- Email: [email protected]
Effect of a clinical skills refresher course on the clinical performance, anxiety and self-efficacy of the final year undergraduate nursing students
Accepted Manuscript Effect of a clinical skills refresher course on the clinical performance, anxiety and selfefficacy of the final year undergraduate nursing students Hooman Shahsavari, Shahrzad Ghiyasvandian, Marian L. Houser, Masomeh Zakeri Moghadam, Sosan Noori Kermanshahi, Sedigheh Torabi PII:
S1471-5953(17)30517-6
DOI:
10.1016/j.nepr.2017.08.006
Reference:
YNEPR 2257
To appear in:
Nurse Education in Practice
Received Date: 16 June 2016 Revised Date:
12 July 2017
Accepted Date: 6 August 2017
Please cite this article as: Shahsavari, H., Ghiyasvandian, S., Houser, M.L., Moghadam, M.Z., Kermanshahi, S.N., Torabi, S., Effect of a clinical skills refresher course on the clinical performance, anxiety and self-efficacy of the final year undergraduate nursing students, Nurse Education in Practice (2017), doi: 10.1016/j.nepr.2017.08.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
EFFECT OF A CLINICAL SKILLS REFRESHER COURSE ON THE CLINICAL ACCEPTED MANUSCRIPT PERFORMANCE, ANXIETY AND SELF-EFFICACY OF THE FINAL YEAR UNDERGRADUATE NURSING STUDENTS Hooman Shahsavari, PhD, RN, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences;
Shahrzad Ghiyasvandian, PhD, RN,
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Faculty of Nursing and Midwifery, Tehran University of Medical Sciences Corresponding Author: Dr. Shahrzad Ghiyasvandian, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Nosrat St., Tohid Sq.,1419733171, Tehran, Iran Email: [email protected] Tel: (+ 98) 21 61054319, Cell phone: (+98)912-21303833 Fax: (+98) 21 66941668
Marian L. Houser, PhD,
Masomeh Zakeri Moghadam, PhD, RN,
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Associate Dean, Faculty Development & Academic Affairs, College of Fine Arts and Communication, Dept. of Communication Studies, Texas State University
Sosan Noori Kermanshahi, BSc, RN,
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Faculty of Nursing and Midwifery, Tehran University of Medical Sciences;
Faculty of Nursing and Midwifery, Tehran University of Medical Sciences;
Sedigheh Torabi, MSc, RN
Faculty of Nursing and Midwifery, Tehran University of Medical Sciences;
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Word count: 3800
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Acknowledgment We would like to thank all study participants and also School of Nursing and Midwifery, Tehran University of Medical Sciences.
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Highlights • Nursing curriculum can be strengthened through the clinical skills refresher course
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• The clinical skills refresher course can reduce students’ anxiety for nursing practice • The clinical skills refresher course can increase students’ clinical self-efficacy
• The clinical skills refresher course can promote nursing students’ clinical abilities
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• The clinical skills refresher course can bridge the nursing theory – practice gap
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INTRODUCTION The bachelor of nursing education program in Iran is a four-year program that includes eight sequential semesters with a fixed, national curriculum determined by the Ministry of Health and Medical
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Education (MoHME). During the first semester of the first year, nursing students are taught clinical skills in a clinical skills lab in the nursing school. When they pass clinical skills’ lab training, they enter into a set of different supervised practicums in hospitals and other clinical settings for the remaining five
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semesters. During the first three years (six semesters), students should become prepared for the final year of education that is a combination of semi- to non-supervised practicum and internship in two semesters.
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This internship program is designed to facilitate students’ transition to the role of the registered nurse. Unfortunately, due to the weaknesses and problems inherent within various clinical settings, some students do not properly/correctly experience all necessary clinical nursing skills. Some students may gradually deviate from standard performance procedures. Aein et al. (2010) reported a serious problem in clinical nursing education programs as “learning from observing inappropriate practice of some
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professional nurses” (p. 195). In Iran, newly graduated nurses reported the clinical incompetency (Joolaee et al., 2015) similar to what has been reported in China (Liao et al., 2016), Australia and UK (Lima et al., 2014). Senior nursing students and newly graduated nurses are well aware of their clinical incompetency
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and consequently experience high levels of anxiety with low self-confidence (Joolaee et al., 2015). Entering students into the internship program with such anxiety and uncertainty can reduce the
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educational effectiveness of their educational final year (Aein et al., 2010). Therefore, in Iran, one of the main concerns of the nursing educational system has always been improving the nursing internship program by introducing new effective strategies. It was assumed that the use of a refresher course in basic clinical skills can empower students to practice independently and improve the quality of the internship program. BACKGROUND
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Nursing is a practice-based discipline. Therefore, clinical competencies are required for all nurse students and practicing registered nurses to ensure that they can meet the clinical needs of patients (Shahsavari et al., 2013). The undergraduate nursing education program is responsible for preparing
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nursing students to properly perform their nursing duties in complex health care systems. These programs must also provide a successful transition to the official nurses’ role. Clinical education and theoretical education play a pivotal role in students’ successful experiences. Oermann et al. (2015) believe that
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during the nursing program, some students have not been provided with opportunities to reach the
proficiency level. Stayt et al. (2013) emphasized that irregularities in clinical skill development makes
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nursing graduates incompetent and increase the possibility of unsafe practice.
It is indicated that most new graduates may not possess clinical competencies required to perform the duties of registered nurses (Liao et al., 2016). Because of a lack of self-efficacy, nurses experience high levels of stress and anxiety (Joolaee et al., 2015). The detrimental effects that are related to a lack of sufficient skills in performing the most practical tasks are considerable. According to Newton et al.
of their preparation.
