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Using a Standardized Patient to Teach Fall Safety
Clinical Simulation in Nursing (2014) 10, e183-e190
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Using a Standardized Patient to Teach Fall Safety Kelly P. Beischel, PhD, RN, CNEa,*, Julie Hart, MSN, RN, CNEb, Sandra Turkelson, MSN, RN, CNEb, Joy Churchill, MSN, RNb a b
Xavier University, 3800 Victory Parkway, Cincinnati, OH 45207 Northern Kentucky University, Nunn Dr., Highland Heights, KY 41099 KEYWORDS standardized patient; simulation; safety; attitudes; teaching strategies; nursing education; fall safety
Abstract Background: Patient falls in acute care settings have become a major public concern. It is important that nurse educators use evidence-based teaching strategies to teach nursing students the necessary measures required to keep patients safe. Methods: Using a multisite, mixed methods, experimental study, we tested the effect of using a standardized patient in simulation on cognitive gains, student attitudes toward patient safety and important simulation design features. Results: Students indicated debriefing followed by fidelity were the most important features of this simulation. Although there was no significant cognitive learning in the experimental group, there was a significant improvement in attitudes toward safety. Conclusion: This study adds to the science of nursing education providing evidence for best teaching practices. Using standardized patients in simulation improves student attitudes toward patient safety. Cite this article: Beischel, K. P., Hart, J., Turkelson, S., & Churchill, J. (2014, April). Using a standardized patient to teach fall safety. Clinical Simulation in Nursing, 10(4), e183-e190. http://dx.doi.org/10.1016/ j.ecns.2013.11.007. Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Patient safety is a national concern among health care institutions. It is estimated that adverse events occur at a rate of 145 per 1,000 hospital admissions with an estimated cost of $19.5 billion (Agency for Healthcare Research and Quality, 2013). The fifth leading preventable adverse event is patient falls, occurring at a rate of 8 per 1,000 hospital admissions (Agency for Healthcare Research and Quality, 2013). The consequences of falling include increased length of hospital stays, increased resource use, (Bates, Pruess, Sourney, & Platt, 1995) pain, serious injury, and
* Corresponding author: [email protected] (K. P. Beischel).
death (Rubenstein, 2006; Tinetti & Kumar, 2010). The health care system likewise incurs a considerable burden when hospitalized patients fall such as loss of revenue, complaint and litigation, and staff anxiety and remorse (Oliver, 2008). Risk prevention though can minimize the number of patient falls (Rubenstein, 2006). Teaching nursing students how to assess for patient fall risks and to prevent falls is important. One strategy for teaching fall risks and consequences to falling is to use a standardized patient (SP), an individual specially trained to portray a patient with a particular condition in a predictable and repeatable way (Association of Standardized Patient Educators, 2011).
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http://dx.doi.org/10.1016/j.ecns.2013.11.007
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Using an SP in a simulation scenario is relatively new in nursing education. Teaching nursing students about falls using a SP can expose students to a realistic high-risk situation while circumventing the devastation of an actual adverse event. However, there are limited data to determine that the use of SPs to teach nursing students is an effecKey Points tive strategy when teaching Teach nursing stufall risks. Moreover, the dents about falls using amount of simulation time an SP offers a realistic required for effectiveness is high risk situation. as yet unknown. Using an SP in a 10 minute simulation to Purpose and Research teach about fall risks increases student apQuestions preciation for patient safety. The primary purpose of this Simulation may be mixed methods study was to more effective at examine the effectiveness of reaching the affective using simulation with SPs domain than the as a strategy to teach patient cognitive domain. safety. The quantitative research questions included: (1) Is there a difference in the cognitive post-test scores between beginning nursing students who receive instruction and a 10-minute SP fall-risk safety simulation and beginning nursing students who receive instruction only? (2) Is there a difference in the attitudes toward safety between beginning nursing students who receive instruction and a 10-minute SP fall risk safety simulation and beginning nursing students who receive instruction only? (3) What design features of a SP fall risk safety simulation are important to beginning nursing students? The secondary purpose of this study was to explain the quantitative results using qualitative reflection. The beginning nursing students in this study were in their first nursing course associated with a clinical experience.
Literature Review Falls More than one in three adults, 65 years and older, fall each year and the likelihood of falling increases with age (Centers for Disease Control and Prevention, 2008; National Institute of Health Senior Health, 2013). Many factors put a patient at increased risk for falling, including altered mental status, use of restraints, history of falls, use of walking assistive devices, impaired balance and gait, decreased strength, medications, age, and impaired functional ability (Evans, Hodgkinson, Lambert, & Wood, 2001; Rubenstein, 2006). Risk prevention, which includes assessing and properly identifying patients at risk, reviewing medication, eliminating physical environmental
hazards, and providing physical assistance when mobilizing patients at highest risk, can minimize the number of patient falls (Evans et al., 2001).
