- Email: [email protected]
Effects of Community Volunteer Children on Student Pediatric Assessment Behaviors
Clinical Simulation in Nursing (2017) 13, 303-308
www.elsevier.com/locate/ecsn
Featured Article
Effects of Community Volunteer Children on Student Pediatric Assessment Behaviors Laura Kubin, PhD, RN, CPN, CHES*, Cecelia Elaine Wilson, PhD, RN, CPN Texas Woman’s University, T. Boone Pickens Institute of Health Sciences Dallas Center, The Houston J. and Florence A. Doswell College of Nursing, Dallas, TX 75235, USA KEYWORDS human patient simulation; high-fidelity simulation; community volunteer children; undergraduate nursing student; simulation; pediatric assessment simulation; pediatric Student Comfort and Worry; undergraduate nursing student stress, anxiety, worry, clinical, simulation
Abstract Background: According to undergraduate nursing students, clinical experiences produce a high degree of stress and anxiety, especially when those experiences involve children. Simulation has been shown to teach assessment skills, and allow experiential and active learning resulting in an increase in the level of a student’s comfort with performance of these skills. However, even with the practice of simulation, only a small number of students report feeling comfortable with assessment. Other experiential opportunities involving standardized patients have been widely used with adult populations; however, there is very little literature describing the use of children as standardized patients. One study with nursing assessment students found that students reported more self-efficacy with community volunteers than high-fidelity simulators. The purpose of this study was to examine the impact of using community volunteer children on physical assessment abilities and comfort levels among undergraduate pediatric nursing students. Methods: Students were administered the Pediatric Student Comfort and Worry Assessment Tool at the beginning of the semester and following intervention. After a didactic class, students were randomly assigned to two groups. One group practiced assessment on high-fidelity simulators programmed to provide verbal feedback to allow for interaction. The second group practiced assessment on community volunteer children. Students were self-evaluated and faculty-evaluated completing a pediatric assessment using the Effective Noticing and Responding domains of the Lasater Clinical Judgment Rubric. Results: Overall, students had similar worry and comfort scores regardless of group; additionally, assessment performances were similar. However, students in both groups significantly rated their observations higher than faculty members. Conclusions: The use of simulation to practice pediatric assessment prior to exposure in the clinical setting is beneficial in reducing student anxiety and stress; however, there may be no difference between practicing assessment on high-fidelity manikins versus community volunteer children. Although one modality did not seem to affect student stress and anxiety over another modality, student satisfaction was positively influenced by working with community volunteers. Cite this article: Kubin, L., & Wilson, C. E. (2017, July). Effects of community volunteer children on student pediatric assessment behaviors. Clinical Simulation in Nursing, 13(7), 303-308. http://dx.doi.org/10.1016/ j.ecns.2017.04.011. Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
The authors have no conflicts of interest or financial disclosures. * Corresponding author: [email protected] (L. Kubin). 1876-1399/$ - see front matter Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2017.04.011
Effects of Community Volunteer Children
304
Purpose The purpose of this study was to compare the findings of using community volunteer children versus high-fidelity simulators on the physical assessment abilities and comfort levels with pediatric patients among undergraduate Key points baccalaureate nursing stu The purpose of this dents. The hypothesis was study was to examine that undergraduate nursing the impact of using students who practiced pecommunity volunteer diatric assessments on comchildren on physical munity volunteer children assessment abilities and would report a higher level comfort levels among of comfort and lower levels undergraduate pediatric of worry and demonstrate nursing students. more effective noticing and Students were randoresponding behaviors durmly split into one of ing pediatric assessment in two groups to practice the clinical setting than stupediatric well-child asdents who practiced on sessments. One group high-fidelity simulators. practiced assessments on high-fidelity simulators, and one group Background practiced on community volunteer children. High-fidelity simulation can Students completed a enhance critical thinking, pre- and post- intervenclinical judgment, and clintion Pediatric Student ical decision making Comfort and Worry (Beauchesne & Douglas, Assessment Tool, and 2011; Hayden, Smiley, were evaluated comAlexander, Kardongpleting a physical asEdgren, & Jeffries, 2014; sessment in the clinical Ironside & Jeffries, 2010; setting. Witherspoon, Phillips, & Overall, students had Wyatt, 2015). The use of similar worry and simulation is increasingly comfort scores and being used to replace and/ assessment performaor enhance clinical learning nces regardless of in nursing education. group. Immersing students in a simulation of real-life experience has been shown to be an effective experiential learning strategy, especially when it is used to complement existing learning activities (Hayden et al., 2014; Miller, 2014; Omer, 2016). Simulation has been well established to enhance nursing student confidence and self-efficacy and to decrease anxiety (Bultas, 2011; Luctkar-Flude, Wilson-Keates, & Laroque, 2012; Megel et al., 2012). Nursing students experience a high degree of anxiety associated with clinical experiences and even more anxiety during experiences involving children (Al-Qaaydeh, Lassche, & MacIntosh, 2012; Lassche, Al-Qaaydeh, MacIntosh, & Black, 2013; Megel et al., 2012). Lassche
et al. (2013) explored factors that produced worry related to nursing students caring for pediatric patients. Assessment and causing pain were the factors causing more worry. Following exposure in the clinical setting, comfort with assessment changed the most, whereas fear of causing pain changed the least. Megel et al. (2012) studied the effects of high-fidelity simulation on anxiety before pediatric clinical and found that simulation decreased anxiety. Standardized patients (SPs) and community volunteers have been used in simulation extensively in medical education and advanced practice nursing education. The use of SPs in prelicensure nursing education is becoming more common, primarily in adult simulation settings. Bornaism, Raiger, Krahn, and El-Masri (2012) compared the outcomes of first semester nursing students practicing health assessments on SPs versus on peers and found that the SP group had better performance outcomes than the peer group. Hampson and Cantrell (2014) used SPs in the maternalenewborn setting. Students conducted postpartum assessments on SPs and newborn assessments on