Background The most significant component in nursing education is clinical experience.
An educational learning environment encompasses a considerable number of conditions that affect students clinical learning results (Dunn 1995). According to Johnson Lewis (2010) in their case study it was shown that methods used in clinical teaching represent one of the crucial matters which are related to education and affect the performance of students in a number of clinical environments. Preparation of nursing students to enter into clinical practice as with other health care students such as medical students has for a long time been based on clinical clerkship programmes in which students is allowed to learn and practice various clinical skills under the supervision of a qualified health practitioner in their respective clinical fields (Neary 1997; Nehls Rather and Guyette 1997; Jalili Mirzazadeh and Azarpira 2008; Kim and Myung 2014).
Real encounters with patients in a hospital setting are a critical component for preparing medical students to apply their preclinical knowledge and skills in real clinical practice. This allows students to develop clinical thinking communication skills and a professional attitude (Kim and Myung 2014). However data from extensive surveys suggest that nursing and medical students do not feel adequately prepared for clinical practice after their respective clinical clerkship programmes (Kim and Myung 2014; Jalili et al. 2008; Linder and Pulsipher 2008). Most of the students who complete their studies successfully have plenty of knowledge but lack a hands-on experience Scheetz (1989 cited in Hakimzadeh Ghodrati Karamdost et al. 2013). It is crucial for students to be exposed to both theoretical and hands-on learning processes to enable them to become professional practitioners of health.
Prince Boshuizen Van Der Vleuten et al. (2005) surveyed fourth-year medical students on the transition from preclinical to clinical practice during clinical clerkship programmes and a majority of students felt they were moderately prepared with regard to applying their preclinical knowledge and skills especially when they had a drastic increase in clinical workload that reduced their study hours.
To enhance the learning experience and self-efficacy of medical students who are in transition from preclinical to clinical practice clinical teaching method that is being continuously applied for teaching medical students at the undergraduate level is called simulation-based medical education (SBME) as a prerequisite or an adjunct to the traditional clinical clerkship programme (Chakravarthy ter Harr Bhat et al. 2011; Sperling Clark and Kang 2013).
Sperling et al. (2013) assessed the impact of SBME on students clinical knowledge and skills acquisition comfort and perceived clinical competence with regards to attending to patients with altered mental status (AMS). It was found that students who attended simulation learning sessions exhibited higher post-test scores than those who did not and they were clinically relaxed in their overall clinical approach to treating AMS patients. These findings strongly indicate that the learning and clinical practice experience of medical students in a clinical clerkship programme can be enhanced by preclinical simulation learning sessions.
An effective learning experience for nursing students might contribute to both learning and achievement. The author a teacher assistant in nursing education recognized that students feel nervous when dealing with real patients and do not have the confidence to provide care in clinical settings. Although nursing education systems attempt to close the gap between theory and practice (Gallagher 2004) in Saudi Arabia the gap has increased. For several reasons the place where the author works does not have a university hospital so patients refuse to receive care from students. Also there is a lack of hospitals and due to their small size they cannot accept a large number of students. Moreover nursing-skills laboratories are not fully equipped and there is a faculty and preceptors shortage as well. Development of students cognitive affect and psychomotor skills has been influenced by the learning environment (Hart and Rotem 1993).
In Saudi Arabia student nurses rely entirely on the clinical clerkship programme and tutors to receive information as opposed to high-fidelity patient simulation. Consequently nursing students have high anxiety levels when they start their clinical clerkship programme and they do not feel impassioned to develop and increase their ability to self-learn. Nursing programmes must address these challenges by using alternative methods of clinical education such as simulation as learning strategy.
High-fidelity patient simulation (HFPS) is one of the successful approaches to SBME with the potential to enhance cognitive associative and self-sufficient nontechnical skills as well as clinical reasoning in medical students on transition from preclinical to clinical practice (Takayesu Farrell Evans et al. 2006). HFPS entails the use of a full-body simulated patient with computerized organ components called manikins (or mannequins) that simulate real-life scenarios in clinical settings and provide feedback. Although the technological advances that come from using HFPS and the potential benefit in practical education it can be available only in limited areas because of the high cost of maintaining the equipment and such sophisticated equipment could require expert operation.