Standardized Patients SPs are used to create realistic simulated clinical situations in a controlled environment. The use of SPs in medical education started in the mid 1960s, offering experiential learning as opposed to textbook learning (Wallace, 1997). Although nursing education has been slower to incorporate SPs into the curricula, their use is growing. Studies indicate that the use of SPs in undergraduate nursing education is an effective strategy to teach communication skills to beginning nursing students (Anderson, Holmes, LeFlore, Nelson, & Jenkins, 2010; Yoo & Yoo, 2003), medication administration, patient positioning, mouth care, and back care (Yoo & Yoo, 2003), as well as basic assessment skills (Bornais, Raiger, Krahn, & El-Masri, 2012). Further, the use of an SP increases knowledge and confidence while decreasing anxiety when used with beginning nursing students for extensive orientation for their first clinical experience (Dearmon et al., 2013). DeBourgh and Prion (2011) using three SP simulations to teach fall risks, demonstrated cognitive improvement after the SP simulation intervention. Using SPs to teach upper level nursing students is likewise effective. When teaching senior nursing students about therapeutic communication and depression using SPs, these students described their learning experience as positive and meaningful compared with those taught using traditional teaching methods (Becker, Rose, Berg, Park, & Shatzer, 2006). Similarly, students who were taught to perform mental status examinations and suicidal risk assessments using SPs reported increased self-confidence, increased critical thinking, and satisfaction with the learning experience (Robinson-Smith, Bradley, & Meakin, 2009). Upper-level students were also highly satisfied when SPs were used during a simulated home visit (Kim-Godwin, Livsey, Ezzell, & Highsmith, 2013). In addition, Sharpnack, Goliat, and Rogers (2013) used SPs to teach upper-level nursing students leadership skills. Students were responsible for delegation, prioritization, and allocation of resources. The simulation was designed to increase awareness of quality and safety competencies. Other health care disciplines also use SPs to teach and assess patient safety. Vyas, Bhutada, and Feng (2012) studied the use of SPs to assess pharmacy students’ core domain abilities. In the randomized, controlled study, third-year pharmacy students (n ¼ 28) were assigned to the simulation group. The results of the study indicated 100% of the participants felt the simulated experience increased their awareness of patient safety. A recent study in medicine used SPs to teach proper prescribing methods for controlled substances (Swiggart, Ghulyan, & Dewey, 2012). SPs have been used in undergraduate nursing education in a variety of ways. However, there are limited data to
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determine the effectiveness of teaching fall risk safety in a 10-minute SP simulation as measured by an increase in knowledge and a change in attitudes toward safety.
institutional review boards of both universities before any collection of data.
Sample and Setting Safety Attitudes Literature concerning health care provider attitudes toward patient safety is limited. Chenot and Daniel (2010) investigated nursing student perceptions of patient safety awareness, skills, and attitudes and found nursing students from associate degree nursing programs, in particular, scored higher in comfort with error reporting. However, Wetzel, Dow, and Mazmanian (2012) discovered that medical students were reluctant to verbally disclose errors to faculty and attending physicians and rarely disclosed errors using the hospital error reporting system. These medical students also indicated that safety errors were caused by individual failures rather than system failures. Vohra, Johnson, Daugherty, Wen, and Barach (2007) demonstrated that knowledge about safety is independent from safety culture and that a culture of safety must be acquired through focused training, indicating the need for improved safety education in health care curricula using appropriate teaching strategies.
Convenience sampling was used to recruit baccalaureate nursing students enrolled in beginning-level nursing courses (n ¼ 136) from two Midwest nursing programs. The study was nested within an already existing pre- posttest evaluation and simulation experience for these students. G*Power 3.1.3 was used to determine, a priori, that a sample size of 54 was required to obtain a moderate effect size of 0.3 with the alpha error probability at 0.05 and power of 0.95 to test for differences between the experimental and control groups. A total of 134 students consented to their data being used as part of this study. To limit contamination between groups, students were assigned to the experimental and control groups per course sections. Usable data was obtained from 128 of the 134 students indicating an adequate sample size.
Quantitative Measures The instruments used in this study were as follows:
Theoretical Framework The Jeffries NLN Simulation Framework consisting of five conceptual components: (1) teacher, (2) students, (3) educational practices, (4) simulation design characteristics, and (5) outcomes were used to build this study (Jeffries, 2005). The concepts are each operationalized using various criteria. Interactions between the teacher, student, and educational practices influence the simulation design characteristics. The simulation design characteristics in turn are moderating variables to the outcomes. This theoretical framework guided both, the development of the simulation experience and the research study.
Methods Design This multisite study used a mixed method quantitative dominant with concurrent qualitative supplemental design (Morse & Niehaus, 2009). The quantitative phase consisted of a pretesteposttest controlled group design. The quantitative data obtained from the pre- and post-test scores, attitudes toward safety survey and simulation design scale were analyzed to determine the effectiveness of using SPs in a simulation experience as a teaching strategy. The qualitative phase allowed for a reflective exploration of the participants’ perceptions concerning their learning in a simulation experience (Creswell & Plano Clark, 2007). Approval was granted from the
Demographic Survey was used to determine age, time spent in clinical sites, and health care work experience. Cognitive outcomes were measured using 25 question multiple-choice pre- and post-tests developed by the research team. The change of scores between pre- and post-tests were used to determine the cognitive learning outcomes. Nearly all of the multiple choice test items were found in nurse educator test banks. The team revised all pre- and post-test questions to increase clarity and accuracy and provided content validity of tests. The research team was composed of experienced nurse educators skilled in test item writing. They judged all items to be clear, appropriate, and measuring the simulation objectives. The pre- and post-tests consisted of the same questions though the order of the questions was altered. The pretest Kuder Richardson Formula 20 was 0.49 and the post-test Kuder Richardson Formula 20 was 0.35. Student Safety Attitudes Survey: A 5-point Likert scale of 13 statements was used to measure student safety attitudes. Quality & Safety Education for Nurses knowledge, skills, and attitudes statements (Cronenwett, et al., 2007) as well as the Attitudes to Patient Safety Questionnaire (Carruthers, Lawton, Sandars, Howe, & Perry, 2009) were used as frameworks in the creation of the survey. The pre- postStudent Safety Attitudes Survey Cronbach alpha yielded 0.74 and 0.76, respectively. Simulation Design Scale: A 5-point Likert scale was used to measure the participants’ perceptions of specific
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simulation design features integral to positive learning outcomes and the level of importance of those features. Content validity of the scale was determined by nine content experts in simulation design and testing. Using Cronbach’s alpha the five practice subscales ranged between 0.92 and 0.96 in Human Patient Simulations (Jeffries, 2007). This study yielded a reliability of 0.79 for the ‘‘Features’’ items and 0.89 for the ‘‘Importance’’ items.
Qualitative Measures Journal Reflections provided qualitative data to explain the relationships discovered in the quantitative phase (Creswell & Plano Clark, 2007).
