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The effects of training with simulation on knowledge, skill and anxiety levels of the nursing students in terms of cardiac auscultation: A randomized controlled study
Nurse Education Today 84 (2020) 104216
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The effects of training with simulation on knowledge, skill and anxiety levels of the nursing students in terms of cardiac auscultation: A randomized controlled study
T
Birgul Vural Doğrua, , Leyla Zengin Aydınb ⁎
a b
Mersin University, Faculty of Nursing, Department of Medical Nursing, 33110 Mersin, Turkey Dicle University, Department of Nursing, 21280 Diyarbakır, Turkey
ARTICLE INFO
ABSTRACT
Keywords: Cardiac auscultation High-fidelity simulator Nursing education Nursing student Traditional teaching method
Background: The use of simulation methods in nursing education is important in terms of decreasing anxiety of students in a safe and realistic environment due to the improvement of knowledge and skills of students in terms of cardiac auscultation and their attitudes to prepare for clinical applications. Objectives: The aim of this study is to compare the effectiveness of high-fidelity simulator and traditional teaching method on nursing students' knowledge and skill development in terms of cardiac auscultation and their anxiety levels. Design: Randomized controlled study. Setting: The study was conducted in the simulation laboratory of the Nursing Department in the Health College and in the inpatient clinics of the Medicine Faculty Hospital. Participants: 72 first-year nursing students (simulation group = 36, control group = 36). Methods: The students were randomly distributed to the simulation and control groups. The students in the simulation group received a cardiac auscultation training by using a high-fidelity simulator while the students in the control group received training with the traditional teaching method. After the training sessions, all students practiced their skills in the laboratory and on real patients in clinical setting under the supervision of the researcher. The data were collected by using the Demographic Information Form, Knowledge Assessment Form for Cardiac Auscultation, Skill Evaluation Form for Cardiac Auscultation and State Anxiety Inventory (SAI). Results: High-fidelity simulators and traditional teaching method were found to be effective in increasing the students' knowledge and skill levels in terms of cardiac auscultation. However, it was found that the high-fidelity simulator method was more effective than the traditional teaching method to increase the students' knowledge (p = 0.001) and skill (p < 0.001) levels; this increase was significant. In addition, it was found that the students in the high-fidelity simulator group showed a significant decrease in anxiety scores compared to the students who were trained with traditional education method (p < 0.001). Conclusions: The results showed that the use of high-fidelity simulator in nursing education was more effective than traditional method in terms of improving the students' knowledge, skill levels for cardiac auscultation and reducing their anxiety.
1. Introduction Nursing students need to gain knowledge, skills and attitudinal behavior to prepare for clinical practice (Chen et al., 2015). In the traditional nursing education, the education is implemented in the form of psychomotor skills, the use of demonstration method in theoretical education, applications on manikins and models in laboratory and application of skills for real patients in clinical environment (Tuzer et al.,
⁎
2016). However, students may experience stress and anxiety due to lack of experience, lack of familiarity with complex and advanced technological tools and equipment, increased awareness of medical errors and fear of making mistakes in clinical applications (Cobbett and SnelgroveClarke, 2016; Ross and Carney, 2017; Tuzer et al., 2016). In addition, inadequate number of clinical trainers, work overload of nurses and fear of taking responsibility of students may lead to inadequate clinical education for students (Karadağ et al., 2015; Tuzer
Corresponding author at: Mersin University, Faculty of Nursing, Department of Medical Nursing, Ciftlikkoy Campus, Yenişehir, 33110 Mersin, Turkey. E-mail address: [email protected] (B. Vural Doğru).
https://doi.org/10.1016/j.nedt.2019.104216 Received 10 April 2019; Received in revised form 12 July 2019; Accepted 14 September 2019 0260-6917/ © 2019 Elsevier Ltd. All rights reserved.
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et al., 2016). Therefore, students complete their education with real patients in the traditional method and this situation increases the risk of making mistakes towards patients (Burton and Hope, 2018). For this reason, it has been suggested that establishing laboratory environments with technical equipments and hardwares in which students can experience patient care before they start clinical applications and communicate well with patients and using interactive methods including technological advancements that enable students to participate actively (Eyikara and Baykara, 2018; Pittman, 2012). The simulation, one of these methods, is a system that provides interactive and effective individualized learning opportunities in which whole or a part of an event, activity or a clinical experience are replicated by the reproduction of them (Burton and Hope, 2018; Coyne et al., 2018). Simulation provides an environment which is suitable for putting the skills into practice by students and the learning process (Coyne et al., 2018). This is achieved without risk for real patients (Burton and Hope, 2018). Students have the chance to detect and correct their mistakes by repeated application during simulation (Pittman, 2012). Simulation is also used to improve students' critical thinking, problem solving and decision-making skills as well as teaching psychomotor skills (Pittman, 2012). For this reason, simulation has been used in many different areas such as vital signs, drug administration, crisis management, and palliative care to facilitate the students to acquire the necessary knowledge and skills. (Aqel and Ahmad, 2014; Chen et al., 2015; Eyikara and Baykara, 2018; Hdaib et al., 2015; MacLean et al., 2017; Smith et al., 2018; Tuzer et al., 2016).
of students' knowledge, skills and attitudes (Aqel and Ahmad, 2014; Cant and Cooper, 2017; Chen et al., 2015; Eyikara and Baykara, 2018; Hdaib et al., 2015; MacLean et al., 2017; Shin et al., 2015; Smith et al., 2018). However, a limited number of studies have been conducted evaluating the effect of high-fidelity simulator and traditional teaching method (Static manicin) on nursing students' knowledge, skill and anxiety levels on cardiac auscultation (Chen et al., 2015; Tuzer et al., 2016). In this context, the study will contribute to the literature. This study was undertaken to answer the following research questions: 1) Is there a difference between the use of high-fidelity simulator or the traditional teaching method in terms of improving the knowledge level of the students about cardiac auscultation? 2) Is there a difference between the use of high-fidelity simulator or traditional teaching method in the development of students' cardiac auscultation skills on a real patient in a clinical setting? 3) Is there a difference between the use of a high-fidelity simulator or traditional teaching method in reducing the anxiety levels of students regarding cardiac auscultation on the real patient in the clinical setting? 2. Methods 2.1. Study design and participants A randomization controlled trial study design was used. The study population comprised 90 students enrolled for the first year at the Nursing Department, School of Health, in a University, Diyarbakır, Turkey, in the 2017–2018 academic year. The study was conducted between April to June 2018. The inclusion criteria were as follows: to have no previous received a cardiac auscultation or auscultation skills training, to have no clinical experience and to accept voluntary participation in the study. The exclusion criteria were students who withdrew from the Fundamentals of Nursing Practicum course or dropped out of school. Seventy-six students met the inclusion criteria, but four students refused to participate. 72 students were divided into 3 groups according to their school success levels which were considered to affect their knowledge and skill scores. The students were randomly distributed into the simulation (36 students) and control (36 students) groups (Fig. 1). The students in the Simulation group were trained with highfidelity simulator in the simulation laboratory while the students in the control group were trained with ‘traditional teaching method’ in the occupational skill laboratory.