manikins. The study results indicated increased student perceptions of self-confidence and critical thinking skills. In a study comparing assessment skills in students in three groups (high-fidelity simulators, SPs, and community volunteers), there were no differences in student self-efficacy. However, students in the high-fidelity simulation group demonstrated higher performance behaviors but had lower satisfaction scores (Luctkar-Flude et al., 2012). There is very little literature describing the use of SPs or community volunteers in pediatric simulation. In an article outlining a simulation program, Anderson, Holmes, LeFlore, Nelson, and Jenkins (2010) discuss using simulation in pediatrics only for history taking and communication. SPs are suggested only as parents, grandparents, and adolescents. Loprieto and Sawyer (2015) state that pediatric simulation-based education is in a growth phase and will continue to increase over the next decade. Using children as actual ‘‘patients’’ in pediatric simulations could serve not only to increase students’ performance outcomes and self-confidence but also, more importantly, to decrease student anxiety and worry related to working with children.
Theoretical Framework Benner’s (2001) novice to expert theory was used as the framework for this study. According to Benner, a novice is new to an experience and is unable to translate skills to the new area that can increase anxiety. They are inflexible and follow inflexible rules that obstruct their growth and judgment and limit their ability to predict what will happen next. Concepts and strategies from Kolb’s experiential learning theory were also applied in this study. Transformation is a concept discussed at length within Kolb’s
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theory. According to Kolb (1984, 2016), participation in real-life experiences allows students the opportunity to undergo a transformation by progressing through the stages of the learning cycle. One experiential strategy used was the immersion of the students into an experience using volunteer children as their simulated patients.
Methods Participants After institutional review board’s approval, an experimental pre- and posttest study with a convenience sample of 99 undergraduate baccalaureate nursing students in a pediatric nursing course was conducted. These students were in the third semester of a four-semester program at a large public university.
Instruments The Pediatric Student Comfort and Worry Assessment Tool (Al-Qaaydeh et al., 2012) measures student comfort and worry related to caring for pediatric patients using a Likert-type scale in two subscales. The first subscale asks six questions related to student comfort with the pediatric clinical setting regarding assessment, explaining procedures and medications to children, administering medications to children, helping children cope with pain, and providing support in times of crisis. The second subscale asks five questions about clinical rotation worries regarding caring for an ill child, causing physical or emotional harm, causing pain, and interacting with a child’s family. Face validity of the questions was determined by a review of nursing and nursing education experts. Further factor analyses were conducted on the questions to determine construct validity. Internal consistency was found to be acceptable using Cronbach’s alpha (comfort ¼ 0.806, worry ¼ 0.766). Lassche et al. (2013) used the tool with students to determine its usability. The researchers found that students used the tool appropriately and completed the tool in less than ten minutes. This tool was used in this study, with permission, to assess student comfort and worry with assessing pediatric patients. The Lasater Clinical Judgment Rubric (Lasater, 2007) provides performance expectations to evaluate an event requiring clinical judgment. The rubric is divided into 11 dimensions in four domains: effective noticing, effective interpreting, effective responding, and effective reflecting. Each dimension is evaluated by four developmental levels: exemplary, accomplished, developing, or beginning. The noticing domain includes the dimensions of focused observation, recognizing abnormals, and information seeking. Maintaining a calm and confident manner, clear communication, well-planned interventions, and being skillful are dimensions included in the responding domain. Because these skills are
most relevant to pediatric assessment, only these domains were used to evaluate students in this study.
Procedure At the beginning of the semester, all students were administered the Pediatric Student Comfort and Worry Assessment Tool (Lassche et al., 2013). After a classroom presentation and hands-on skills lab providing theoretical and didactic content about pediatric assessment, students were randomly split into one of two groups to practice pediatric well-child assessments. One group practiced assessments on high-fidelity simulators, and one group practiced on community volunteer children. Students in each group were given 20 minutes to assess their assigned ‘‘patients.’’ As a normal teaching methodology in this pediatric course each semester, students participate in a high-fidelity assessment simulation. During the semester of this study, the opportunity arose to involve children in this simulation. Therefore, because this portion of the study was considered a teaching methodology, only those students randomized to the community volunteer group assessed children. The methodology was not repeated for the other group. High-fidelity Simulation Group Simulators were programmed with age-appropriate vital signs and assessment findings within normal limits for a well-child assessment to be consistent with the ages of the children in the community volunteer group. Simulators were programmed to provide verbal feedback to students so that interaction would be as realistic as possible. There were no parents present in the high-fidelity group. Faculty were present to guide students through the assessment and to answer questions. Community Volunteer Children Group There were ten community volunteer children aged 6 months to 5 years with no significant medical history. Children were not given scripts to follow or coached to behave in any particular manner. Children were given age-appropriate toys to keep them occupied during the activity. Parents accompanied the community volunteer children, and faculty were present to guide students through assessments and answer questions. Students rotated through the cohort of community volunteer children in groups of ten, every 20 minutes (one student/child), so each child served as a ‘‘patient’’ for up to five students in a two-hour period. All students then completed a pediatric assessment during their first inpatient clinical day at a pediatric facility. Using the effective noticing and responding domains of the Lasater Clinical Judgment Rubric (Lasater, 2007), students’ assessment behaviors were self-evaluated and faculty-evaluated. Immediately following the inpatient assessment, students completed a postintervention Pediatric Student Comfort and Worry Assessment Tool survey (Lassche et al., 2013).