Procedures All students completed the Pre-Student Safety Attitudes and Demographic Surveys during the consenting period. All students received a document that outlined the simulation guidelines, student objectives and goals, expected student activities during simulation, and a pre-simulation assignment. Three faculty members delivered a safety lecture including fall risks to all students enrolled in the beginning-level nursing courses. The Power PointÒ used for the safety lecture was created by two research team members who were also two of the three faculty members who delivered the lecture. The third faculty member worked closely with the research team in an effort to deliver the safety lecture using the same style and length of time. Students were randomly divided into either the experimental or control group by their clinical sections. The experimental group consisted of 28 students from school A and 39 students from school B. The control group consisted of 29 students from school A and 37 from school B.
Table 1
Experimental Group Two days after the lecture, students in the experimental group took the Pre-Cognitive Test at the beginning of class. After the pretest, students in the experimental group proceeded into the simulation laboratory in groups of five to six students. While awaiting their turn for the simulation experience, the remaining students practiced assessments with their clinical instructor or sat waiting for their turn. Before entering the simulation laboratory, a member of the research team read the change of shift report to the group and gave them each a badge identifying randomly assigned nurse or observer participant roles to be worn during the simulation and debriefing period. Students were instructed to complete an assessment on the patient and administer patient care as needed. The simulation concluded at 10 minutes. A debriefing period was conducted with the whole class after all experimental groups completed the simulation experience. The SP was present during the debriefing period and offered input related to her experience as a patient. Table 1 details the intervention. The experimental group submitted journal reflections of their simulation experience and completed the Simulation Design Scale via Survey Monkey.
Control Group Two days after the lecture, students in the control group took the Pre-Cognitive Test at the beginning of class. Students in the control group participated in a regularly scheduled learning experience unassociated with safety after they took Pre-Cognitive Test. The students in the control group were given the same simulation experience later in the semester and were required at that time to complete journal reflections and the Simulation Design Scale via Survey Monkey as well. All students in both the experimental and control groups were given a Post-Cognitive Test 1 week after the simulation experience. Students in both groups also
Intervention
Component
Explanation
Before Simulation Procedure
Experimental participants were given simulation guidelines with homework as preparation for the simulation.
Scenario
Debriefing
Experimental participants signed a confidentiality agreement and were placed in groups of five to six team members. Each team member was randomly assigned a role of either nurse or observer. There were four nurses and one or two observers. The SP was a 78-year-old woman with a history of falls, muscle weakness, and difficulty swallowing admitted for diagnostic workup and evaluation. Participants were given this report before entering the room. They found the patient in a hospital bed with the side rails in the down position. The floor was cluttered with newspapers, as was the patient bed. The over-the-bed table that held the food tray was located at the foot of the bed. The patient’s glasses were out of the patient’s reach. The lights were dimmed. The patient was confused and repeatedly called for her cat, often leaning out of the bed to look for the cat. Each simulation scenario lasted 10 minutes. A debriefing session was conducted for 20 minutes at the conclusion of the groups’ simulation scenarios.
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Sample Demographics (N ¼ 133)
Variable Age (y) 18-23 24-29 30-41 Number of clinical days attended 1 2 3 4 Health care work experience Yes As a nurse assistant (patient care) In acute hospital setting In home health setting In nursing home setting No
N
%
119 9 5
89.5 6.8 3.8
2 38 16 77
1.5 28.6 12.0 57.9
39 18 26 3 14 93
29.5 46.2 66.7 7.7 35.9 70.5 Figure 1
Cognitive scores.
completed a Post-Student Safety Attitudes Survey via Survey Monkey at that time.
Results Quantitative Data Analysis Demographic Data Data were coded for confidentiality purposes. IBM SPSS 19 for Windows was used to complete the data analysis (SPSS, Inc., Chicago, IL). Descriptive statistics were used to summarize the demographic data as well as the Simulation Design Scale. A two-way between-group repeated measures analysis of variance was conducted to explore the impact of simulation on cognitive test scores as measured by the Pre- and Post-Cognitive tests as well as Pre- and Post-Student Safety Attitude Survey.
Qualitative Data Analysis Journals were examined for themes to uncover the students’ perceptions concerning the impact simulation had on learning, attitudes, and important features. Data were sorted and classified independently by three members of the research team, first using the journal questions and second, the research questions. Categories were created from which themes and patterns were determined independently. An independent research team member conducted a peer audit and determined the validity of the themes.
Mixed-Methods Data Analysis In a sequential mixed-methods study, the analysis of the first database informs the analysis of the second database (Morse & Niehaus, 2009). Three stages were used in the mixed methods data analysis. Quantitative data were analyzed and then reviewed to determine which results required explanation. The qualitative results were then applied to the quantitative results.
Students completed a demographic survey during the consenting period that included age, number of clinical days attended, and work experience in a health care setting. Participant ages ranged from 18 to 41 with 89.5% in the 18to 23-year-old age group. A little more than half of participants (57.9%) had attended four clinical days and the majority of the participants (70.5%) had no health care work experience. Of the participants who had health care work experience (29.5%) nearly half were patient care assistants (46.2%) and most were in acute hospital settings (66.7%; Table 2).