1.1. Background Although the task scope of nurses does not include clinical diagnosis, identifying physical findings and reporting these findings to a professional team by nurses are important for patient evaluation and management (Chen et al., 2015). Physical examination skills are one of the basic elements of nursing care used in the evaluation of health (Tuzer et al., 2016). Cardiac evaluation and auscultation skills constitute a part of these basic skills (Chen et al., 2015). These skills play an important role in collecting objective data to identify patients' problems and to take into account their needs. Therefore, it helps to improve the quality of nursing care while helping to make right nursing diagnoses (Tuzer et al., 2016). However, it is known that some systems such as cardiac system require more attention when the general deficiencies and inadequacies of students in these skills are taken into account (Chen et al., 2015). All cardiac auscultation sounds, especially abnormal voices, are not always available in encountering a routine patient, therefore there are limited opportunities for experiencing the normal and abnormal cardiac findings and sounds. For this reason, a number of technological methods such as simulation are used to facilitate students acquiring the necessary knowledge and skills (Butter et al., 2010; Chen et al., 2015; McKinney et al., 2013). Low, medium and high quality simulators and simulation techniques containing standard patients can be applied to teach different clinical concepts (Pittman, 2012; Shin et al., 2015). High-fidelity simulators are one of the methods used to teach more complex critical events to students in a safe and realistic environment (Pittman, 2012). By using this method, it has been stated that students can intervene in acute clinical situations in scenarios by managing time; they have positive learning experience and participate more actively in team work (Aqel and Ahmad, 2014; McCaughey and Traynor, 2010). It has been reported that simulation provides a realistic environment for students to improve their cognitive, affective and psychomotor skills, to make fewer medical errors and to ensure patient safety (Cant and Cooper, 2017; McCaughey and Traynor, 2010; Neill and Wotton, 2011). Accordingly, it is ensured that students' self-confidence in clinical practice increases, their anxiety is reduced and they are more willing to practice (Chuang et al., 2018; Eyikara and Baykara, 2018). In several studies, it has been stated that the use of high-fidelity simulators in nursing education has positive effects on the development
2.2. Measuring tools The data were collected by using the Demographic Information Form, Knowledge Evaluation Form for Cardiac Auscultation, Skill Evaluation Form for Cardiac Auscultation while the State Anxiety Inventory (SAI) was used to determine the students' anxiety levels. The demographic information form contained six questions on the sociodemographic characteristics of the students, such as academic achievement status, age and gender (Lewis et al., 2016; Seidel et al., 2010; Butter et al., 2010; Bremner et al., 2006). The Knowledge Evaluation Form for Cardiac Auscultation and Skill Evaluation Form of Cardiac Auscultation were prepared by the researchers in order to determine the students' knowledge level and application skills in terms of cardiac auscultation (Lewis et al., 2016; Seidel et al., 2010; Butter et al., 2010; Bremner et al., 2006). In order to ensure the content validity of the data collection forms before the application, both forms were evaluated by 3 lecturers who were experts in the subject and necessary arrangements were made depending on the expert recommendations. In the evaluation made by both forms, the level of knowledge and skill of the students about cardiac auscultation increase when their scores on the whole test increase. 2
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Fig. 1. Study flow diagram.
Knowledge Evaluation Form for Cardiac Auscultation: The form consisted of 11 multiple-choice questions about subjects of cardiac auscultation. The lowest score from the test was 0 while the highest score from the test was 100. In the evaluation, the level of knowledge about cardiac auscultation increase when the scores obtained from the whole test increase. Skill Evaluation Form for Cardiac Auscultation: It consisted of 18 items containing the steps of application of cardiac auscultation. Psychomotor steps of the students who received training in simulation and occupational skills laboratories were evaluated with check lists. The evaluation was made by marking the correct/complete (2 points), incomplete/incorrect (1 point), not observed (0 points) choices after each step of a student' application. The highest score from the test was 36 and the lowest score from the test was 0. To assess skill levels, students in the simulation and control groups completed the Objective Structural Clinical Assessment (OSCE). At the evaluation stage, the same scenario
was given to the students in the simulation and control groups. The students were asked to read the scenario and complete the Objective Structural Clinical Assessment (OSCE). This consisted of two stations, Cardiac Auscultation preparation examination station (OSCE 1), Cardiac Auscultation assessment examination station (OSCE 2). These were used to evaluate students' cardiac auscultation skills on high-fidelity simulator and static manicin. OSCE 1 consisted of 7 items including preparation of hands, such as washing hands, giving information and position to the patient. OSCE 2 consisted of 11 items, including the identification, listening and evaluation of heart foci, listening and evaluation normal and additional heart sounds. The students were scored separately by two instructors who were experienced in simulation applications and were not involved in the application stage and then agreed a score. State Anxiety Inventory (SAI): This inventory, developed by Oner and Le Compte (1983), consists of 20 questions. It can be applied to individuals over 14 years of age (11). The validity and reliability tests of 3
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SAI in Turkey were conducted by Oner and Le Compte (1983). This scale is a 4-point Likert type scale ranging from “None” to “Completely”. SAI is a highly sensitive tool for evaluating sudden changes in emotive reactions. The total score obtained from the scale varies between 20 and 80. Cronbach's Alpha reliability coefficient of the State Anxiety Inventory was found to be between 0.94 and 0.96. The testretest reliability coefficient was found to be between 0.26 and 0.68 for various applications (11). A higher score indicates a high level of anxiety while a low score indicates a low level of anxiety.
2.5. Data analysis Data were analyzed using the Statistical Package for Social Science 22.0 (SPSS, IBM Corp., Armonk, NY, USA). Shapiro-Wilk test was performed to examine the normal distribution similarity. Independent ttests and Chi-squared tests were conducted to examine demographic differences between the two groups. The Mann Whitney-U and Wilcoxon signed-rank tests were employed for variables that were not normally distributed for comparison between the experimental and the control groups. The results were evaluated at a 95% level of reliability and p < 0.05 was evaluated as statistically significant.
2.3. Data collection procedures Cardiac auscultation were taught to students by the researcher using lecturing methods via a PowerPoint® presentation and videos. The students were informed about the listening focuses of the heart sounds and the normal and additional heart sounds. After the 2 h long theoretical presentation of Cardiac auscultation, the Demographic Information Form and Knowledge Evaluation Form for Cardiac Auscultation (pre-test) were applied to the all participant students. Then students were divided into the simulation and control groups by randomization method. It was demonstrated to the students in the simulation group by using the high-fidelity simulator according to the practice instruction in the simulation laboratory while It was demonstrated to the students in the control group by using the static manikin in the skill laboratory. The simulation system was introduced to the students in the Simulation group and information was given on how to do the application. The students in the Simulation group were asked to perform auscultation on the simulator. The students in the control group were allowed to practice on static manikin with the instructor at least once. The questions of the students in both groups were answered after they repeated the application; if necessary, they had the opportunity to apply again. After the application under the supervision of the instructor, the students had free working hours. When the students stated that they were ready by feeling comfortable and secure, the study was terminated. An informing session was performed for the students in both groups to recognize their mistakes; their questions were answered, if they had any questions. In the evaluation stage, the same scenario was used for the static manikin and high-fidelity simulator. After the application step, each student in the control group performed the application of cardiac auscultation on the static manic while each student in the simulation group performed the application of cardiac auscultation on the high-fidelity simulator. Meanwhile, the students in both the control and simulation groups were observed by two instructors who were was experienced in simulation applications and not involved in the application step. The instructors recorded the performances for each student in the Skill Evaluation Form for Cardiac Auscultation (Pre-test). All students were asked to complete the SAI to evaluate their anxiety level related to cardiac auscultation (Pre-test). The students were asked to complete the Knowledge Evaluation Form for Cardiac Auscultation as a final test (Post-test). Two weeks after the laboratory application, the students in both groups performed cardiac auscultation on the real patients and they were evaluated by the same instructors (Observing in laboratory stage) by using the Skill Evaluation Form for Cardiac Auscultation (post-test). The students in both study groups were asked to fill the SAI after performing cardiac auscultation on the real patient (post-test). A flow diagram is presented in Fig. 1.
