Anxiety and stress of the nursing student related to the use of simulation is a recurring theme in the literature (Beischel, 2013; Cato, 2013; de Souza Teixeira, et al., 2015; Deegan & Terry, 2013; Gantt, 2013; Halabi-Najjar et al., 2015; Page & Morin, 2015). Nursing students specifically commented on the lack of preparation as a cause of the anxiety or stress (Beischel, 2013; Cato, 2013; Gantt, 2013; Najjar et al., 2015; Paige & Morin, 2015). Simulation anxiety was reported to remain even after the conclusion of the simulation experience, with numerous students commenting, “I go home that night thinking why I am doing this course? I'm going to kill someone” (Deegan & Terry, 2013, p. 594) and “I don't know, I am still a little nervous and can't think clearly” (de Souza Teixeira, et al., 2015, p. 288).
A mixed-methods study found that students rated feeling nervous during simulation as moderate on a 5-point Likert scale (Kameg, Englert, Howard, & Perozzi, 2013). Cato (2013) found that that the most common request from these anxious or stressed nursing students were to have a mini interactive experience with simulation prior to their first actual simulation.
The sophomore year is the first year that students at a college of nursing in a large state university in the Midwest are exposed to simulation as a teaching strategy. Traditionally, the faculty provide a brief orientation through verbal lecture for the students directly at the bedside just prior to the simulation. The authors of this quality improvement project thought that a more interactive orientation led by a high-fidelity simulator may stimulate greater student engagement and allow them to feel more comfortable with the actual simulation when it occurred.
Objectives
- Students who received the active simulation orientation will rate and describe less stress/anxiety in subsequent simulations compared to students in the traditional lecture orientation.
- Students who received the active simulation orientation will rate and describe more confidence in subsequent simulations compared to students in the traditional lecture orientation.
Methods
The authors applied for IRB review and it was deemed a quality improvement project for which no further human subjects’ research review was needed. The data collected was only for an internal quality improvement project (not research) and any publication would be a factual account of our orientation program through a quality improvement effort without an attempt to generalize findings.
The authors collaborated with the sophomore undergraduate course lead to arrange a time to provide an alternative orientation to simulation during the lab time for roughly half of the student groups. The other half of students were provided the traditional orientation with less interaction. Convenience samples of intact clinical groups were used.
The students were brought in during a lab time and a script was followed for the operator of the high-fidelity simulator. The operator instructed the students to assess pupils, auscultate lungs, heart and bowel sounds, then to assess pulses. Students were provided an opportunity to perform these skills and interact with the simulator during this 10-minute orientation.
After the students’ first simulation, a paper and pencil simulation orientation survey was administered to the students after their first simulation. This 12 question survey was modified from two scales: The Spielberg State Trait Anxiety Inventory (STAI) and the General Self-Efficacy (GSE) scale. The questions were answered using the same Likert-style scale as the GSE from 1-4 with 1 being not at all true, 2 being hardly true, 3 being moderately true, and 4 being exactly true. Three qualitative questions were asked to understand the lived experience of the students in simulation and included: What would you change?, What would you keep the same?, and Any other comments?
There were no identifying data or demographic data collected on the surveys. Students were made aware that participation was voluntary and that participation would not affect his/her grades in any manner as no faculty were present during administration of surveys. Data were manually entered into an Excel spreadsheet. Quantitative Data were analyzed for descriptive statistics using Excel and SPSS. Qualitative data were analyzed by sorting like data, assigning common language to exposed themes verbatim as much as possible, checking for accuracy by reading data passages in context, and triangulating with quantitative data.
Results
There were 145 respondents, 67 from the traditional lecture orientation (control group) and 78 from the active orientation (treatment group). After completing a quantitative analysis of the data using SPSS for the Likert-style questions, authors found one statistically significant item: I am usually able to handle it no matter what comes my way during simulation. X2 (3, N = 145) = 9.69, p = .021. The group receiving the traditional lecture orientation felt more confident in simulation. There were no significant differences in anxiety or stress levels between the two groups.
Qualitative data gleaned from the open-ended question regarding desired changes in simulation revealed a few themes, including: wanting an active role without observer or family member, changing roles to maximize learning, more role preparation, and more skill practice. The open-ended question regarding things students wanted to remain the same in simulation, included: opportunity for critical thinking, well-designed simulation, pre-simulation preparation assignment, learning in teams, reflective debriefing, relaxed learning environment, experience with multiple roles, use of electronic health record, safe learning environment, and incorporation of spontaneity and unexpectedness.
Discussion/Future Implications
From this survey, interesting data from our student population has been gathered regarding their experiences and preferences in simulation. It is likely that the qualitative data regarding students’ desire to have more active roles and to experience multiple roles within a simulation experience may lead to greater confidence. It is clear that the less active roles of observer and patient family member are not as valued by the students and may not positively impact their confidence or stress level. The plan is to minimize the less active roles and to allow students to experience more roles within a single simulation and repeat the survey to see if this is more effective in increasing confidence and decreasing stress associated with simulated learning experiences in prelicensure nursing education.