Cognitive Test Scores Although there was an increase in the scores from pre to post for both groups, it was not a statistically significant improvement [F(1, 125) ¼ 2.327; p ¼ .130]. The scores were higher, on average, for the experimental group than the control group, but that was true on the pretest and posttest [F(1, 125) ¼ 3.735, p ¼ .056]. The improvements in mean scores from pre to post were not different for the two groups [F(1, 125) ¼ 0.024; p ¼ .878; Figure 1]. Likewise, there was no difference between the scores for the two schools [F(1, 123) ¼ 2.465; p ¼ .119]. Although the quantitative measures indicated significant differences in cognitive learning did not occur as a result of the simulation, comments from students were in direct opposition of this, such as ‘‘I learned to make sure the patient is safe at all times and if the patient is at risk for falls, the bed alarm should be on at all times, and at least
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Figure 2
Simulation Design Scale (N ¼ 67)
Simulation Feature
Mean
Standard Deviation
Objectives/information Support Problem solving Feedback Fidelity
4.33 4.10 4.24 4.64 4.56
0.67 0.84 0.72 0.64 0.58
learning experience through the debriefing.’’ Fidelity closely followed as the second most perceived important simulation feature by these participants with a mean of 4.56 (SD ¼ 0.58). Students were surprised that the patient was an SP rather than a mannequin but many perceived this as a benefit illustrated by comments such as, ‘‘I think having a real person there was a much better idea than the mannequin because it allowed us to reason as if we were actually in the clinical setting,’’ and ‘‘I believe that having a live person had more of an influence on me and what I was doing to keep her safe.’’
Attitude scores.
three side rails up.’’ Comments such as, ‘‘I thought I understood it, but being engaged in a simulation setting made it apparent how important it is to keep the patient safe because if they are not in a safe environment, then more complications will arise,’’ were threaded throughout the journal reflections.
Attitude Scores There was a significant increase in the scores from pre to post [F(1, 127) ¼ 42.128; p .005] and the improvements in mean attitude scores from pre to post were significantly higher for beginning nursing students who received instruction and simulation than for students who received instruction only [F(1, 127) ¼ 11.456; p ¼ .001]. Figure 2. There was no difference in the mean scores between schools [F(1, 125) ¼ 0.730; p ¼ .394). Comments such as, ‘‘I learned that in addition to assessment, safety is a top priority in the health care setting. We must always keep a patient as safe as possible,’’ were echoed throughout the journal reflections. Another student exemplified a change in attitude stating, ‘‘During the simulation, I learned that if the patient is not safe, nothing else matters. I have a new respect for safety.’’
Important Design Features The findings indicate that facilitated feedback is the most important feature (m ¼ 4.64; SD ¼ 0.58) to beginning nursing students participating in a fall safety simulation using SPs (Table 3). It is interesting to note that 100% of the participants agreed that feedback from the teacher after the simulation was the most important design feature. This finding is illustrated by student comments such as, ‘‘my instructors really did do a great job on facilitating our
Discussion and Limitations The findings suggest that a fall safety simulation does not produce significant cognitive gains. This finding is similar to that of Dobbs, Sweitzer, and Jeffries (2006), but is contradictory to what DeBourgh and Prion (2011) and Shinnick, Woo, and Evangelista (2012) found. There are several possible reasons for this. First, there were many multiple choice test items on which participants answered correctly. In addition, nearly 25% of the cognitive tests consisted of select all that apply questions. Study participants were beginning nursing students who had little exposure to this type of alternative test question. It is quite likely these issues affected the reliability of the test. Second, the post-test was given 5 days after the simulation. Given that most nursing students are in cohort classes together, it is reasonable to believe that there was contamination between the experimental and controls groups despite participants having signed confidentiality agreements. Third, although the three faculty members who taught the safety lecture worked closely together to ensure consistency between classes, interrater reliability was not obtained. It is possible that the style with which the content was delivered varied between classes. It is probable that the cognitive tests were not indicators of the knowledge students actually gained in this simulation. For example, when asked what they learned during this simulation students reported, ‘‘to expect the unexpected,’’ ‘‘to be prepared for anything,’’ and ‘‘I need to communicate better with the rest of the team.’’ This type of knowledge, although important, was not measured on the cognitive tests. On the other hand, the results of this study indicate that using an SP in a 10-minute simulation scenario is effective
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in improving beginning student attitudes toward patient safety. Students in the intervention group improved particularly in their confidence to prevent falls, valuing their role in preventing errors and monitoring patients for risk of harm. A student exemplified this by reporting, ‘‘Protecting the patient from harm is the number one goal of a nurse.’’ The intervention group also reported they believe safety issues are best taught in clinical situations. Students made comments such as, ‘‘learning and ‘knowing’ is one thing.Practicing in a scenario actually really helped more’’ and ‘‘the best way to learn this kind of material is first hand.’’ As supported in other research findings, the results of this study suggest using simulation as a teaching strategy may be more effective at reaching the affective domain than the cognitive domain (Beischel, 2013; Dobbs et al., 2006). This study’s results strengthen the literature that emphasizes the importance of conducting a thorough debriefing period subsequent to all simulation learning experiences (Dobbs et al., 2006; Wang & Fitzpatrick, 2013) as well as attending to the fidelity of the simulation (Dobbs et al., 2006). Debriefing is a valuable tool to prompt reflection because it moves students toward critical reasoning and assists in bridging the gap between theory and practice. Using an SP who either attempted to get out of bed, fell out of bed, or slipped on the floor when students failed to use protective measures emphasized the realism of caring for a patient at risk for falling. Further studies will be important to determine whether a change in attitudes results in safer care. As with all research, limitations to this study exist. The findings from this multisite study are more generalizable than a single site study affords (Flynn, 2009) because the participants have somewhat varied demographics and are from private and public universities in two different states. However, both schools are in the Midwest and are 4-year programs, thus limiting the generalizability to all nursing students. A convenience sample was used in this study. The simulation was piloted using beginning nursing students the semester before the study; however, the cognitive tests were not. Piloting the test questions may have increased the internal consistency of the tests.
Summary This simulation experience gave beginning nursing students from two diverse universities exposure to their first simulation experience using SPs. Using SPs in the nursing curriculum is a relatively new but effective teaching strategy. It is probable that, as nursing school enrollments continue to grow and clinical sites become scarcer, the use of simulation will increase. This study indicates the use of SPs in a 10-minute simulation with a subsequent debriefing period can expose nursing students to realistic clinical situations and influence student attitudes toward patient
safety in a relatively short period. Preparing students using an SP and an environment that closely mimics the safety hazards students will encounter ultimately moves beginning nursing students closer toward improving patient safety.