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Results
Regardless of group, students rated their observation higher than faculty members.
Student Comfort and Worry
Student and Faculty Comments
There were 45 students in the Community Volunteer Children group and 54 students in the High-Fidelity Simulation Group. A 2 (time) by 2 (group), factorial analysis of variance (ANOVA) was conducted to test for differences in student’s perceived distress related to pediatric nursing as measured by the Pediatric Comfort and Worry Assessment Tool. Students reported significantly greater comfort and less stress at posttest than at pretest on the following measures related to comfort with the pediatric clinical setting: performing a pediatric assessment and explaining procedures/medications/therapies to a child, administering medications to a child, and administering therapy to a child (p < .01). However, there was not a significant main effect of group on any of the measures, indicating that overall students had similar scores regardless of whether or not they received practice with community volunteers. There was a significant interaction effect of time and group on the following measures on both subscales: administering medications to a child, providing support to children and their families during times of crisis and grief, worry about caring for an ill child, and worry about causing pain (p < .05). Those in the simulation group had significant pre/posttest differences on the following measures in the comfort with clinical setting subscale: providing support to children and their families during times of crisis and grief and helping children and their families cope during painful procedures (p < .05). Whereas those in the community volunteer group had significant pre/posttest differences on the following measures of the clinical rotation worry subscale: worry about causing a child pain and worry about caring for an ill child (p < .05).
Assessment Measures (Self-Evaluation) A 2 (time) by 2 (group), factorial ANOVA was conducted to test for differences in student’s perceived ability to perform clinical assessments. There was not a significant main effect of group on any of the domains measured, indicating that overall students had similar scores regardless of whether they practiced on community volunteers.
Assessment Measures (Student and Faculty Evaluation) A 2 (rater) by 2 (group) factorial ANOVA was conducted to test for differences in student’s performance on clinical assessments at posttest. There was not a significant main effect of group on assessment performance, indicating that students in both groups had similar performance. There was a significant effect of rater on the observation scores.
Students were given an opportunity on the final course evaluations to provide open-ended comments regarding this experience. Students commented that the practice session was a valuable experience and made them feel more comfortable about pediatric assessment prior to entering the clinical setting. One student stated that ‘‘The assessment lab was helpful in allowing us to practice before we had to do it on real kids. Even though we’ve had assessment before, this was a good review.’’ Students in the community volunteer group stated that working with the children helped them to feel more comfortable interacting with children: ‘‘I was afraid to approach the child and did not know how to begin an assessment, but once I got in there with a real child, it was not so bad.’’ Another student stated that ‘‘I would have not been able to do this in the hospital without seeing a normal child first.’’ Students in the high-fidelity simulation group overwhelmingly commented that they were disappointed that they did not have the opportunity to practice on ‘‘real’’ children: ‘‘I suggest that all students have the opportunity to assess the kids before going to the hospital because even though it was helpful to practice on the mannequin, I think it would make us feel more comfortable.’’ Another student commented that ‘‘I was really sad I did not get the experience of working with the real kids, I think I would have learned more if I could have practiced with the them.’’ During a faculty team meeting to plan for the next semester, faculty discussed student outcomes and evaluation of the simulation. Faculty commented that during the simulation, students in the community volunteer group were more engaged, noticed more developmental milestones, and overall interacted more appropriately with children. Several faculty stated that ‘‘In the hospital, they missed several things during their assessments, and it did not matter what group they were in during the simulation.’’ Yet, another faculty commented that ‘‘I did notice that the students who assessed the community volunteer children did pick up on developmental milestones much better than the other students.’’ Finally, one faculty member stated ‘‘I think most of the students interacted well with the children, but the ones who assessed the community volunteers seemed to be less hesitant and jumped in easier than the students who were with the simulators.’’