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(2007), one of the obstacles to the transfer of students to the nurse's role is improving our underestimating
The final year of the nursing education program for the proper transition to the professional role
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is a critical stage. In this regard, Nash et al. (2009) expressed that the final year acts as a pre-transition process and enables nursing students to “build their clinical confidence and consolidate their clinical
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skills, while also developing positive professional qualities and work attitudes” (p. 49). Teoh et al. (2013) emphasized on the role of “tailored graduate program, realities of practice and support and coping mechanism” (p. 144) as the determinants of the appropriate transition to practice journey. Many different educational models and programs have been proposed to assist the schools of nursing in creating support for students during this final year. One-year internships (Heslop et al., 2001), supervised clinical practicums (Budgen et al,. 2008), preceptorships (Watt et al., 2016), mentorships (Lúanaigh, 2015), the collaborative model of clinical placement (Nash et al., 2009), community of practice (CoP)( Thrysoe et
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al., 2010), reflective practices (Rees, 2013), simulated learning environment (Liaw et al., 2014; Mills et al., 2016) and fitness for practice curriculum model (Holland,, 2010) have also been suggested to help students get prepared for practice. The goal of each model is to empower nursing students to take on the
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nursing role upon graduation. These educational models are imperative as the feelings of incompetence in clinical skills can influence how nursing students approach their future profession. According to previous studies, the
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formation of such feelings typically occurs prior to graduation (Cantrell and Browne, 2005) and can act as a source of anxiety and stress among nursing students (Gaberson et al., 2010). In addition, the sense of
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inadequacy can cause students to leave the nursing profession prematurely (Cantrell and Browne, 2005). Clinical incompetence and the fear following it in new graduates can lead to job dissatisfaction, reduce quality of care, increase legal liabilities and negatively impact retention (Kenny et al., 2016). Nursing educators and planners hold the key to reduce anxiety felt by nursing students. Therefore, strategies should be devised to eliminate or resolve this troubling experience (Reeve et al., 2012). The current study
OBJECTIVES
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assesses the effect of the clinical skills refresher course to promote confidence among nursing students.
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To investigate the effect of a refresher course tailored for undergraduate nursing students during the final year on their clinical performance, anxiety and self-efficacy.
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METHODS
Design
This was a nonrandomized controlled trial. A pretest-posttest design with a nonrandomized
control group was utilized. The sample was consisted of 160 final year undergraduate nursing students, that were prepared to enter their one-year internship program in the largest medical science university in Iran. The intervention was a three-day basic clinical skills refresher program in a clinical skills lab.
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Participants and Setting All students (n = 160) were beginning the final year of the bachelors nursing program including the one-year internship. They passed all theoretical credits of the nursing bachelor’s curriculum had the
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experience of caring for patients in different clinical wards in the supervised clinical practicum. Because of administrative and educational constraints and to prevent contamination, they were recruited from two sequential semesters, were assigned to either intervention or control groups using a nonrandom method.
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Therefore, all students entered to the final year were assigned to the control group (n=79) and the
following semester, another new student group entered their final year of the bachelor program was
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assigned to the intervention group (n=81).
Inclusion criteria were: 1) senior student in the nursing bachelor program, 2) eligible to enter the internship program (e.g., passing all previous credits and courses) and 3) no existing work experiences in nursing except the formal educational experience within the current nursing program. Exclusion criteria were 1) no desire to participate in the study, 2) physical or mental disability (e.g., a psychological
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disorder such as depression and chronic anxiety according to students’ self-report) and 3) lack of willingness to continue participation in the study.
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Data Collection Tools
Three measures were considered outcome measures for this refresher course: level of anxiety, clinical
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self-efficacy and clinical performance. In addition, demographic data of the students was collected. To examine student anxiety, the Spielberger’s State-Trait Anxiety Inventory (STAI) (only situational anxiety) was used. To measure clinical self-efficacy, the researchers used an instrument developed by Cherghi et al., (2010), for the Iranian context. Finally, clinical skills were assessed by a 13-items checklist developed by the researchers. The Spielberger’s inventory is a self-report instrument that has been used extensively in research and clinical practice (Debyser et al., 2011). This instrument was comprised of two subscales: the State-
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Anxiety form (S-Anxiety) that assessed the situational anxiety and the Trait-Anxiety form (T-Anxiety) that assessed personal anxiety (Debyser et al., 2011; Palese et al., 2012). Each subscale was consisted of 20 items with a 5-point Likert-scale (1= not at all and 5=very much). The scores for each subscale ranged
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from 20 to 80 with higher scores representing higher anxiety. Reliability and validity of this scale were reported adequate (Debyser et al., 2011; Palese et al., 2012). The Cronbach's alpha coefficient of the stateanxiety subscale of the Farsi version of this instrument was reported as 0.9. The clinical self-efficacy
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instrument was developed by Cheraghi et al., (2010) as a self-report instrument with 37 items and a 10point Likert scale with four subscales. Based on the Cheraghi et al.'s report, concurrent validity of this
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instrument by comparison with the general self-efficacy questionnaire was acceptable (p<0.01). Also, the reported Cronbach's alpha coefficient (α = 0.96) indicated a good internal consistency of this instrument. The Cronbach's alpha coefficient for dimensions ranged between 0.90-0.92. The test-retest with a two week-interval demonstrated the acceptable reliability of this instrument (r = 0.94) (Cheraghi et al., 2010). The clinical skills’ rating scale for measuring practical performance of the students had 13 items related to
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10 basic clinical skills. They included intramuscular injection, intravenous injection, subcutaneous injection, suction, nasogastric tube insertion, gastric tube, intravenous catheter insertion and IV therapy, blood sampling and wound dressing. Each item could be rated from 1-not satisfactory to 5 completely
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satisfactory. The clinical performance of each nursing student was assessed by a rater (clinical instructor). One question was added to this questionnaire to obtain a global rating of the students’ clinical
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performance by the rater. Finally, the sum of all scores of items was reported as the student score of clinical performance. Before using this scale, it was tested with 16 pairs of observations in the clinical skills lab. Inter-rater reliability was measured via Cohen's Kappa. The scale showed a high level of rater’s agreement with each item scoring above 0.71 and with an overall score of 0.813. Procedure The list of all final year nursing students was stored in the education office and all eligible students from this list were invited to a briefing session and were informed about the study purposes. Those instructors
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who participated in the study were also identified and informed about the study and their roles as trainers in the clinical skills lab or assessors in a clinical setting. The same instructors were maintained for both control and intervention groups.