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Using a Standardized Patient to Teach Fall Safety Kelly P. Beischel, PhD, RN, CNEa,*, Julie Hart, MSN, RN, CNEb, Sandra Turkelson, MSN, RN, CNEb, Joy Churchill, MSN, RNb a b
Xavier University, 3800 Victory Parkway, Cincinnati, OH 45207 Northern Kentucky University, Nunn Dr., Highland Heights, KY 41099 KEYWORDS standardized patient; simulation; safety; attitudes; teaching strategies; nursing education; fall safety
Abstract Background: Patient falls in acute care settings have become a major public concern. It is important that nurse educators use evidence-based teaching strategies to teach nursing students the necessary measures required to keep patients safe. Methods: Using a multisite, mixed methods, experimental study, we tested the effect of using a standardized patient in simulation on cognitive gains, student attitudes toward patient safety and important simulation design features. Results: Students indicated debriefing followed by fidelity were the most important features of this simulation. Although there was no significant cognitive learning in the experimental group, there was a significant improvement in attitudes toward safety. Conclusion: This study adds to the science of nursing education providing evidence for best teaching practices. Using standardized patients in simulation improves student attitudes toward patient safety. Cite this article: Beischel, K. P., Hart, J., Turkelson, S., & Churchill, J. (2014, April). Using a standardized patient to teach fall safety. Clinical Simulation in Nursing, 10(4), e183-e190. http://dx.doi.org/10.1016/ j.ecns.2013.11.007. Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
Patient safety is a national concern among health care institutions. It is estimated that adverse events occur at a rate of 145 per 1,000 hospital admissions with an estimated cost of $19.5 billion (Agency for Healthcare Research and Quality, 2013). The fifth leading preventable adverse event is patient falls, occurring at a rate of 8 per 1,000 hospital admissions (Agency for Healthcare Research and Quality, 2013). The consequences of falling include increased length of hospital stays, increased resource use, (Bates, Pruess, Sourney, & Platt, 1995) pain, serious injury, and
* Corresponding author: [email protected] (K. P. Beischel).
death (Rubenstein, 2006; Tinetti & Kumar, 2010). The health care system likewise incurs a considerable burden when hospitalized patients fall such as loss of revenue, complaint and litigation, and staff anxiety and remorse (Oliver, 2008). Risk prevention though can minimize the number of patient falls (Rubenstein, 2006). Teaching nursing students how to assess for patient fall risks and to prevent falls is important. One strategy for teaching fall risks and consequences to falling is to use a standardized patient (SP), an individual specially trained to portray a patient with a particular condition in a predictable and repeatable way (Association of Standardized Patient Educators, 2011).
1876-1399/$ - see front matter Ó 2014 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ecns.2013.11.007
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Using an SP in a simulation scenario is relatively new in nursing education. Teaching nursing students about falls using a SP can expose students to a realistic high-risk situation while circumventing the devastation of an actual adverse event. However, there are limited data to determine that the use of SPs to teach nursing students is an effecKey Points tive strategy when teaching Teach nursing stufall risks. Moreover, the dents about falls using amount of simulation time an SP offers a realistic required for effectiveness is high risk situation. as yet unknown. Using an SP in a 10 minute simulation to Purpose and Research teach about fall risks increases student apQuestions preciation for patient safety. The primary purpose of this Simulation may be mixed methods study was to more effective at examine the effectiveness of reaching the affective using simulation with SPs domain than the as a strategy to teach patient cognitive domain. safety. The quantitative research questions included: (1) Is there a difference in the cognitive post-test scores between beginning nursing students who receive instruction and a 10-minute SP fall-risk safety simulation and beginning nursing students who receive instruction only? (2) Is there a difference in the attitudes toward safety between beginning nursing students who receive instruction and a 10-minute SP fall risk safety simulation and beginning nursing students who receive instruction only? (3) What design features of a SP fall risk safety simulation are important to beginning nursing students? The secondary purpose of this study was to explain the quantitative results using qualitative reflection. The beginning nursing students in this study were in their first nursing course associated with a clinical experience.
Literature Review Falls More than one in three adults, 65 years and older, fall each year and the likelihood of falling increases with age (Centers for Disease Control and Prevention, 2008; National Institute of Health Senior Health, 2013). Many factors put a patient at increased risk for falling, including altered mental status, use of restraints, history of falls, use of walking assistive devices, impaired balance and gait, decreased strength, medications, age, and impaired functional ability (Evans, Hodgkinson, Lambert, & Wood, 2001; Rubenstein, 2006). Risk prevention, which includes assessing and properly identifying patients at risk, reviewing medication, eliminating physical environmental
hazards, and providing physical assistance when mobilizing patients at highest risk, can minimize the number of patient falls (Evans et al., 2001).