Discussion Study results indicate that having students practice pediatric assessments prior to clinical experiences can reduce stress and worry whether they practice with high-fidelity simulators or community volunteer children. Overall,
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students in this study had similar scores regardless of group and reported decreased worry and stress from pre- to posttest. The area with the greatest change was being comfortable in performing a pediatric assessment, which is consistent with the findings reported by Lassche et al. (2013). Posttest scores revealed an increase in comfort for the high-fidelity simulation group with helping children and their families cope during painful procedures and providing support to children and their families during times of crisis and grief. These findings are interesting because the simulation group did not interact with children or parents during the practice. Another interesting finding is that students in the community volunteer group reported less worry on posttest about causing a child pain and about caring for an ill child. Lassche et al. (2013) reported that worry about causing a child pain was the most significant source of anxiety for nursing students pre- and postclinical exposure and suggested this as an area for educational improvement. Findings of this present study suggest that prior exposure to community volunteers and the ability to interact and communicate with children and their families prior to clinical exposure might positively influence this factor. Assessment behaviors were similar for both groups. However, students in both groups rated their assessment behaviors higher than faculty members. Mehrdad, Bigdeli, and Ebrahimi (2012) conducted a study evaluating clinical skills of junior nursing students comparing evaluations of self, peers, and clinical teachers. This study found a significant correlation between the self- and peer evaluations but no correlation between the clinical teacher and the self- or peer evaluations. Thus, suggesting that self- and peer evaluations are not a good substitute for clinical teacher evaluations of student clinical skills. However, other studies have found positive correlations between student, peer, faculty, and even patient evaluations (Adib-Hajbaghery, Karbasi-Valarheri, & Heidari-Haratmeh, 2012; Sadeghi & Loripoor, 2016). Therefore, the validity of student self-evaluation versus faculty evaluation requires further study.
Limitations The small sample size in this study was a limitation; repeating the study with a larger sample is recommended to increase the generalizability of the study results. Additionally, this study was conducted in a single educational institution with only baccalaureate nursing students that limits generalizability. Other limitations that might have affected the outcomes of the results of this study include the background of students. Demographic data were not collected; therefore, prior and concurrent experience with children, work experience, and other factors that may influence stress and worry were not evaluated.
Although faculty were present during the practice sessions to provide guidance and answer questions, it was noted that students were confused about how to proceed with assessments. Students in the community volunteer group were reluctant to approach the children and take initiative to begin assessments without prompting from faculty and/or parents. Community volunteer children were not given scripts to follow or coached on how to behave during the simulation. Although this was intentional to allow for students to experience realistic child behaviors during assessments, this lack of control of variables between children may have affected study results.
Conclusions This is one of few studies to evaluate the use of child community volunteers in teaching pediatric assessment to undergraduate nursing students. Results of this study indicate that practicing pediatric assessment prior to beginning clinical experiences is beneficial to decreasing student stress and anxiety; however, there may be no difference between practicing assessment with high-fidelity simulators versus community volunteer children. Both experiential strategies demonstrated a benefit to the student in contributing to a decrease in student stress and anxiety; however, based on student and faculty comments, satisfaction seemed to be higher with community volunteer children. Therefore, the authors of this study have continued solely using the community volunteer method of teaching pediatric assessment. Faculty presence has been increased during the practice sessions to allow for one-on-one guidance with the students during the assessment practice. Further research using children as community volunteers and SPs during simulated pediatric experiences is necessary. The use of simulation in pediatrics is a growing area for undergraduate baccalaureate nursing education, and best practices need to be established. Community volunteers and SPs are successfully used to enhance the simulated learning experiences in many other health care areas; therefore, it behooves nursing educators to explore this methodology in pediatric nursing education as well.
References Adib-Hajbaghery, M., Karbasi-Valarheri, K., & Heidari-Haratmeh, A. (2012). Correlation of clinical skills self-assessment of nursing internship trainees with their teachers’ evaluation. Nursing and Midwifery Studies, 1(2), 94-99. Al-Qaaydeh, S., Lassche, M., & MacIntosh, C. I. (2012). Exploratory factor analysis of the pediatric nursing student clinical comfort and worry assessment tool. Journal of Pediatric Nursing, 27, e39-e43. Anderson, M., Holmes, T. L., LeFlore, J. L., Nelson, K. A., & Jenkins, T. (2010). Standardized patients in educating student nurses: One school’s experience. Clinical Simulation in Nursing, 6, e61-e66.
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Beauchesne, M. A., & Douglas, B. (2011). Simulation: Enhancing pediatric advanced practice nursing education. Newborn & Infant Nursing Reviews, 11(1), 28-34. Benner, P. (2001). In Conmer, M. (Ed.), From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall Health. Bornaism, J. A. K., Raiger, J. E., Krahn, R. E., & El-Masri, M. M. (2012). Evaluating undergraduate nursing students’ learning using standardized patients. Journal of Professional Nursing, 28(5), 291-296. Bultas, M. W. (2011). Enhancing the pediatric undergraduate nursing curriculum through simulation. Journal of Pediatric Nursing, 26, 224-229. Hampson, S. J., & Cantrell, S. (2014). Does the use of standardized patients in maternal-newborn simulation increase student confidence prior to entering the clinical setting? Journal of Obstetric, Gynecologic and Neonatal Nursing, 43, s48. Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). NCSBN national simulation study. A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2), S1-S64. Ironside, P. M., & Jefferies, P. R. (2010). Using multiple-patient simulation experiences to foster clinical judgment. Journal of Nursing Regulation, 1(2), 38-41. Kolb, D. A. (2016). Experiential learning: Experience as the source of learning and development (2nd ed.). New Jersey: Prentice-Hall. Kolb, D. A. (1984). Experiential learning: Experience as the source of learning and development. New Jersey: Prentice-Hall. Lasater, K. (2007). Clinical judgment development: Using simulation to create an assessment rubric. Journal of Nursing Education, 46(11), 496-503.