3. Results 3.1. Samples and characteristics of students The average age of the students was 19.95 ± 1.77 years. Of a total of 72 students, 46 were females (63.9%) and 26 were males (36.1). The majority lived with their family (75%), 42 have voluntarily chosen nursing profession (58.3%) and 45 have no computers (62.5%). There were no statistical differences between the demographic characteristics of the groups at the baseline (Table 1). 3.2. Knowledge and skill scores of cardiac auscultation There was no significant difference between the simulation and control groups in terms of the pre-test median scores of cardiac auscultation knowledge (z = −1.603, p = 0.109) and skill (z = −0.643, p = 0.520). The post median scores of the students in the simulation group for cardiac auscultation knowledge (z = −3.307, p = 0.001) and skill (z = −7.102, p = 0.001) were determined as higher than those in the control group; the difference between the groups was statistically significant. However, the post-test median scores of the students in the simulation and control groups for cardiac auscultation knowledge and skill were found to be significantly higher than their pre-test median scores (p < 0.001) (Table 2, Table 3). 3.3. Anxiety in cardiac auscultation There was no significant difference between the median pre-test cardiac auscultation anxiety scores of the students in the simulation and control groups (z = −0.660, p = 0.509). The median post-test cardiac auscultation anxiety score of the students in the Simulation group was lower compared to those of the students in the control group; the difference between the groups was statistically significant (z = −7.149, p < 0.001). In the intragroup measurements, the median post-test cardiac auscultation anxiety score of the students in the control group was significantly lower than the median pre-test cardiac auscultation anxiety score of them (p < 0.001), but no significant difference was found between the median pre- and post-test scores of the students in the control group (Table 4). 4. Discussion The National Council of State Boards of Nursing (NCSBN) suggests that learning by using simulation depends on high-quality simulation (Hayden et al., 2014). It has been stated that the use of high-fidelity simulators in nursing education increases the self-esteem and satisfaction, including effective learning and knowledge; it also brings students a critical perspective (Cant and Cooper, 2017; Karadağ et al., 2015; Luo and Petrini, 2018; Neill and Wotton, 2011). The aim of this study is to compare the effectiveness of simulation and traditional education method in determining and listening heart foci, and in gaining basic skills and knowledge for listening to normal and additional heart sounds. Another objective is to determine the effectiveness of simulation in the application of cardiac auscultation skills on real patients and on students' anxiety in the clinical setting.
2.4. Ethical considerations Ethical approval was obtained from the Mardin Artuklu University Ethical Committee (No: 2018/1-9). Written permission was attained from the Health School where the study was conducted. Students were informed of the aims of the study via the researchers and their verbal consents and written permission were acquired. All students were informed that their participation was voluntary, and they were free to withdraw at any time without affecting their learning or academic grade. 4
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Table 1 Demographic characteristics of students at the baseline (N = 72). Variable Academic achievement status Successful (> 76) Normal (70–76) Unsuccessful (< 70) Gender Female Male Living status With family Other Conditions for choosing nursing as a profession Voluntary Involuntary Having a computer Yes No Age (years)
x2
p
0.000
1.000
22 (61.1) 14 (38.9)
0.241
0.806
24 (66.7) 12 (33.3)
30 (83.3) 6 (16.7)
2.667
0.425
42 (58.3) 30 (41.7)
18 (50.0) 18 (50.0)
24 (66.7) 12 (33.3)
2.057
0.232
27 (37.5) 45 (62.5) X = 19.95 ± 1.77
10 (27.8) 26 (72.2) X = 19.69 ± 1.23
17 (47.2) 19 (52.8) X = 20.22 ± 2.17
2.904
0.144
Total (N = 72) n (%)
Simulation group n (%)
Control group n (%)
24 (33.3) 24 (33.3) 24 (33.3)
12 (33.3) 12 (33.3) 12 (33.3)
12 (33.3) 12 (33.3) 12 (33.3)
46 (63.9) 26 (36.1)
24 (66.7) 12 (33.3)
54 (75.0) 18 (25.0)
t
−1.263
0.211
Table 2 Comparison of cardiac auscultation knowledge scores of pre- and post-test (N = 72) Knowledge
Pre test Post test Pre- and post-test comparison of group
Simulation group
Control group
X (min ± max)
X (min ± max)
za
p
64.00 (8.00 ± 100.00) 92.00 (62.00 ± 100.00) Zb = −5.220 p < 0.001
69 (28.00 ± 92.00) 83.00(36.00 ± 100.00) Zb = −3.689 p < 0.001
−1.603 −3.307
0.109 0.001
X = Median. a Mann Whitney U test z value. b Wilcoxon test Z value.
Table 3 Comparison of cardiac auscultation skill scores of pre- and post-test (N = 72). Skill
Pre test Post test Pre- and post-test comparison of group
Simulation group
Control group
X (min ± max)
X (min ± max)
za
14.00 (0.00 ± 18.00) 25.00 (22.00 ± 27.00) Zb = −5.239 p < 0.001
13.50 (5.00 ± 32.00) 17.00 (9.00 ± 24.00) Zb = −4.242 p < 0.001
−0.643
0.520
−7.102
< 0.001
Table 4 Comparison of pre- and post-test anxiety scores for cardiac auscultation (N = 72). Anxiety
p
Pre test Post test Pre- and post-test comparison of group
X = Median. a Mann Whitney U test z value. b Wilcoxon test Z value.
Simulation group
Control group
X min ± max)
X min ± max)
za
p
40.50 (22.00 ± 74.00) 32.00 (20.00 ± 40.00) Zb = −5.089 p < 0.001
41.00 (32.00 ± 80.00) 44.00 (35.00 ± 52.00) Zb = −0.513 0.608
−0.660
0.509
−7.149
< 0.001
X = Median. a Mann Whitney U test z value. b Wilcoxon test Z value.