HFPS provides medical students with a safe and controlled simulated learning environment in which to develop nontechnical skills. An HFPS learning environment allows students to make mistakes and correct them in real time without the fear of compromising patient safety (Durham and Alden 2008; Kneebone and ApSimon 2001). This might achieve some proficiency prior to a clinical setting allow repetitive practice at the learners own pace experiential and reflective learning as well as team training (Lewis et al. 2012; Decker Sportsman Putz et al. 2008). As HFPS provide an opportunity for risk-free learning by trial and error therefore students do not have the expertise to work on people in practical situation could be lethal for patient. According to Kneebone and ApSimon (2001) gaining experience in the early stage of training has become increasingly unacceptable because of ethical consideration.
HFPS was chosen for undergraduate nursing students in this project because most nursing schools use low-fidelity simulation which is used for beginner students to learn basic procedures and cannot be used for advanced procedures. As HFPS has become an effective method for training medical students the author attempted to see the impact of HFPS on her field particularly on undergraduate nursing students.
HFPS has for a long time been used in medical and military schools. It is rapidly becoming essential in nursing schools (Weaver 2011) as it overcomes challenges such as a limited number of clinical sites especially in rural hospitals where certain types of patients or disease conditions are rare or patients have a shorter hospital stay (Piette Muchirahondo Mangezi et al. 2015) .There is extensive evidence as summarized in recent systematic reviews indicating that HFPS is useful in nursing and midwifery education (Cook Hatala and Brydge et al. 2011; Cooper Cant Porter et al. 2012 ; Lapkin Levett-Jones Bellchambers et al. 2010 ; OLeary Nash and Lewis 2015). Evidence in these systematic reviews consistently indicates that the use of HFPS by undergraduate student nurses improves their knowledge acquisition psychomotor skills and clinical reasoning skills and satisfaction. However there is a gap in knowledge regarding the effect of HFPS in students anxiety levels and self-efficacy.
Anxiety in learning settings is common among undergraduate nursing students being introduced to clinical clerkship programmes (Zargarzadeh and Shirazi 2014). Nursing students considered that inadequate supervision lack of supportive relationships and teacher inaccessibility contributed to anxiety and stress in clinical learning (Cook 2005; Reid-Searl Moxham Walker et al. 2009). Moreover nursing students who rely on traditional lecture-based curricula faced anxiety in clinical learning (Melo Williams and Ross 2010). As such their assigned routines are often characterized by feelings of distrust dissatisfaction anxiety sadness anger and distress (Barboza and Soares 2012).
Self-efficacy refers to individual judgments of ones abilities to arrange and execute strategies to achieve assigned objectives (Bandura 1977). The most important point in self-efficacy theory is the level of motivation which has an effect on students belief and behaviour. More specifically they experience feelings of anxiety in a learning situation which has a direct impact on nursing students response to clinical learning their ability to achieve particular goals and self-efficacy. Therefore it is important to review the best available evidence on the utility of HFPS in student anxiety and self-efficacy skills during their nursing practice.Review question It is evident from the reviewed literature that SBME is effective in improving the clinical competence of nurses as well as their nontechnical skills. This review was inspired by the research question as to whether HFPS has an effect on students anxiety levels and self-efficacy skills in undergraduate nursing students. PICO framework was used to formulate the research question which is presented below.Participants
Intervention
Comparison
Outcomes
Undergraduate nursing students
High fidelity patient simulation (HFPS)
Traditional training case studies and lectures
Students anxiety levels and Self-efficacy skillsReview aim and objective The aim of this review is to evaluate the overall impact of HFPS on students anxiety and self-efficacy outcomes of learning in undergraduate nursing students. The specific objectives of the review are:To identify the best available evidence about the effects of HFPS on students anxiety and self-efficacy in undergraduate nursing students.