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Due to the constraints of the educational program, all students who entered into their final year of the study were assigned to the control group. During the next semester, all new students who entered into their final year were chosen for the intervention group. For baseline information, the student age, gender
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and the mean score of their third year practicum were gathered. Before beginning their first year of the internship program, the students in the control group completed the initial measure of the clinical self-
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efficacy and anxiety questionnaires. The intervention group, on the other hand, completed a 3-day refresher course of basic clinical skills that focused on 10 basic skills in a clinical skills lab. The basic skills were selected based on clinical instructors’ and students’ comments about the most common procedures, which is used in clinical situations. Specifically, these selected skills were intramuscular injection, intravenous injection, subcutaneous injection, airway suction, inserting a nasogastric tube,
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nasogastric tube feeling, intravenous catheter insertion and IV therapy, blood sampling and wound dressing. For teaching purposes, during the first day of the refresher course, students in the intervention group were divided into eight groups of ten (one group eleven). Time limit and organizational constraints
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led us to plan this refresher course for three days. Each of the groups was assigned to a room within a clinical skills lab with an experienced instructor where the refreshing was conducted in four sequential
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parts: the particular procedure demonstrated by the instructor; a discussion on students' real experiences with the specific procedure; student supervised exercises and student-led exercises. All procedures were performed on human models and mannequins. After that the intervention groups completed their 3-day refresher course, the students returned to their routine internship program. Two weeks after the start of their routine internship program, all students again completed the anxiety and clinical self-efficacy questionnaires. Following this, the clinical instructors assessed students' clinical performance via the clinical skills rating scale, and finally gathered data was analyzed. Data Analysis
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The study participants completed two questionnaires at baseline and a few added questions about demographic information. Data were analyzed using the Statistical Package for the Social Science (SPSS version 16). During the analysis, the level of significance (a significant difference) was set at 0.05
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for all statistical tests. The normality of the distribution was assessed for all study variables. The chisquare test (for categorical variables) and the t-test (for continuous variables) were used for the
comparison between groups regarding baseline collected information. Since all collected data from
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anxiety, clinical self-efficacy, and clinical performance instrument were continuous, t-test was conducted to compare the scores of the students in the intervention and control groups.
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Ethical Considerations
This study was approved by the Ethics Committee of Research of Tehran University of Medical Sciences. The researchers informed the students about the research purposes, potential benefits and disadvantages of participation, the option to refuse to participate, and confidentiality of their information. Once the informed consent form was signed, the participants were assured that the result of the study had
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no effects on their evaluation.
RESULTS
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All questionnaires were completed and returned by the students and observers. Missing data was unremarkable, except in the clinical skills rating scale. For this rating scale, 3 items were excluded for the
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data analysis, because missing data was higher than 20%. There were no statistically significant differences between the groups in terms of gender and age. Baseline characteristics and comparison data of the participants for two groups were presented in table 1. The mean scores of pre- and post-intervention anxiety for groups’ comparison were presented in table 2. The mean score of anxiety just before starting the internship at the beginning of the final year of the bachelor program for both group was 42.30 (SD=12.30). No significant difference in the mean scores of anxiety between the groups before the intervention (p=0. 442, df=146). Following the intervention and second completion of the measures, the mean anxiety score was significantly different from the control in
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comparison to the intervention groups (p=0.000, df=143). The change in anxiety score from the first measure to the second measure in the control group was non-significant (p=0.78, df=75); in contrast, the change score was significant for the intervention group (p=0.00, df=69).
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The mean scores for pre- and post-intervention clinical self-efficacy and the comparison between the groups were presented in table 2. No significant difference in the mean scores of clinical self-efficacy between the groups before the intervention was reported (p=0. 90, df=152). After the second measure, the
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mean score for clinical self-efficacy was significantly different between the groups (p=0. 003, df=153). The change in clinical self-efficacy from the first measure to the second semester in the control group was
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non-significant (p=0.54, df=76); in contrast, this change was significant for the intervention group (p=0.00, df=76).
The total mean score for the third year clinical practicum (Medical-Surgical practicum) participants and the mean score of clinical performance after the intervention and group comparison scores were presented in Table 3. No significant difference in the mean score of the third year clinical practicum between the
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groups before the intervention was reported (p=0. 628, df=157). Following the intervention, the two groups were different significantly in both the sum (p=0. 009, df=157) and global (p=0. 003, df=157) scores for clinical performance.
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DISCUSSION
The results of this study indicated that before entering the internship program, final year nursing
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student experienced moderate levels of anxiety. While the source of this anxiety is not only the feelings of inadequacy in clinical skills, such a feeling has a huge impact students. The refresher course in basic clinical skills prior to entering the internship period significantly reduced students’ anxiety. Previous studies showed a high level of anxiety among nursing students and newly graduated nurses as they entered the workplace and a hospital internship (Grobecker, 2016; Higgins et al., 2010). Similarly, Christensen et al. (2016) reported moderate anxiety, feeling of self-doubt and inadequately among nursing students in the final year of their bachelor program. Enhancing the clinical skills of students through a
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short refresher course within a clinical skills lab could reduce their anxiety prior to entering the internship. This finding is of vital importance to the bachelor of nursing program as a previous study showed that a primary source of stress in new nursing graduates was the feeling of clinical incompetency
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in completing clinical tasks (Higgins et al., 2010). The feelings of inadequacy to take on the professional nursing role, its related anxiety and the resultant decision to leave nursing consistently develop in the final year of the bachelor of nursing program. Such feelings are typically triggered among those students who
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become aware of their inability and forthcoming legal responsibilities (Cantrell and Browne, 2005). Christensen et al. (2016), emphasized the role of the curriculum in students’ perceived preparedness for
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practice. Hence, they believed that difference between graduates’ feeling of preparedness in New Zealand, UK and Australia were due to differences in their curricula. Holland et al. (2010) with regard to the fitness for practice curriculum model in Scotland, the UK stated that the recent nursing graduates were “fit for practice”. They stressed that earlier concerns that nursing students were ‘unfit for practice’ emphasized the perceived lack of clinical skills at the point of registration not on competence to practice.
