Virtual Simulation Learning among Student Nurses in the Post ...

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14 Νοε 2013 (πριν από 3 χρόνια και 9 μήνες)

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第五屆台菲學術交流研討會
:
數位人文與文化研究



2012 Fifth Taiwan
-
Philippines Academic Conference:

Digital Humanities and Cultural Studies


Virtual Simulation

Learning
among

Student Nurses in the

Post Anesthesia Care Unit


Domino B. Puson

1
;
Emiliano Ian Suson II
2
;
Jezyl T. Cempron
3

1,2,3
Faculty
,
Cebu Normal University
-

College of Nursing


Abstract


Preparing student nurses to be ready for cl
inical setting is very vital and is a huge
challenge of the nursing academe. One strategy is through the use of high fidelity virtual
simulations. The virtual simulation environment is both a strategy and an evaluation tool.
This is a new trend in nursing
education in which it provides more opportunity to learn
through experience. Virtual simulations facilitate the increased use of learning technology
and promote experiential learning thus enhancing their readiness to care for actual patients.
The virtual l
aboratory provides nursing students with meaningful experience and freedom to
practice nursing interventions in an environment which is safe and risk free. This study aims
to determine the effectiveness of the virtual simulation experience in the preparati
on of
students in caring for post anesthetic care unit clients. An after


only or post
-

test design
was used in this study. The study was conducted in the Virtual Simulation Center in Cebu
Normal University


College of Nursing, Philippines. There were 9
3 Level III nursing
students participated in the simulation experience using Emergency Care Simulator (ECS)


Standard Man’. Each group underwent a 4 hour customized “Care of PACU Client”
simulation. After the experience they were asked to rate the effecti
veness of the simulation
using the modified standardized “Simulation Effectiveness Tool”. The results showed that the
Virtual Learning Experience played an important role in the learning process and
preparation of the students. The computed mean average sh
owed the exposure to the virtual
learning simulation prior to hospital duty is indeed very effective in helping the students to be
more ready and more confident in caring for actual patients.


Keywords
: Virtual simulation learning, student nurses, post ane
sthesia care unit, simulator





















Domino B. Puson, Emiliano Ian Suson II, Jezyl T. Cempron

Introduction


Background and Rationale of the Study


An immediate post
-
operative client Mr. Stanley was admitted in the Post Anesthesia
Care Unit

(PACU)
.
Mr. Stanley has undergone exploratory laparotomy
due
to raptured
appendicitis
and received
Isoflurane a
general anesthetics
,

according to the intraoperative
nurse’s endorsement. The student nurses were tensed since it was their first time in the area.
As soon as they have transferred Mr. Stanley in the PACU
bed, his vital signs changed. The
respiratory rate dropped and
the patient was trembling as if he was feeling cold. A sudden
alarm was overheard by the student nurses, which signify that there is something wrong with
the patients Pulse Oxygenation. The stu
dent nurses also noticed that the blood pressure
reading in the monitor is flashing.
The students reviewed the lesson learned during their
classes

but were uncertain which intervention is to be applied first because they were troubled
by their anxiety. Th
e clinical instructor called for a “time out” and brought the students into
the viewing room. The simulation
instructor assessed what happened to the students and
performs

a playback of the video and audio recording of the simulation exercise.

The virtual

simulation environment is both a strategy and an evaluation tool
. This is a
new trend in nursing education in which it provides more opportunity to learn through
experience.
Virtual simulations facilitate

the “increased use of learning technology”. Throug
h
simulations l
earning is based on outcomes tha
n process
-
based.

Finally, with its use
students
are
provide
d

with evidenced
-
base education strategies and curriculum
(
Li, S., 2007).

Instructors use virtual simulations for several reasons. The primary reason
s are patient
safety, promote better preparation of new nurses, support innovative teaching strategies and
overcome
faculty and preceptor shortages and lack of clinical sites (
Li, S., 2007).

There are several types of simulations which includes, screen
-
ba
sed / PC
-
based
simulation; virtual patients; partial task trainers; human patient simulator

(HPS)
; standardized
patients and integrated models (
Li, S., 2007).

Most university uses the Human Patient
Simulation because it is a “high fidelity
interactive
expe
rience, animating theoretical
knowledge within the context of clinical reality, using emotional and sensory components of
learning, good for critical thinking, decision
-
making and delegation
as well as

knowledge
integration
involving

high
ly intellectual

st
udents” (
Li, S., 2007)
.