To evaluate the potential for future curricular development using simulation particularly HFPS as learning strategies in undergraduate nursing education programmes in Saudi Arabia.Methodology The method of this project was chosen as a systematic review because of the need to assess the effectiveness impact feasibility and appropriateness of HFPS interventions on nursing students. Systematic review is a strategy used to reduce bias and random errors (Cook Sackett and Spitzer 1995). Other approaches are more prone to include only research selected by the authors thereby introducing bias. Systematic reviews are work-heightened and require expertise in the subject and review systems.Criteria for considering studies for this reviewEligibility criteria are detailed in accordance with PICOS (Participant Intervention Controls Outcome and Studies).Type of participants This review component will consider quantitative studies that have enrolled undergraduate nursing students with different race and ethnicity who are specialized in different cases with paediatric adult and maternity patients and in special care such as critical emergency and intensive care unit. The setting includes nursing schools and hospitals that include HFPS. As such studies that enrolled graduate and post-graduate student nurses will not be considered for the review.Type of intervention The proposed systematic review will consider quantitative studies that evaluate the cognitive effectiveness or value of HFPS for adult and paediatric manikins compared to the traditional tinning case studies and lectures. Studies that use other technological intervention such as medium- or low-fidelity simulation will not be considered for the review.Type of outcome measures This component of the review will consider only studies that assess anxiety levels self-efficacy and self-confidence as the primary outcome measures of the cognitive value of HFPS. However to be included studies must have assessed anxiety and self-efficacy scores using the following validated psychometric instrument. The State-Trait Anxiety Inventory (STAI) is a tool that has been declared appropriate for assessing present state anxiety with respect to questionnaire items for instance S-Anxiety; State Anxiety Scale which evaluate the subjective feelings of tension uneasiness worry nervousness as well as automatic nervous system stimulation. The STAI also measures the stability aspects of anxiety susceptibility and based on separable questionnaire items (Trait Anxiety Scale; T-Anxiety) it measures states of calmness self- confidence and security (Julian 2011; Megel Black Clark et al. 2012). Student self-efficacy self-confidence as well as satisfaction in learning is also assessed.Type of studies This review component will consider evidence from comparative and evaluation studies that evaluate the effectiveness or the impact of HFPS on the self-efficacy (self-confidence) and level of anxiety in undergraduate student nurses entering nursing clinical practice. Moreover it aims to demonstrate a causal association between HFPS and anxiety level and self-efficacy. This review takes a quantitative approach as this will allow measurement of student nurse anxiety levels and self-efficacy before and after using the HFPS learning concept. Therefore randomized controlled trials (RCTs) quantitative pre- and post-test non-random assignment quasi-experimental mixed methods and single-test designs will be considered for the review though the robustness of the non-RCT designs may be open to question (Harris McGregor Perencevich et al. 2006). While the non-RCT and quasi-randomised trials are susceptible to group allocation bias they are suitable for this type of study in which setting up a control arm is not possible due to high probability of cross-contamination of the study groups. In absence of experimental studies observational study design will be included. Nonexperimental studies for example qualitative descriptive papers such as plain reviews opinion papers and commentaries will not be sought.Search strategy to identification of studies To minimize publication bias that is inherent in various electronic bibliographic databases this review devised a comprehensive search strategy for the identification of published and unpublished studies or papers.Prime electronic literature searches The list below highlights five Evidence Based-Medicine (EBM) electronic databases for bibliographic materials and search engines that will be accessed online:Medical Literature Analysis and Retrieval System Online (Medlinevia PubMed)
Excerpta Medica databaseEMBASE
Cumulative Index to Nursing & Allied Health LiteratureCINAHL
American Psychological Associations PsycINFO.
the Cochrane Central Register of Controlled Trials (CENTRALthe Cochrane Library)Suitable index terms and key text words describing the target studies articles will be first search will be done in English language on MEDLINE through PubMed and CINAHL from the beginning until the 8th of January 2016. This will be attained through an analysis of the words used in the title abstracts and key terms. This will be achieved by an analysis of the text words contained in the title and abstracts as well as the index terms (Medical Subject HeadingsMeSH terms for MEDLINE) used to describe the aims of the target studies PICO (Participant Intervention Comparison and Outcome) questions. As such the electronic searches in the above five EBM resource databases will be based on the multi-strand approach which involves combining text words and index terms for each PICO definition using Boolean operators (AND OR & NOT). The preliminary keywords and MeSH terms identified in PubMed are listed in Table 1 below and its corresponding search strategy is shown in Appendix 1.