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Therefore, addressing competence is more important than just dealing with procedural skills. The present study indicated that the creation of a simulated environment in clinical training skills via the safe learning situation promoted the competent practice of clinical skills and reduced anxiety. Similarly,
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previous studies acknowledged that while the clinical setting itself was a unique learning situation, students still perceived it as a stressful and threatening situation (Pulido-Martos et al., 212). Simulated
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clinical environments, on the other hand, not only offer the benefits of actual clinical settings (Foronda et al., 2013) but also help reduce students' anxiety (Ignacio et al., 2016). In addition, in this study, the improvement of clinical self-efficacy for nursing students who participated in being retrained in basic clinical skills programs was realized. Self-efficacy could influence initiating behaviors and also the degree of persistence applied to overcoming barriers to fulfill a task (Rice, 2015). It was linked to a sense of well-being in nursing students (Gibbons et al., 2011). Furthermore, Gibbons et al. (2011) suggested that self-efficacy alone could be a good adaptive strategy to combat stress and
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anxiety. On the other hand, Watt et al. 2016 reported that student’s self-efficacy could be affected by increased anxiety. Although the one-year internship course in the final year of the bachelors’ in nursing program is
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incredibly useful, it appears that a reinforcement program, such as refresher basic clinical skills, adds to the confidence students feel in the real situations. This mirrors the finding of a previous study that also stresses the need for a course to provide nursing students professionally as they took on their roles in
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clinical situations (Nash et al., 2009). The deterioration of clinical skills is a major problem unless
refresher training is provided (Bhoi et al., 2016). Using clinical skills improvement modalities such as a
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short basic clinical skills refresher program can better prepare students to engage in their role as nurses (Everett-Thomas et al., 2016). Watts et al. (2011) concurred and suggested that a three-day simulation training course in clinical nursing skills should help reduce anxiety and improve self-efficacy. CONCLUSIONS
This experimental study introduced a short and inexpensive educational course based on a basic clinical
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skills refresher in a clinical skills lab to help students effectively complete their final year of the bachelors of nursing program. The short refresher course for basic clinical skills in clinical skills lab can provide nursing students an opportunity to improve their clinical performance, increase their levels of self-
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efficacy and reduce their anxiety. In addition, the advantages of conducting basic clinical skills training in clinical skills lab should not be limited and could prove even prove useful for junior students in the
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primary years of the nursing education program. The documented benefits for senior nursing students completing a refresher course include educational and clinical benefits that assist with a smoother transition from student nurse to registered nurse. As an extended benefit of this research project, it is hoped to inspire nurse educators, nurse experts, nurse leaders and curriculum designers both nationally and internationally to incorporate a clinical skills refresher course for senior nursing students at some time during their senior year of the bachelor of nursing program. In many countries, all staff nurses are not a good role model for students to learning clinical skills. This problem can be there in nursing education in
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other countries. Dealing with such improper role models in the clinical environment is unavoidable for nursing students. Therefore, before graduation students need to have an opportunity to refresh their clinical skills. In this study,the refresher course was limited to three days with 10 basic clinical skills
of time and content given the contextual characteristics. Limitations of the study
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program, but it should be noted that more studies are needed to offer the best refresher program in terms
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The main limitation of this study was the inevitable nonrandom allocation of the control and intervention groups. A true random sampling was not possible due to educational and institutional constraints. In
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response to this limitation, the researchers grouped the students according to the final semester of education. The two semesters were similar in term of educational settings (hospital wards and facilities), clinical instructors, educational goals, and contents. Also, using of several raters (clinical instructors) can affect the students’ scores of the clinical performance; however, all raters were unchanged for both groups.
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The final limitation was related to the 13-item checklist developed to measure clinical performance. Missing data in some items on this checklist were due to the lack of opportunity for students to perform some procedures in a given clinical situation. Therefore, the researchers excluded the items (three items)
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with more than 20% of missing data from the analysis process. Hence, the presented score of clinical performance is limited to 10 items. Therefore, the changes noted in clinical performance was analyzed
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and reported on total and global scores.
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Shahsavari, H., Parsa Yekta, Z., Houser, M., & Ghiyasvandian, S., (2013). Perceived clinical constraints
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in the nurse student - instructor interactions: A qualitative study. Nurse Education in Practice.
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13(6), 546-552.
Stayt, L. C., & Merriman, C. (2013). A descriptive survey investigating pre-registration student nurses' perceptions of clinical skill development in clinical placements. Nurse Education Today 33(4), 425-430.
Teoh, Y. T. E., Pua, L. H., & Chan, M. F. (2013). Lost in transition—A review of qualitative literature of
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newly qualified Registered Nurses' experiences in their transition to practice journey. Nurse Education Today 33(2), 143-147.
Thrysoe, L., Hounsgaard, L., Dohn, N. B., & Wagner, L. (2010). Participating in a community of practice
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as a prerequisite for becoming a nurse–Trajectories as final year nursing students. Nurse
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Education in Practice, 10(6), 361-366. Watt, E., Murphy, M., MacDonald, L., Pascoe, E., Storen, H., & Scanlon, A. (2016). An evaluation of a structured learning program as a component of the clinical practicum in undergraduate nurse
education: A repeated measures analysis. Nurse education today, 36, 172-177.
Watt, E., Murphy, M., Pascoe, E., Scanlon, A., & Gan, S., (2011). An evaluation of a structured learning programme as a component of the clinical practicum in final year bachelor of nursing programme: a pre and post-test analysis. Journal of Clinical Nursing 20, 2286-2293.
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Watts, T.E., (2011). Supporting undergraduate nursing students through structured personal tutoring:
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Some reflections. Nurse Education Today 31, 214-218.
