- Email: [email protected]
Moving nurse educators towards transcendence in simulation comfort
Accepted Manuscript Moving nurse educators towards transcedence in simulation comfort Tracey Simes, Sherre Roy, Barbara O'Neill, Colleen Ryan, Samuel Lapkin, Elizabeth Curtis PII:
S1471-5953(16)30282-7
DOI:
10.1016/j.nepr.2017.10.024
Reference:
YNEPR 2317
To appear in:
Nurse Education in Practice
Received Date: 23 December 2016 Revised Date:
19 September 2017
Accepted Date: 17 October 2017
Please cite this article as: Simes, T., Roy, S., O'Neill, B., Ryan, C., Lapkin, S., Curtis, E., Moving nurse educators towards transcedence in simulation comfort, Nurse Education in Practice (2017), doi: 10.1016/j.nepr.2017.10.024. 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.
ACCEPTED MANUSCRIPT
Title page Article title: MOVING NURSE EDUCATORS TOWARDS TRANSCEDENCE IN SIMULATION COMFORT.
Tracey Simes, BN, PGDCC, PGDBM, GCTE CertIVTAE RN 1
Barbara O’Neill, BA, BSN, GCNE, RN3 Colleen Ryan, BhlthSc, GCHPE CertIVTAE, MHPE, RN4
Elizabeth Curtis BN, RN, MN 6
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Samuel Lapkin, PhD, BN Hons (1st Class), GCTE, RN 5
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Sherre Roy, PhD, M Learn Innov, B Bus (Hons), CertIVTAE 2
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Author information
1. Central Queensland University, School of Nursing and Midwifery, 90 Goodchap Street, Noosaville, QLD 4566 Australia Telephone +0617 5440 7028, Email
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[email protected]
2. Central Queensland University, Learning and Teaching Services, Building 7, University Drive, Bundaberg, QLD 4670 Australia. Telephone +617 4150 7052,
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Email [email protected]
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3. Central Queensland University, School of Nursing and Midwifery, Bruce Highway Bldg 18, Rockhampton, QLD 4702 Australia. Telephone +617 4923 2617, Email [email protected]
4. Central Queensland University, School of Nursing and Midwifery, 90 Goodchap Street, Noosaville, QLD 4566 Australia Telephone +06175 4407018, Email [email protected]
ACCEPTED MANUSCRIPT 5. University of Wollongong, School of Nursing, Faculty of Science, Medicine and Health, Wollongong NSW 2522, Australia. Telephone: +612 9113 1567 Email [email protected] 6. University of Western Sydney, School of Nursing and Midwifery, Campbelltown
[email protected]
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Corresponding author
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Campus, NSW 2560, Australia. Telephone: +012 4620 3522, Email
Tracey Simes, RN
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Central Queensland University School of Nursing & Midwifery and Social Furfures 90 Goodchap Street Noosaville, QLD,4566 ,Australia
Telephone +0617 5440 7028 / 0410 728 600 [email protected]
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Disclaimer: The views expressed in the submitted article are our own and not an official position of the institution or funder. Author initials throughout paper have been blacked out.
Source of support: The research was supported in part by a $4950 Internal Scholarship
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of Learning and Teaching grant administered by Central Queensland University. Additional in-kind services of $4938 contributed to the research.
Acknowledgements: The authors would like to express their deepest gratitude to the
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participants of the study for making this research possible by contributing their valuable time and thoughts.
Word count: Abstract: 165 Article: 4933
Tables: 4 Conflict of interest declaration: None to report
ACCEPTED MANUSCRIPT Abstract
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Expensive simulation equipment continues to sit idle in nursing learning and teaching
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environments. To identify factors that influence nursing educator comfort in the use of
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simulation at an Australian university an explorative qualitative research project was
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undertaken using an interpretative constructivist methodology. The Goodwin, Sener and
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Steiner (2007) adapted Comfort Theory for nursing education has been used. The aim of
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the study was to identify factors that influence nurse educator’s comfort in the use of
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simulation. Research question asked was: What are the barriers and enhancers to using
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simulation as a learning and teaching modality. Thematic analysis of data from focus groups
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on four different campus sites was undertaken. Four themes identified that affected
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participants’ comfort in this study were: 1) Personal barriers; 2) Human resource barriers; 3)
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Structural barriers and 4) Suggestions to address barriers. Further understanding of the
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themes and how they relate to educator comfort with simulation are shared with the reader.
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The paper also outlines emerging recommendations to improve educator comfort.
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HIGHLIGHTS
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educator comfort with simulation use.
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Personal barriers, human resource barriers, and structural barriers influence
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The establishment of a central digital repository of simulation resources is recommended.
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Formal mentorship simulation programs are needed for educators.
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Time needs to be allocated for simulation preparation and delivery in workload
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scheduling.
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The use of Goodwin, Sener and Steiner (2007) adapted Comfort Theory assists in the articulation of educator comfort. KEYWORDS
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Comfort; Simulation; Educator; Nursing; Workload.
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Introduction
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In 2005, Pamela Jefferies, a nursing leader in simulation, stated that educators must feel
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prepared and comfortable to use simulation, yet over a decade later it appears comfort has
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not been fully explained nor explored. Many nursing educators remain reluctant to engage
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with simulation pedagogy and simulation equipment (Adamson 2010, King et al., 2008, Al-
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Ghareeb & Cooper, 2016) despite strong evidence that simulation plays a vital role in
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preparing student nurses for clinical placements (Burns, O’Donnell, & Artman 2010, Jansen
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et al., 2010, Kardong-Edgren, Starkweather & Ward, 2008). Therefore, a qualitative
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research project was designed to explore current barriers and enhancers to the
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implementation of simulation learning activities from the perspective of nurse educators.
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The study aimed to identify factors that influence nursing educators comfort in the use of
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simulation. Results of this study provided three recommendations to improve nurse
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educator comfort with the delivery of simulation as a learning and teaching tool;
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recommendations that may pave the way toward comfort for nurse educators using
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simulation. The following paper will provide a brief background to the issue of educator
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simulation comfort, a description of the theoretical framework used to articulate educator
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comfort, an explanation of the research design used, along with the findings and
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recommendations of the study.
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ACCEPTED MANUSCRIPT Background
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One explanation for the reluctance of nurse educators to embrace simulation has been
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related to a lack of familiarity with simulation equipment (Jones & Hegge 2007). Nursing
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literature infers that this situation may have arisen because nursing program administrators
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throughout the world have allocated financial resources to equipping clinical laboratories
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with simulation technology, but have neglected to allocate resources for supporting
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educators in both the use of the equipment and simulation pedagogy (Adamson 2010,
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Medley & Horne 2005). Adamson (2010) reported that less than 7% of initial simulation
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investment was spent on maintenance, training and implementation of simulation programs.
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Successful uptake of simulation in nursing has been attributed to the failure to understand
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and manage ongoing staff costs, resources and time required for simulation design and
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implementation (Lapkin & Levett-Jones 2011).
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Furthermore, Harder, Ross and Paul (2013) reported that high-fidelity simulation was not
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something that nursing educators undertook if they were uncomfortable or unfamiliar with
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the simulation modality. Another contributing factor to educator reluctance to use
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simulation has been the fear of failure and looking unprepared and incompetent in front of
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students (Jansen et al., 2010). This reluctance to use simulation is what Blazeck (2011) refers
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to as simulation anxiety syndrome. While the factors that contribute to educators
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discomfort with simulation are often reported, factors that would assist to provide educator
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comfort with simulation have not been clearly articulated in the literature. To articulate
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educator comfort a theoretical framework is needed.
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Theoretical framework
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ACCEPTED MANUSCRIPT Comfort is difficult to define due to its individual and abstract nature. Comfort is a core
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nursing care concept that has been explored by theorists such as Morse, Watson, and
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Kolcaba (Apostolo 2009). Kolcaba’s work on Comfort Theory in nursing was introduced in
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the 1990s and remains in use today in the nursing clinical, educational and research
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environments. Comfort Theory comprises of three complex reality states for individuals: (1)
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relief, when specific comfort needs are met; (2) ease, a state of calm; and (3) transcendence,
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when one rises above the problem. Each experience state occurs in four contexts: physical,
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psychospiritual, environmental and sociocultural (Kolcaba, Tilton & Drouin 2006). Kolcaba,
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Tilton and Drouin (2006) further explained physical comfort pertains to positive body
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sensations and homeostatic body mechanisms. Psychospiritual comfort is defined as the
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mental, emotional and spiritual components of self which include self-worth, and self-
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esteem. The external environment is defined as external surroundings, conditions and
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influences such as noise, light, and equipment. Sociocultural comfort is the relationship
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between self and family and society and takes into account education, support, and cultural
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customs.
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Goodwin, Sener and Steiner (2007) further adapted Comfort Theory for use in nursing
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education. Goodwin, Sener and Steiner work (2007) situates Comfort Theory in the context
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of creating a culture of comfort for students around learning and professional development.
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The authors of this study posed Goodwin, Sener and Steiner (2007) work on comfort could
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also be extended to defining a culture of comfort for educator use of simulation. Before
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further investments in simulation equipment are made, King et al., (2008) recommended
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there needed to be a greater understanding of what will enable nurse educators to be more
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comfortable in adopting simulation pedagogy into their teaching.