Standardized Patients SPs are used to create realistic simulated clinical situations in a controlled environment. The use of SPs in medical education started in the mid 1960s, offering experiential learning as opposed to textbook learning (Wallace, 1997). Although nursing education has been slower to incorporate SPs into the curricula, their use is growing. Studies indicate that the use of SPs in undergraduate nursing education is an effective strategy to teach communication skills to beginning nursing students (Anderson, Holmes, LeFlore, Nelson, & Jenkins, 2010; Yoo & Yoo, 2003), medication administration, patient positioning, mouth care, and back care (Yoo & Yoo, 2003), as well as basic assessment skills (Bornais, Raiger, Krahn, & El-Masri, 2012). Further, the use of an SP increases knowledge and confidence while decreasing anxiety when used with beginning nursing students for extensive orientation for their first clinical experience (Dearmon et al., 2013). DeBourgh and Prion (2011) using three SP simulations to teach fall risks, demonstrated cognitive improvement after the SP simulation intervention. Using SPs to teach upper level nursing students is likewise effective. When teaching senior nursing students about therapeutic communication and depression using SPs, these students described their learning experience as positive and meaningful compared with those taught using traditional teaching methods (Becker, Rose, Berg, Park, & Shatzer, 2006). Similarly, students who were taught to perform mental status examinations and suicidal risk assessments using SPs reported increased self-confidence, increased critical thinking, and satisfaction with the learning experience (Robinson-Smith, Bradley, & Meakin, 2009). Upper-level students were also highly satisfied when SPs were used during a simulated home visit (Kim-Godwin, Livsey, Ezzell, & Highsmith, 2013). In addition, Sharpnack, Goliat, and Rogers (2013) used SPs to teach upper-level nursing students leadership skills. Students were responsible for delegation, prioritization, and allocation of resources. The simulation was designed to increase awareness of quality and safety competencies. Other health care disciplines also use SPs to teach and assess patient safety. Vyas, Bhutada, and Feng (2012) studied the use of SPs to assess pharmacy students’ core domain abilities. In the randomized, controlled study, third-year pharmacy students (n ¼ 28) were assigned to the simulation group. The results of the study indicated 100% of the participants felt the simulated experience increased their awareness of patient safety. A recent study in medicine used SPs to teach proper prescribing methods for controlled substances (Swiggart, Ghulyan, & Dewey, 2012). SPs have been used in undergraduate nursing education in a variety of ways. However, there are limited data to
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determine the effectiveness of teaching fall risk safety in a 10-minute SP simulation as measured by an increase in knowledge and a change in attitudes toward safety.
institutional review boards of both universities before any collection of data.
Sample and Setting Safety Attitudes Literature concerning health care provider attitudes toward patient safety is limited. Chenot and Daniel (2010) investigated nursing student perceptions of patient safety awareness, skills, and attitudes and found nursing students from associate degree nursing programs, in particular, scored higher in comfort with error reporting. However, Wetzel, Dow, and Mazmanian (2012) discovered that medical students were reluctant to verbally disclose errors to faculty and attending physicians and rarely disclosed errors using the hospital error reporting system. These medical students also indicated that safety errors were caused by individual failures rather than system failures. Vohra, Johnson, Daugherty, Wen, and Barach (2007) demonstrated that knowledge about safety is independent from safety culture and that a culture of safety must be acquired through focused training, indicating the need for improved safety education in health care curricula using appropriate teaching strategies.
Convenience sampling was used to recruit baccalaureate nursing students enrolled in beginning-level nursing courses (n ¼ 136) from two Midwest nursing programs. The study was nested within an already existing pre- posttest evaluation and simulation experience for these students. G*Power 3.1.3 was used to determine, a priori, that a sample size of 54 was required to obtain a moderate effect size of 0.3 with the alpha error probability at 0.05 and power of 0.95 to test for differences between the experimental and control groups. A total of 134 students consented to their data being used as part of this study. To limit contamination between groups, students were assigned to the experimental and control groups per course sections. Usable data was obtained from 128 of the 134 students indicating an adequate sample size.
Quantitative Measures The instruments used in this study were as follows:
Theoretical Framework The Jeffries NLN Simulation Framework consisting of five conceptual components: (1) teacher, (2) students, (3) educational practices, (4) simulation design characteristics, and (5) outcomes were used to build this study (Jeffries, 2005). The concepts are each operationalized using various criteria. Interactions between the teacher, student, and educational practices influence the simulation design characteristics. The simulation design characteristics in turn are moderating variables to the outcomes. This theoretical framework guided both, the development of the simulation experience and the research study.
Methods Design This multisite study used a mixed method quantitative dominant with concurrent qualitative supplemental design (Morse & Niehaus, 2009). The quantitative phase consisted of a pretesteposttest controlled group design. The quantitative data obtained from the pre- and post-test scores, attitudes toward safety survey and simulation design scale were analyzed to determine the effectiveness of using SPs in a simulation experience as a teaching strategy. The qualitative phase allowed for a reflective exploration of the participants’ perceptions concerning their learning in a simulation experience (Creswell & Plano Clark, 2007). Approval was granted from the
Demographic Survey was used to determine age, time spent in clinical sites, and health care work experience. Cognitive outcomes were measured using 25 question multiple-choice pre- and post-tests developed by the research team. The change of scores between pre- and post-tests were used to determine the cognitive learning outcomes. Nearly all of the multiple choice test items were found in nurse educator test banks. The team revised all pre- and post-test questions to increase clarity and accuracy and provided content validity of tests. The research team was composed of experienced nurse educators skilled in test item writing. They judged all items to be clear, appropriate, and measuring the simulation objectives. The pre- and post-tests consisted of the same questions though the order of the questions was altered. The pretest Kuder Richardson Formula 20 was 0.49 and the post-test Kuder Richardson Formula 20 was 0.35. Student Safety Attitudes Survey: A 5-point Likert scale of 13 statements was used to measure student safety attitudes. Quality & Safety Education for Nurses knowledge, skills, and attitudes statements (Cronenwett, et al., 2007) as well as the Attitudes to Patient Safety Questionnaire (Carruthers, Lawton, Sandars, Howe, & Perry, 2009) were used as frameworks in the creation of the survey. The pre- postStudent Safety Attitudes Survey Cronbach alpha yielded 0.74 and 0.76, respectively. Simulation Design Scale: A 5-point Likert scale was used to measure the participants’ perceptions of specific
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simulation design features integral to positive learning outcomes and the level of importance of those features. Content validity of the scale was determined by nine content experts in simulation design and testing. Using Cronbach’s alpha the five practice subscales ranged between 0.92 and 0.96 in Human Patient Simulations (Jeffries, 2007). This study yielded a reliability of 0.79 for the ‘‘Features’’ items and 0.89 for the ‘‘Importance’’ items.
Qualitative Measures Journal Reflections provided qualitative data to explain the relationships discovered in the quantitative phase (Creswell & Plano Clark, 2007).