The potential advantages of simulation are the following: it “reduces training
variability and increases standardization, guarantees experience for every students, can be
customized for individualized learning, it is more accurate
reflective learning especially with
HPS, it is a student

centered learning

that

allows independent critical
-
thinking and decision
-
making, and delegation and most importantly it allows immediate feedback” (
Li, S., 2007).

Simulation also offers opportunity
to practice rare and critical events

which
can be designed
and manipulated
.

In addition, it
gives way to calibration and update, can be reproduced, can
be scheduled, offers opportunities to make and learn from mistakes, is safe and respectful for
patients
, allows deliberate practice and
likewise

uses the c
oncept of experiential learning (
(
Li,
S., 2007).


This study was conceptualized i
n the hope of providing empirical data on the
influence of virtual simulation
,

utilizing human
patient simulators
,

on the l
earning, client
safety and competence
in caring for po
st anesthetic care unit clients
among Level III Nursing
Students in Cebu Normal University.




Virtual Simulation Learning among Student Nurses in the

Post Anesthesia Care Unit

Th
eoretical
-
Conceptual
Framework


This study is anchored on B.F. Skinner’s
Operant conditioning

theory
or i
nstrumental
conditioning

(1937) which maintains that
learning
is
an individual behavior
that can be

modified by its consequences
.

T
he behavior may change in form, frequency, or strength.
(
scienceofpsychology.
com, n.d.
).

Through operant conditioning, an ass
ociation is made
between a behavior and a consequence for that behavior. This acquired behavior can be
strengthened or increased through positive reinforcement. Positive reinforcements are
favorable events or outcomes that are presented after the behavior.

(Cherry, Kendra, n.d.).
Figure 1 illustrates the theoretical
-
conceptual framework of the study.








Figure 1. Theoretical
-
Conceptual Framework of the study





In this study, situations that reflect positive reinfor
cement encompasses the conduct of
debriefing and processing of the virtual simulation responses of the students, which were also
coupled with giving of compliments such as praise or a direct reward.
Application of
Operant Condition
includes

exposing
the s
tudents
to

virtual simulations
depicting real
-
life
clinical scenarios while the client is admitted in the PACU
. This vi
r
tual simulation activity

was deemed as

a form of behavioral modification of the students prior to their exposure in the

said care settin
g
.
The experiences in the simulations are thought to enhance the performance
of the students to attain a degree of competency and confidence in the care of client in their
post anesthetic experience.


Statement of the Problem


This study
wa
s primarily don
e to determine the effectiveness of virtual simulation
exposure
on the degree of competency and confidence among Level III Nursing students
prior to clinical duty

in the PACU
.


Hypothes
is


Ha
1
:
Virtual simulation is an effective learning aid.


Significance

of the Study


The research was carried out for the benefit of the following:

Nursing Students.

This study will enhance the student nurses


preparation before
clinical exposures. The result will enhance their capability for caring patients in post
-
surgical

ar
ea and high quality simulations
.

Nursing Instructors.

The outcome of this research will
enable them to maximize

s
imulation

activities
as part of their strategy in giving quality lectures to their students.

OPERANT CONDITIONING

(B.F. Skinner, 1937)

Domino B. Puson, Emiliano Ian Suson II, Jezyl T. Cempron

Virtual
Simulation Instructors.

The findings o
f this study will provide them with
information to improve the quality of simulations making it more realistic
.



Colleges of Nursing.

The outcome of the study will boost the teaching capability of
instructors as well as learning capability of the students
.


Virtual Simulation Manufacturers.

The result of this research will support their claims
that simulation equipment can aid in the knowledge and skills development of the students.
The cost of simulation equipmen
t equ
ate
s

its functions and goals in prepa
ring students in real
situations.

University Administration.

The findings of this study will justify
the university’s

investm
ent in state of the art teaching
-
learning facility.


Review

of Literature


As a child you watched, listened, played, and were intr
igued by the colors, shapes and
sounds and the surest way to find out something worked was by playing and using it.
V
irtual
simulations equipment
adopts

these basic principles of learning to produce fun, compelling
and memorable end results. These types of

equipment are used to recreate interactive
scenarios which imitate real
-
life situations (
skills2learn, 2010)
.

A breakthrough in providing education and training for nurses or any medical
practitioner

is the use of virtual simulations. The simulations pre
pared students and develop
their skills in accommodating simulated real life situations before applying it to actual
patients.

The first medical simulators were simple models of human patients.