In our study, both high-fidelity simulators and traditional teaching method have been found to be effective in increasing the knowledge and skill levels of the nursing students on heart auscultation (p < 0.001, Tables 2, 3). However, the high-fidelity simulator method was found to be significantly more effective than the traditional teaching method (laboratory study) in increasing the students' knowledge and skill levels (p = 0.001, Table 2; p < 0.001, Table 3). In the literature, there was a limited number of studies evaluating the effects of high-fidelity simulator and traditional teaching method on the knowledge and skill levels of nursing students on heart auscultation (Tuzer et al., 2016; Chen et al., 2015). However, there are many studies evaluating the effects of highrealistic simulators and different training methods on the development of nursing students' knowledge, skills and attitudes (Aqel and Ahmad, 2014; Cant and Cooper, 2017; Eyikara and Baykara, 2018; Hdaib et al., 2015; MacLean et al., 2017; Shin et al., 2015; Smith et al., 2018). This showed the authenticity of our study. In contrast to our study, the use of
standardized patients by Tuzer et al. (2016) was found to be more effective than the high-fidelity simulator to increase the scores of nursing students for thoracic-pulmonary and cardiac examination knowledge, but the skill scores were found to be similar. It was stated that the lower knowledge scores of the students in the high-fidelity simulator group might be related to the lack of realism, interaction and getting feedback (Tuzer et al., 2016). Chen et al. (2015) determined that the cardiac, respiratory auscultation and physical examination skill scores of the students in the low-fidelity simulation group were higher than those of the students in the high-fidelity simulation group in all measurements, but there was no significant difference between the two methods. Therefore, it has been stated that very complex learning environments may cause ineffective learning of students by increasing extraneous cognitive load (Chen et al., 2015). In some studies conducted with the medical students, it was reported that simulation-based education was effective in developing the students' 5
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knowledge and skills in terms of cardiac auscultation similar to our study (Butter et al., 2010; McKinney et al., 2013). In other studies, the nursing students trained with the high-fidelity simulator were found to perform better in information-based assessments related to cardio-pulmonary resuscitation, vital signs and end-of-life care (Aqel and Ahmad, 2014; Eyikara and Baykara, 2018; Tamaki et al., 2019). In our study, it has thought that planned and repetitive applications made by direct contact with the high-fidelity simulator are due to the fact that the students are more equipped and effective in gaining the knowledge and skills of cardiac auscultation by increasing their confidence and experiences. It has been also considered to be important to identify and correct errors and more importantly, give feedback to students on their performance. Two of the strengths of our study is that the skills learned through the simulation can be put into real clinical practice and the students' skill scores increased significantly in the clinical practices on real patients compared to the students who were trained by using the traditional teaching method (Post-test; p < 0.001, Table 3). Similarly, Eyikara and Baykara (2018) showed that the students in the simulation group had significantly higher skills to measure vital signs of healthy adults and real patients compared to the students who were trained by using the traditional teaching method. Tuzer et al. (2016) stated that the training with standardized patient and high-fidelity simulator method significantly increased the skill scores of the students in the evaluation made on the real patients, but there was no significant difference between the groups. Ross (2015) stated that the IM injection skills of the students in the simulation group were higher compared to the students in the traditional method group; but this difference was not significant. Although these findings were not significant in these two studies, these findings supported that simulation is an effective teaching method to develop psychomotor skills (Ross, 2015; Tuzer et al., 2016). It is thought that the low level of cardiac auscultation skill scores in the practice performed on the real patient in the clinical setting of the group who were educated with traditional teaching method was caused by the fact that the students could not benefit from simulated heart sounds in the laboratory, could not communicate and could not be interactive. Another important finding of this study was that the students in the high-fidelity simulator group had significantly reduced cardiac auscultation anxiety score in the clinical applications on the real patients compared to the students in the traditional training method group (Posttest; p < 0.001, Table 4). In the literature, it has been stated that entering the clinical setting for the first time, fear of making mistakes, using skills on real patients, interacting with health professionals, feeling insufficient and evaluating by instructors cause significant anxiety in students (Cobbett and Snelgrove-Clarke, 2016; Ross and Carney, 2017; Szpak and Kameg, 2013). It has been stated that decreasing students' anxiety helps to improve the therapeutic relationship between nurses and patients and care outcomes (Ross and Carney, 2017; Szpak and Kameg, 2013). In our study, it was found that the students who trained with the traditional education method had an increase in their level of cardiac auscultation anxiety in the clinical application on the real patients while the students who were trained with the simulation had a decreased level of cardiac auscultation anxiety in the clinical application on the real patients. Similarly, Khalaila (2014) determined that the training with the simulation decreased the nursing students' anxiety levels and increased their self-confidence, care ability and satisfaction in the first clinical application. Szpak and Kameg (2013) found that nursing students receiving high-fidelity simulator training before starting clinical practice and communicating with mentally ill individuals, had reduced anxiety levels. In our study, it has been suggested that the decreased anxiety levels of the students were as the result of increasing knowledge, skills and self-confidence after receiving training with the simulation.
the study is that the results cannot be generalized to all undergraduate nursing students in Turkey because the results of the study were from one university. The reason is that some nursing departments in other universities had simulation laboratories while some of them did not have simulation laboratories and applied different training methods. It has been recommended that our study should be carried out as a multicentered study in different universities with a larger sample size. In addition, new evidence-based studies comparing the effectiveness of different simulation and training methods are needed for the development of clinical knowledge and skills of nursing students. 6. Conclusion The knowledge level of nursing students on cardiac auscultation in the high-fidelity simulator group showed a significant improvement compared to the students trained with traditional method. It was observed that the training with high-fidelity simulator had positive effects on the nursing students' cardiac auscultation skills and anxiety levels on the real patients. Our research results showed that high-fidelity simulation provided an opportunity to the students to practice different clinical scenarios for cardiac auscultation without risk for patients by providing a learning experience in an interactive, safe and controlled environment. Therefore, it was suggested that the integration of simulation training into the nursing undergraduate curriculum may help to overcome the problems such as the lack of clinical areas for education in many courses and the increase in the number of nursing students and ensuring safe and effective care for patients by reducing errors in clinical practice. Declaration of competing interest The authors declare no conflict of interest. Acknowledgments The authors are grateful to the nursing students and teaching assistants for participating in the study. Source of support There are no financial support. Contribution B. Vural Doğru: Study concepts, study design, data acquisition, data analysis and interpretation, statistical analysis, manuscript preparation, manuscript editing, revising manuscript critically for important intellectual content, manuscript review. L. Zengin Aydın: Study concepts, study design, data acquisition, data analysis and interpretation, manuscript preparation, revising manuscript critically for important intellectual content. Ethical approval Ethical approval was obtained from the Mardin Artuklu University Ethical Committee (No: 2018/1-9). Written permission was attained from the Health School where the study was conducted. References Aqel, A.A., Ahmad, M.M., 2014. High-fidelity simulation effects on CPR knowledge, skills, acquisition. and Retention in Nursing Students. Worldviews Evid-Based Nurs. 11 (6), 394–400. https://doi.org/10.1111/wvn.12063. Bremner, M.N., Aduddell, K., Bennett, D.N., VanGeest, J.B., 2006. The use of human patient simulators: best practices with novice nursing students. Nurse Educ. 31 (4), 170–174. Burton, R., Hope, A., 2018. Simulation based education and expansive learning in health
5. Limitations The limitation of this study is that the study was conducted with only first year students in a certain academic year. Other limitation of 6
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org/10.1515/fon-2018-0023. MacLean, S., Kelly, M., Geddes, F., Della, P., 2017. Use of simulated patients to develop communication skills in nursing education: an integrative review. Nurse Educ. Today 48, 90–98. https://doi.org/10.1016/j.nedt.2016.09.018. McCaughey, C.S., Traynor, M.K., 2010. The role of simulation in nurse education. Nurse Educ. Today 30 (8), 827–832. https://doi.org/10.1016/j.nedt.2010.03.005. McKinney, J., Cook, D.A., Wood, D., Hatala, R., 2013. Simulation-based training for cardiac auscultation skills: systematic review and meta-analysis. J. Gen. Intern. Med. 28 (2), 283–291. https://doi.org/10.1007/s11606-012-2198-y. Neill, M.A., Wotton, K., 2011. High-fidelity debriefing in nursing education: a literature review. Clin Simul Nurs. 7, e161–e168. https://doi.org/10.1016/j.ecns.2011.02.001. Oner, N., Le Compte, A., 1983. State-trait Handbook of Anxiety Inventory, 1st edition. Bogazici University Publications, Istanbul, pp. 1–26. Pittman, O.A., 2012. The use of simulation with advanced practice nursing students. J. Am. Acad. Nurse Pract. 24 (9), 516–520. https://doi.org/10.1111/j.1745-7599.2012. 00760.x. Ross, J.G., 2015. The effect of simulation training on baccalaureate nursing students' competency in performing intramuscular injection. Nurs. Educ. Perspect. 36 (1), 48–49. https://doi.org/10.5480/13-1075.1. Ross, J.G., Carney, H., 2017. The effect of formative capstone simulation scenarios on novice nursing students' anxiety and self-confidence related to initial clinical practicum. Clin Simul Nurs. 13 (3), 116–120. https://doi.org/10.1016/j.ecns.2016.11. 001. Seidel, H.M., Ball, J.W., Dains, J.E., Solomon, B.S., Flynn, J.A., Stewart, R.W., 2010. Mosby's Physical Examination Handbook-E-Book. (Elsevier Health Sciences). Shin, S., Park, J.H., Kim, J.H., 2015. Effectiveness of patient simulation in nursing education: meta-analysis. Nurse Educ. Today 35 (1), 176–182. https://doi.org/10.1016/ j.nedt.2014.09.009. Smith, M.B., Macieira, T.G.R., Bumbach, M.D., Garbutt, S.J., Citty, S.W., Stephen, A., ... Keenan, G., 2018. The use of simulation to teach nursing students and clinicians palliative care and end-of-life communication: a systematic review. Am J Hosp Palliat Care. 35 (8), 1140–1154. https://doi.org/10.1177/1049909118761386. Szpak, J.L., Kameg, K.M., 2013. Simulation decreases nursing student anxiety prior to communication with mentally ill patients. Clin Simul Nurs. 9 (1), e13–e19. https:// doi.org/10.1016/j.ecns.2011.07.003. Tamaki, T., Inumaru, A., Yokoi, Y., Fujii, M., Tomita, M., Inoue, Y., ... Tsujikawa, M., 2019. The effectiveness of end-of-life care simulation in undergraduate nursing education: a randomized controlled trial. Nurse Educ. Today 76, 1–7. https://doi. org/10.1016/j.nedt.2019.01.005. Tuzer, H., Dinc, L., Elcin, M., 2016. The effects of using high-fidelity simulators and standardized patients on the thorax, lung, and cardiac examination skills of undergraduate nursing students. Nurse Educ. Today 45, 120–125. https://doi.org/10. 1016/j.nedt.2016.07.002.