Lassche, M., Al-Qaaydeh, S., MacIntosh, C. I., & Black, M. (2013). Identifying changes in comfort and worry among pediatric nursing students following clinical rotations. Journal of Pediatric Nursing, 28, 48-54. Loprieto, J. O., & Sawyer, T. (2015). Simulation-based medical education in pediatrics. Academic Pediatrics, 15(2), 134-142. Luctkar-Flude, M., Wilson-Keates, B., & Laroque, M. (2012). Evaluating high-fidelity human simulators and standardized patients in an undergraduate nursing health assessment course. Nurse Education Today, 32, 448-452. Megel, M. E., Black, J., Clark, L., Cerstens, P., Jenkins, L. D., Promes, J., ., & Goodman, J. (2012). Effect of high-fidelity simulation on pediatric nursing students’ anxiety. Clinical Simulation in Nursing, 8(9), e419e428. Mehrdad, N., Bigdeli, S., & Ebrahimi, H. (2012). A comparative study on self, peer, and teacher evaluation to evaluate clinical skills of nursing students. Social and Behavioral Sciences, 47, 1847-1852. Miller, K. (2014). The effect of simulation activities on maternal-newborn knowledge in a practical nursing course: Implications for Practice. International Journal of Childbirth Education, 29, 41-45. Omer, T. (2016). Nursing students’ perceptions of satisfaction and selfconfidence with clinical simulation experience. Journal of Education and Practice, 7(5), 131-138. Sadeghi, T., & Loripoor, M. (2016). Usefulness of 360 degree evaluation in evaluating nursing students in Iran. Korean Journal of Medical Education, 28(2), 195-200. Witherspoon, D. L., Phillips, K., & Wyatt, T. H. (2015). Effect of electronic interactive simulation on senior bachelor of science in nursing students’ clinical reasoning and clinical judgment skills. Clinical Simulation in Nursing, 11, 126-133.
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www.elsevier.com/locate/ecsn
Featured Article
Effects of Community Volunteer Children on Student Pediatric Assessment Behaviors Laura Kubin, PhD, RN, CPN, CHES*, Cecelia Elaine Wilson, PhD, RN, CPN Texas Woman’s University, T. Boone Pickens Institute of Health Sciences Dallas Center, The Houston J. and Florence A. Doswell College of Nursing, Dallas, TX 75235, USA KEYWORDS human patient simulation; high-fidelity simulation; community volunteer children; undergraduate nursing student; simulation; pediatric assessment simulation; pediatric Student Comfort and Worry; undergraduate nursing student stress, anxiety, worry, clinical, simulation
Abstract Background: According to undergraduate nursing students, clinical experiences produce a high degree of stress and anxiety, especially when those experiences involve children. Simulation has been shown to teach assessment skills, and allow experiential and active learning resulting in an increase in the level of a student’s comfort with performance of these skills. However, even with the practice of simulation, only a small number of students report feeling comfortable with assessment. Other experiential opportunities involving standardized patients have been widely used with adult populations; however, there is very little literature describing the use of children as standardized patients. One study with nursing assessment students found that students reported more self-efficacy with community volunteers than high-fidelity simulators. The purpose of this study was to examine the impact of using community volunteer children on physical assessment abilities and comfort levels among undergraduate pediatric nursing students. Methods: Students were administered the Pediatric Student Comfort and Worry Assessment Tool at the beginning of the semester and following intervention. After a didactic class, students were randomly assigned to two groups. One group practiced assessment on high-fidelity simulators programmed to provide verbal feedback to allow for interaction. The second group practiced assessment on community volunteer children. Students were self-evaluated and faculty-evaluated completing a pediatric assessment using the Effective Noticing and Responding domains of the Lasater Clinical Judgment Rubric. Results: Overall, students had similar worry and comfort scores regardless of group; additionally, assessment performances were similar. However, students in both groups significantly rated their observations higher than faculty members. Conclusions: The use of simulation to practice pediatric assessment prior to exposure in the clinical setting is beneficial in reducing student anxiety and stress; however, there may be no difference between practicing assessment on high-fidelity manikins versus community volunteer children. Although one modality did not seem to affect student stress and anxiety over another modality, student satisfaction was positively influenced by working with community volunteers. Cite this article: Kubin, L., & Wilson, C. E. (2017, July). Effects of community volunteer children on student pediatric assessment behaviors. Clinical Simulation in Nursing, 13(7), 303-308. http://dx.doi.org/10.1016/ j.ecns.2017.04.011. Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
The authors have no conflicts of interest or financial disclosures. * Corresponding author: [email protected] (L. Kubin). 1876-1399/$ - see front matter Ó 2017 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2017.04.011
Effects of Community Volunteer Children
304