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ACCEPTED MANUSCRIPT To this end, researchers at an Australian university conducted an exploratory qualitative
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study aimed to identify factors that influenced nurse educator comfort. The research
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question posed was: What are the current barriers and enhancers to the use of simulation
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as a learning and teaching modality?
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Research design
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Participants and setting
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The project was undertaken at one Australian university’s school of nursing. The university
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has 16 campuses, but the study was limited to the four campuses where nurse educators
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teach. The campuses where the study was undertaken have significant geographical
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distances of more than 185 miles (298 km) between each. A purposive sample of nursing
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education staff (n = 44) were invited to participate via email and flyer. Sixteen staff
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participated, representing 36% of the educators; 12 were university lecturers and four were
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registered nurses working as laboratory technicians; one participant was male and fifteen
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female. Laboratory technicians assist in the education of students within the simulation
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learning environment; thus their involvement was considered important. All sixteen
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participants (100%) stated that they use task trainers and role play; eight participants (50%)
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use Mask-Ed TM (KRS simulation); seven participants use Sim Anne with SimPadTM technology
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(44%); and two participant use 3G (12%). (Table 1). There are a number of studies that
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report a lack of use of high fidelity simulation in nursing education (Harder, Ross & Paul,
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2013; King et al., 2008 ) and the demographic data that follows (Table 1) infers that both
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medium and high fidelity simulation are not fully embraced by participants in this study.
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ACCEPTED MANUSCRIPT Data collection
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A semi-structured focus group conducted by a facilitator engaged by the research team, was
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held at each campus. The facilitators were chosen for their qualitative research experience
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and impartiality. To increase rigour and consistency with data collection, each facilitator
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attended a one-hour training workshop. This workshop was conducted by the chief
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investigator (TS). The workshop included discussion of the interview questions and a review
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of the aim of the research project. The open-ended questions comprised of two simulation
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participant profile questions and two interview questions related directly to the research
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question. Questions are listed in Table 2. Each group facilitator encouraged everyone to
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participate, and sessions lasted until the discussion waned, approximately 30-45 minutes.
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Sessions were audiotaped and transcribed verbatim by a transcription service.
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Ethical considerations
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Ethical clearance was gained from the University’s Human Research Ethics Committee
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(H14/06-145). Participation was voluntary and signed consent forms were received from
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each participant. No participant incentives were offered for attendance. As the majority of
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the research team, including the chief investigator, were also members of the nursing
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teaching faculty, they were not eligible to participate in the focus group sessions. All data
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was de-identified at the time of transcription.
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Data analysis
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Thematic analysis techniques described by Guest, Macqueen and Namey (2011) and Braun
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and Clarke (2013), were employed for data analysis against focus group interview transcripts.
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ACCEPTED MANUSCRIPT Thematic analysis was chosen as it is a flexible research tool that allows the researcher to
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gain a rich contextual understanding of a phenomenon through interaction with the data
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(Braun & Clarke 2013). Thematic analysis allows the interpretation and construction of the
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complexity of meaning that supports the interpretative constructivist methodology of this
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study (Guest, Macqueen & Namey 2011).
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Inductive analysis was used to explore the data from the bottom up (Guest, Macqueen &
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Namey 2011). Familiarisation of data occurred through reading and re- reading transcripts,
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whilst listening to corresponding interview recordings. After familiarisation with transcripts,
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initial codes for each question was developed (Braun & Clarke 2013). The initial codes for
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each focus group transcript was organised using NVivo software version 11. A code matrix
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for each focus group against each question was developed. This process was undertaken
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separately by two members of the research team (TS & SR). Initial codes where compared
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and discussed referring to raw data to reach an initial code consensus. Once consensus was
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reached the initial codes were then applied across all the transcripts. This was a cyclic
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process of going back and forth from each transcript, increasing the rigor of the coding
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process and the refinement of codes names (Braun & Clarke 2013). The two research team
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members (TS, SR) undertook this process together to facilitate discussion and consensus of
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final code names. Final codes were then placed within a vertical and horizontal relational
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matrix. The matrix facilitated the identification and construction of potential themes within
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the varying data codes (See Table 3). Member checking with two participants from each
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focus group was done to validate the final codes. Participants agreed that the codes
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reflected the discussion content.
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ACCEPTED MANUSCRIPT Findings and discussion
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Four themes were identified that expressed factors for educator comfort when using
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simulation in the learning environment. The themes were: (1) Personal barriers; (2) Human
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resource barriers; (3) Structural barriers, and (4) Suggestions to address barriers. To ensure
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the trustworthiness of themes, examples are provided to demonstrate the participants’
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voice in study findings (Graneheim, Lindgren, & Lundman 2017). Examples include a
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participant identifier where “G” along with a number indicates the focus group number (1-4)
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and “P” indicates the participant and number assigned. For example, G4P2 indicates focus
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group 4, participant 2. Goodwin, Sener and Steiner (2007) adaptation of Comfort Theory
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has been applied to the findings (See Table 4).
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Personal barriers
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Many participants in this study disclosed anxiety due to their own perceived student
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performance expectations of a simulation event. This anxiety also extended into the
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expectations the participants placed upon themselves as simulation facilitators. The anxiety
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created by these perceived pressures was heard in participant’s strained tone of voice and
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in accelerated speed of speech in statements such as:
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The learning hopes are so high that if we blow it, really it does blow it. (G4P2)
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Accounts about past experiences regarding difficulties in engaging students and the
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negative effect that these experiences had upon the implementation of future simulation
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where shared. An example of these accounts are:
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Once you start getting the students loitering they start getting a little bit ugly and
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your residential school can go to hell. (G2P1) 8
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When we’re dealing with 20-30 students at a time you have to work out a way to get
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them all engaged otherwise they will just zone out. (G1P3) The participants in this study expressed anxiety about utilising equipment they had received
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little education on, had limited experience with, or had not used for a period of time.
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Shared comments indicating past simulation experiences had not proceeded as planned and
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these experiences contributed to ongoing anxiety:
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I think that [training for the educator] is really important because you lose credibility
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in front of the students. I remember doing a simulation where the patient was
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supposed to stop breathing, but I had forgotten to turn it [the manikin’s] breathing
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off. (G1P2)
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Being prepared, knowing what it is that you’re doing, it’s embarrassing if you do not.
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(G3P4)
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Anxiety shared by participants indicated that many felt personally uncomfortable
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functioning within the simulation environment and felt pressured to use unfamiliar
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simulation modalities. As one participant explained:
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Some people may have been pushed into an area of simulation that they don’t like.
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(G3P4)
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To summarise this theme, as the literature shows, educators resist implementing simulation
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for fear of looking foolish (unprepared or incompetent) in front of students. (Adamson
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2010; Blazeck 2011; Harder, Ross & Paul 2013; Jansen et al., 2010). This fear gives rise to
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the perceptions that the risk of using simulation is greater than the benefits. Although these
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findings are not new, and are well documented in the literature, the findings in this study
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ACCEPTED MANUSCRIPT further supports that issues of simulation anxiety remains a significant concern for the
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progression of simulation in the learning and teaching space
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Human resource barriers
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Participants were pleased investments had been made in simulation equipment but felt
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current education administrators needed to better understand that staff needs must be
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considered to better support and prepare them in using the equipment. One participant
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stated:
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There’s no discussion of what we might want or need, stuff just turned up and it was,
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you can use this now, and we couldn’t. (G2P1)
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Participants reported a lack of understanding of the regular training required for the
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successful implementation of simulation from both administrators and themselves.
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Participants recalled having received limited training in the use of simulation equipment,
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describing their experiences as: “Ad hoc” (G2P3) and “Little snippets here and there” (G3P2).
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One participant explained:
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I’ve had 3G training which was well over 12 months ago it wasn’t followed up. It was
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quick, it was a real quickie training into 3G where if I went out there now I would not
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feel really confident. If you are not playing with that you can’t be competent with it. You really have to put the time in and I think that’s an issue for all of us, we need to
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have some form of consistency in how are going to keep up with those technologies.
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(G3P4)
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There was also a consensus regarding the lack of understanding of time needed by an
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educator for preparation and delivery of simulation. 10
ACCEPTED MANUSCRIPT Time is a big thing, and apart from running the scenarios, it is time for preparation
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and time for learning. At the moment there is no real allowance for that … (G1P3)
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It’s juggling it between your workload, residential schools and whatever else you are
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studying it’s hard to get in there and find time just play. (G3P2)
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…time; time getting into that costume is time consuming. It is not a solo activity.
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(G1P4)
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High student ratio to simulation facilitator was a common concern regarding use of human
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resources. Expression of this concern included:
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Yes, when you’ve got groups of 40 it is quite difficult. You have to get through as
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many [students] as you can. (G4P3)
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It is very time consuming where you can do three hours of simulation and still not
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have everyone covered. (G1P3)
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These findings highlight that although the provision of physical resources has provided
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comfort relief, participants continue to feel uncomfortable with the lack of human resources
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and time provided to successfully implement simulation activities. Studies undertaken by
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Jansen et al., (2009) and Akhtar-Danesh et al., (2009) identified the issue of time needed to
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develop and deliver simulations. This study echoes these concerns. The lack for formal
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simulation education program for hands on practice and skill development identified by
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Jefferies (2008) and Anderson et al., (2012) remain an issue. The physical requirements of
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regular training, educator time and student numbers needs to be addressed for educators
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to feel comfort ease in use of simulation.