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The effects of training with simulation on knowledge, skill and anxiety levels of the nursing students in terms of cardiac auscultation: A randomized controlled study
T
Birgul Vural Doğrua, , Leyla Zengin Aydınb ⁎
a b
Mersin University, Faculty of Nursing, Department of Medical Nursing, 33110 Mersin, Turkey Dicle University, Department of Nursing, 21280 Diyarbakır, Turkey
ARTICLE INFO
ABSTRACT
Keywords: Cardiac auscultation High-fidelity simulator Nursing education Nursing student Traditional teaching method
Background: The use of simulation methods in nursing education is important in terms of decreasing anxiety of students in a safe and realistic environment due to the improvement of knowledge and skills of students in terms of cardiac auscultation and their attitudes to prepare for clinical applications. Objectives: The aim of this study is to compare the effectiveness of high-fidelity simulator and traditional teaching method on nursing students' knowledge and skill development in terms of cardiac auscultation and their anxiety levels. Design: Randomized controlled study. Setting: The study was conducted in the simulation laboratory of the Nursing Department in the Health College and in the inpatient clinics of the Medicine Faculty Hospital. Participants: 72 first-year nursing students (simulation group = 36, control group = 36). Methods: The students were randomly distributed to the simulation and control groups. The students in the simulation group received a cardiac auscultation training by using a high-fidelity simulator while the students in the control group received training with the traditional teaching method. After the training sessions, all students practiced their skills in the laboratory and on real patients in clinical setting under the supervision of the researcher. The data were collected by using the Demographic Information Form, Knowledge Assessment Form for Cardiac Auscultation, Skill Evaluation Form for Cardiac Auscultation and State Anxiety Inventory (SAI). Results: High-fidelity simulators and traditional teaching method were found to be effective in increasing the students' knowledge and skill levels in terms of cardiac auscultation. However, it was found that the high-fidelity simulator method was more effective than the traditional teaching method to increase the students' knowledge (p = 0.001) and skill (p < 0.001) levels; this increase was significant. In addition, it was found that the students in the high-fidelity simulator group showed a significant decrease in anxiety scores compared to the students who were trained with traditional education method (p < 0.001). Conclusions: The results showed that the use of high-fidelity simulator in nursing education was more effective than traditional method in terms of improving the students' knowledge, skill levels for cardiac auscultation and reducing their anxiety.
1. Introduction Nursing students need to gain knowledge, skills and attitudinal behavior to prepare for clinical practice (Chen et al., 2015). In the traditional nursing education, the education is implemented in the form of psychomotor skills, the use of demonstration method in theoretical education, applications on manikins and models in laboratory and application of skills for real patients in clinical environment (Tuzer et al.,
⁎
2016). However, students may experience stress and anxiety due to lack of experience, lack of familiarity with complex and advanced technological tools and equipment, increased awareness of medical errors and fear of making mistakes in clinical applications (Cobbett and SnelgroveClarke, 2016; Ross and Carney, 2017; Tuzer et al., 2016). In addition, inadequate number of clinical trainers, work overload of nurses and fear of taking responsibility of students may lead to inadequate clinical education for students (Karadağ et al., 2015; Tuzer
Corresponding author at: Mersin University, Faculty of Nursing, Department of Medical Nursing, Ciftlikkoy Campus, Yenişehir, 33110 Mersin, Turkey. E-mail address: [email protected] (B. Vural Doğru).
https://doi.org/10.1016/j.nedt.2019.104216 Received 10 April 2019; Received in revised form 12 July 2019; Accepted 14 September 2019 0260-6917/ © 2019 Elsevier Ltd. All rights reserved.
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et al., 2016). Therefore, students complete their education with real patients in the traditional method and this situation increases the risk of making mistakes towards patients (Burton and Hope, 2018). For this reason, it has been suggested that establishing laboratory environments with technical equipments and hardwares in which students can experience patient care before they start clinical applications and communicate well with patients and using interactive methods including technological advancements that enable students to participate actively (Eyikara and Baykara, 2018; Pittman, 2012). The simulation, one of these methods, is a system that provides interactive and effective individualized learning opportunities in which whole or a part of an event, activity or a clinical experience are replicated by the reproduction of them (Burton and Hope, 2018; Coyne et al., 2018). Simulation provides an environment which is suitable for putting the skills into practice by students and the learning process (Coyne et al., 2018). This is achieved without risk for real patients (Burton and Hope, 2018). Students have the chance to detect and correct their mistakes by repeated application during simulation (Pittman, 2012). Simulation is also used to improve students' critical thinking, problem solving and decision-making skills as well as teaching psychomotor skills (Pittman, 2012). For this reason, simulation has been used in many different areas such as vital signs, drug administration, crisis management, and palliative care to facilitate the students to acquire the necessary knowledge and skills. (Aqel and Ahmad, 2014; Chen et al., 2015; Eyikara and Baykara, 2018; Hdaib et al., 2015; MacLean et al., 2017; Smith et al., 2018; Tuzer et al., 2016).