Since antiquity, these representations in clay and stone were

used to demonstrate
clinical features of disease states and their effects on humans. Models have been found from
many cultures and continents. These models have been used in some cultures (e.g., Chinese
culture) as a "diagnostic" instrument, allowing wome
n to consult male physicians while
maintaining social laws of modesty. Models are used today to help students learn the
anatomy of the musculoskeletal system and organ systems.

Simulation is the imitation of the operation of a real
-
world process or system
over
time. The act of simulating something first requires that a model be developed; this model
represents the key characteristics or behaviors of the selected physical or abstract system or
process. The model represents the system itself, whereas the sim
ulation represents the
operation of the system over time.

Simulation is used in many contexts, such as simulation of technology for
performance optimization, safety engineering, testing, training, education, and video games.
Training simulators include fli
ght simulators for training aircraft pilots to provide them with a
lifelike experience. Simulation is also used with scientific modeling of natural systems or
human systems to gain insight into their functioning. Simulation can be used to show the
eventual

real effects of alternative conditions and courses of action. Simulation is also used
when the real system cannot be engaged, because it may not be accessible, or it may be
dangerous or unacceptable to engage, or it is being designed but not yet built, or

it may
simply not exist (
bit.com.my, 1995
)
.

Virtual simulations have

a high future practical relevance and a high economic impact
according
to
a research conducted by S. Strassburger

(ieeexplore.ieee.org, 2008).

Simulation is extensively used for educati
onal purposes. It is frequently used by way
of adaptive hypermedia. Simulation is often used in the training of civilian and military
Virtual Simulation Learning among Student Nurses in the

Post Anesthesia Care Unit

personnel. This usually occurs when it is prohibitively expensive or simply too dangerous to
allow trainees to use the rea
l equipment in the real world
.

Medical simulators are increasingly being developed and deployed to teach
therapeutic and diagnostic procedures as well as medical concepts and decision making to
personnel in the health professions. Simulators have been deve
loped for training procedures
ranging from the basics such as blood draw, to laparoscopic surgery and trauma care. They
are also important to help on prototyping new devices for biomedical engineering problems.
Currently, simulators are applied to research

and develop tools for new therapies, treatments
and early diagnosis in medicine.

Many medical simulators involve a computer connected to a plastic simulation of the
relevant anatomy

(
rmsolutions.net, 29 Apr 2010).


Sophisticated simulators of this type
em
ploy a life size mannequin that responds to injected drugs and can be programmed to
create simulations of life
-
threatening emergencies. In other simulations, visual components of
the procedure are reproduced by computer graphics techniques, while touch
-
bas
ed
components are reproduced by haptic feedback devices combined with physical simulation
routines computed in response to the user's actions. Medical simulations of this sort will often
use 3D CT or MRI scans of patient data to enhance realism. Some medic
al simulations are
developed to be widely distributed (such as web
-
enabled simulations and procedural
simulations that can be viewed via standard web browsers) and can be interacted with using
standard computer interfaces, such as the keyboard and mouse.

A
nother important medical application of a simulator


although, perhaps, denoting
a slightly different meaning of simulator


is the use of a placebo drug, a formulation that
simulates the active drug in trials of drug efficacy.

Patient safety is a concern

in the medical industry. Patients have been known to suffer
injuries and even death due to management error, and lack of using best standards of care and
training. According to Building a National Agenda for Simulation
-
Based Medical Education
(Eder
-
Van Ho
ok, Jackie, 2004), “A health care provider’s ability to react prudently in an
unexpected situation is one of the most critical factors in creating a positive outcome in
medical emergency, regardless of whether it occurs on the battlefield, freeway, or hosp
ital
emergency room.” simulation. Eder
-
Van Hook (2004) also noted that medical errors kill up
to 98,000 with an estimated cost between $37 and $50 million and $17 to $29 billion for
preventable adverse events dollars per year. “Deaths due to preventable ad
verse events
exceed deaths attributable to motor vehicle accidents, breast cancer, or AIDS” Eder
-
Van
Hook (2004). With these types of statistics it is no wonder that improving patient safety is a
prevalent concern in the industry.