Procedures All students completed the Pre-Student Safety Attitudes and Demographic Surveys during the consenting period. All students received a document that outlined the simulation guidelines, student objectives and goals, expected student activities during simulation, and a pre-simulation assignment. Three faculty members delivered a safety lecture including fall risks to all students enrolled in the beginning-level nursing courses. The Power PointÒ used for the safety lecture was created by two research team members who were also two of the three faculty members who delivered the lecture. The third faculty member worked closely with the research team in an effort to deliver the safety lecture using the same style and length of time. Students were randomly divided into either the experimental or control group by their clinical sections. The experimental group consisted of 28 students from school A and 39 students from school B. The control group consisted of 29 students from school A and 37 from school B.
Table 1
Experimental Group Two days after the lecture, students in the experimental group took the Pre-Cognitive Test at the beginning of class. After the pretest, students in the experimental group proceeded into the simulation laboratory in groups of five to six students. While awaiting their turn for the simulation experience, the remaining students practiced assessments with their clinical instructor or sat waiting for their turn. Before entering the simulation laboratory, a member of the research team read the change of shift report to the group and gave them each a badge identifying randomly assigned nurse or observer participant roles to be worn during the simulation and debriefing period. Students were instructed to complete an assessment on the patient and administer patient care as needed. The simulation concluded at 10 minutes. A debriefing period was conducted with the whole class after all experimental groups completed the simulation experience. The SP was present during the debriefing period and offered input related to her experience as a patient. Table 1 details the intervention. The experimental group submitted journal reflections of their simulation experience and completed the Simulation Design Scale via Survey Monkey.
Control Group Two days after the lecture, students in the control group took the Pre-Cognitive Test at the beginning of class. Students in the control group participated in a regularly scheduled learning experience unassociated with safety after they took Pre-Cognitive Test. The students in the control group were given the same simulation experience later in the semester and were required at that time to complete journal reflections and the Simulation Design Scale via Survey Monkey as well. All students in both the experimental and control groups were given a Post-Cognitive Test 1 week after the simulation experience. Students in both groups also
Intervention
Component
Explanation
Before Simulation Procedure
Experimental participants were given simulation guidelines with homework as preparation for the simulation.
Scenario
Debriefing
Experimental participants signed a confidentiality agreement and were placed in groups of five to six team members. Each team member was randomly assigned a role of either nurse or observer. There were four nurses and one or two observers. The SP was a 78-year-old woman with a history of falls, muscle weakness, and difficulty swallowing admitted for diagnostic workup and evaluation. Participants were given this report before entering the room. They found the patient in a hospital bed with the side rails in the down position. The floor was cluttered with newspapers, as was the patient bed. The over-the-bed table that held the food tray was located at the foot of the bed. The patient’s glasses were out of the patient’s reach. The lights were dimmed. The patient was confused and repeatedly called for her cat, often leaning out of the bed to look for the cat. Each simulation scenario lasted 10 minutes. A debriefing session was conducted for 20 minutes at the conclusion of the groups’ simulation scenarios.
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Sample Demographics (N ¼ 133)
Variable Age (y) 18-23 24-29 30-41 Number of clinical days attended 1 2 3 4 Health care work experience Yes As a nurse assistant (patient care) In acute hospital setting In home health setting In nursing home setting No
N
%
119 9 5
89.5 6.8 3.8
2 38 16 77
1.5 28.6 12.0 57.9
39 18 26 3 14 93
29.5 46.2 66.7 7.7 35.9 70.5 Figure 1
Cognitive scores.
completed a Post-Student Safety Attitudes Survey via Survey Monkey at that time.
Results Quantitative Data Analysis Demographic Data Data were coded for confidentiality purposes. IBM SPSS 19 for Windows was used to complete the data analysis (SPSS, Inc., Chicago, IL). Descriptive statistics were used to summarize the demographic data as well as the Simulation Design Scale. A two-way between-group repeated measures analysis of variance was conducted to explore the impact of simulation on cognitive test scores as measured by the Pre- and Post-Cognitive tests as well as Pre- and Post-Student Safety Attitude Survey.
Qualitative Data Analysis Journals were examined for themes to uncover the students’ perceptions concerning the impact simulation had on learning, attitudes, and important features. Data were sorted and classified independently by three members of the research team, first using the journal questions and second, the research questions. Categories were created from which themes and patterns were determined independently. An independent research team member conducted a peer audit and determined the validity of the themes.
Mixed-Methods Data Analysis In a sequential mixed-methods study, the analysis of the first database informs the analysis of the second database (Morse & Niehaus, 2009). Three stages were used in the mixed methods data analysis. Quantitative data were analyzed and then reviewed to determine which results required explanation. The qualitative results were then applied to the quantitative results.
Students completed a demographic survey during the consenting period that included age, number of clinical days attended, and work experience in a health care setting. Participant ages ranged from 18 to 41 with 89.5% in the 18to 23-year-old age group. A little more than half of participants (57.9%) had attended four clinical days and the majority of the participants (70.5%) had no health care work experience. Of the participants who had health care work experience (29.5%) nearly half were patient care assistants (46.2%) and most were in acute hospital settings (66.7%; Table 2).