of students' knowledge, skills and attitudes (Aqel and Ahmad, 2014; Cant and Cooper, 2017; Chen et al., 2015; Eyikara and Baykara, 2018; Hdaib et al., 2015; MacLean et al., 2017; Shin et al., 2015; Smith et al., 2018). However, a limited number of studies have been conducted evaluating the effect of high-fidelity simulator and traditional teaching method (Static manicin) on nursing students' knowledge, skill and anxiety levels on cardiac auscultation (Chen et al., 2015; Tuzer et al., 2016). In this context, the study will contribute to the literature. This study was undertaken to answer the following research questions: 1) Is there a difference between the use of high-fidelity simulator or the traditional teaching method in terms of improving the knowledge level of the students about cardiac auscultation? 2) Is there a difference between the use of high-fidelity simulator or traditional teaching method in the development of students' cardiac auscultation skills on a real patient in a clinical setting? 3) Is there a difference between the use of a high-fidelity simulator or traditional teaching method in reducing the anxiety levels of students regarding cardiac auscultation on the real patient in the clinical setting? 2. Methods 2.1. Study design and participants A randomization controlled trial study design was used. The study population comprised 90 students enrolled for the first year at the Nursing Department, School of Health, in a University, Diyarbakır, Turkey, in the 2017–2018 academic year. The study was conducted between April to June 2018. The inclusion criteria were as follows: to have no previous received a cardiac auscultation or auscultation skills training, to have no clinical experience and to accept voluntary participation in the study. The exclusion criteria were students who withdrew from the Fundamentals of Nursing Practicum course or dropped out of school. Seventy-six students met the inclusion criteria, but four students refused to participate. 72 students were divided into 3 groups according to their school success levels which were considered to affect their knowledge and skill scores. The students were randomly distributed into the simulation (36 students) and control (36 students) groups (Fig. 1). The students in the Simulation group were trained with highfidelity simulator in the simulation laboratory while the students in the control group were trained with ‘traditional teaching method’ in the occupational skill laboratory.
1.1. Background Although the task scope of nurses does not include clinical diagnosis, identifying physical findings and reporting these findings to a professional team by nurses are important for patient evaluation and management (Chen et al., 2015). Physical examination skills are one of the basic elements of nursing care used in the evaluation of health (Tuzer et al., 2016). Cardiac evaluation and auscultation skills constitute a part of these basic skills (Chen et al., 2015). These skills play an important role in collecting objective data to identify patients' problems and to take into account their needs. Therefore, it helps to improve the quality of nursing care while helping to make right nursing diagnoses (Tuzer et al., 2016). However, it is known that some systems such as cardiac system require more attention when the general deficiencies and inadequacies of students in these skills are taken into account (Chen et al., 2015). All cardiac auscultation sounds, especially abnormal voices, are not always available in encountering a routine patient, therefore there are limited opportunities for experiencing the normal and abnormal cardiac findings and sounds. For this reason, a number of technological methods such as simulation are used to facilitate students acquiring the necessary knowledge and skills (Butter et al., 2010; Chen et al., 2015; McKinney et al., 2013). Low, medium and high quality simulators and simulation techniques containing standard patients can be applied to teach different clinical concepts (Pittman, 2012; Shin et al., 2015). High-fidelity simulators are one of the methods used to teach more complex critical events to students in a safe and realistic environment (Pittman, 2012). By using this method, it has been stated that students can intervene in acute clinical situations in scenarios by managing time; they have positive learning experience and participate more actively in team work (Aqel and Ahmad, 2014; McCaughey and Traynor, 2010). It has been reported that simulation provides a realistic environment for students to improve their cognitive, affective and psychomotor skills, to make fewer medical errors and to ensure patient safety (Cant and Cooper, 2017; McCaughey and Traynor, 2010; Neill and Wotton, 2011). Accordingly, it is ensured that students' self-confidence in clinical practice increases, their anxiety is reduced and they are more willing to practice (Chuang et al., 2018; Eyikara and Baykara, 2018). In several studies, it has been stated that the use of high-fidelity simulators in nursing education has positive effects on the development
2.2. Measuring tools The data were collected by using the Demographic Information Form, Knowledge Evaluation Form for Cardiac Auscultation, Skill Evaluation Form for Cardiac Auscultation while the State Anxiety Inventory (SAI) was used to determine the students' anxiety levels. The demographic information form contained six questions on the sociodemographic characteristics of the students, such as academic achievement status, age and gender (Lewis et al., 2016; Seidel et al., 2010; Butter et al., 2010; Bremner et al., 2006). The Knowledge Evaluation Form for Cardiac Auscultation and Skill Evaluation Form of Cardiac Auscultation were prepared by the researchers in order to determine the students' knowledge level and application skills in terms of cardiac auscultation (Lewis et al., 2016; Seidel et al., 2010; Butter et al., 2010; Bremner et al., 2006). In order to ensure the content validity of the data collection forms before the application, both forms were evaluated by 3 lecturers who were experts in the subject and necessary arrangements were made depending on the expert recommendations. In the evaluation made by both forms, the level of knowledge and skill of the students about cardiac auscultation increase when their scores on the whole test increase. 2
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Fig. 1. Study flow diagram.
Knowledge Evaluation Form for Cardiac Auscultation: The form consisted of 11 multiple-choice questions about subjects of cardiac auscultation. The lowest score from the test was 0 while the highest score from the test was 100. In the evaluation, the level of knowledge about cardiac auscultation increase when the scores obtained from the whole test increase. Skill Evaluation Form for Cardiac Auscultation: It consisted of 18 items containing the steps of application of cardiac auscultation. Psychomotor steps of the students who received training in simulation and occupational skills laboratories were evaluated with check lists. The evaluation was made by marking the correct/complete (2 points), incomplete/incorrect (1 point), not observed (0 points) choices after each step of a student' application. The highest score from the test was 36 and the lowest score from the test was 0. To assess skill levels, students in the simulation and control groups completed the Objective Structural Clinical Assessment (OSCE). At the evaluation stage, the same scenario
was given to the students in the simulation and control groups. The students were asked to read the scenario and complete the Objective Structural Clinical Assessment (OSCE). This consisted of two stations, Cardiac Auscultation preparation examination station (OSCE 1), Cardiac Auscultation assessment examination station (OSCE 2). These were used to evaluate students' cardiac auscultation skills on high-fidelity simulator and static manicin. OSCE 1 consisted of 7 items including preparation of hands, such as washing hands, giving information and position to the patient. OSCE 2 consisted of 11 items, including the identification, listening and evaluation of heart foci, listening and evaluation normal and additional heart sounds. The students were scored separately by two instructors who were experienced in simulation applications and were not involved in the application stage and then agreed a score. State Anxiety Inventory (SAI): This inventory, developed by Oner and Le Compte (1983), consists of 20 questions. It can be applied to individuals over 14 years of age (11). The validity and reliability tests of 3
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SAI in Turkey were conducted by Oner and Le Compte (1983). This scale is a 4-point Likert type scale ranging from “None” to “Completely”. SAI is a highly sensitive tool for evaluating sudden changes in emotive reactions. The total score obtained from the scale varies between 20 and 80. Cronbach's Alpha reliability coefficient of the State Anxiety Inventory was found to be between 0.94 and 0.96. The testretest reliability coefficient was found to be between 0.26 and 0.68 for various applications (11). A higher score indicates a high level of anxiety while a low score indicates a low level of anxiety.
2.5. Data analysis Data were analyzed using the Statistical Package for Social Science 22.0 (SPSS, IBM Corp., Armonk, NY, USA). Shapiro-Wilk test was performed to examine the normal distribution similarity. Independent ttests and Chi-squared tests were conducted to examine demographic differences between the two groups. The Mann Whitney-U and Wilcoxon signed-rank tests were employed for variables that were not normally distributed for comparison between the experimental and the control groups. The results were evaluated at a 95% level of reliability and p < 0.05 was evaluated as statistically significant.