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Table 1 Comparison of demographic variables between intervention and control groups Characteristics
Intervention group (n = 81)
Control group (n = 79)
Statistical test P -value
Sex 47
X2=0.210 p= 0.647
34
36
22.00 ± 2.03
21.59 ± 2.13
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Age (Mean _ SD)
43
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Female (frequency) Male (frequency)
t=0.961 p=0.338 df=157
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Table 2 Comparison of the level of anxiety and clinical self efficacy between groups before and after the intervention Characteristics Intervention group Control group Statistical test (n = 81) (n = 79) P-value Mean _ SD Mean _ SD
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Anxiety 41.463 ± 13.626
43.025 ± 11.040
33.521 ± 8.496
42.013 ± 13.087
Before
6.141 ± 1.972
6.105 ±1.685
After
7.246 ± 1.358
Before
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Clinical Self Efficacy
p=0.442
t= 4.582 df=143
p= 0.00
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After
t= 0.769 df=146
6.500 ± 1.756
t= 0.120 df=152
p= 0.903
t= 2.958 df=153
p= 0.003
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(Based on students' scores in past clinical practicum)
18.228 ± 0.955
18.295 ± 0.788
3.925 ± 0.868
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Before
3.718 ± 0.524
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(Global scores on rating scales)
3.519 ± 1.060
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After (Sum score of rating scales)
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Table 3 Comparison of the clinical skills scores between groups before and after the intervention Intervention group Control group Statistical test and P Characteristics (n = 81) (n =79) value Mean _ SD Mean _ SD Clinical Skills
3.390 ± 0.821
t=.486 p=.628 df=157
t=2.643 p=.009 df=157 t=3.007 p=.003 df=157
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S1471-5953(17)30517-6
DOI:
10.1016/j.nepr.2017.08.006
Reference:
YNEPR 2257
To appear in:
Nurse Education in Practice
Received Date: 16 June 2016 Revised Date:
12 July 2017
Accepted Date: 6 August 2017
Please cite this article as: Shahsavari, H., Ghiyasvandian, S., Houser, M.L., Moghadam, M.Z., Kermanshahi, S.N., Torabi, S., Effect of a clinical skills refresher course on the clinical performance, anxiety and self-efficacy of the final year undergraduate nursing students, Nurse Education in Practice (2017), doi: 10.1016/j.nepr.2017.08.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
EFFECT OF A CLINICAL SKILLS REFRESHER COURSE ON THE CLINICAL ACCEPTED MANUSCRIPT PERFORMANCE, ANXIETY AND SELF-EFFICACY OF THE FINAL YEAR UNDERGRADUATE NURSING STUDENTS Hooman Shahsavari, PhD, RN, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences;
Shahrzad Ghiyasvandian, PhD, RN,
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Faculty of Nursing and Midwifery, Tehran University of Medical Sciences Corresponding Author: Dr. Shahrzad Ghiyasvandian, Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Nosrat St., Tohid Sq.,1419733171, Tehran, Iran Email: [email protected] Tel: (+ 98) 21 61054319, Cell phone: (+98)912-21303833 Fax: (+98) 21 66941668
Marian L. Houser, PhD,
Masomeh Zakeri Moghadam, PhD, RN,
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Associate Dean, Faculty Development & Academic Affairs, College of Fine Arts and Communication, Dept. of Communication Studies, Texas State University
Sosan Noori Kermanshahi, BSc, RN,
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Faculty of Nursing and Midwifery, Tehran University of Medical Sciences;
Faculty of Nursing and Midwifery, Tehran University of Medical Sciences;
Sedigheh Torabi, MSc, RN
Faculty of Nursing and Midwifery, Tehran University of Medical Sciences;
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Word count: 3800
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Acknowledgment We would like to thank all study participants and also School of Nursing and Midwifery, Tehran University of Medical Sciences.
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Highlights • Nursing curriculum can be strengthened through the clinical skills refresher course
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• The clinical skills refresher course can reduce students’ anxiety for nursing practice • The clinical skills refresher course can increase students’ clinical self-efficacy
• The clinical skills refresher course can promote nursing students’ clinical abilities
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• The clinical skills refresher course can bridge the nursing theory – practice gap
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INTRODUCTION The bachelor of nursing education program in Iran is a four-year program that includes eight sequential semesters with a fixed, national curriculum determined by the Ministry of Health and Medical
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Education (MoHME). During the first semester of the first year, nursing students are taught clinical skills in a clinical skills lab in the nursing school. When they pass clinical skills’ lab training, they enter into a set of different supervised practicums in hospitals and other clinical settings for the remaining five
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semesters. During the first three years (six semesters), students should become prepared for the final year of education that is a combination of semi- to non-supervised practicum and internship in two semesters.
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This internship program is designed to facilitate students’ transition to the role of the registered nurse. Unfortunately, due to the weaknesses and problems inherent within various clinical settings, some students do not properly/correctly experience all necessary clinical nursing skills. Some students may gradually deviate from standard performance procedures. Aein et al. (2010) reported a serious problem in clinical nursing education programs as “learning from observing inappropriate practice of some
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professional nurses” (p. 195). In Iran, newly graduated nurses reported the clinical incompetency (Joolaee et al., 2015) similar to what has been reported in China (Liao et al., 2016), Australia and UK (Lima et al., 2014). Senior nursing students and newly graduated nurses are well aware of their clinical incompetency
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and consequently experience high levels of anxiety with low self-confidence (Joolaee et al., 2015). Entering students into the internship program with such anxiety and uncertainty can reduce the
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educational effectiveness of their educational final year (Aein et al., 2010). Therefore, in Iran, one of the main concerns of the nursing educational system has always been improving the nursing internship program by introducing new effective strategies. It was assumed that the use of a refresher course in basic clinical skills can empower students to practice independently and improve the quality of the internship program. BACKGROUND
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Nursing is a practice-based discipline. Therefore, clinical competencies are required for all nurse students and practicing registered nurses to ensure that they can meet the clinical needs of patients (Shahsavari et al., 2013). The undergraduate nursing education program is responsible for preparing
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nursing students to properly perform their nursing duties in complex health care systems. These programs must also provide a successful transition to the official nurses’ role. Clinical education and theoretical education play a pivotal role in students’ successful experiences. Oermann et al. (2015) believe that
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during the nursing program, some students have not been provided with opportunities to reach the
proficiency level. Stayt et al. (2013) emphasized that irregularities in clinical skill development makes
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nursing graduates incompetent and increase the possibility of unsafe practice.
It is indicated that most new graduates may not possess clinical competencies required to perform the duties of registered nurses (Liao et al., 2016). Because of a lack of self-efficacy, nurses experience high levels of stress and anxiety (Joolaee et al., 2015). The detrimental effects that are related to a lack of sufficient skills in performing the most practical tasks are considerable. According to Newton et al.
of their preparation.