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Structural barriers
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ACCEPTED MANUSCRIPT Structural barriers are obstacles participants felt prevented them from running a simulation
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scenario comfortably. The structural barrier theme includes the educators’ understanding of
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available equipment and access to learning and teaching simulation resources. Participants
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suggested they may be more comfortable with utilising simulation pedagogy if they received
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guidance and support in understanding how to run a simulation scenario.
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I really thought that I could rock up and explain different scenarios to the students
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and I would be able to, on the SimPads™, to just adjust what the vital signs are, the
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sounds of the patient. I could mimic a deteriorating patient and have them react
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accordingly. I did not have in place structured roles; I did not have a structured
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debrief, I did not have a structured pre-brief, and it was an absolute disaster. … I
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really thought I could wing it. It was awful for me. (G4P2)
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Participants also expressed feelings of being pressed for time. As explained by the following
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participants:
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[We are] time poor. G4P2
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[We are] time limited. G3P5
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Sufficient resources for all the students was also a concern. Participants reported it was
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hard to run a scenario if each student was not fully equipped with the required resources.
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One participant stated:
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They introduce all these things to us right, but then we’ve got to fight to actually get
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the resources that we need; G2P2
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ACCEPTED MANUSCRIPT Although there are guidelines such as The International Nursing Association for Clinical
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Simulation and Learning (INACSL) Standards of best practice: simulation (2016) available for
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structured simulation scenario development and delivery, educators at the coal face often
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do not know about these resources nor have easy access to these resources. Participants
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linked this physical need for delivery and scenario structure for educator comfort ease.
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Suggestions to address barriers
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The participants also provided suggestions on how to address barriers to simulation that
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were coded into eight subthemes: (1) provide mentor opportunities; (2) allot staff time for
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preparation and delivery of simulation activities; (3) encourage peer support; (4) share
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simulation scenarios; (5) provide more and regular simulation training; (6) allow academics
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to have a choice on the types of simulation used; (7) conduct trial runs and have a backup
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plan; (8) and provide the appropriate level of staffing and resources. The first subtheme of
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having mentors, for example, was seen to alleviate some of the discomfort around
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simulation, as evidenced in the following statement:
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The experienced lead made all the difference for me; the demonstration done by
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quite experienced people in sim, that was key to learning for me or maybe that’s just
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how I learn; clear roles for the lecturers. It really helped me that I knew exactly what my role was. I knew exactly when to come in, I know how I will benefit the scenario. (G4P2)
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It really does help if you have someone that has done a lot of it. I’ve been quite lucky
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with the people that I’ve worked with it in my courses that they’ve done quite a bit of
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simulation. (G3P2)
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ACCEPTED MANUSCRIPT The need to take into account staff time for simulation preparation and delivery was
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frequently mentioned. Participants said there was a need for themselves and university
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administrators to allocate sufficient time to prepare and deliver simulation for learning and
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teaching. One participant stated that it was important to:
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Make time to learn how to do this before you can actually come and run it and that is a
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factor that is not really taken into account for workloads. (G1P3)
Participants also felt that it was vital to support one another, not only in the preparation
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and delivery of scenarios, but also in the sharing of personal stories of the discomfort
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experienced around teaching with simulation. Evidenced by:
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Sitting here today and talking about this may be valuable for the staff that are doing
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residential schools to come together to talk about simulation experiences and what
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went well and what didn’t at how they felt as well. (G3P4)
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The participants also acknowledged that it would be good to share simulation scenarios. The
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sharing of scenarios would save time and ensure consistency in the presentation of
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simulation activities across the nursing curriculum providing comfort to the educator. One
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participant shared:
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I think it does take time to do the scenarios but once we get a bank of them that time
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factor will drop considerably because all we would do is just pick what we want to do
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and I think that would work. (G1P3)
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Participants suggested they also needed to feel comfortable with the modality of simulation
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they were delivering and should therefore have a choice in the type of simulation.
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Participants expressed a desire for more and regular training with the equipment. Many felt
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that annual competency-based training could be implemented that would help to ensure
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simulation skills remained current and therefore enforcing comfort ease. As one participant
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states: I think that if you are comfortable in the delivery style that you are going to use then
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you will get a positive outcome from that. I think that it’s being familiar with what
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the session need to achieve, what resources are going to use, and I practice enough
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with the SimPad™, so I don’t look like a fool in front of the students. (G3P7).
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Participants expressed reluctance to place themselves in vulnerable positions. The necessity
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of having trial runs and back-up plans was seen as essential. One participant stated she
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often created up to four back-up plans for one simulation experience because she did not
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want to look foolish:
We have plans A, B, C, D, E. (G1P1)
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Finally, participants felt that due to high student numbers having “more staff” (G3P2) and
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sufficient equipment to engage students is needed. One participant was emphatic that
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resources were key:
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The resources, if we don’t provide proper resources for the simulation that we are
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running then we automatically set up something to fail. (G3P6)
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Simulation experts, such as Hodge et al. (2008), Jefferies (2008), Starkweather and Kardong-
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Edgren (2008), and Waxman and Telles (2009), recommend the establishment of formal
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simulation education programs for academics. Participants in this study felt that it was not
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only additional formal education that was required, but also feedback, support and
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guidance from an expert in simulation. To sustain and advance simulation there is also a 15
ACCEPTED MANUSCRIPT need for financial investment in staff time, as expressed by participants in this study and
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others (Adamson 2010; Sole et al., 2012; Bray et al., 2009).
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Recommendations
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The four identified themes indicated how the participants in this study defined educator
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comfort in simulation. The concerns expressed in these themes have resulted in three
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recommendations for the transition of educators to what Kolcaba, Tilton and Drouin (2006)
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refers to as comfort in simulation to relief and ease. The three recommendations from the
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study are: (1) management of simulation resources though a central digital repository; (2)
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implementation of formal mentorship simulation programs; and (3) time allocation for
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simulation preparation and delivery in workload allocations.
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1) Management of simulation resources though a central digital repository
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Considering the academics’ concerns about time constraints, as well as the need for peer
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support and the desire to share resources, one recommendation is the implementation of a
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central digital repository where academics could readily access simulation information. This
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is a way to decrease anxiety and increase comfort by decreasing the time required in the
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development of scenarios and trying to find information on how to run particular
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simulations. The central digital repository would be a university-owned online resource
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where staff could obtain information and training regarding simulation, equipment
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availability and usage information, access to simulation mentors, and tested scenarios. The
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information would be accessible from any site at any time and be tailored to the
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requirements of the nursing curriculum.
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The second recommendation is the implementation of formal mentorship programs to
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support role-modelling. Educators new to or unsure of particular simulation modalities need
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to have the opportunity to watch and be supported by an experienced educator within a
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student simulation experience. Mentors have the opportunity to decrease simulation
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discomfort by providing direction and reassurance that they are there to fall back on if
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something does not go according to plan. They can also assist in the development of back-
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up plans. Thus, a positive learning experience can be provided instead of an “ad hoc”
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experience that has the potential to be embarrassing and stressful.
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3) Time allocation for simulation preparation and delivery in work load allocations.
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The third recommendation was a call for university administrators to acknowledge the time
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required for the preparation and delivery of simulation. Although scenarios can be shared
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though a central repository, the development of simulation scenarios takes time. The
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conceptual scenario needs to be tested and refined to ensure that learning objectives are
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met. Time is also needed for educators to learn the scenario and pedagogical framework for
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the deliverance of the scenario to students. Experiential learning for educators that is
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guided by mentors needs to be planned in workload allocation for educators to feel
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comfortable engaging in simulation (Reid et al., 2013)
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Study limitations
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As the data is self-reported though focus group discussion, individual biases may exist and
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participants may have selective memory about their experiences. The risk that certain
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participants may dominate the discussion, or participants feeling uncomfortable revealing
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ACCEPTED MANUSCRIPT their true feelings in front of their peers, is acknowledged. The facilitators were aware of
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these risks and were familiar with steps to address them if they arose. It is also possible
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educators who opposed or feared simulation did not participate. Furthermore, while there
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were representatives from a variety of settings and campuses participating in the
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discussions, which reflected a diverse group of participants, each participant’s formal
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training in simulation was not articulated.
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Conclusion
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This study identified four themes that influence educators’ feelings of ‘comfort’ with
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implementing simulation. Literature acknowledges comfort as a significant component to
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successful simulation implementation. The three recommendations from the study require
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urgent consideration by both educators and university administrators to increase and
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advance simulation usage. The three recommendations are 1) management of simulation
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resources though a central digital repository; 2) implementation of formal mentorship
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simulation programs; and 3) time allocation for simulation preparation and delivery in
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workload allocations. Further research is needed to determine if the recommendations
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implemented provide comfort relief and / or ease and if there are any further activities or
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actions needed to achieve transcendence into simulation comfort.
