000. O f the students who had the know ledge at tht ime of the po sttest, 93 percent retained the informat ion. It was cocluded that students who answered correctly on both the posttest anthe f inal examination did significantly better than guessing on tposttest, suggesting that knowledge was retained.

SUMMARY For the question being analyzed, there was s trong evdence that there was improvement instudents' subject matter knowedge during the s imulation. Th e f indings also indicated that 93 perceof the students who had the correct subject matter knowledge at thposttest retained that knowledge unti l the f inal exam.

AR D S Q U ES T IO N EX AMP L E A client is intubated and receivimechanical ventilation.The nurse has added 7 cm positive end expiratopressure (PEEP) to the client's ventilator settings.The nurse assesses fwhich of the fol lowing expected but adverse effects of PEEP?a. Systolic blo od pressure decrease fro m 122 to 9 8 m m H Gb. Decreased heart rate from 78 beats per minute to 64c. Decreased peak pressure on the venti latord. Increased temperature from 98 degrees Fahrenheit to 100 degree

Table 2. Comparison of Pre- and Posttest Scores for Nursing 402, Mastectomy Content

PI Mastectomy questionpre-act answer -Mastectomy questionpost-act answer

M EAN

Lower

.375

PAIRED DIFFERENCESSTD. STD. 95% CONFIDENCE

DEVIA TION ERROR INTERVAL O FMEAN DIFFERENCE

Upper Lower Upper Lower

.586 .093 .188

tM EAN

Upper df Sig. (2-tai led

.562 4.050 39 .000

Marrh / April 1010 Vol .3 1 No.2 9


4/5

T E A C H l YM TEC M KOlL@iE V / L E A R N I N G OU TC OM ES

DETAILED ANALYSIS Thirty-four people answered incorrectly tostart with and were correct on the posttest. Only one person got thequestion correct to start with and was incorrect on the posttest. Eightgot both the pre- and postsimulation questions correct. No studentswho were correct before the simulation answered incorrectly afterward.

The number of students who improved from pre- to posttest wassignificant at a .000 level.The fi-value of .000 indicates that this improve-ment was statistically significant. In the comparison, the findings forknowledge retention were not encouraging. Twenty-one studentsanswered the question correctly on both the posttest and the matchedquestion on the final exam. However, 21 students answered correctly onthe posttest and answered incorrectly on the final exam, indicating thatknowledge was retained by only 50 percent of the students. The meanIn the one sample test was lower than 1.75; thus, this finding is signifi-cant for "better than guessing."

SUMMARY For the question being analyzed, there was strong evi-dence that there was improvement in knowledge during the simulation.A paired t-test using pre- and postsimulation scores showed significantimprovement {p = .000). A one-sample t-test assessing learning amongthose students who answered incorrectly before the simulation foundthat a significantly larger proportion than 25 percent (the percentageexpected by random guessing) answered correctly after the simulation{p = .000). However, knowledge was not retained between the simula-tion and the exam.Only 50 percent of the students who answered cor-rectly after the simulation also answered correctly on the exam. A one-sample t-test gauging retention among those students who answeredthe question correctly during the postsimulation test found that thisfinding was significantly better than guessing (p - .005).

Discussion and Implications Findings from the study indicatethat the simulation-related content matter knowledge significantlyimproved for students in both courses. These findings indicate that theintended simulation learning outcomes were achieved. The results alsoimply that the simulation faculty were effective in their simulation teaching.

The findings are mixed with respect to learning retention. While 93percent of the students in the second-year course retained knowledgefrom their posttests to the final, only 50 percent of the students in thethird-year high acuity course retained the subject matter knowledge. Itis difficult to know how to fully interpret this finding. Given the gap in

knowledge retention in the third-year students, there is clear a need explore an educational intervention aimed toward achieving greatknowledge retention in this high acuity course.

While knowing more about student gain and retention in simulatisubject matter is beneficial, the critical question is how such knowledcan inform simulation teaching practices. In one congestive heart failusimulation, the number of correct responses for a question dealing wthe priority action for assessing heart failure actually decreased fropre- to postsimulation.The initial findings were troubling, but upon futher examination, faculty determined that during the simulation, thhad placed a great deal of time and emphasis on the correct placemeof EKG leads.They determined that their disproportionate emphasis EKG leads influenced student judgment. As a result, faculty made certato stress the importance of assessing for oxygnation as the prioriassessment for congestive heart failure going forward.

Conciusion As simulations gains wider use in the nursing curriclum, efforts to evaluate their effectiveness will also need to expanThis research, while limited to cognitive knowledge, has providevaluable insight regarding the cues that students focus on in simultions and need for clarity regarding the instructional cue sets prsented. Further research is needed on how to best structure, timand provide assistance to students using salient simulation cue setMore also needs to be understood about how to improve simulatioknowledge retention, [^-^t

About the Authors Victoria L Elfrink, PhD, RN-BC, is associate professor of clinical nursing at the Ohio State UniveCollege of Nursing, Columbus. Bonnie Kirkpatrick, MS, RN, CCNL, is an auxiliary clinical instructor at the Ohio State UniverCollege of Nursing. Jami Nininger, MS, RN, a former instructothe Ohio State University College of Nursing, is program coortor at Knox County Career Center School of Practical NursingVernon, Ohio. Carolyn Schubert, MS, RN, BC, is a clinical instor at the Ohio State University College of Nursing. ContactElfrink at [email protected] Words Learning Outcomes - Simulation - Situated Learnin- Mastery Learning - Retention

ReferencesHammond, G. (2006) Multiple methods ofassess-ment Retrieved fromhttp://xnet.rrc.mb.ca/glenh/masteryjearning.htmJacobsen, W. (1996). Learning, culture and learn-ing culture. Adu/t Education Quarterly. 47(1), 15-28 .Jeffries, R (2005). A framework for designing,implementing and evaluating simulations used as

teaching strategies in nursing. Nursing EducationPerspectives 26,96-103.Nehrig, W, & Lashley, R (2004). Current use andopinions regarding human patient simulators innursing education: An international survey.Nursing Education Perspeaives 25, 244-248.Nehrig, W, Lashley, R, & Ellis, F. (2002). Criticalindicident nursing management using humanpatient simulators. Nursing Education Perspectives,23, 129-132.

Shor, I. (1996). When students have power:Negotiating authority in a critical pedagogy. Chuniversity of Chicago Press.Simpson, E., & Courtney, M. (2002). Critical thining in nursing education: Literature review.International journal of Nursing Practice, 8, 89-Stein, D. (1998). Situated learning in adult eduction. Retrieved from www.ericdigests.org/1998-3/adult-education.html

1 0 0 N u r s i n g E d u c a t i o n P e r s p e c t i v e s


5/5

Copyright of Nursing Education Perspectives is the property of National League for Nursing and its content

may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express

written permission. However, users may print, download, or email articles for individual use.

jurnal buat klmpk 5 & 7

Documents