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(2007), one of the obstacles to the transfer of students to the nurse's role is improving our underestimating
The final year of the nursing education program for the proper transition to the professional role
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is a critical stage. In this regard, Nash et al. (2009) expressed that the final year acts as a pre-transition process and enables nursing students to “build their clinical confidence and consolidate their clinical
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skills, while also developing positive professional qualities and work attitudes” (p. 49). Teoh et al. (2013) emphasized on the role of “tailored graduate program, realities of practice and support and coping mechanism” (p. 144) as the determinants of the appropriate transition to practice journey. Many different educational models and programs have been proposed to assist the schools of nursing in creating support for students during this final year. One-year internships (Heslop et al., 2001), supervised clinical practicums (Budgen et al,. 2008), preceptorships (Watt et al., 2016), mentorships (Lúanaigh, 2015), the collaborative model of clinical placement (Nash et al., 2009), community of practice (CoP)( Thrysoe et
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al., 2010), reflective practices (Rees, 2013), simulated learning environment (Liaw et al., 2014; Mills et al., 2016) and fitness for practice curriculum model (Holland,, 2010) have also been suggested to help students get prepared for practice. The goal of each model is to empower nursing students to take on the
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nursing role upon graduation. These educational models are imperative as the feelings of incompetence in clinical skills can influence how nursing students approach their future profession. According to previous studies, the
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formation of such feelings typically occurs prior to graduation (Cantrell and Browne, 2005) and can act as a source of anxiety and stress among nursing students (Gaberson et al., 2010). In addition, the sense of
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inadequacy can cause students to leave the nursing profession prematurely (Cantrell and Browne, 2005). Clinical incompetence and the fear following it in new graduates can lead to job dissatisfaction, reduce quality of care, increase legal liabilities and negatively impact retention (Kenny et al., 2016). Nursing educators and planners hold the key to reduce anxiety felt by nursing students. Therefore, strategies should be devised to eliminate or resolve this troubling experience (Reeve et al., 2012). The current study
OBJECTIVES
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assesses the effect of the clinical skills refresher course to promote confidence among nursing students.
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To investigate the effect of a refresher course tailored for undergraduate nursing students during the final year on their clinical performance, anxiety and self-efficacy.
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METHODS
Design
This was a nonrandomized controlled trial. A pretest-posttest design with a nonrandomized
control group was utilized. The sample was consisted of 160 final year undergraduate nursing students, that were prepared to enter their one-year internship program in the largest medical science university in Iran. The intervention was a three-day basic clinical skills refresher program in a clinical skills lab.
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Participants and Setting All students (n = 160) were beginning the final year of the bachelors nursing program including the one-year internship. They passed all theoretical credits of the nursing bachelor’s curriculum had the
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experience of caring for patients in different clinical wards in the supervised clinical practicum. Because of administrative and educational constraints and to prevent contamination, they were recruited from two sequential semesters, were assigned to either intervention or control groups using a nonrandom method.
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Therefore, all students entered to the final year were assigned to the control group (n=79) and the
following semester, another new student group entered their final year of the bachelor program was
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assigned to the intervention group (n=81).
Inclusion criteria were: 1) senior student in the nursing bachelor program, 2) eligible to enter the internship program (e.g., passing all previous credits and courses) and 3) no existing work experiences in nursing except the formal educational experience within the current nursing program. Exclusion criteria were 1) no desire to participate in the study, 2) physical or mental disability (e.g., a psychological
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disorder such as depression and chronic anxiety according to students’ self-report) and 3) lack of willingness to continue participation in the study.
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Data Collection Tools
Three measures were considered outcome measures for this refresher course: level of anxiety, clinical
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self-efficacy and clinical performance. In addition, demographic data of the students was collected. To examine student anxiety, the Spielberger’s State-Trait Anxiety Inventory (STAI) (only situational anxiety) was used. To measure clinical self-efficacy, the researchers used an instrument developed by Cherghi et al., (2010), for the Iranian context. Finally, clinical skills were assessed by a 13-items checklist developed by the researchers. The Spielberger’s inventory is a self-report instrument that has been used extensively in research and clinical practice (Debyser et al., 2011). This instrument was comprised of two subscales: the State-
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Anxiety form (S-Anxiety) that assessed the situational anxiety and the Trait-Anxiety form (T-Anxiety) that assessed personal anxiety (Debyser et al., 2011; Palese et al., 2012). Each subscale was consisted of 20 items with a 5-point Likert-scale (1= not at all and 5=very much). The scores for each subscale ranged
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from 20 to 80 with higher scores representing higher anxiety. Reliability and validity of this scale were reported adequate (Debyser et al., 2011; Palese et al., 2012). The Cronbach's alpha coefficient of the stateanxiety subscale of the Farsi version of this instrument was reported as 0.9. The clinical self-efficacy
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instrument was developed by Cheraghi et al., (2010) as a self-report instrument with 37 items and a 10point Likert scale with four subscales. Based on the Cheraghi et al.'s report, concurrent validity of this
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instrument by comparison with the general self-efficacy questionnaire was acceptable (p<0.01). Also, the reported Cronbach's alpha coefficient (α = 0.96) indicated a good internal consistency of this instrument. The Cronbach's alpha coefficient for dimensions ranged between 0.90-0.92. The test-retest with a two week-interval demonstrated the acceptable reliability of this instrument (r = 0.94) (Cheraghi et al., 2010). The clinical skills’ rating scale for measuring practical performance of the students had 13 items related to
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10 basic clinical skills. They included intramuscular injection, intravenous injection, subcutaneous injection, suction, nasogastric tube insertion, gastric tube, intravenous catheter insertion and IV therapy, blood sampling and wound dressing. Each item could be rated from 1-not satisfactory to 5 completely
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satisfactory. The clinical performance of each nursing student was assessed by a rater (clinical instructor). One question was added to this questionnaire to obtain a global rating of the students’ clinical
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performance by the rater. Finally, the sum of all scores of items was reported as the student score of clinical performance. Before using this scale, it was tested with 16 pairs of observations in the clinical skills lab. Inter-rater reliability was measured via Cohen's Kappa. The scale showed a high level of rater’s agreement with each item scoring above 0.71 and with an overall score of 0.813. Procedure The list of all final year nursing students was stored in the education office and all eligible students from this list were invited to a briefing session and were informed about the study purposes. Those instructors
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who participated in the study were also identified and informed about the study and their roles as trainers in the clinical skills lab or assessors in a clinical setting. The same instructors were maintained for both control and intervention groups.