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References
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Adamson, K.,Adamson, K., 2010, Integrating human patient simulation into associate degree nursing curricula: faculty experiences, barriers, and facilitators, Clinical Simulation in Nursing, 6, e75-e81. Akhtar-Danesh, N., Baxter, P., Valaitis, R.K., Stanyon, W., Sproul, S., 2009. Nurse faculty perceptions of simulation use in nursing education. West. J. Nurs. Res. 31 (3), 312–329. htp://dx.doi.org/10.1177/0193945908328264 Al-Ghareb, A. Z. & Cooper, S. J., 2016, Barriers and enablers to the use of high-fidelity patient simulation manikins in nurse education: an integrative review, Nurse Education Today, 36, 281-286. http://dx.doi.org/10.1016/j.nedt.2015.08.005
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Anderson, M., Bond, M.L., Holmes, T.L., Cason, C.L., 2012. Acquisition of simulation skills: survey of users. Clin. Simul. Nurs. 8 (2), e59–e65. http://dx.doi.org/10.1016/j.ecns.2010.07.002 Apostolo, J. L. A., 2009, Comfort in nursing theories. Concept Analysis and Theoretical Meaning Revista de Enfermagem Referência, 61-67. Blazeck, A., 2011, Simulation anxiety syndrome: presentation and treatment., Clinical Simulation in Nursing, 7, e57-e60. doi:10.1016/j.ecns.2010.05.002 Braun, V., & Clarke, V., 2013, Successful qualitative research: a practical guide for beginners, Sage publications, London, UK Bray, B., Schwartz, C.R., Weeks, D.L. and Kardong-Edgren, S., 2009. Human patient simulation technology: perceptions from a multidisciplinary sample of health care educators. Clinical Simulation in Nursing, 5(4), pp.e145-e150. https://doi.org/10.1016/j.ecns.2009.02.002 Burns, H. K., O'Donnell, J. & Artman, J., 2010, High-fidelity simulation in teaching problem solving to 1st-year nursing students: a novel use of the nursing process,Clinical Simulation in Nursing, 6, e87-e95. https://doi.org/10.1016/j.ecns.2009.07.005 Guest, G., MacQueen, K., & Namey, E., 2011, Applied thematic analysis. Sage Publications, California Goodwin, M., Sener, I. & Steiner, S. H., 2007, A novel theory for nursing education, Journal of Holistic Nursing, 25, 278-285. 10.1177/0898010107306199 Graneheim, U.H., Lindgren, B.M., & Lundman, B., 2017., Methodological challenges in qualitative content analysis: A discussion paper. Nurse Education Today. 10.1016/j.nedt.2017.06.002 Harder, B. N., Ross, C. J. M. & Paul, P., 2013, Instructor comfort level in high-fidelity simulation, Nurse education today, 33, 1242. 10.1016/j.nedt.2012.09.003 Hodge, M., Martin, C., Tavernier, D., Perea-Ryan, M., & Alcala-Van Houten, L., (2008). Integrating simulation across the curriculum. Nurse Educator, 33(5), 210-214. doi:10.1097/01.NME.0000312221.59837.38 Jansen, D. A., Berry, C., Brenner, G. H., Johnson, N. & Larson, G., 2010, A collaborative project to influence nursing faculty interest in simulation, Clinical Simulation in Nursing, 6, e223-e229. doi:10.1016/j.ecns.2009.08.006 Jeffries, P. R., 2008. Getting in S. T. E. P. with simulation: simulations take educator preparation. Nurse Education Perspective, 29 (2), 70–73. Jeffries, P. R., 2005, A framework for designing, implementing, and evaluating: simulations used as teaching strategies in nursing, Nursing Education Perspectives, 26, 96-103. Jones, A. L. & Hegge, M., 2007, Faculty comfort levels with simulation, Clinical Simulation in Nursing, 3, e15-e19. doi:10.1016/j.ecns.2009.05.034 Kardong-Edgren, S. E., Starkweather, A. R. & Ward, L. D., 2008, The integration of simulation into a clinical foundations of nursing course: student and faculty perspectives, International Journal of Nursing Education Scholarship, 5, 1-16. https://doi.org/10.2202/1548-923X.1603 King, C. J., Moseley, S., Hindenlang, B. & Kuritz, P.,2008, Limited use of the human patient simulator by nurse faculty: an intervention program designed to increase use, International Journal of Nursing Education Scholarship, 5, 117. https://doi.org/10.2202/1548-923X.1546 Kolcaba, K., Tilton, C. & Drouin, C., 2006, Comfort theory: a unifying framework to enhance the practice environment, Journal of Nursing Administration, 36, 538-544.
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Lapkin, S. & Levett-Jones, T., 2011, A cost-utility analysis of medium vs. high-fidelity human patient simulation manikins in nursing education, Journal of Clinical Nursing, 20, 35433552. 10.1111/j.1365-2702.2011.03843.x Medley, C. F. & Horne, C., 2005, Educational innovations using simulation technology for undergraduate nursing education, Journal of Nursing Education, 44, 31-34. Reid, T. P., Hinderer, K. A., Jarosinski, J. M., Mister, B. J. & Seldomridge, L. A., 2013,Expert clinician to clinical teacher: developing a faculty academy and mentoring initiative, Nurse Education in Practice, 13, 288-293. https://doi.org/10.1016/j.nepr.2013.03.022 Sole, M.L., Guimond, M.E.B., Amidei, C., 2012. An analysis of simulation resources. Clinical Simulation in Nursing, e1–e7 http://dx.doi.org/10.1016/j.ecns. 2012.03.003 Starkweather, A.R. and Kardong-Edgren, S., 2008. Diffusion of innovation: Embedding simulation into nursing curricula. International Journal of Nursing Education Scholarship, 5(1), pp.1-11. https://doi.org/10.2202/1548-923X.1567 Waxman, K.T. and Telles, C.L., 2009. The use of Benner's framework in high-fidelity simulation faculty development: The Bay Area Simulation Collaborative model. Clinical Simulation in Nursing, 5(6), pp.e231-e235. doi:10.3928/01484834-20090916-07
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ACCEPTED MANUSCRIPT Table 1 Participant focus group profile Low Fidelity Participant
Technician
Undergraduate Lecturer
Post Graduate Lecturer
Role play
Sim Annie & SimPad™,
High Fidelity 3G ™
Mask ED™
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G1P1 G1P2 G1P3 G1P4 G2P1 G2P2 G2P3 G3P1 G3P2 G3P3 G3P4 G3P5 G3P6 G4P1 G4P2 G4P3
Task trainers
Medium Fidelity
Table 2: Focus group interview questions
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Simulation Profile Questions Can you describe briefly the nursing course(s) that you have taught/currently teach? What type of simulation experiences you have used? Research Questions What were the barriers to the simulation experience? What were the facilitators to the simulation experience?
Simulated patients
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Educator intrinsic barriers.
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Human resource barriers.
Structural barriers.
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Educator own performance expectation Educator perceived student expectations Past student engagement difficulties Past technical challenges Concern regarding currency of skills Feeling pressured to use unfamiliar simulation modalities Not feeling prepared High student number per educator Insufficient time allocated in workloads for simulation preparation Insufficient time for skill practice and peer review Regular training Need for expert direction and advice Lack of staff skill Scenarios with clear learning objectives mapped to curriculum Sufficient equipment for student numbers Access to tried and tested scenarios Expert mentorship Peer support. Annual competence Increase staff time for simulation preparation and delivery Decreased student to staff ratio Sharing of tested scenarios Access to equipment to meet student requirements Back up plans
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• • • • • •
Enhancers to address barriers
ACCEPTED MANUSCRIPT Table 4: Comfort Theory taxonomic structure for educator simulation comfort. State of ease and / or transcendence
Educator problem
State of relief
Physical
Upset and stressed as evident by verbal cues.
Acknowledges that this is a normal physical response to a new or unfamiliar situation.
Psychospiritual
Anxiety, frustration, fear of looking foolish, unrealistic individual selfperformance expectations, sense of loss, and concern over credibility, embarrassment.
Practice, trial runs, backup plans.
Environmental
Large student group sizes, insufficient equipment, insufficient human resource allocation, inadequate staff-to-student ratios, unfamiliarity with equipment, lack of time to prepare and deliver simulation experiences.
Equipment, Knowing how to operate equipment, smaller student group sizes, higher staff-to-student ratios, preparation time, management support.
Simulation training. Working alongside an experienced lead. Pre-packed simulation scenarios. Access to simulation resources in a central repository. Support from simulation operators. Time allocated in workload to prepare and deliver simulation experiences.
Sociocultural
Avoidance, little education with the use of equipment, reluctance, negative past experiences with simulation, pressure to function within the environment, unrealistic performance and knowledge expectations from university administrators, lack of understanding of training and time needed from both administrators and management.
Training, participation in equipment purchase decisions, sharing simulation concerns and challenges with peers.
Awareness of the type of simulation that suits individuals. Access to mentors and role models. Consistent guidelines for simulation development and delivery. Provision of time for simulation design. Access to existing simulation scenarios.