Table 1: The key/text words and MeSH terms identified for PubMedPICO definition
Key/text words
PubMed MeSH termsPopulation
Student nurse student midwifes undergraduate nurses undergraduate nursing nurses roles baccalaureate nursing students
Preregistration nurse midwifery students nursing/psychology education medical undergraduate education nursing baccalaureate/methods anxiety/psychology anxiety/prevention & control fear/psychologyIntervention (new)
high fidelity simulation hi fidelity simulation Hi-Fi simulation high fidelity patient simulation
Computer-assisted instruction/methods patient simulation manikins simulation learningComparator intervention (routine or standard)
Lecture-based learning case-based discussion Clinical clerkship programmerOutcome
anxiety score anxiety levels self-efficacy
Anxiety score self-efficacy personal satisfaction clinical competence psychometrics
Although the electronic searches will be performed in English the returned hits will not be narrowed to citations published only in the English language. However relevant studies and reports that will be excluded because of language ineligibility will be reported.Supplemental literature searchesThe primary electronic search strategies in the selected EBM resource databases may not be adequately sensitive to capture all relevant published studies. Supplemental electronic searches for unpublished papers will be performed in the following electronic databases using a simple search strategy high-fidelity patient simulation AND anxiety or self-efficacy:OpenGrey
BASE the Bielefeld Academic Search Engine
JBI/University of Adelaide databasesThe reference lists or bibliographies of full-text records of the identified studies will be hand-searched manually for additional relevant studies. The searches will be updated to capture the most recent literature.Screening for citations and studies selectionSelections of studies from the primary online search strategies of literature will be informed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart by Moher Liberati Tetzalff et al. (2009). (See Appendix 2). The returned search hits from individual EBM resource databases will be screened manually by two independent reviewers (R1 and R2) for inclusion and exclusion based titles. At this stage irrelevant citations and duplicates will be excluded. Additional screening of the potentially important sources which will be remaining will be conducted based on abstracts where the entire paper records of potentially significant researches will be retrieved for decisive eligibility assessment with regard to the consistency of target PICO elements as well as methodologies. Resolution of any disagreements developing between reviewers on the basis of inclusion and/or criteria will arrived at via a mutual discussion or through involvement of a third reviewer.Review methods Critical appraisal Appraisal of consistency and robustness of methodologies will be conducted using Critical Appraisal Quality checklist which is aimed at evaluating the validity of research and determinations of origin of biases. The Joanna Briggs Institute (2014) Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (see Appendix 3) will be used for appraisal of randomized controlled trials and quasi-experiments. The design of the studies will be checked and the explanations given in each step evaluated for the level of methodological thoroughness of the data as well as adopted statistical analyses. Additionally just as stated above any disagreements developing between reviewers will be resolved via involvement of a third review or through a mutual discussion.Data Extraction Extraction of quantitative data will be done from appropriate studies via standardized tools of extraction from the Joanna Briggs InstituteData Extraction Form for Experimental and Observational Studies. (See appendix 4). Data derived from experiments will include specific details like name of author publication year design of study and country size of sample participant attributes intervention details measurements and outcomes. The instrument is used in minimization of risk of error during data extraction as well as making sure the same idea is captured for every study that is included. Again any disagreements developing between reviewers will be resolved via involvement of a third review or through a mutual discussion.Assessment of risk bias in included studies Assessment of the quality of the studies regarding their methodologies will be done by the first and second reviewer via the Cochrane Collaborations domain-based instrument for bias risk assessment (Higgins and Green 2006). Elements assessed include allocation cover up personnel and participant blinding examination of results blinding partial result data and selective reporting of results.Measure of impact of intervention The expression of the intervention effect will be in the form of relative risk with 95% confidence intervals (CI) where there will be availability of dichotomous data lake HFPS exposure. On the other hand where continuous data like self-efficacy anxiety score and satisfaction levels among students will be available the effect size will be approximated through calculating the standardized difference between means at 95% CI.Heterogeneity assessment Assessment of heterogeneity will be done statistically via I2given by Higgins and Green (2006) which highlights that the proportion of total variation across studies is a consequence of heterogeneity in stead of chance. A meta-analysis would not be carried out if the is increased heterogeneity levels.Data synthesis This review takes a quantitative approach therefore synthesizes quantitative psychometrics data related to anxiety self-efficacy self-confidence as well as satisfaction in student learning using the innovative HFPS learning concept. As such where meta-analysis is possible the quantitative psychometrics data will be pooled using means. This will involve calculating the average anxiety scores from each paper. Where statistical pooling is not possible the findings will be narrative which could be a structure summary and discussion for the studies characteristics and findings including tables and figures to aid in data presentation when appropriate.Conflicts of interest There is no conflict of interest to declare in this study.Acknowledgments I would like to thank my supervisor for his guidance and support me to produce this piece of work.