Purpose The purpose of this study was to compare the findings of using community volunteer children versus high-fidelity simulators on the physical assessment abilities and comfort levels with pediatric patients among undergraduate Key points baccalaureate nursing stu The purpose of this dents. The hypothesis was study was to examine that undergraduate nursing the impact of using students who practiced pecommunity volunteer diatric assessments on comchildren on physical munity volunteer children assessment abilities and would report a higher level comfort levels among of comfort and lower levels undergraduate pediatric of worry and demonstrate nursing students. more effective noticing and Students were randoresponding behaviors durmly split into one of ing pediatric assessment in two groups to practice the clinical setting than stupediatric well-child asdents who practiced on sessments. One group high-fidelity simulators. practiced assessments on high-fidelity simulators, and one group Background practiced on community volunteer children. High-fidelity simulation can Students completed a enhance critical thinking, pre- and post- intervenclinical judgment, and clintion Pediatric Student ical decision making Comfort and Worry (Beauchesne & Douglas, Assessment Tool, and 2011; Hayden, Smiley, were evaluated comAlexander, Kardongpleting a physical asEdgren, & Jeffries, 2014; sessment in the clinical Ironside & Jeffries, 2010; setting. Witherspoon, Phillips, & Overall, students had Wyatt, 2015). The use of similar worry and simulation is increasingly comfort scores and being used to replace and/ assessment performaor enhance clinical learning nces regardless of in nursing education. group. Immersing students in a simulation of real-life experience has been shown to be an effective experiential learning strategy, especially when it is used to complement existing learning activities (Hayden et al., 2014; Miller, 2014; Omer, 2016). Simulation has been well established to enhance nursing student confidence and self-efficacy and to decrease anxiety (Bultas, 2011; Luctkar-Flude, Wilson-Keates, & Laroque, 2012; Megel et al., 2012). Nursing students experience a high degree of anxiety associated with clinical experiences and even more anxiety during experiences involving children (Al-Qaaydeh, Lassche, & MacIntosh, 2012; Lassche, Al-Qaaydeh, MacIntosh, & Black, 2013; Megel et al., 2012). Lassche
et al. (2013) explored factors that produced worry related to nursing students caring for pediatric patients. Assessment and causing pain were the factors causing more worry. Following exposure in the clinical setting, comfort with assessment changed the most, whereas fear of causing pain changed the least. Megel et al. (2012) studied the effects of high-fidelity simulation on anxiety before pediatric clinical and found that simulation decreased anxiety. Standardized patients (SPs) and community volunteers have been used in simulation extensively in medical education and advanced practice nursing education. The use of SPs in prelicensure nursing education is becoming more common, primarily in adult simulation settings. Bornaism, Raiger, Krahn, and El-Masri (2012) compared the outcomes of first semester nursing students practicing health assessments on SPs versus on peers and found that the SP group had better performance outcomes than the peer group. Hampson and Cantrell (2014) used SPs in the maternalenewborn setting. Students conducted postpartum assessments on SPs and newborn assessments on manikins. The study results indicated increased student perceptions of self-confidence and critical thinking skills. In a study comparing assessment skills in students in three groups (high-fidelity simulators, SPs, and community volunteers), there were no differences in student self-efficacy. However, students in the high-fidelity simulation group demonstrated higher performance behaviors but had lower satisfaction scores (Luctkar-Flude et al., 2012). There is very little literature describing the use of SPs or community volunteers in pediatric simulation. In an article outlining a simulation program, Anderson, Holmes, LeFlore, Nelson, and Jenkins (2010) discuss using simulation in pediatrics only for history taking and communication. SPs are suggested only as parents, grandparents, and adolescents. Loprieto and Sawyer (2015) state that pediatric simulation-based education is in a growth phase and will continue to increase over the next decade. Using children as actual ‘‘patients’’ in pediatric simulations could serve not only to increase students’ performance outcomes and self-confidence but also, more importantly, to decrease student anxiety and worry related to working with children.
Theoretical Framework Benner’s (2001) novice to expert theory was used as the framework for this study. According to Benner, a novice is new to an experience and is unable to translate skills to the new area that can increase anxiety. They are inflexible and follow inflexible rules that obstruct their growth and judgment and limit their ability to predict what will happen next. Concepts and strategies from Kolb’s experiential learning theory were also applied in this study. Transformation is a concept discussed at length within Kolb’s
pp 303-308 Clinical Simulation in Nursing Volume 13 Issue 7
Effects of Community Volunteer Children
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theory. According to Kolb (1984, 2016), participation in real-life experiences allows students the opportunity to undergo a transformation by progressing through the stages of the learning cycle. One experiential strategy used was the immersion of the students into an experience using volunteer children as their simulated patients.
Methods Participants After institutional review board’s approval, an experimental pre- and posttest study with a convenience sample of 99 undergraduate baccalaureate nursing students in a pediatric nursing course was conducted. These students were in the third semester of a four-semester program at a large public university.
