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The Nature and Determinants of Presence Among Nursing Students

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The Nature and Determinants of Presence Among Nursing Students The Nature and Determinants of Presence Among Nursing Students Participating in High Fidelity Human Patient Simulation Dissertation Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy in the Graduate School of the Ohio State University By Renee M. Dunnington MSN RN Graduate Program in Education The Ohio State University 2012 Dissertation Committee: Richard J. Voithofer, Advisor Patti Lather Bryan Warnick Victoria Elfrink Cordi Copyrighted by Renee M. Dunnington MSN RN 2012 Abstract Human patient simulation is increasingly becoming an integral component of nursing education based on a variety of professional, educational, social, economic, political, and safety factors propelling its use. Yet the pedagogical science to support education with simulation remains underdeveloped. Scholarship on presence in virtual simulations has shown positive impact on learning outcomes. Yet presence as a variable of potential impact on learning outcomes with dynamic, scenario based, high fidelity human patient simulation (HF-HPS) has been little studied. The aim of this grounded theory study was to examine the nature of presence in baccalaureate nursing students participating in HF-HPS and to develop a conceptual model that could explain the dimensions and determinants of presence as they may impact learning outcomes. A total of 36 simulation encounters were observed including 16 simulations from the sample of baccalaureate prelicensure nursing students, 12 simulations from the comparative sample of experienced registered nurses and 8 simulations from a comparative sample of second degree prelicensure nursing students. From these encounters, interviews were conducted with 60 nursing students from the primary sample and with comparative samples of 30 professional nurses, 32 second degree nursing students, 20 educators and 3 administrators for a total sample size of 145 participants. The nature of presence was found to be a dynamic state of being with a centricity between the simulation and the natural environment where students perceived the stimuli from ii one environment as salient over the other. The results revealed that presence was experienced in the domains of exocentricity, endocentricity, or bicentricity relative to the perceived salience of the simulation environment. Furthermore, the presence of students in scenario based HF-HPS was impacted by pedagogical factors, individual student factors, and group factors. Pedagogical factors found in this study included simulation design, stream of stimuli, and instructional process. Individual factors included personality characteristics, referential experiences, preconceptions, emotional responses, and entry competencies. Group dynamics and group structure were also found to be determinative of the nature of presence in HF-HPS. The Nature and Determinants of Presence Model emerged from the study data to explain the articulation of the determinants of presence, the nature of presence, and learning outcomes. In this model, pedagogical, individual, and group factors are theorized to be determinative of the centricity of presence. Furthermore, presence centricity is theorized to impact learning outcomes. The Nature and Determinants of Presence Model in HF-HPS is presented to further guide research on presence as a factor that may impact learning outcomes in HF-HPS. This model is also offered to support continued development of a pedagogical science for education with clinical simulation. iii Dedication This work is dedicated to my dear husband and soul mate, Bradley. My heart is filled with gratitude for his steadfast and unwavering support. The waves forever flow, The winds so gently blow, The voyage sails on To the places we dream to know. This work is also dedicated to my son, Aaron, my daughter-in-law, Kelly, my son, Brenton, and my daughter-in-law, Ann Marie. I feel very blessed to have such a wonderful family. I wish to express my appreciation for their patience, kindness, and loving support throughout this journey. iv Acknowledgments I wish to express my sincere and deep appreciation to each of my committee members. Thank you to Rick Voithofer for serving as my advisor. I appreciate his expert guidance in the area of instructional technology and his gentle advocacy. Thank you to Bryan Warnick for opening my eyes to the beauty of philosophy. Thank you to Victoria Elfrink Cordi for her extraordinary expertise in the area of clinical simulation and her words of encouragement. Thank you to Patti Lather for her brilliant perspectives on qualitative inquiry. A special remembrance is also given here to Suzanne Damarin. She was the inspiration for this project at its inception. I