2.3. Data collection procedures Cardiac auscultation were taught to students by the researcher using lecturing methods via a PowerPoint® presentation and videos. The students were informed about the listening focuses of the heart sounds and the normal and additional heart sounds. After the 2 h long theoretical presentation of Cardiac auscultation, the Demographic Information Form and Knowledge Evaluation Form for Cardiac Auscultation (pre-test) were applied to the all participant students. Then students were divided into the simulation and control groups by randomization method. It was demonstrated to the students in the simulation group by using the high-fidelity simulator according to the practice instruction in the simulation laboratory while It was demonstrated to the students in the control group by using the static manikin in the skill laboratory. The simulation system was introduced to the students in the Simulation group and information was given on how to do the application. The students in the Simulation group were asked to perform auscultation on the simulator. The students in the control group were allowed to practice on static manikin with the instructor at least once. The questions of the students in both groups were answered after they repeated the application; if necessary, they had the opportunity to apply again. After the application under the supervision of the instructor, the students had free working hours. When the students stated that they were ready by feeling comfortable and secure, the study was terminated. An informing session was performed for the students in both groups to recognize their mistakes; their questions were answered, if they had any questions. In the evaluation stage, the same scenario was used for the static manikin and high-fidelity simulator. After the application step, each student in the control group performed the application of cardiac auscultation on the static manic while each student in the simulation group performed the application of cardiac auscultation on the high-fidelity simulator. Meanwhile, the students in both the control and simulation groups were observed by two instructors who were was experienced in simulation applications and not involved in the application step. The instructors recorded the performances for each student in the Skill Evaluation Form for Cardiac Auscultation (Pre-test). All students were asked to complete the SAI to evaluate their anxiety level related to cardiac auscultation (Pre-test). The students were asked to complete the Knowledge Evaluation Form for Cardiac Auscultation as a final test (Post-test). Two weeks after the laboratory application, the students in both groups performed cardiac auscultation on the real patients and they were evaluated by the same instructors (Observing in laboratory stage) by using the Skill Evaluation Form for Cardiac Auscultation (post-test). The students in both study groups were asked to fill the SAI after performing cardiac auscultation on the real patient (post-test). A flow diagram is presented in Fig. 1.
3. Results 3.1. Samples and characteristics of students The average age of the students was 19.95 ± 1.77 years. Of a total of 72 students, 46 were females (63.9%) and 26 were males (36.1). The majority lived with their family (75%), 42 have voluntarily chosen nursing profession (58.3%) and 45 have no computers (62.5%). There were no statistical differences between the demographic characteristics of the groups at the baseline (Table 1). 3.2. Knowledge and skill scores of cardiac auscultation There was no significant difference between the simulation and control groups in terms of the pre-test median scores of cardiac auscultation knowledge (z = −1.603, p = 0.109) and skill (z = −0.643, p = 0.520). The post median scores of the students in the simulation group for cardiac auscultation knowledge (z = −3.307, p = 0.001) and skill (z = −7.102, p = 0.001) were determined as higher than those in the control group; the difference between the groups was statistically significant. However, the post-test median scores of the students in the simulation and control groups for cardiac auscultation knowledge and skill were found to be significantly higher than their pre-test median scores (p < 0.001) (Table 2, Table 3). 3.3. Anxiety in cardiac auscultation There was no significant difference between the median pre-test cardiac auscultation anxiety scores of the students in the simulation and control groups (z = −0.660, p = 0.509). The median post-test cardiac auscultation anxiety score of the students in the Simulation group was lower compared to those of the students in the control group; the difference between the groups was statistically significant (z = −7.149, p < 0.001). In the intragroup measurements, the median post-test cardiac auscultation anxiety score of the students in the control group was significantly lower than the median pre-test cardiac auscultation anxiety score of them (p < 0.001), but no significant difference was found between the median pre- and post-test scores of the students in the control group (Table 4). 4. Discussion The National Council of State Boards of Nursing (NCSBN) suggests that learning by using simulation depends on high-quality simulation (Hayden et al., 2014). It has been stated that the use of high-fidelity simulators in nursing education increases the self-esteem and satisfaction, including effective learning and knowledge; it also brings students a critical perspective (Cant and Cooper, 2017; Karadağ et al., 2015; Luo and Petrini, 2018; Neill and Wotton, 2011). The aim of this study is to compare the effectiveness of simulation and traditional education method in determining and listening heart foci, and in gaining basic skills and knowledge for listening to normal and additional heart sounds. Another objective is to determine the effectiveness of simulation in the application of cardiac auscultation skills on real patients and on students' anxiety in the clinical setting.
2.4. Ethical considerations Ethical approval was obtained from the Mardin Artuklu University Ethical Committee (No: 2018/1-9). Written permission was attained from the Health School where the study was conducted. Students were informed of the aims of the study via the researchers and their verbal consents and written permission were acquired. All students were informed that their participation was voluntary, and they were free to withdraw at any time without affecting their learning or academic grade. 4
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Table 1 Demographic characteristics of students at the baseline (N = 72). Variable Academic achievement status Successful (> 76) Normal (70–76) Unsuccessful (< 70) Gender Female Male Living status With family Other Conditions for choosing nursing as a profession Voluntary Involuntary Having a computer Yes No Age (years)
x2
p
0.000
1.000
22 (61.1) 14 (38.9)
0.241
0.806
24 (66.7) 12 (33.3)
30 (83.3) 6 (16.7)
2.667
0.425
42 (58.3) 30 (41.7)
18 (50.0) 18 (50.0)
24 (66.7) 12 (33.3)
2.057
0.232
27 (37.5) 45 (62.5) X = 19.95 ± 1.77
10 (27.8) 26 (72.2) X = 19.69 ± 1.23
17 (47.2) 19 (52.8) X = 20.22 ± 2.17
2.904
0.144
Total (N = 72) n (%)
Simulation group n (%)
Control group n (%)
24 (33.3) 24 (33.3) 24 (33.3)
12 (33.3) 12 (33.3) 12 (33.3)
12 (33.3) 12 (33.3) 12 (33.3)
46 (63.9) 26 (36.1)
24 (66.7) 12 (33.3)
54 (75.0) 18 (25.0)
t
−1.263
0.211
Table 2 Comparison of cardiac auscultation knowledge scores of pre- and post-test (N = 72) Knowledge
Pre test Post test Pre- and post-test comparison of group
Simulation group
Control group
X (min ± max)
X (min ± max)
za
p
64.00 (8.00 ± 100.00) 92.00 (62.00 ± 100.00) Zb = −5.220 p < 0.001
69 (28.00 ± 92.00) 83.00(36.00 ± 100.00) Zb = −3.689 p < 0.001
−1.603 −3.307
0.109 0.001
X = Median. a Mann Whitney U test z value. b Wilcoxon test Z value.
Table 3 Comparison of cardiac auscultation skill scores of pre- and post-test (N = 72). Skill
Pre test Post test Pre- and post-test comparison of group
Simulation group
Control group
X (min ± max)
X (min ± max)
za
14.00 (0.00 ± 18.00) 25.00 (22.00 ± 27.00) Zb = −5.239 p < 0.001
13.50 (5.00 ± 32.00) 17.00 (9.00 ± 24.00) Zb = −4.242 p < 0.001
−0.643
0.520
−7.102
< 0.001
Table 4 Comparison of pre- and post-test anxiety scores for cardiac auscultation (N = 72). Anxiety
p
Pre test Post test Pre- and post-test comparison of group
X = Median. a Mann Whitney U test z value. b Wilcoxon test Z value.
Simulation group
Control group
X min ± max)
X min ± max)
za
p
40.50 (22.00 ± 74.00) 32.00 (20.00 ± 40.00) Zb = −5.089 p < 0.001
41.00 (32.00 ± 80.00) 44.00 (35.00 ± 52.00) Zb = −0.513 0.608
−0.660
0.509
−7.149
< 0.001
X = Median. a Mann Whitney U test z value. b Wilcoxon test Z value.