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Simulation training. Mentorship and role modelling programs. Allocated time for simulation development.
Source: Adaptation of Goodwin, Sener and Steiner (2007) application of Kolcaba and DiMarco’s (2005) Comfort Theory.
S1471-5953(16)30282-7
DOI:
10.1016/j.nepr.2017.10.024
Reference:
YNEPR 2317
To appear in:
Nurse Education in Practice
Received Date: 23 December 2016 Revised Date:
19 September 2017
Accepted Date: 17 October 2017
Please cite this article as: Simes, T., Roy, S., O'Neill, B., Ryan, C., Lapkin, S., Curtis, E., Moving nurse educators towards transcedence in simulation comfort, Nurse Education in Practice (2017), doi: 10.1016/j.nepr.2017.10.024. 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.
ACCEPTED MANUSCRIPT
Title page Article title: MOVING NURSE EDUCATORS TOWARDS TRANSCEDENCE IN SIMULATION COMFORT.
Tracey Simes, BN, PGDCC, PGDBM, GCTE CertIVTAE RN 1
Barbara O’Neill, BA, BSN, GCNE, RN3 Colleen Ryan, BhlthSc, GCHPE CertIVTAE, MHPE, RN4
Elizabeth Curtis BN, RN, MN 6
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Samuel Lapkin, PhD, BN Hons (1st Class), GCTE, RN 5
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Sherre Roy, PhD, M Learn Innov, B Bus (Hons), CertIVTAE 2
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Author information
1. Central Queensland University, School of Nursing and Midwifery, 90 Goodchap Street, Noosaville, QLD 4566 Australia Telephone +0617 5440 7028, Email
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[email protected]
2. Central Queensland University, Learning and Teaching Services, Building 7, University Drive, Bundaberg, QLD 4670 Australia. Telephone +617 4150 7052,
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Email [email protected]
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3. Central Queensland University, School of Nursing and Midwifery, Bruce Highway Bldg 18, Rockhampton, QLD 4702 Australia. Telephone +617 4923 2617, Email [email protected]
4. Central Queensland University, School of Nursing and Midwifery, 90 Goodchap Street, Noosaville, QLD 4566 Australia Telephone +06175 4407018, Email [email protected]
ACCEPTED MANUSCRIPT 5. University of Wollongong, School of Nursing, Faculty of Science, Medicine and Health, Wollongong NSW 2522, Australia. Telephone: +612 9113 1567 Email [email protected] 6. University of Western Sydney, School of Nursing and Midwifery, Campbelltown
[email protected]
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Corresponding author
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Campus, NSW 2560, Australia. Telephone: +012 4620 3522, Email
Tracey Simes, RN
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Central Queensland University School of Nursing & Midwifery and Social Furfures 90 Goodchap Street Noosaville, QLD,4566 ,Australia
Telephone +0617 5440 7028 / 0410 728 600 [email protected]
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Disclaimer: The views expressed in the submitted article are our own and not an official position of the institution or funder. Author initials throughout paper have been blacked out.
Source of support: The research was supported in part by a $4950 Internal Scholarship
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of Learning and Teaching grant administered by Central Queensland University. Additional in-kind services of $4938 contributed to the research.
Acknowledgements: The authors would like to express their deepest gratitude to the
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participants of the study for making this research possible by contributing their valuable time and thoughts.
Word count: Abstract: 165 Article: 4933
Tables: 4 Conflict of interest declaration: None to report
ACCEPTED MANUSCRIPT Abstract
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Expensive simulation equipment continues to sit idle in nursing learning and teaching
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environments. To identify factors that influence nursing educator comfort in the use of
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simulation at an Australian university an explorative qualitative research project was
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undertaken using an interpretative constructivist methodology. The Goodwin, Sener and
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Steiner (2007) adapted Comfort Theory for nursing education has been used. The aim of
7
the study was to identify factors that influence nurse educator’s comfort in the use of
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simulation. Research question asked was: What are the barriers and enhancers to using
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simulation as a learning and teaching modality. Thematic analysis of data from focus groups
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on four different campus sites was undertaken. Four themes identified that affected
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participants’ comfort in this study were: 1) Personal barriers; 2) Human resource barriers; 3)
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Structural barriers and 4) Suggestions to address barriers. Further understanding of the
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themes and how they relate to educator comfort with simulation are shared with the reader.
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The paper also outlines emerging recommendations to improve educator comfort.
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HIGHLIGHTS
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educator comfort with simulation use.
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Personal barriers, human resource barriers, and structural barriers influence
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The establishment of a central digital repository of simulation resources is recommended.
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Formal mentorship simulation programs are needed for educators.
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•
Time needs to be allocated for simulation preparation and delivery in workload
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scheduling.
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The use of Goodwin, Sener and Steiner (2007) adapted Comfort Theory assists in the articulation of educator comfort. KEYWORDS
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Comfort; Simulation; Educator; Nursing; Workload.
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Introduction
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In 2005, Pamela Jefferies, a nursing leader in simulation, stated that educators must feel
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prepared and comfortable to use simulation, yet over a decade later it appears comfort has
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not been fully explained nor explored. Many nursing educators remain reluctant to engage
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with simulation pedagogy and simulation equipment (Adamson 2010, King et al., 2008, Al-
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Ghareeb & Cooper, 2016) despite strong evidence that simulation plays a vital role in
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preparing student nurses for clinical placements (Burns, O’Donnell, & Artman 2010, Jansen
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et al., 2010, Kardong-Edgren, Starkweather & Ward, 2008). Therefore, a qualitative
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research project was designed to explore current barriers and enhancers to the
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implementation of simulation learning activities from the perspective of nurse educators.
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The study aimed to identify factors that influence nursing educators comfort in the use of
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simulation. Results of this study provided three recommendations to improve nurse
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educator comfort with the delivery of simulation as a learning and teaching tool;
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recommendations that may pave the way toward comfort for nurse educators using
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simulation. The following paper will provide a brief background to the issue of educator
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simulation comfort, a description of the theoretical framework used to articulate educator
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comfort, an explanation of the research design used, along with the findings and
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recommendations of the study.
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ACCEPTED MANUSCRIPT Background
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One explanation for the reluctance of nurse educators to embrace simulation has been
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related to a lack of familiarity with simulation equipment (Jones & Hegge 2007). Nursing
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literature infers that this situation may have arisen because nursing program administrators
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throughout the world have allocated financial resources to equipping clinical laboratories
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with simulation technology, but have neglected to allocate resources for supporting
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educators in both the use of the equipment and simulation pedagogy (Adamson 2010,
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Medley & Horne 2005). Adamson (2010) reported that less than 7% of initial simulation
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investment was spent on maintenance, training and implementation of simulation programs.
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Successful uptake of simulation in nursing has been attributed to the failure to understand
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and manage ongoing staff costs, resources and time required for simulation design and
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implementation (Lapkin & Levett-Jones 2011).
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Furthermore, Harder, Ross and Paul (2013) reported that high-fidelity simulation was not
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something that nursing educators undertook if they were uncomfortable or unfamiliar with
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the simulation modality. Another contributing factor to educator reluctance to use
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simulation has been the fear of failure and looking unprepared and incompetent in front of
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students (Jansen et al., 2010). This reluctance to use simulation is what Blazeck (2011) refers
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to as simulation anxiety syndrome. While the factors that contribute to educators
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discomfort with simulation are often reported, factors that would assist to provide educator
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comfort with simulation have not been clearly articulated in the literature. To articulate
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educator comfort a theoretical framework is needed.
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Theoretical framework
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ACCEPTED MANUSCRIPT Comfort is difficult to define due to its individual and abstract nature. Comfort is a core
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nursing care concept that has been explored by theorists such as Morse, Watson, and
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Kolcaba (Apostolo 2009). Kolcaba’s work on Comfort Theory in nursing was introduced in
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the 1990s and remains in use today in the nursing clinical, educational and research
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environments. Comfort Theory comprises of three complex reality states for individuals: (1)
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relief, when specific comfort needs are met; (2) ease, a state of calm; and (3) transcendence,
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when one rises above the problem. Each experience state occurs in four contexts: physical,
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psychospiritual, environmental and sociocultural (Kolcaba, Tilton & Drouin 2006). Kolcaba,
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Tilton and Drouin (2006) further explained physical comfort pertains to positive body
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sensations and homeostatic body mechanisms. Psychospiritual comfort is defined as the
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mental, emotional and spiritual components of self which include self-worth, and self-
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esteem. The external environment is defined as external surroundings, conditions and
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influences such as noise, light, and equipment. Sociocultural comfort is the relationship
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between self and family and society and takes into account education, support, and cultural
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customs.
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Goodwin, Sener and Steiner (2007) further adapted Comfort Theory for use in nursing
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education. Goodwin, Sener and Steiner work (2007) situates Comfort Theory in the context
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of creating a culture of comfort for students around learning and professional development.
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The authors of this study posed Goodwin, Sener and Steiner (2007) work on comfort could
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also be extended to defining a culture of comfort for educator use of simulation. Before
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further investments in simulation equipment are made, King et al., (2008) recommended
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there needed to be a greater understanding of what will enable nurse educators to be more
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comfortable in adopting simulation pedagogy into their teaching.