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Appendices
Appendix 1: Search strategy for Medline via PubMedSearch attemptSearch string
hits
Time#21
Add
Search (((((computer assisted instruction/methods[MeSH Terms]) AND patient simulations[Text Word]) OR patient simulation[MeSH Terms]) OR manikins[MeSH Terms])) AND (high fidelity simulation[Text Word]) OR hi fidelity simulation[Text Word]) OR high fidelity patient simulation[Text Word])) AND manikins[MeSH Terms]))) AND ((((((student nurse[Text Word]) OR undergraduate nurses[Text Word]) OR midwifery students[Text Word]) OR baccalaureate nursing students)) OR (((((students nursing/psychology[MeSH Terms]) OR anxiety/psychology[MeSH Terms]) OR fear/psychology[MeSH Terms]) OR students nursing/psychology[MeSH Terms]) OR (anxiety/prevention and control[MeSH Terms]))))
13
9:13:24#20
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Search ((((((student nurse[Text Word]) OR undergraduate nurses[Text Word]) OR midwifery students[Text Word]) OR baccalaureate nursing students)) OR (((((students nursing/psychology[MeSH Terms]) OR anxiety/psychology[MeSH Terms]) OR fear/psychology[MeSH Terms]) OR students nursing/psychology[MeSH Terms]) OR (anxiety/prevention and control[MeSH Terms])))
36645
9:13:06#19
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Search (((computer assisted instruction/methods[MeSH Terms]) AND patient simulations[Text Word]) OR patient simulation[MeSH Terms]) OR manikins[MeSH Terms])) AND (high fidelity simulation[Text Word]) OR hi fidelity simulation[Text Word]) OR high fidelity patient simulation[Text Word])) AND manikins[MeSH Terms]))
128
9:12:51#18
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Search ((((((((computer assisted instruction/methods[MeSH Terms]) AND patient simulations[Text Word]) OR patient simulation[MeSH Terms]) AND manikins[MeSH Terms])) OR (((high fidelity simulation[Text Word]) OR hi fidelity simulation[Text Word]) OR high fidelity patient simulation[Text Word]))) AND ((((((student nurse[Text Word]) OR undergraduate nurses[Text Word]) OR midwifery students[Text Word]) OR baccalaureate nursing students)) AND (((((students nursing/psychology[MeSH Terms]) OR anxiety/psychology[MeSH Terms]) OR fear/psychology[MeSH Terms]) OR students nursing/psychology[MeSH Terms]) OR (anxiety/prevention and control[MeSH Terms]))))
4
9:12:37#17
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Search ((((((student nurse[Text Word]) OR undergraduate nurses[Text Word]) OR midwifery students[Text Word]) OR baccalaureate nursing students)) AND (((((students nursing/psychology[MeSH Terms]) OR anxiety/psychology[MeSH Terms]) OR fear/psychology[MeSH Terms]) OR students nursing/psychology[MeSH Terms]) OR (anxiety/prevention and control[MeSH Terms])))
631
9:12:23#16
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Search ((((((computer assisted instruction/methods[MeSH Terms]) AND patient simulations[Text Word]) OR patient simulation[MeSH Terms]) AND manikins[MeSH Terms])) OR (((high fidelity simulation[Text Word]) OR hi fidelity simulation[Text Word]) OR high fidelity patient simulation[Text Word]))
809
9:12:05#15
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Search ((((((((students nursing/psychology[MeSH Terms]) OR anxiety/psychology[MeSH Terms]) OR fear/psychology[MeSH Terms]) OR students nursing/psychology[MeSH Terms]) OR (anxiety/prevention and control[MeSH Terms]))) AND ((((computer assisted instruction/methods[MeSH Terms]) AND patient simulations[Text Word]) OR patient simulation[MeSH Terms]) AND manikins[MeSH Terms])) AND (((high fidelity simulation[Text Word]) OR hi fidelity simulation[Text Word]) OR high fidelity patient simulation[Text Word]))
1
9:11:36#13
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Search (((((((((((student nurse[Text Word]) OR undergraduate nurses[Text Word]) OR pre-register student nurse[Text Word]) OR baccalaureate nursing students[Text Word]) AND computer assisted instruction/methods[MeSH Terms]) AND patient simulations[Text Word]) OR patient simulations[MeSH Terms]) AND manikins[MeSH Terms]) AND high fidelity simulation[Text Word]) OR hi fidelity simulation[Text Word]) OR high fidelity patient simulation[Text Word]) AND manikins[MeSH Terms] 0
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