In our study, both high-fidelity simulators and traditional teaching method have been found to be effective in increasing the knowledge and skill levels of the nursing students on heart auscultation (p < 0.001, Tables 2, 3). However, the high-fidelity simulator method was found to be significantly more effective than the traditional teaching method (laboratory study) in increasing the students' knowledge and skill levels (p = 0.001, Table 2; p < 0.001, Table 3). In the literature, there was a limited number of studies evaluating the effects of high-fidelity simulator and traditional teaching method on the knowledge and skill levels of nursing students on heart auscultation (Tuzer et al., 2016; Chen et al., 2015). However, there are many studies evaluating the effects of highrealistic simulators and different training methods on the development of nursing students' knowledge, skills and attitudes (Aqel and Ahmad, 2014; Cant and Cooper, 2017; Eyikara and Baykara, 2018; Hdaib et al., 2015; MacLean et al., 2017; Shin et al., 2015; Smith et al., 2018). This showed the authenticity of our study. In contrast to our study, the use of
standardized patients by Tuzer et al. (2016) was found to be more effective than the high-fidelity simulator to increase the scores of nursing students for thoracic-pulmonary and cardiac examination knowledge, but the skill scores were found to be similar. It was stated that the lower knowledge scores of the students in the high-fidelity simulator group might be related to the lack of realism, interaction and getting feedback (Tuzer et al., 2016). Chen et al. (2015) determined that the cardiac, respiratory auscultation and physical examination skill scores of the students in the low-fidelity simulation group were higher than those of the students in the high-fidelity simulation group in all measurements, but there was no significant difference between the two methods. Therefore, it has been stated that very complex learning environments may cause ineffective learning of students by increasing extraneous cognitive load (Chen et al., 2015). In some studies conducted with the medical students, it was reported that simulation-based education was effective in developing the students' 5
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knowledge and skills in terms of cardiac auscultation similar to our study (Butter et al., 2010; McKinney et al., 2013). In other studies, the nursing students trained with the high-fidelity simulator were found to perform better in information-based assessments related to cardio-pulmonary resuscitation, vital signs and end-of-life care (Aqel and Ahmad, 2014; Eyikara and Baykara, 2018; Tamaki et al., 2019). In our study, it has thought that planned and repetitive applications made by direct contact with the high-fidelity simulator are due to the fact that the students are more equipped and effective in gaining the knowledge and skills of cardiac auscultation by increasing their confidence and experiences. It has been also considered to be important to identify and correct errors and more importantly, give feedback to students on their performance. Two of the strengths of our study is that the skills learned through the simulation can be put into real clinical practice and the students' skill scores increased significantly in the clinical practices on real patients compared to the students who were trained by using the traditional teaching method (Post-test; p < 0.001, Table 3). Similarly, Eyikara and Baykara (2018) showed that the students in the simulation group had significantly higher skills to measure vital signs of healthy adults and real patients compared to the students who were trained by using the traditional teaching method. Tuzer et al. (2016) stated that the training with standardized patient and high-fidelity simulator method significantly increased the skill scores of the students in the evaluation made on the real patients, but there was no significant difference between the groups. Ross (2015) stated that the IM injection skills of the students in the simulation group were higher compared to the students in the traditional method group; but this difference was not significant. Although these findings were not significant in these two studies, these findings supported that simulation is an effective teaching method to develop psychomotor skills (Ross, 2015; Tuzer et al., 2016). It is thought that the low level of cardiac auscultation skill scores in the practice performed on the real patient in the clinical setting of the group who were educated with traditional teaching method was caused by the fact that the students could not benefit from simulated heart sounds in the laboratory, could not communicate and could not be interactive. Another important finding of this study was that the students in the high-fidelity simulator group had significantly reduced cardiac auscultation anxiety score in the clinical applications on the real patients compared to the students in the traditional training method group (Posttest; p < 0.001, Table 4). In the literature, it has been stated that entering the clinical setting for the first time, fear of making mistakes, using skills on real patients, interacting with health professionals, feeling insufficient and evaluating by instructors cause significant anxiety in students (Cobbett and Snelgrove-Clarke, 2016; Ross and Carney, 2017; Szpak and Kameg, 2013). It has been stated that decreasing students' anxiety helps to improve the therapeutic relationship between nurses and patients and care outcomes (Ross and Carney, 2017; Szpak and Kameg, 2013). In our study, it was found that the students who trained with the traditional education method had an increase in their level of cardiac auscultation anxiety in the clinical application on the real patients while the students who were trained with the simulation had a decreased level of cardiac auscultation anxiety in the clinical application on the real patients. Similarly, Khalaila (2014) determined that the training with the simulation decreased the nursing students' anxiety levels and increased their self-confidence, care ability and satisfaction in the first clinical application. Szpak and Kameg (2013) found that nursing students receiving high-fidelity simulator training before starting clinical practice and communicating with mentally ill individuals, had reduced anxiety levels. In our study, it has been suggested that the decreased anxiety levels of the students were as the result of increasing knowledge, skills and self-confidence after receiving training with the simulation.
the study is that the results cannot be generalized to all undergraduate nursing students in Turkey because the results of the study were from one university. The reason is that some nursing departments in other universities had simulation laboratories while some of them did not have simulation laboratories and applied different training methods. It has been recommended that our study should be carried out as a multicentered study in different universities with a larger sample size. In addition, new evidence-based studies comparing the effectiveness of different simulation and training methods are needed for the development of clinical knowledge and skills of nursing students. 6. Conclusion The knowledge level of nursing students on cardiac auscultation in the high-fidelity simulator group showed a significant improvement compared to the students trained with traditional method. It was observed that the training with high-fidelity simulator had positive effects on the nursing students' cardiac auscultation skills and anxiety levels on the real patients. Our research results showed that high-fidelity simulation provided an opportunity to the students to practice different clinical scenarios for cardiac auscultation without risk for patients by providing a learning experience in an interactive, safe and controlled environment. Therefore, it was suggested that the integration of simulation training into the nursing undergraduate curriculum may help to overcome the problems such as the lack of clinical areas for education in many courses and the increase in the number of nursing students and ensuring safe and effective care for patients by reducing errors in clinical practice. Declaration of competing interest The authors declare no conflict of interest. Acknowledgments The authors are grateful to the nursing students and teaching assistants for participating in the study. Source of support There are no financial support. Contribution B. Vural Doğru: Study concepts, study design, data acquisition, data analysis and interpretation, statistical analysis, manuscript preparation, manuscript editing, revising manuscript critically for important intellectual content, manuscript review. L. Zengin Aydın: Study concepts, study design, data acquisition, data analysis and interpretation, manuscript preparation, revising manuscript critically for important intellectual content. Ethical approval Ethical approval was obtained from the Mardin Artuklu University Ethical Committee (No: 2018/1-9). Written permission was attained from the Health School where the study was conducted. References Aqel, A.A., Ahmad, M.M., 2014. High-fidelity simulation effects on CPR knowledge, skills, acquisition. and Retention in Nursing Students. Worldviews Evid-Based Nurs. 11 (6), 394–400. https://doi.org/10.1111/wvn.12063. Bremner, M.N., Aduddell, K., Bennett, D.N., VanGeest, J.B., 2006. The use of human patient simulators: best practices with novice nursing students. Nurse Educ. 31 (4), 170–174. Burton, R., Hope, A., 2018. Simulation based education and expansive learning in health
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