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Due to the constraints of the educational program, all students who entered into their final year of the study were assigned to the control group. During the next semester, all new students who entered into their final year were chosen for the intervention group. For baseline information, the student age, gender
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and the mean score of their third year practicum were gathered. Before beginning their first year of the internship program, the students in the control group completed the initial measure of the clinical self-
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efficacy and anxiety questionnaires. The intervention group, on the other hand, completed a 3-day refresher course of basic clinical skills that focused on 10 basic skills in a clinical skills lab. The basic skills were selected based on clinical instructors’ and students’ comments about the most common procedures, which is used in clinical situations. Specifically, these selected skills were intramuscular injection, intravenous injection, subcutaneous injection, airway suction, inserting a nasogastric tube,
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nasogastric tube feeling, intravenous catheter insertion and IV therapy, blood sampling and wound dressing. For teaching purposes, during the first day of the refresher course, students in the intervention group were divided into eight groups of ten (one group eleven). Time limit and organizational constraints
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led us to plan this refresher course for three days. Each of the groups was assigned to a room within a clinical skills lab with an experienced instructor where the refreshing was conducted in four sequential
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parts: the particular procedure demonstrated by the instructor; a discussion on students' real experiences with the specific procedure; student supervised exercises and student-led exercises. All procedures were performed on human models and mannequins. After that the intervention groups completed their 3-day refresher course, the students returned to their routine internship program. Two weeks after the start of their routine internship program, all students again completed the anxiety and clinical self-efficacy questionnaires. Following this, the clinical instructors assessed students' clinical performance via the clinical skills rating scale, and finally gathered data was analyzed. Data Analysis
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The study participants completed two questionnaires at baseline and a few added questions about demographic information. Data were analyzed using the Statistical Package for the Social Science (SPSS version 16). During the analysis, the level of significance (a significant difference) was set at 0.05
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for all statistical tests. The normality of the distribution was assessed for all study variables. The chisquare test (for categorical variables) and the t-test (for continuous variables) were used for the
comparison between groups regarding baseline collected information. Since all collected data from
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anxiety, clinical self-efficacy, and clinical performance instrument were continuous, t-test was conducted to compare the scores of the students in the intervention and control groups.
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Ethical Considerations
This study was approved by the Ethics Committee of Research of Tehran University of Medical Sciences. The researchers informed the students about the research purposes, potential benefits and disadvantages of participation, the option to refuse to participate, and confidentiality of their information. Once the informed consent form was signed, the participants were assured that the result of the study had
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no effects on their evaluation.
RESULTS
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All questionnaires were completed and returned by the students and observers. Missing data was unremarkable, except in the clinical skills rating scale. For this rating scale, 3 items were excluded for the
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data analysis, because missing data was higher than 20%. There were no statistically significant differences between the groups in terms of gender and age. Baseline characteristics and comparison data of the participants for two groups were presented in table 1. The mean scores of pre- and post-intervention anxiety for groups’ comparison were presented in table 2. The mean score of anxiety just before starting the internship at the beginning of the final year of the bachelor program for both group was 42.30 (SD=12.30). No significant difference in the mean scores of anxiety between the groups before the intervention (p=0. 442, df=146). Following the intervention and second completion of the measures, the mean anxiety score was significantly different from the control in
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comparison to the intervention groups (p=0.000, df=143). The change in anxiety score from the first measure to the second measure in the control group was non-significant (p=0.78, df=75); in contrast, the change score was significant for the intervention group (p=0.00, df=69).
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The mean scores for pre- and post-intervention clinical self-efficacy and the comparison between the groups were presented in table 2. No significant difference in the mean scores of clinical self-efficacy between the groups before the intervention was reported (p=0. 90, df=152). After the second measure, the
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mean score for clinical self-efficacy was significantly different between the groups (p=0. 003, df=153). The change in clinical self-efficacy from the first measure to the second semester in the control group was
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non-significant (p=0.54, df=76); in contrast, this change was significant for the intervention group (p=0.00, df=76).
The total mean score for the third year clinical practicum (Medical-Surgical practicum) participants and the mean score of clinical performance after the intervention and group comparison scores were presented in Table 3. No significant difference in the mean score of the third year clinical practicum between the
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groups before the intervention was reported (p=0. 628, df=157). Following the intervention, the two groups were different significantly in both the sum (p=0. 009, df=157) and global (p=0. 003, df=157) scores for clinical performance.
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DISCUSSION
The results of this study indicated that before entering the internship program, final year nursing
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student experienced moderate levels of anxiety. While the source of this anxiety is not only the feelings of inadequacy in clinical skills, such a feeling has a huge impact students. The refresher course in basic clinical skills prior to entering the internship period significantly reduced students’ anxiety. Previous studies showed a high level of anxiety among nursing students and newly graduated nurses as they entered the workplace and a hospital internship (Grobecker, 2016; Higgins et al., 2010). Similarly, Christensen et al. (2016) reported moderate anxiety, feeling of self-doubt and inadequately among nursing students in the final year of their bachelor program. Enhancing the clinical skills of students through a
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short refresher course within a clinical skills lab could reduce their anxiety prior to entering the internship. This finding is of vital importance to the bachelor of nursing program as a previous study showed that a primary source of stress in new nursing graduates was the feeling of clinical incompetency
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in completing clinical tasks (Higgins et al., 2010). The feelings of inadequacy to take on the professional nursing role, its related anxiety and the resultant decision to leave nursing consistently develop in the final year of the bachelor of nursing program. Such feelings are typically triggered among those students who
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become aware of their inability and forthcoming legal responsibilities (Cantrell and Browne, 2005). Christensen et al. (2016), emphasized the role of the curriculum in students’ perceived preparedness for
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practice. Hence, they believed that difference between graduates’ feeling of preparedness in New Zealand, UK and Australia were due to differences in their curricula. Holland et al. (2010) with regard to the fitness for practice curriculum model in Scotland, the UK stated that the recent nursing graduates were “fit for practice”. They stressed that earlier concerns that nursing students were ‘unfit for practice’ emphasized the perceived lack of clinical skills at the point of registration not on competence to practice.