Cognitive Test Scores Although there was an increase in the scores from pre to post for both groups, it was not a statistically significant improvement [F(1, 125) ¼ 2.327; p ¼ .130]. The scores were higher, on average, for the experimental group than the control group, but that was true on the pretest and posttest [F(1, 125) ¼ 3.735, p ¼ .056]. The improvements in mean scores from pre to post were not different for the two groups [F(1, 125) ¼ 0.024; p ¼ .878; Figure 1]. Likewise, there was no difference between the scores for the two schools [F(1, 123) ¼ 2.465; p ¼ .119]. Although the quantitative measures indicated significant differences in cognitive learning did not occur as a result of the simulation, comments from students were in direct opposition of this, such as ‘‘I learned to make sure the patient is safe at all times and if the patient is at risk for falls, the bed alarm should be on at all times, and at least
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Figure 2
Simulation Design Scale (N ¼ 67)
Simulation Feature
Mean
Standard Deviation
Objectives/information Support Problem solving Feedback Fidelity
4.33 4.10 4.24 4.64 4.56
0.67 0.84 0.72 0.64 0.58
learning experience through the debriefing.’’ Fidelity closely followed as the second most perceived important simulation feature by these participants with a mean of 4.56 (SD ¼ 0.58). Students were surprised that the patient was an SP rather than a mannequin but many perceived this as a benefit illustrated by comments such as, ‘‘I think having a real person there was a much better idea than the mannequin because it allowed us to reason as if we were actually in the clinical setting,’’ and ‘‘I believe that having a live person had more of an influence on me and what I was doing to keep her safe.’’
Attitude scores.
three side rails up.’’ Comments such as, ‘‘I thought I understood it, but being engaged in a simulation setting made it apparent how important it is to keep the patient safe because if they are not in a safe environment, then more complications will arise,’’ were threaded throughout the journal reflections.
Attitude Scores There was a significant increase in the scores from pre to post [F(1, 127) ¼ 42.128; p .005] and the improvements in mean attitude scores from pre to post were significantly higher for beginning nursing students who received instruction and simulation than for students who received instruction only [F(1, 127) ¼ 11.456; p ¼ .001]. Figure 2. There was no difference in the mean scores between schools [F(1, 125) ¼ 0.730; p ¼ .394). Comments such as, ‘‘I learned that in addition to assessment, safety is a top priority in the health care setting. We must always keep a patient as safe as possible,’’ were echoed throughout the journal reflections. Another student exemplified a change in attitude stating, ‘‘During the simulation, I learned that if the patient is not safe, nothing else matters. I have a new respect for safety.’’
Important Design Features The findings indicate that facilitated feedback is the most important feature (m ¼ 4.64; SD ¼ 0.58) to beginning nursing students participating in a fall safety simulation using SPs (Table 3). It is interesting to note that 100% of the participants agreed that feedback from the teacher after the simulation was the most important design feature. This finding is illustrated by student comments such as, ‘‘my instructors really did do a great job on facilitating our
Discussion and Limitations The findings suggest that a fall safety simulation does not produce significant cognitive gains. This finding is similar to that of Dobbs, Sweitzer, and Jeffries (2006), but is contradictory to what DeBourgh and Prion (2011) and Shinnick, Woo, and Evangelista (2012) found. There are several possible reasons for this. First, there were many multiple choice test items on which participants answered correctly. In addition, nearly 25% of the cognitive tests consisted of select all that apply questions. Study participants were beginning nursing students who had little exposure to this type of alternative test question. It is quite likely these issues affected the reliability of the test. Second, the post-test was given 5 days after the simulation. Given that most nursing students are in cohort classes together, it is reasonable to believe that there was contamination between the experimental and controls groups despite participants having signed confidentiality agreements. Third, although the three faculty members who taught the safety lecture worked closely together to ensure consistency between classes, interrater reliability was not obtained. It is possible that the style with which the content was delivered varied between classes. It is probable that the cognitive tests were not indicators of the knowledge students actually gained in this simulation. For example, when asked what they learned during this simulation students reported, ‘‘to expect the unexpected,’’ ‘‘to be prepared for anything,’’ and ‘‘I need to communicate better with the rest of the team.’’ This type of knowledge, although important, was not measured on the cognitive tests. On the other hand, the results of this study indicate that using an SP in a 10-minute simulation scenario is effective
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in improving beginning student attitudes toward patient safety. Students in the intervention group improved particularly in their confidence to prevent falls, valuing their role in preventing errors and monitoring patients for risk of harm. A student exemplified this by reporting, ‘‘Protecting the patient from harm is the number one goal of a nurse.’’ The intervention group also reported they believe safety issues are best taught in clinical situations. Students made comments such as, ‘‘learning and ‘knowing’ is one thing.Practicing in a scenario actually really helped more’’ and ‘‘the best way to learn this kind of material is first hand.’’ As supported in other research findings, the results of this study suggest using simulation as a teaching strategy may be more effective at reaching the affective domain than the cognitive domain (Beischel, 2013; Dobbs et al., 2006). This study’s results strengthen the literature that emphasizes the importance of conducting a thorough debriefing period subsequent to all simulation learning experiences (Dobbs et al., 2006; Wang & Fitzpatrick, 2013) as well as attending to the fidelity of the simulation (Dobbs et al., 2006). Debriefing is a valuable tool to prompt reflection because it moves students toward critical reasoning and assists in bridging the gap between theory and practice. Using an SP who either attempted to get out of bed, fell out of bed, or slipped on the floor when students failed to use protective measures emphasized the realism of caring for a patient at risk for falling. Further studies will be important to determine whether a change in attitudes results in safer care. As with all research, limitations to this study exist. The findings from this multisite study are more generalizable than a single site study affords (Flynn, 2009) because the participants have somewhat varied demographics and are from private and public universities in two different states. However, both schools are in the Midwest and are 4-year programs, thus limiting the generalizability to all nursing students. A convenience sample was used in this study. The simulation was piloted using beginning nursing students the semester before the study; however, the cognitive tests were not. Piloting the test questions may have increased the internal consistency of the tests.
Summary This simulation experience gave beginning nursing students from two diverse universities exposure to their first simulation experience using SPs. Using SPs in the nursing curriculum is a relatively new but effective teaching strategy. It is probable that, as nursing school enrollments continue to grow and clinical sites become scarcer, the use of simulation will increase. This study indicates the use of SPs in a 10-minute simulation with a subsequent debriefing period can expose nursing students to realistic clinical situations and influence student attitudes toward patient
safety in a relatively short period. Preparing students using an SP and an environment that closely mimics the safety hazards students will encounter ultimately moves beginning nursing students closer toward improving patient safety.
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