Instruments The Pediatric Student Comfort and Worry Assessment Tool (Al-Qaaydeh et al., 2012) measures student comfort and worry related to caring for pediatric patients using a Likert-type scale in two subscales. The first subscale asks six questions related to student comfort with the pediatric clinical setting regarding assessment, explaining procedures and medications to children, administering medications to children, helping children cope with pain, and providing support in times of crisis. The second subscale asks five questions about clinical rotation worries regarding caring for an ill child, causing physical or emotional harm, causing pain, and interacting with a child’s family. Face validity of the questions was determined by a review of nursing and nursing education experts. Further factor analyses were conducted on the questions to determine construct validity. Internal consistency was found to be acceptable using Cronbach’s alpha (comfort ¼ 0.806, worry ¼ 0.766). Lassche et al. (2013) used the tool with students to determine its usability. The researchers found that students used the tool appropriately and completed the tool in less than ten minutes. This tool was used in this study, with permission, to assess student comfort and worry with assessing pediatric patients. The Lasater Clinical Judgment Rubric (Lasater, 2007) provides performance expectations to evaluate an event requiring clinical judgment. The rubric is divided into 11 dimensions in four domains: effective noticing, effective interpreting, effective responding, and effective reflecting. Each dimension is evaluated by four developmental levels: exemplary, accomplished, developing, or beginning. The noticing domain includes the dimensions of focused observation, recognizing abnormals, and information seeking. Maintaining a calm and confident manner, clear communication, well-planned interventions, and being skillful are dimensions included in the responding domain. Because these skills are
most relevant to pediatric assessment, only these domains were used to evaluate students in this study.
Procedure At the beginning of the semester, all students were administered the Pediatric Student Comfort and Worry Assessment Tool (Lassche et al., 2013). After a classroom presentation and hands-on skills lab providing theoretical and didactic content about pediatric assessment, students were randomly split into one of two groups to practice pediatric well-child assessments. One group practiced assessments on high-fidelity simulators, and one group practiced on community volunteer children. Students in each group were given 20 minutes to assess their assigned ‘‘patients.’’ As a normal teaching methodology in this pediatric course each semester, students participate in a high-fidelity assessment simulation. During the semester of this study, the opportunity arose to involve children in this simulation. Therefore, because this portion of the study was considered a teaching methodology, only those students randomized to the community volunteer group assessed children. The methodology was not repeated for the other group. High-fidelity Simulation Group Simulators were programmed with age-appropriate vital signs and assessment findings within normal limits for a well-child assessment to be consistent with the ages of the children in the community volunteer group. Simulators were programmed to provide verbal feedback to students so that interaction would be as realistic as possible. There were no parents present in the high-fidelity group. Faculty were present to guide students through the assessment and to answer questions. Community Volunteer Children Group There were ten community volunteer children aged 6 months to 5 years with no significant medical history. Children were not given scripts to follow or coached to behave in any particular manner. Children were given age-appropriate toys to keep them occupied during the activity. Parents accompanied the community volunteer children, and faculty were present to guide students through assessments and answer questions. Students rotated through the cohort of community volunteer children in groups of ten, every 20 minutes (one student/child), so each child served as a ‘‘patient’’ for up to five students in a two-hour period. All students then completed a pediatric assessment during their first inpatient clinical day at a pediatric facility. Using the effective noticing and responding domains of the Lasater Clinical Judgment Rubric (Lasater, 2007), students’ assessment behaviors were self-evaluated and faculty-evaluated. Immediately following the inpatient assessment, students completed a postintervention Pediatric Student Comfort and Worry Assessment Tool survey (Lassche et al., 2013).
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Results
Regardless of group, students rated their observation higher than faculty members.
Student Comfort and Worry
Student and Faculty Comments
There were 45 students in the Community Volunteer Children group and 54 students in the High-Fidelity Simulation Group. A 2 (time) by 2 (group), factorial analysis of variance (ANOVA) was conducted to test for differences in student’s perceived distress related to pediatric nursing as measured by the Pediatric Comfort and Worry Assessment Tool. Students reported significantly greater comfort and less stress at posttest than at pretest on the following measures related to comfort with the pediatric clinical setting: performing a pediatric assessment and explaining procedures/medications/therapies to a child, administering medications to a child, and administering therapy to a child (p < .01). However, there was not a significant main effect of group on any of the measures, indicating that overall students had similar scores regardless of whether or not they received practice with community volunteers. There was a significant interaction effect of time and group on the following measures on both subscales: administering medications to a child, providing support to children and their families during times of crisis and grief, worry about caring for an ill child, and worry about causing pain (p < .05). Those in the simulation group had significant pre/posttest differences on the following measures in the comfort with clinical setting subscale: providing support to children and their families during times of crisis and grief and helping children and their families cope during painful procedures (p < .05). Whereas those in the community volunteer group had significant pre/posttest differences on the following measures of the clinical rotation worry subscale: worry about causing a child pain and worry about caring for an ill child (p < .05).
Assessment Measures (Self-Evaluation) A 2 (time) by 2 (group), factorial ANOVA was conducted to test for differences in student’s perceived ability to perform clinical assessments. There was not a significant main effect of group on any of the domains measured, indicating that overall students had similar scores regardless of whether they practiced on community volunteers.
Assessment Measures (Student and Faculty Evaluation) A 2 (rater) by 2 (group) factorial ANOVA was conducted to test for differences in student’s performance on clinical assessments at posttest. There was not a significant main effect of group on assessment performance, indicating that students in both groups had similar performance. There was a significant effect of rater on the observation scores.
