Improving pedagogical practices with undergraduate nursing students in high-fidelity simulation
Nurse educators are required to consider how to best prepare students in order to avoid injury to patients presenting with complex conditions. This study examined one nurse educator’s question: “How can I improve my pedagogical practices working with undergraduate students in the high-fidelity simulation environment?” The aims were to (1) develop a personal living theory on how to design and implement high-fidelity simulation; (2) involve nursing students as co-researchers; and (3) inform the University’s design and implementation of high-fidelity simulation.
A total convenience sample of 146 final-year, undergraduate nursing students, aged 18-35, with previous exposure to the high-fidelity simulation environment, were recruited from a New Zealand university. An action research ‘living theory’ methodology was used to guide three investigation cycles. The first action cycle began with observing current educational practice using high-fidelity simulation with one student cohort; from which 15 students were purposively recruited for a focus group discussion on how learning experiences might be redesigned. Data were analysed using NVivo™ to develop a descriptive thematic analysis. The main themes emerging from this cycle included students’ need for, (1) friendly and concise feedback from educators, (2) educators available in the room to assist students during the simulation and, (3) roles within the simulation which allowed students to focus on one or two things instead of the entire complex patient situation.
These themes were operationalised and evaluated in the second action cycle with a convenience sample of 125 students. Participants completed pre- and post-simulation questionnaires rating their most and least valued aspects of the revised high-fidelity simulation using a 5 point Likert scale. The students most valued academic staff modelling how to perform each role in the simulation, having an opportunity to repeat each scenario, and receiving clear friendly feedback. Students least valued not having more high-fidelity simulation earlier in the programme, not being shown how to use the ISBAR communication tool earlier in the programme, and the lack of a coordinated simulation plan in the undergraduate nursing curriculum. Subsequently, 35 purposively recruited nurse educators completed a questionnaire to gather their opinions on what resources were required to assist student learning using high-fidelity simulation.
Twenty-one students from the final semester of the nursing degree volunteered to participate in the third action cycle which integrated pre-briefing modules, pre-and post-simulation tests, modelling clips performed by educators and debriefing, into a simulation suite of three scenarios that were video recorded. Participants completed pre- and post-simulation tests measuring content knowledge around each simulation topic. Students’ mean post-test scores improved by an average of 2 points over their pre-simulation tests for each scenario. This result suggests that involvement in the high-fidelity simulation and associated activities improved content knowledge. Student performance was also evaluated by educators using the Lasater Clinical Judgment Rubric to measure students’ performance in noticing, interpreting, responding, and reflecting skills. The students’ observer-rated scores improved by an average of 2.5 points from the first to the third simulation, showing improved clinical assessment, clinical judgment and reasoning, and reflection skills. To complete the third cycle, eight students from the same cohort were purposively recruited for one of two focus group interviews. The data were analysed using NVivo™. The results showed student learning as maximised when the high-fidelity simulation was designed to include modular learning, repetition, and skills training in the simulation environment, as well as having nurse educators model expected behaviours, give specific feedback and engage students in post-simulation debriefing. These findings suggest student learning is best when educators are actively involved in the design and running of high-fidelity simulation, giving students access to their thinking and reasoning during, and in the debriefing, of high-fidelity simulation. The contribution of knowledge offered by this thesis is a theory of practice, personal yet transferable to others, of how to design and implement simulation in order to provide an integrated simulation programme for undergraduate nurses.