wish to also acknowledge the nursing faculty at Capital University, School of Natural Science, Nursing and Health. I appreciate their encouragement and support. I especially appreciate their dedication to excellence in nursing education. Lastly, I wish to thank all the dedicated nursing students, faculty and professional nurses that gave of their time to participate in this study. Their willingness to share their experiences and their insights made a significant contribution to this research. It is hoped that their words conveyed in this work will help to advance the pedagogical science to support the application of clinical simulation in nursing education and through that may also support safety and quality in healthcare. v Vita 1978................................................................B.S.N. Nursing, Capital University 1989................................................................M.S.N. Parent-Child Nursing, Kent State University Publications Dunnington, R. M. & Glazer, G. (1991). Maternal identity and early mothering behavior in previously infertile and never infertile women. JOGNN, 20(4), 309-317. Dunnington, R.M. & Estok, P. (1991). Potential psychologic attachments of donors involved in fertility technology: Another side to infertility. The Nurse Practitioner, 16(11), 41-48. Fields of Study Major Field: Educational Policy and Leadership: Technology and Media Clinical Specialization: Maternal-Child Nursing Areas of Expertise: Instructional Technology, Informatics and Qualitative Inquiry vi Table of Contents Abstract………………………………………………………………………………..... ii Dedication………………………………………………………………………………. iv Acknowledgments………………………………………………………………….…... v Vita……………………………………………………………………………………… vi List of Tables…………………………………………………………………………... xiii List of Figures………………………………………………………………………...... xiv Chapter 1: Introduction………………………………………………………................ 1 Background………………………………………………………………………….. 1 Research Questions………………………………………………………………….. 7 Definition of Terms………………………………………………………………….. 8 Relevance of Study in the Technological Age……………………………...……….. 10 Summary…………………………………………………………………………….. 12 Chapter 2: Literature Review………………………………………………………….. 14 Introduction………………………………………………………………………..... 14 Simulation…………………………………………………………………………… 15 Evolution of Clinical Simulation……………………………………………….... 15 Current Trends Concerning HF-HPS in Nursing Education…………..…………. 17 Definitions / Conceptualizations of Simulation………………………………...... 19 vii Scholarship on High Fidelity Human Patient Simulation………………………... 23 Research on HF-HPS in Medicine and Anesthesia…………………………… 24 Research on HF-HPS in Nursing Education………………………………….. 25 Evaluation Research – Student Experience…………………………………... 26 Evaluation Research, Educational Practices………………………………….. 34 Outcomes Research…………………………………………………………… 39 Knowledge-HF-HPS Outcomes…………………………………………… 39 Clinical Agency-HF-HPS Outcomes……………………………………… 44 Methodological Research……………………………………………………... 50 Models and Theoretical Frameworks Grounding HF-HPS……………………… 53 Crisis Resource Management Model…………………………………………. 53 The Nursing Education Simulation Framework……………………………… 55 Learning Theories and Simulation……………………………………………. 57 Presence and Human Patient Simulation……………………………………………. 61 Presence Conceptualizations……………………………………………………... 62 Evolution of the Concept of Presence………………………………………… 63 Presence Definitions………………………………………………………….. 70 Environmental/Physical Presence Definitions…………………………….. 77 Engagement/Immersion Presence Definitions ……………………………. 77 Actional/Agentic Presence Definitions …………………………………… 78 Perceptual/Illusional Presence Definitions ……………………………….. 78 viii Cognitive/Perceptual Definitions………………………………………….. 80 Sociocultural Presence Definitions ……………………………………….. 80 Multidimensional Presence Definitions …………………………………... 81 Dimensions and Determinants of Presence…………………………………… 81 Emerging Presence Research ………………………………………………… 88 Presence and Outcomes …………………………………………………... 89 Presence Intensity ………………………………………………………… 91 Measurement of Presence ……………………………………………………. 93 Assumptions on Reality in Virtual Environments and Presence ………………... 98 Presence in High Fidelity Human Patient Simulation and Nursing Education……. 100 Conclusion…………………………………………………………………………. 105 Chapter 3: Methods …………………………………………………………………... 109 Introduction………………………………………………………………………… 109 Classical Grounded Theory………………………………………………………… 112 Glaserian Grounded Theory…………………………………………………….. 113 Straussian Grounded Theory……………………………………………………. 117 Rigor in Classical Grounded Theory…………………………………………… 120 Benefits and Limitations of Classical Grounded Theory……………………….. 122 Second Generation Grounded Theory……………………………………………... 125 Constructionism………………………………………………………………… 126 Charmazian Grounded Theory………………………………………………….. 128 Clarkesian Grounded Theory……………………………………………………
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