Students were given an opportunity on the final course evaluations to provide open-ended comments regarding this experience. Students commented that the practice session was a valuable experience and made them feel more comfortable about pediatric assessment prior to entering the clinical setting. One student stated that ‘‘The assessment lab was helpful in allowing us to practice before we had to do it on real kids. Even though we’ve had assessment before, this was a good review.’’ Students in the community volunteer group stated that working with the children helped them to feel more comfortable interacting with children: ‘‘I was afraid to approach the child and did not know how to begin an assessment, but once I got in there with a real child, it was not so bad.’’ Another student stated that ‘‘I would have not been able to do this in the hospital without seeing a normal child first.’’ Students in the high-fidelity simulation group overwhelmingly commented that they were disappointed that they did not have the opportunity to practice on ‘‘real’’ children: ‘‘I suggest that all students have the opportunity to assess the kids before going to the hospital because even though it was helpful to practice on the mannequin, I think it would make us feel more comfortable.’’ Another student commented that ‘‘I was really sad I did not get the experience of working with the real kids, I think I would have learned more if I could have practiced with the them.’’ During a faculty team meeting to plan for the next semester, faculty discussed student outcomes and evaluation of the simulation. Faculty commented that during the simulation, students in the community volunteer group were more engaged, noticed more developmental milestones, and overall interacted more appropriately with children. Several faculty stated that ‘‘In the hospital, they missed several things during their assessments, and it did not matter what group they were in during the simulation.’’ Yet, another faculty commented that ‘‘I did notice that the students who assessed the community volunteer children did pick up on developmental milestones much better than the other students.’’ Finally, one faculty member stated ‘‘I think most of the students interacted well with the children, but the ones who assessed the community volunteers seemed to be less hesitant and jumped in easier than the students who were with the simulators.’’
Discussion Study results indicate that having students practice pediatric assessments prior to clinical experiences can reduce stress and worry whether they practice with high-fidelity simulators or community volunteer children. Overall,
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students in this study had similar scores regardless of group and reported decreased worry and stress from pre- to posttest. The area with the greatest change was being comfortable in performing a pediatric assessment, which is consistent with the findings reported by Lassche et al. (2013). Posttest scores revealed an increase in comfort for the high-fidelity simulation group with helping children and their families cope during painful procedures and providing support to children and their families during times of crisis and grief. These findings are interesting because the simulation group did not interact with children or parents during the practice. Another interesting finding is that students in the community volunteer group reported less worry on posttest about causing a child pain and about caring for an ill child. Lassche et al. (2013) reported that worry about causing a child pain was the most significant source of anxiety for nursing students pre- and postclinical exposure and suggested this as an area for educational improvement. Findings of this present study suggest that prior exposure to community volunteers and the ability to interact and communicate with children and their families prior to clinical exposure might positively influence this factor. Assessment behaviors were similar for both groups. However, students in both groups rated their assessment behaviors higher than faculty members. Mehrdad, Bigdeli, and Ebrahimi (2012) conducted a study evaluating clinical skills of junior nursing students comparing evaluations of self, peers, and clinical teachers. This study found a significant correlation between the self- and peer evaluations but no correlation between the clinical teacher and the self- or peer evaluations. Thus, suggesting that self- and peer evaluations are not a good substitute for clinical teacher evaluations of student clinical skills. However, other studies have found positive correlations between student, peer, faculty, and even patient evaluations (Adib-Hajbaghery, Karbasi-Valarheri, & Heidari-Haratmeh, 2012; Sadeghi & Loripoor, 2016). Therefore, the validity of student self-evaluation versus faculty evaluation requires further study.
Limitations The small sample size in this study was a limitation; repeating the study with a larger sample is recommended to increase the generalizability of the study results. Additionally, this study was conducted in a single educational institution with only baccalaureate nursing students that limits generalizability. Other limitations that might have affected the outcomes of the results of this study include the background of students. Demographic data were not collected; therefore, prior and concurrent experience with children, work experience, and other factors that may influence stress and worry were not evaluated.
Although faculty were present during the practice sessions to provide guidance and answer questions, it was noted that students were confused about how to proceed with assessments. Students in the community volunteer group were reluctant to approach the children and take initiative to begin assessments without prompting from faculty and/or parents. Community volunteer children were not given scripts to follow or coached on how to behave during the simulation. Although this was intentional to allow for students to experience realistic child behaviors during assessments, this lack of control of variables between children may have affected study results.
Conclusions This is one of few studies to evaluate the use of child community volunteers in teaching pediatric assessment to undergraduate nursing students. Results of this study indicate that practicing pediatric assessment prior to beginning clinical experiences is beneficial to decreasing student stress and anxiety; however, there may be no difference between practicing assessment with high-fidelity simulators versus community volunteer children. Both experiential strategies demonstrated a benefit to the student in contributing to a decrease in student stress and anxiety; however, based on student and faculty comments, satisfaction seemed to be higher with community volunteer children. Therefore, the authors of this study have continued solely using the community volunteer method of teaching pediatric assessment. Faculty presence has been increased during the practice sessions to allow for one-on-one guidance with the students during the assessment practice. Further research using children as community volunteers and SPs during simulated pediatric experiences is necessary. The use of simulation in pediatrics is a growing area for undergraduate baccalaureate nursing education, and best practices need to be established. Community volunteers and SPs are successfully used to enhance the simulated learning experiences in many other health care areas; therefore, it behooves nursing educators to explore this methodology in pediatric nursing education as well.
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