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Therefore, addressing competence is more important than just dealing with procedural skills. The present study indicated that the creation of a simulated environment in clinical training skills via the safe learning situation promoted the competent practice of clinical skills and reduced anxiety. Similarly,
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previous studies acknowledged that while the clinical setting itself was a unique learning situation, students still perceived it as a stressful and threatening situation (Pulido-Martos et al., 212). Simulated
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clinical environments, on the other hand, not only offer the benefits of actual clinical settings (Foronda et al., 2013) but also help reduce students' anxiety (Ignacio et al., 2016). In addition, in this study, the improvement of clinical self-efficacy for nursing students who participated in being retrained in basic clinical skills programs was realized. Self-efficacy could influence initiating behaviors and also the degree of persistence applied to overcoming barriers to fulfill a task (Rice, 2015). It was linked to a sense of well-being in nursing students (Gibbons et al., 2011). Furthermore, Gibbons et al. (2011) suggested that self-efficacy alone could be a good adaptive strategy to combat stress and
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anxiety. On the other hand, Watt et al. 2016 reported that student’s self-efficacy could be affected by increased anxiety. Although the one-year internship course in the final year of the bachelors’ in nursing program is
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incredibly useful, it appears that a reinforcement program, such as refresher basic clinical skills, adds to the confidence students feel in the real situations. This mirrors the finding of a previous study that also stresses the need for a course to provide nursing students professionally as they took on their roles in
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clinical situations (Nash et al., 2009). The deterioration of clinical skills is a major problem unless
refresher training is provided (Bhoi et al., 2016). Using clinical skills improvement modalities such as a
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short basic clinical skills refresher program can better prepare students to engage in their role as nurses (Everett-Thomas et al., 2016). Watts et al. (2011) concurred and suggested that a three-day simulation training course in clinical nursing skills should help reduce anxiety and improve self-efficacy. CONCLUSIONS
This experimental study introduced a short and inexpensive educational course based on a basic clinical
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skills refresher in a clinical skills lab to help students effectively complete their final year of the bachelors of nursing program. The short refresher course for basic clinical skills in clinical skills lab can provide nursing students an opportunity to improve their clinical performance, increase their levels of self-
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efficacy and reduce their anxiety. In addition, the advantages of conducting basic clinical skills training in clinical skills lab should not be limited and could prove even prove useful for junior students in the
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primary years of the nursing education program. The documented benefits for senior nursing students completing a refresher course include educational and clinical benefits that assist with a smoother transition from student nurse to registered nurse. As an extended benefit of this research project, it is hoped to inspire nurse educators, nurse experts, nurse leaders and curriculum designers both nationally and internationally to incorporate a clinical skills refresher course for senior nursing students at some time during their senior year of the bachelor of nursing program. In many countries, all staff nurses are not a good role model for students to learning clinical skills. This problem can be there in nursing education in
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other countries. Dealing with such improper role models in the clinical environment is unavoidable for nursing students. Therefore, before graduation students need to have an opportunity to refresh their clinical skills. In this study,the refresher course was limited to three days with 10 basic clinical skills
of time and content given the contextual characteristics. Limitations of the study
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program, but it should be noted that more studies are needed to offer the best refresher program in terms
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The main limitation of this study was the inevitable nonrandom allocation of the control and intervention groups. A true random sampling was not possible due to educational and institutional constraints. In
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response to this limitation, the researchers grouped the students according to the final semester of education. The two semesters were similar in term of educational settings (hospital wards and facilities), clinical instructors, educational goals, and contents. Also, using of several raters (clinical instructors) can affect the students’ scores of the clinical performance; however, all raters were unchanged for both groups.
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The final limitation was related to the 13-item checklist developed to measure clinical performance. Missing data in some items on this checklist were due to the lack of opportunity for students to perform some procedures in a given clinical situation. Therefore, the researchers excluded the items (three items)
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with more than 20% of missing data from the analysis process. Hence, the presented score of clinical performance is limited to 10 items. Therefore, the changes noted in clinical performance was analyzed
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and reported on total and global scores.
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Some reflections. Nurse Education Today 31, 214-218.
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Table 1 Comparison of demographic variables between intervention and control groups Characteristics
Intervention group (n = 81)
Control group (n = 79)
Statistical test P -value
Sex 47
X2=0.210 p= 0.647
34
36
22.00 ± 2.03
21.59 ± 2.13
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Age (Mean _ SD)
43
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Female (frequency) Male (frequency)
t=0.961 p=0.338 df=157
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Table 2 Comparison of the level of anxiety and clinical self efficacy between groups before and after the intervention Characteristics Intervention group Control group Statistical test (n = 81) (n = 79) P-value Mean _ SD Mean _ SD
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Anxiety 41.463 ± 13.626
43.025 ± 11.040
33.521 ± 8.496
42.013 ± 13.087
Before
6.141 ± 1.972
6.105 ±1.685
After
7.246 ± 1.358
Before
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Clinical Self Efficacy
p=0.442
t= 4.582 df=143
p= 0.00
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After
t= 0.769 df=146
6.500 ± 1.756
t= 0.120 df=152
p= 0.903
t= 2.958 df=153
p= 0.003
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(Based on students' scores in past clinical practicum)
18.228 ± 0.955
18.295 ± 0.788
3.925 ± 0.868
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Before
3.718 ± 0.524
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(Global scores on rating scales)
3.519 ± 1.060
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After (Sum score of rating scales)
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Table 3 Comparison of the clinical skills scores between groups before and after the intervention Intervention group Control group Statistical test and P Characteristics (n = 81) (n =79) value Mean _ SD Mean _ SD Clinical Skills
3.390 ± 0.821
t=.486 p=.628 df=157
t=2.643 p=.009 df=157 t=3.007 p=.003 df=157
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