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ACCEPTED MANUSCRIPT To this end, researchers at an Australian university conducted an exploratory qualitative
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study aimed to identify factors that influenced nurse educator comfort. The research
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question posed was: What are the current barriers and enhancers to the use of simulation
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as a learning and teaching modality?
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Research design
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Participants and setting
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The project was undertaken at one Australian university’s school of nursing. The university
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has 16 campuses, but the study was limited to the four campuses where nurse educators
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teach. The campuses where the study was undertaken have significant geographical
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distances of more than 185 miles (298 km) between each. A purposive sample of nursing
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education staff (n = 44) were invited to participate via email and flyer. Sixteen staff
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participated, representing 36% of the educators; 12 were university lecturers and four were
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registered nurses working as laboratory technicians; one participant was male and fifteen
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female. Laboratory technicians assist in the education of students within the simulation
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learning environment; thus their involvement was considered important. All sixteen
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participants (100%) stated that they use task trainers and role play; eight participants (50%)
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use Mask-Ed TM (KRS simulation); seven participants use Sim Anne with SimPadTM technology
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(44%); and two participant use 3G (12%). (Table 1). There are a number of studies that
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report a lack of use of high fidelity simulation in nursing education (Harder, Ross & Paul,
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2013; King et al., 2008 ) and the demographic data that follows (Table 1) infers that both
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medium and high fidelity simulation are not fully embraced by participants in this study.
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A semi-structured focus group conducted by a facilitator engaged by the research team, was
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held at each campus. The facilitators were chosen for their qualitative research experience
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and impartiality. To increase rigour and consistency with data collection, each facilitator
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attended a one-hour training workshop. This workshop was conducted by the chief
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investigator (TS). The workshop included discussion of the interview questions and a review
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of the aim of the research project. The open-ended questions comprised of two simulation
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participant profile questions and two interview questions related directly to the research
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question. Questions are listed in Table 2. Each group facilitator encouraged everyone to
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participate, and sessions lasted until the discussion waned, approximately 30-45 minutes.
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Sessions were audiotaped and transcribed verbatim by a transcription service.
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Ethical considerations
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Ethical clearance was gained from the University’s Human Research Ethics Committee
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(H14/06-145). Participation was voluntary and signed consent forms were received from
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each participant. No participant incentives were offered for attendance. As the majority of
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the research team, including the chief investigator, were also members of the nursing
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teaching faculty, they were not eligible to participate in the focus group sessions. All data
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was de-identified at the time of transcription.
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Data analysis
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Thematic analysis techniques described by Guest, Macqueen and Namey (2011) and Braun
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and Clarke (2013), were employed for data analysis against focus group interview transcripts.
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ACCEPTED MANUSCRIPT Thematic analysis was chosen as it is a flexible research tool that allows the researcher to
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gain a rich contextual understanding of a phenomenon through interaction with the data
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(Braun & Clarke 2013). Thematic analysis allows the interpretation and construction of the
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complexity of meaning that supports the interpretative constructivist methodology of this
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study (Guest, Macqueen & Namey 2011).
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Inductive analysis was used to explore the data from the bottom up (Guest, Macqueen &
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Namey 2011). Familiarisation of data occurred through reading and re- reading transcripts,
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whilst listening to corresponding interview recordings. After familiarisation with transcripts,
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initial codes for each question was developed (Braun & Clarke 2013). The initial codes for
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each focus group transcript was organised using NVivo software version 11. A code matrix
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for each focus group against each question was developed. This process was undertaken
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separately by two members of the research team (TS & SR). Initial codes where compared
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and discussed referring to raw data to reach an initial code consensus. Once consensus was
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reached the initial codes were then applied across all the transcripts. This was a cyclic
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process of going back and forth from each transcript, increasing the rigor of the coding
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process and the refinement of codes names (Braun & Clarke 2013). The two research team
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members (TS, SR) undertook this process together to facilitate discussion and consensus of
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final code names. Final codes were then placed within a vertical and horizontal relational
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matrix. The matrix facilitated the identification and construction of potential themes within
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the varying data codes (See Table 3). Member checking with two participants from each
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focus group was done to validate the final codes. Participants agreed that the codes
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reflected the discussion content.
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Four themes were identified that expressed factors for educator comfort when using
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simulation in the learning environment. The themes were: (1) Personal barriers; (2) Human
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resource barriers; (3) Structural barriers, and (4) Suggestions to address barriers. To ensure
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the trustworthiness of themes, examples are provided to demonstrate the participants’
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voice in study findings (Graneheim, Lindgren, & Lundman 2017). Examples include a
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participant identifier where “G” along with a number indicates the focus group number (1-4)
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and “P” indicates the participant and number assigned. For example, G4P2 indicates focus
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group 4, participant 2. Goodwin, Sener and Steiner (2007) adaptation of Comfort Theory
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has been applied to the findings (See Table 4).
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Personal barriers
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Many participants in this study disclosed anxiety due to their own perceived student
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performance expectations of a simulation event. This anxiety also extended into the
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expectations the participants placed upon themselves as simulation facilitators. The anxiety
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created by these perceived pressures was heard in participant’s strained tone of voice and
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in accelerated speed of speech in statements such as:
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The learning hopes are so high that if we blow it, really it does blow it. (G4P2)
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Accounts about past experiences regarding difficulties in engaging students and the
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negative effect that these experiences had upon the implementation of future simulation
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where shared. An example of these accounts are:
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Once you start getting the students loitering they start getting a little bit ugly and
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your residential school can go to hell. (G2P1) 8
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When we’re dealing with 20-30 students at a time you have to work out a way to get
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them all engaged otherwise they will just zone out. (G1P3) The participants in this study expressed anxiety about utilising equipment they had received
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little education on, had limited experience with, or had not used for a period of time.
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Shared comments indicating past simulation experiences had not proceeded as planned and
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these experiences contributed to ongoing anxiety:
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I think that [training for the educator] is really important because you lose credibility
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in front of the students. I remember doing a simulation where the patient was
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supposed to stop breathing, but I had forgotten to turn it [the manikin’s] breathing
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off. (G1P2)
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Being prepared, knowing what it is that you’re doing, it’s embarrassing if you do not.
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(G3P4)
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Anxiety shared by participants indicated that many felt personally uncomfortable
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functioning within the simulation environment and felt pressured to use unfamiliar
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simulation modalities. As one participant explained:
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Some people may have been pushed into an area of simulation that they don’t like.
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EP
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(G3P4)
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To summarise this theme, as the literature shows, educators resist implementing simulation
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for fear of looking foolish (unprepared or incompetent) in front of students. (Adamson
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2010; Blazeck 2011; Harder, Ross & Paul 2013; Jansen et al., 2010). This fear gives rise to
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the perceptions that the risk of using simulation is greater than the benefits. Although these
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findings are not new, and are well documented in the literature, the findings in this study
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progression of simulation in the learning and teaching space
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Human resource barriers
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Participants were pleased investments had been made in simulation equipment but felt
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current education administrators needed to better understand that staff needs must be
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considered to better support and prepare them in using the equipment. One participant
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stated:
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There’s no discussion of what we might want or need, stuff just turned up and it was,
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you can use this now, and we couldn’t. (G2P1)
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Participants reported a lack of understanding of the regular training required for the
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successful implementation of simulation from both administrators and themselves.
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Participants recalled having received limited training in the use of simulation equipment,
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describing their experiences as: “Ad hoc” (G2P3) and “Little snippets here and there” (G3P2).
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One participant explained:
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I’ve had 3G training which was well over 12 months ago it wasn’t followed up. It was
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quick, it was a real quickie training into 3G where if I went out there now I would not
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feel really confident. If you are not playing with that you can’t be competent with it. You really have to put the time in and I think that’s an issue for all of us, we need to
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have some form of consistency in how are going to keep up with those technologies.
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(G3P4)
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There was also a consensus regarding the lack of understanding of time needed by an
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educator for preparation and delivery of simulation. 10
ACCEPTED MANUSCRIPT Time is a big thing, and apart from running the scenarios, it is time for preparation
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and time for learning. At the moment there is no real allowance for that … (G1P3)
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It’s juggling it between your workload, residential schools and whatever else you are
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studying it’s hard to get in there and find time just play. (G3P2)
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…time; time getting into that costume is time consuming. It is not a solo activity.
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(G1P4)
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High student ratio to simulation facilitator was a common concern regarding use of human
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resources. Expression of this concern included:
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Yes, when you’ve got groups of 40 it is quite difficult. You have to get through as
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many [students] as you can. (G4P3)
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It is very time consuming where you can do three hours of simulation and still not
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have everyone covered. (G1P3)
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These findings highlight that although the provision of physical resources has provided
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comfort relief, participants continue to feel uncomfortable with the lack of human resources
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and time provided to successfully implement simulation activities. Studies undertaken by
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Jansen et al., (2009) and Akhtar-Danesh et al., (2009) identified the issue of time needed to
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develop and deliver simulations. This study echoes these concerns. The lack for formal
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simulation education program for hands on practice and skill development identified by
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Jefferies (2008) and Anderson et al., (2012) remain an issue. The physical requirements of
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regular training, educator time and student numbers needs to be addressed for educators
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to feel comfort ease in use of simulation.