Innovative simulation tra
ining solutions are now being used to train medical
professionals in an attempt to reduce the number of safety concerns that have adverse effects
on the patients. However, according to the article Does Simulation Improve Patient Safety?
Self
-
efficacy, Comp
etence, Operational Performance, and Patient Safety (Nishisaki A., Keren
R., and Nadkarni, V., 2007), the jury is still out.
Nishisaki

states that “There is good evidence
that simulation training improves provider and team self
-
efficacy and competence on
m
anikins. There is also good evidence that procedural simulation improves actual operational
performance in clinical settings. However, no evidence yet shows that crew resource
management training through simulation, despite its promise, improves team opera
tional
performance at the bedside. Also, no evidence to date proves that simulation training actually
improves patient outcome. Even so, confidence is growing in the validity of medical
simulation as the training tool of the future.” This could be because
there are not enough
research studies yet conducted to effectively determine the success of simulation initiatives to
improve patient safety. Examples of [recently implemented] research simulations used to
improve patient care [and its funding] can be foun
d at Improving Patient Safety through
Domino B. Puson, Emiliano Ian Suson II, Jezyl T. Cempron

Simulation Research (US Department of Human Health Services)
http://www.ahrq.gov/qual/simulproj.htm
.

One such attempt to improve patient safety through the use of
simulations training is
pediatric care to deliver just
-
in
-
time service or/and just
-
in
-
place. This training consists of 20
minutes of simulated training just before workers report to shift. It is hoped that the
recentness of the training will increase the p
ositive and reduce the negative results that have
generally been associated with the procedure. The purpose of this study is to determine if
just
-
in
-
time training improves patient safety and operational performance of orotracheal
intubation and decrease oc
currences of undesired associated events and “to test the
hypothesis that high fidelity simulation may enhance the training efficacy and patient safety
in simulation settings.” The conclusion as reported in Abstract P38: Just
-
In
-
Time Simulation
Training Im
proves ICU Physician Trainee Airway Resuscitation Participation without
Compromising Procedural Success or Safety (Nishisaki A., 2008), were that simulation
training improved resident participation in real cases; but did not sacrifice the quality of
servic
e. It could be therefore hypothesized that by increasing the number of highly trained
residents through the use of simulation training, that the simulation training does in fact
increase patient safety. This hypothesis would have to be researched for valid
ation and the
results may or may not generalize to other situations.

The result of
study conducted by
Alinier
,

Hunt, Gordon and Harwood (2006)

and
others finds out that Intermediate
-
fidelity simulation is a useful training technique. According
to them Inte
rmediate

-

fidelity simulation enables small groups of students to practice in a
safe and controlled environment how to react adequately in a critical patient care situation.
This type of training is very valuable to equip students with a minimum of techni
cal and non
-
technical skills before they use them in practice settings.


Research Methodology


Research
Design


The
study is a quasi
-
experimental design specifically
utiliz
ing

the
one
-
group

after
-
only or post
-
test design

(
Polit and Beck,

2009
)
.

After
-
only
experimental designs measures of
the independent variable are only taken after the experimental subjects have been exposed to
the independent variable.
In this study, a single measure is recorded, after the simulation
activity is carried out, pertaining to

the subjects’ perception on its effectiveness towards
their
learning and competence.


Research
Locale


The study was conducted at Cebu Normal University
-

College of Nursing Virtual
Simulation Center which is located
in

Cebu, Philippines.
Established in 1
982,
Cebu Normal
University


College
of Nursing

is

recognized

as the Center
of

Excellence in Nursing
Education
for consistently posing a high performance rating and producing topnotchers
during the National Licensure Examinations
. In addition, the College

currently gained
Level
IV Accredited Status by the Accrediting Agency of Chartered Colleges and Universities in
the Philippines (AACCUP), Inc.

for its baccalaureate and master

s degree programs.

For

the
first semester of

school year 2012


2013, t
here ar
e

260 students

enrolled

in the
undergraduate course
.


A very valuable possession acquired by the department
is the
“Active

Simulation

Model”

particularly the
Emergency Care Simulator

which is the Standard Man
. Active
Virtual Simulation Learning among Student Nurses in the

Post Anesthesia Care Unit

models that attempt to reprodu
ce livin
g anatomy or physiology

are

capable of

simulat
ing

many of the physical findings including vital signs and many others
(
Lateef, Fatimah, 2008)
.


Research

Participants and

Sampling Technique


All of the n
inety three
third year

students were recruited to par
ticipate in the study.

Twenty four groups

of
three (
3
)

to
four (
4
)

members
each
were formed

so as to be
accommodated in the simulation laboratory as well as to maximize their hands
-
on experience
.



Research
Instrument


The tool used for this study
was the
14
-
item

Simulation

Effectiveness Tool (SET).
The Simulation Effectiveness Tool (SET) from the Program for Nursing Curriculum
Integration (PNCI®) has recently undergone a multi
-
site research study under the leadership
of Vicky Elfrink from Ohio State Univer
sity College of Nursing (OSUCON). This tool
was

used to measure of the effectiveness of a simula
ted clinical experience (SCE) d
ue to the
significant results of this study in identifying the SET as a highly reliable instrument for

t
otal
simulation effective
ness score and reliability of two associated subscales (confidence and
learning).
This standardized simulation evaluation tool
employed

a
Five
-
point Likert
-
type
scale.
The SET is a highly reliable i
nstrument for its total effectiveness tool and for the
“co
nfidence” and “learning” subscale scores.

