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Research evidence; however, is sparse regarding comparisons of CDM accuracy between roles. To our knowledge, no studies have been done that examine clinical decision making accuracy between active and passive roles within the simulation setting. Therefore, our innovative inquiry is necessary to inform nurse educators and about this aspect of simulation.
Purpose and Framework: The purpose of this presentation is to present findings from a quantitative study that examined clinical decision making accuracy (cue acquisition; diagnosis; action) among simulation roles in fourth semester associate degree nursing students. The theoretical framework used to undergird the study is built upon the Nursing Education Simulation Framework (Jefferies & Rogers, 2007). This framework was used as a guide when developing the components involved in the simulation scenario used in this study.
Design: The study utilized a mixed factorial design with stopping points (shortness of breath [SOB] and rhythm change) and decision phase (cue acquisition, diagnosis, and action) as within subjects’ factors and simulation role (observer, family, primary nurse, and auxiliary nurses) as between subjects’ factors. Decision making accuracy among fourth semester students in a simulation scenario was examined. The research question for this study was: Are there differences in clinical decision making accuracy among the different roles in an acute care simulation scenario with fourth semester ASN students?
Methods: Students participated in an acute care scenario (a two-day post open heart surgery patient) as part of their regularly scheduled simulation experience. Roles within the scenario were randomly assigned prior to the start of the scenario. Students who consented to participate in the study completed a CDM form at two distinct decision stopping points (SOB and Atrial Fibrillation [AFib]).
The stopping points were intentionally designed to be clinically different and distinct. Shortness of breath is a clinical situation familiar to fourth semester nursing students and nursing actions to resolve the problem may be more easily anticipated. New onset cardiac rhythm change (AFib) is new content to fourth semester students and there is one primary action which should be taken – call the provider to obtain orders for antiarrhythmic medications.
The CDM form completed by participants was comprised of three questions: (A) What are you noticing about the patient right now?; (B) What do you think is going on right now with the patient?; (C) What specific action(s) should the nurse take at this time? These items gathered data about the cue acquisition diagnosis, and action/intervention phases of the CDM process respectively (Elstein, Shulman & Sprafka, 1978).
Results: CDM accuracy forms were scored independently by two doctorally prepared certified nurse educators (the first two authors). Several statistically significant findings (p < 0.05) were revealed related to the relationship between demographic variables and CDM accuracy on the two stopping points. Within the SOB situation age was negatively correlated with cue acquisition (r = -0.21) and grade point average was positively related to decision about nursing actions (r = 0.2). In the AFib situation prior patient care experience was positively associated with cue acquisition (r = 0.19).
Data were analyzed to examine within subject differences between the two stopping points. Stopping point #1 (SOB) was a familiar situation for students. As a result of their familiarity, students were most accurate (74% accuracy) with recognizing cues in the patient. It was not surprising that the diagnosis phase of CDM was the least accurate (29% accuracy) since many diagnoses for SOB exist. Often students associated SOB with only one reason, despite that they were instructed to be specific and thorough with their answers. Once focused on a single diagnosis, their subsequent action plan became limited. Stopping point #2 (AFib) was new content for all students. Due to the unfamiliarly of a cardiac rhythm change, often students were able to recognize an increase in heart rate (56% accuracy) but less likely to recognize a change in rhythm (48% accuracy). Subsequently, their plan of action was often incorrect (27% accuracy). Unlike the SOB situation where a number of nursing actions were appropriate, there was truly just one correct action for the AFib situation – call the provider for orders.
When examining CDM accuracy across stopping points and simulation role, one statistically significant finding was revealed. During the AFib situation, mean levels of cue acquisition accuracy differed across role: observers (67%), medication and education nurses (50%), primary nurse (46%), and family members (41%). The significant role effect (p = 0.03) in the AFib situation indicated observers were statistically more accurate with cue acquisition than family members. Overall CDM accuracy in the AFib stopping point, though not statistically significant (p = 0.07), revealed observers were most accurate in the CDM process while family members were the least accurate. During the SOB situation, despite their role, students performed comparably regarding CDM accuracy.
Nursing Implications: Simulation is used in schools of nursing for various reasons such as skill mastery, team building, and priority setting. This study is the first to examine simulation roles and accuracy of CDM; therefore findings may provide a catalyst for change within simulation settings. The findings have implications for both nursing education as well as nursing practice. In nursing education today, clinical groups often exceed 10 students. Out of necessity educators assign more students to the passive observer role in the simulation lab, despite limited evidence to support this practice. This study found the observer role in simulation to be beneficial related to CDM accuracy. Typically nurse educators as well as students see active roles in simulation as most valuable (Harder, Ross, & Paul, 2013). However, observers may actually gain substantially from the experience because they are under less scrutiny, experience less stress, and are able to collaborate with peers. For these reasons, CDM among observers may actually improve.
This study concluded, related to CDM accuracy, the family member role may be less beneficial; as was the case in the AFib stopping point. When assigning the family member role, the student is often instructed to remain “in-role”. Consequently, a student in a wife role is thinking about what a wife would do or say; not what a nurse would do or say. Nurse educators should be mindful of a simulation experience’s goal when determining role assignment. If the intended goal is practicing the process of CDM and accuracy, educators might use caution when assigning family member roles.