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Structural barriers
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ACCEPTED MANUSCRIPT Structural barriers are obstacles participants felt prevented them from running a simulation
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scenario comfortably. The structural barrier theme includes the educators’ understanding of
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available equipment and access to learning and teaching simulation resources. Participants
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suggested they may be more comfortable with utilising simulation pedagogy if they received
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guidance and support in understanding how to run a simulation scenario.
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I really thought that I could rock up and explain different scenarios to the students
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and I would be able to, on the SimPads™, to just adjust what the vital signs are, the
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sounds of the patient. I could mimic a deteriorating patient and have them react
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accordingly. I did not have in place structured roles; I did not have a structured
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debrief, I did not have a structured pre-brief, and it was an absolute disaster. … I
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really thought I could wing it. It was awful for me. (G4P2)
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Participants also expressed feelings of being pressed for time. As explained by the following
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participants:
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[We are] time poor. G4P2
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[We are] time limited. G3P5
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Sufficient resources for all the students was also a concern. Participants reported it was
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hard to run a scenario if each student was not fully equipped with the required resources.
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One participant stated:
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They introduce all these things to us right, but then we’ve got to fight to actually get
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the resources that we need; G2P2
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Simulation and Learning (INACSL) Standards of best practice: simulation (2016) available for
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structured simulation scenario development and delivery, educators at the coal face often
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do not know about these resources nor have easy access to these resources. Participants
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linked this physical need for delivery and scenario structure for educator comfort ease.
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Suggestions to address barriers
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The participants also provided suggestions on how to address barriers to simulation that
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were coded into eight subthemes: (1) provide mentor opportunities; (2) allot staff time for
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preparation and delivery of simulation activities; (3) encourage peer support; (4) share
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simulation scenarios; (5) provide more and regular simulation training; (6) allow academics
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to have a choice on the types of simulation used; (7) conduct trial runs and have a backup
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plan; (8) and provide the appropriate level of staffing and resources. The first subtheme of
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having mentors, for example, was seen to alleviate some of the discomfort around
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simulation, as evidenced in the following statement:
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The experienced lead made all the difference for me; the demonstration done by
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quite experienced people in sim, that was key to learning for me or maybe that’s just
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how I learn; clear roles for the lecturers. It really helped me that I knew exactly what my role was. I knew exactly when to come in, I know how I will benefit the scenario. (G4P2)
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It really does help if you have someone that has done a lot of it. I’ve been quite lucky
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with the people that I’ve worked with it in my courses that they’ve done quite a bit of
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simulation. (G3P2)
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frequently mentioned. Participants said there was a need for themselves and university
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administrators to allocate sufficient time to prepare and deliver simulation for learning and
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teaching. One participant stated that it was important to:
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Make time to learn how to do this before you can actually come and run it and that is a
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factor that is not really taken into account for workloads. (G1P3)
Participants also felt that it was vital to support one another, not only in the preparation
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and delivery of scenarios, but also in the sharing of personal stories of the discomfort
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experienced around teaching with simulation. Evidenced by:
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Sitting here today and talking about this may be valuable for the staff that are doing
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residential schools to come together to talk about simulation experiences and what
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went well and what didn’t at how they felt as well. (G3P4)
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The participants also acknowledged that it would be good to share simulation scenarios. The
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sharing of scenarios would save time and ensure consistency in the presentation of
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simulation activities across the nursing curriculum providing comfort to the educator. One
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participant shared:
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I think it does take time to do the scenarios but once we get a bank of them that time
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factor will drop considerably because all we would do is just pick what we want to do
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and I think that would work. (G1P3)
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Participants suggested they also needed to feel comfortable with the modality of simulation
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they were delivering and should therefore have a choice in the type of simulation.
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Participants expressed a desire for more and regular training with the equipment. Many felt
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that annual competency-based training could be implemented that would help to ensure
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simulation skills remained current and therefore enforcing comfort ease. As one participant
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states: I think that if you are comfortable in the delivery style that you are going to use then
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you will get a positive outcome from that. I think that it’s being familiar with what
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the session need to achieve, what resources are going to use, and I practice enough
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with the SimPad™, so I don’t look like a fool in front of the students. (G3P7).
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Participants expressed reluctance to place themselves in vulnerable positions. The necessity
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of having trial runs and back-up plans was seen as essential. One participant stated she
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often created up to four back-up plans for one simulation experience because she did not
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want to look foolish:
We have plans A, B, C, D, E.
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Finally, participants felt that due to high student numbers having “more staff” (G3P2) and
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sufficient equipment to engage students is needed. One participant was emphatic that
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resources were key:
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The resources, if we don’t provide proper resources for the simulation that we are
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running then we automatically set up something to fail. (G3P6)
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Simulation experts, such as Hodge et al. (2008), Jefferies (2008), Starkweather and Kardong-
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Edgren (2008), and Waxman and Telles (2009), recommend the establishment of formal
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simulation education programs for academics. Participants in this study felt that it was not
329
only additional formal education that was required, but also feedback, support and
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guidance from an expert in simulation. To sustain and advance simulation there is also a 15
ACCEPTED MANUSCRIPT need for financial investment in staff time, as expressed by participants in this study and
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others (Adamson 2010; Sole et al., 2012; Bray et al., 2009).
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Recommendations
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The four identified themes indicated how the participants in this study defined educator
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comfort in simulation. The concerns expressed in these themes have resulted in three
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recommendations for the transition of educators to what Kolcaba, Tilton and Drouin (2006)
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refers to as comfort in simulation to relief and ease. The three recommendations from the
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study are: (1) management of simulation resources though a central digital repository; (2)
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implementation of formal mentorship simulation programs; and (3) time allocation for
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simulation preparation and delivery in workload allocations.
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1) Management of simulation resources though a central digital repository
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Considering the academics’ concerns about time constraints, as well as the need for peer
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support and the desire to share resources, one recommendation is the implementation of a
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central digital repository where academics could readily access simulation information. This
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is a way to decrease anxiety and increase comfort by decreasing the time required in the
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development of scenarios and trying to find information on how to run particular
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simulations. The central digital repository would be a university-owned online resource
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where staff could obtain information and training regarding simulation, equipment
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availability and usage information, access to simulation mentors, and tested scenarios. The
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information would be accessible from any site at any time and be tailored to the
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requirements of the nursing curriculum.
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ACCEPTED MANUSCRIPT 2) Implementation of formal mentorship simulation programs
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The second recommendation is the implementation of formal mentorship programs to
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support role-modelling. Educators new to or unsure of particular simulation modalities need
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to have the opportunity to watch and be supported by an experienced educator within a
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student simulation experience. Mentors have the opportunity to decrease simulation
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discomfort by providing direction and reassurance that they are there to fall back on if
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something does not go according to plan. They can also assist in the development of back-
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up plans. Thus, a positive learning experience can be provided instead of an “ad hoc”
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experience that has the potential to be embarrassing and stressful.
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3) Time allocation for simulation preparation and delivery in work load allocations.
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The third recommendation was a call for university administrators to acknowledge the time
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required for the preparation and delivery of simulation. Although scenarios can be shared
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though a central repository, the development of simulation scenarios takes time. The
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conceptual scenario needs to be tested and refined to ensure that learning objectives are
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met. Time is also needed for educators to learn the scenario and pedagogical framework for
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the deliverance of the scenario to students. Experiential learning for educators that is
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guided by mentors needs to be planned in workload allocation for educators to feel
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comfortable engaging in simulation (Reid et al., 2013)
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Study limitations
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As the data is self-reported though focus group discussion, individual biases may exist and
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participants may have selective memory about their experiences. The risk that certain
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participants may dominate the discussion, or participants feeling uncomfortable revealing
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ACCEPTED MANUSCRIPT their true feelings in front of their peers, is acknowledged. The facilitators were aware of
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these risks and were familiar with steps to address them if they arose. It is also possible
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educators who opposed or feared simulation did not participate. Furthermore, while there
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were representatives from a variety of settings and campuses participating in the
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discussions, which reflected a diverse group of participants, each participant’s formal
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training in simulation was not articulated.
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Conclusion
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This study identified four themes that influence educators’ feelings of ‘comfort’ with
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implementing simulation. Literature acknowledges comfort as a significant component to
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successful simulation implementation. The three recommendations from the study require
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urgent consideration by both educators and university administrators to increase and
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advance simulation usage. The three recommendations are 1) management of simulation
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resources though a central digital repository; 2) implementation of formal mentorship
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simulation programs; and 3) time allocation for simulation preparation and delivery in
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workload allocations. Further research is needed to determine if the recommendations
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implemented provide comfort relief and / or ease and if there are any further activities or
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actions needed to achieve transcendence into simulation comfort.