(
Alinier, Guillaume, Barry Hunt, Ray Gordon
& Colin Harwood,
2006)
.

Perceptions are categorized as follows:


Numerical Score





Verbal Description

01
-
23



=



not effective

24
-
45



=



effective

46
-
70



=



very effective


Dat
a Gathering Procedures


The 93
L
evel III students

who voluntarily consented to be part of the study

were
subdivided into
group
s

with three

(
3
)

to four

(4) members each
.
The students were briefed
with regards to simulation procedure b
efore their actual exposure to the simulated scenario
involving care of the client admitted in the PACU.
Each group w
as

scheduled for
a
four
-
hour
exposure to the
researcher
-
made virtual simulation scenarios
.
The
simulation activity
r
a
n for
six (6) months d
uration
. At the end of the simulation
,

debriefing was conducted incorporating
a review of the performance of the group
.

Thereafter, the participants’ perception on the
effectiveness of
exposing them
to

simulati
on

scenarios involving ECS Standard Man was
do
ne using

the
Simulation Effectiveness Tool (SET).



Statistical Treatment

of Data


The
researcher utilized Frequency Distributions, Percentages, and weighted mean
to
measure the level of effectiveness

of the vir
tual simulation activity

on the learning and
competence of the participants
.


Results
and
Discussion


This chapter presents the tabulated data and its textual interpretation. The contents are
answers to the sub
-
problems of the study.

Domino B. Puson, Emiliano Ian Suson II, Jezyl T. Cempron


Frequency Distribution of Students’ Perception on the Effectivene
ss of Virtual Simulation

Figure 2 shows that majority of the students consider the virtual laboratory as a very effective
instrument in
helping the students to be more ready and more confident in caring for actual patients.

0
11
82
Not Effective
Effective
Very Effective

F
igure
2

Frequency Distribution of Students’ Perception on the Effectiveness of Virtual Simulation


Participants’ response
s clearly
acknowledged that

the respondent’s learning
experience

in the
virtual simulation center
has greatly influenced their learning

and
competence in the care of clients admitted in the PACU

with corresponding
weighted
mean

of

53.29

(“very effective”).

Nobody from the respondents believed that the virtual
simulations were not effective.

The results showed that the Virtual Learning Ex
perience played an important role in
the learning process and preparations of the students
. Furthermore, the computed weighted
mean confirmed
a very significant result to the learning of the student readiness
and

competence
. Though a couple of respondents
(11) were not totally convinced of the
effectiveness of the virtual laboratory simulated cases for nursing competence and readiness,
the result is still conclusive in answering the research problem which is

to
determine the
effectiveness of virtual laborat
ory simulation exposure prior to clinical duty
.


Conclusion

and Discussions


Conclusion


Based on the findings of the study,
Virtual
s
imulation activity

utilizing “Active
Simulation Model”

boosts students’ learning and
effectively increases their
clinical
competence
thus enhancing their readiness in the care of
actual
clients

in the clinical area
.


Recommendation
s



In the light of the findings of the study
,
the researchers highly recommend
utilization
of

virtual simulators
to augment the

competence and pre
paredness of the students prior to
actual clinical exposure

in the Post Anesthesia Care Unit



Bibliography

Online Source


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Virtual Simulation Learning among Student Nurses in the

Post Anesthesia Care Unit


intermediate
-
fidelity simulation training techn
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Virtual Simulation Learning among Student Nurses in the

Post Anesthesia Care Unit

Appendices


Appendix A

Researcher Modified
METI
Simulation Evaluation Tool























Domino B. Puson, Emiliano Ian Suson II, Jezyl T. Cempron

Appendix B

Data of the 93 Participants





























Virtual Simulation Learning among Student Nurses in the

Post Anesthesia Care Unit

Appendix C

Confidentiality Agreement and Consent to Audio & Video Recording

















































Domino B. Puson, Emiliano Ian Suson II, Jezyl T. Cempron

Appendix D

Documentation





























A student participating in a simulated reality in Virtual Simulations Center

in Cebu Nor
mal University


College of Nursing, Philippines.

A virtual simulation instructor controlling the simulated experience of the
students through the Control Center of the Simulation Laboratory.