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References
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Adamson, K.,Adamson, K., 2010, Integrating human patient simulation into associate degree nursing curricula: faculty experiences, barriers, and facilitators, Clinical Simulation in Nursing, 6, e75-e81. Akhtar-Danesh, N., Baxter, P., Valaitis, R.K., Stanyon, W., Sproul, S., 2009. Nurse faculty perceptions of simulation use in nursing education. West. J. Nurs. Res. 31 (3), 312–329. htp://dx.doi.org/10.1177/0193945908328264 Al-Ghareb, A. Z. & Cooper, S. J., 2016, Barriers and enablers to the use of high-fidelity patient simulation manikins in nurse education: an integrative review, Nurse Education Today, 36, 281-286. http://dx.doi.org/10.1016/j.nedt.2015.08.005
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Anderson, M., Bond, M.L., Holmes, T.L., Cason, C.L., 2012. Acquisition of simulation skills: survey of users. Clin. Simul. Nurs. 8 (2), e59–e65. http://dx.doi.org/10.1016/j.ecns.2010.07.002 Apostolo, J. L. A., 2009, Comfort in nursing theories. Concept Analysis and Theoretical Meaning Revista de Enfermagem Referência, 61-67. Blazeck, A., 2011, Simulation anxiety syndrome: presentation and treatment., Clinical Simulation in Nursing, 7, e57-e60. doi:10.1016/j.ecns.2010.05.002 Braun, V., & Clarke, V., 2013, Successful qualitative research: a practical guide for beginners, Sage publications, London, UK Bray, B., Schwartz, C.R., Weeks, D.L. and Kardong-Edgren, S., 2009. Human patient simulation technology: perceptions from a multidisciplinary sample of health care educators. Clinical Simulation in Nursing, 5(4), pp.e145-e150. https://doi.org/10.1016/j.ecns.2009.02.002 Burns, H. K., O'Donnell, J. & Artman, J., 2010, High-fidelity simulation in teaching problem solving to 1st-year nursing students: a novel use of the nursing process,Clinical Simulation in Nursing, 6, e87-e95. https://doi.org/10.1016/j.ecns.2009.07.005 Guest, G., MacQueen, K., & Namey, E., 2011, Applied thematic analysis. Sage Publications, California Goodwin, M., Sener, I. & Steiner, S. H., 2007, A novel theory for nursing education, Journal of Holistic Nursing, 25, 278-285. 10.1177/0898010107306199 Graneheim, U.H., Lindgren, B.M., & Lundman, B., 2017., Methodological challenges in qualitative content analysis: A discussion paper. Nurse Education Today. 10.1016/j.nedt.2017.06.002 Harder, B. N., Ross, C. J. M. & Paul, P., 2013, Instructor comfort level in high-fidelity simulation, Nurse education today, 33, 1242. 10.1016/j.nedt.2012.09.003 Hodge, M., Martin, C., Tavernier, D., Perea-Ryan, M., & Alcala-Van Houten, L., (2008). Integrating simulation across the curriculum. Nurse Educator, 33(5), 210-214. doi:10.1097/01.NME.0000312221.59837.38 Jansen, D. A., Berry, C., Brenner, G. H., Johnson, N. & Larson, G., 2010, A collaborative project to influence nursing faculty interest in simulation, Clinical Simulation in Nursing, 6, e223-e229. doi:10.1016/j.ecns.2009.08.006 Jeffries, P. R., 2008. Getting in S. T. E. P. with simulation: simulations take educator preparation. Nurse Education Perspective, 29 (2), 70–73. Jeffries, P. R., 2005, A framework for designing, implementing, and evaluating: simulations used as teaching strategies in nursing, Nursing Education Perspectives, 26, 96-103. Jones, A. L. & Hegge, M., 2007, Faculty comfort levels with simulation, Clinical Simulation in Nursing, 3, e15-e19. doi:10.1016/j.ecns.2009.05.034 Kardong-Edgren, S. E., Starkweather, A. R. & Ward, L. D., 2008, The integration of simulation into a clinical foundations of nursing course: student and faculty perspectives, International Journal of Nursing Education Scholarship, 5, 1-16. https://doi.org/10.2202/1548-923X.1603 King, C. J., Moseley, S., Hindenlang, B. & Kuritz, P.,2008, Limited use of the human patient simulator by nurse faculty: an intervention program designed to increase use, International Journal of Nursing Education Scholarship, 5, 117. https://doi.org/10.2202/1548-923X.1546 Kolcaba, K., Tilton, C. & Drouin, C., 2006, Comfort theory: a unifying framework to enhance the practice environment, Journal of Nursing Administration, 36, 538-544.
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Lapkin, S. & Levett-Jones, T., 2011, A cost-utility analysis of medium vs. high-fidelity human patient simulation manikins in nursing education, Journal of Clinical Nursing, 20, 35433552. 10.1111/j.1365-2702.2011.03843.x Medley, C. F. & Horne, C., 2005, Educational innovations using simulation technology for undergraduate nursing education, Journal of Nursing Education, 44, 31-34. Reid, T. P., Hinderer, K. A., Jarosinski, J. M., Mister, B. J. & Seldomridge, L. A., 2013,Expert clinician to clinical teacher: developing a faculty academy and mentoring initiative, Nurse Education in Practice, 13, 288-293. https://doi.org/10.1016/j.nepr.2013.03.022 Sole, M.L., Guimond, M.E.B., Amidei, C., 2012. An analysis of simulation resources. Clinical Simulation in Nursing, e1–e7 http://dx.doi.org/10.1016/j.ecns. 2012.03.003 Starkweather, A.R. and Kardong-Edgren, S., 2008. Diffusion of innovation: Embedding simulation into nursing curricula. International Journal of Nursing Education Scholarship, 5(1), pp.1-11. https://doi.org/10.2202/1548-923X.1567 Waxman, K.T. and Telles, C.L., 2009. The use of Benner's framework in high-fidelity simulation faculty development: The Bay Area Simulation Collaborative model. Clinical Simulation in Nursing, 5(6), pp.e231-e235. doi:10.3928/01484834-20090916-07
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ACCEPTED MANUSCRIPT Table 1 Participant focus group profile Low Fidelity Participant
Technician
Undergraduate Lecturer
Post Graduate Lecturer
Role play
Sim Annie & SimPad™,
High Fidelity 3G ™
Mask ED™
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G1P1 G1P2 G1P3 G1P4 G2P1 G2P2 G2P3 G3P1 G3P2 G3P3 G3P4 G3P5 G3P6 G4P1 G4P2 G4P3
Task trainers
Medium Fidelity
Table 2: Focus group interview questions
•
• •
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Simulation Profile Questions Can you describe briefly the nursing course(s) that you have taught/currently teach? What type of simulation experiences you have used? Research Questions What were the barriers to the simulation experience? What were the facilitators to the simulation experience?
Simulated patients
ACCEPTED MANUSCRIPT Table 3: Themes that effect educator comfort.
• • • •
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Educator intrinsic barriers.
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Human resource barriers.
Structural barriers.
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Educator own performance expectation Educator perceived student expectations Past student engagement difficulties Past technical challenges Concern regarding currency of skills Feeling pressured to use unfamiliar simulation modalities Not feeling prepared High student number per educator Insufficient time allocated in workloads for simulation preparation Insufficient time for skill practice and peer review Regular training Need for expert direction and advice Lack of staff skill Scenarios with clear learning objectives mapped to curriculum Sufficient equipment for student numbers Access to tried and tested scenarios Expert mentorship Peer support. Annual competence Increase staff time for simulation preparation and delivery Decreased student to staff ratio Sharing of tested scenarios Access to equipment to meet student requirements Back up plans
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• • • • • •
Enhancers to address barriers
ACCEPTED MANUSCRIPT Table 4: Comfort Theory taxonomic structure for educator simulation comfort. State of ease and / or transcendence
Educator problem
State of relief
Physical
Upset and stressed as evident by verbal cues.
Acknowledges that this is a normal physical response to a new or unfamiliar situation.
Psychospiritual
Anxiety, frustration, fear of looking foolish, unrealistic individual selfperformance expectations, sense of loss, and concern over credibility, embarrassment.
Practice, trial runs, backup plans.
Environmental
Large student group sizes, insufficient equipment, insufficient human resource allocation, inadequate staff-to-student ratios, unfamiliarity with equipment, lack of time to prepare and deliver simulation experiences.
Equipment, Knowing how to operate equipment, smaller student group sizes, higher staff-to-student ratios, preparation time, management support.
Simulation training. Working alongside an experienced lead. Pre-packed simulation scenarios. Access to simulation resources in a central repository. Support from simulation operators. Time allocated in workload to prepare and deliver simulation experiences.
Sociocultural
Avoidance, little education with the use of equipment, reluctance, negative past experiences with simulation, pressure to function within the environment, unrealistic performance and knowledge expectations from university administrators, lack of understanding of training and time needed from both administrators and management.
Training, participation in equipment purchase decisions, sharing simulation concerns and challenges with peers.
Awareness of the type of simulation that suits individuals. Access to mentors and role models. Consistent guidelines for simulation development and delivery. Provision of time for simulation design. Access to existing simulation scenarios.
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Simulation training. Mentorship and role modelling programs. Allocated time for simulation development.
Source: Adaptation of Goodwin, Sener and Steiner (2007) application of Kolcaba and DiMarco’s (2005) Comfort Theory.