The Effect of Simulation on Knowledge, Self-Confidence
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THE EFFECT OF SIMULATION ON KNOWLEDGE, SELF-CONFIDENCE, AND SKILL PERFORMANCE by ANN MARIE BOWLING Submitted in partial fulfillment of the requirements For the degree of Doctor of Philosophy Dissertation Advisor: Patricia W. Underwood Ph.D., RN, FAAN Dissertation Committee Members John M. Clochesy Ph.D., RN, FAAN, FCCM Marjorie M. Heinzer, Ph.D., PNP-BC, CRNP David A. Kolb, Ph.D. Frances Payne Bolton School of Nursing CASE WESTERN RESERVE UNIVERSITY August 2011 ii Dedication This dissertation is dedicated to my family who supported me through this endeavor and assisted me with completing this journey. They journey has been long and filled with bumps in the road but ultimately it has been worth it. Thanks to my husband Doug; and my children David, Jonathon, and Maria who are the light of my world. iii Table of Contents Page List of Tables vii List of Figures viii Acknowledgements ix Abstract x Chapter I – Introduction 1 Background and Significance 1 Theoretical Framework 3 Kolb’s Experiential Learning Theory 4 Zull’s Further Explanation of Kolb’s Theory 4 Research Question 9 Research Hypotheses 9 Chapter II – Literature Review 10 Experiential Learning Experience 10 Outcomes of Experiential Learning Experience 11 Knowledge 12 Improvement in Knowledge Between Groups 13 Knowledge Increase, No Difference Between Groups 14 No Knowledge Difference between Posttest Scores 17 No Increase in Knowledge 18 Gaps in Knowledge Literature 19 Confidence 19 Difference in Confidence Level 20 No Difference in Confidence Level 23 Gaps in Confidence Literature 24 Skill Performance 24 Evaluation of Skill Performance by Simulation 24 Evaluation of Skill Performance by OSCE 27 Simulation Versus the Control Group 28 Evaluation of Skill Performance by Other Methods 29 Summary of Skill Performance Literature 31 Summary and Gaps in the Literature 31 Chapter III – Methods 34 Study Design 34 Threats to Internal Validity 35 Diffusion of Treatment 35 Maturation 38 Selection 39 Testing and Instrumentation 39 History 40 iv Chapter III (Continued) Page Sampling and Setting 40 Recruitment Procedure 41 Inclusion and Exclusion Criteria 42 Determination of Sample Size/Power Analysis 42 Experimental Intervention: Medium-Fidelity Simulation Education 43 Comparison Group: Low-Fidelity Simulation (Paper/Pencil Case Study) Education 43 Instruments 44 Demographic and Clinical Experience Data 44 Knowledge Test 44 Self-Confidence in Learning 45 Objective Structured Clinical Examination (OSCE) 46 Pilot Study 49 Recruitment Procedure 49 Procedure 49 Data Analysis 50 Procedure for Primary Study 50 Protection of Human Subjects 51 Data Management 51 Summary 52 Chapter IV – Results 53 Sample Characteristics for Pilot 53 Psychometric Tests of Pilot Study Instruments 54 Knowledge Instrument 55 Modified Knowledge Instrument for Full Study 55 Self-Confidence in Learning 56 Objective Structured Clinical Examination (OSCE) 56 Modified OSCE Instrument for Full Study 57 Research Questions for Pilot Study 57 Research Question 57 Assumptions for Independent Sample t-test 57 Statistical Analysis – Independent Sample t-test 58 Sample Characteristics for Study 59 Psychometric Tests of Study Instruments 61 Knowledge Instrument 61 Self-Confidence in Learning 61 Objective Structured Clinical Examination 62 Research Question One and Three – ANCOVA versus ANOVA 62 Research Question One Results – Knowledge 63 Question One Hypothesis 63 Assumptions for Repeated Measures ANOVA 63 Statistical Analysis – Repeated Measures ANOVA 64 Research Question Two Results – Self-Confidence 65 Question Two Hypothesis 65 v Chapter IV (Cont) Page Research Question Two Results – Self-Confidence Assumptions for Independent Sample t-test 65 Statistical Analysis – Independent Sample t-test 65 Further Review of Self-Confidence in Learning 66 Research Question Three Results – Skill Performance 68 Question Three Hypothesis 68 Assumptions for Repeated Measures ANOVA 68 Statistical Analysis – Repeated Measures ANOVA 69 Additional Exploratory Analysis 70 SBAR 70 Patient Identification 71 Safe Medication Administration 72 Summary 73 Chapter V – Discussion 75 Discussion of Pilot Study Data 76 Discussion of Full Study Data 77 Instruments 77 Research Question One 77 Research Question Two 78 Research Question Three 79 Discussion of Additional Exploratory Analyses 80 SBAR 80 Patient Identification 81 Safe Medication Administration 82 Cost of Simulation 82 Study Limitations 84 Implications of Study Findings 87 Theory 87 Nursing Education 88 Recommendations for Future Research 89 Summary 90 Appendices Appendix A – Cover Letter 92 Appendix B – Medium Fidelity Simulation 93 Appendix C – Case Study 102 Appendix D – Pre Simulation Survey: Demographics 108 Appendix E – Post Simulation Survey: Demographics 109 Appendix F – Permission Letter from NLN 110 Appendix G – Instrument: Self-Confidence in Learning 111 Appendix H – Instrument: Objective Structured Clinical Examination 112 Appendix I – Instrument: Revised OSCE 126 References 136 vi List of Tables Page Table 1: Clinical Groups and Patterns of Clinical Experience 36 Table 2: Setting and Format of Clinical Experience 37 Table 3: Reliability Coefficients for Pilot Study Instruments 55 Table 4: Comparison of Pilot Study Groups 58 Table 5: Demographic Characteristics – Main Study Sample 59 Table 6: Comparison of Clinical Experiences by Study Group 60 Table 7: Reliability Coefficients for the Study Instruments 61 Table 8: Comparison of Self-Confidence by Group 66 Table 9: Frequency Data for Self-Confidence 68 Table 10: Skill Performance – Descriptive Statistics 69 Table 11: SBAR – Frequencies 71 Table 12: Patient Identification – Frequencies 72 Table 13: Medication Administration – Frequencies 73 vii List of Figures Page Figure 1: Integration of Zull’s Brain Activity and Kolb’s Experiential 6 Learning Theory Figure 2: Research Design 38 Figure 3: Knowledge Means 65 Figure 4: Skill Performance Means 70 viii Acknowledgements I would like to thank all of the pediatric nursing students who participated in this research study. Your time and energy were appreciated. This study is the beginning of my adventure to improve nursing education, you all were part of that beginning and should be proud of the role that you played. Many thanks to my dissertation committee. Dr. Patricia Underwood for her assistance with the challenges related to educational research and the IRB process. Dr. John Clochesy for his support since I began the program at Case and his assistance with issues related to simulation. Dr. Peg Heinzer for her assistance with developing the instruments that focused on caring for the pediatric patient and sticking with me this last year. Dr. David Kolb for his Experiential Learning Theory that was the fundamental theory of my research. All have challenged me and encouraged me to work through the research process to develop the most sound research design that was possible for this study. I also want to thank my colleagues, Jeanie Bochenek, Mikki Lukens, Chris Riggle, and Lisa-kay Clark who assisted me with the data collection process for the full study. I also want to thank my colleagues Deb Arms, Barb Bradley, and Jeanie Bochenek who assisted with data collection for the pilot study. Last of all, a final thank you to my colleagues Karen Findley, Susie Heimbach, and Marlene Stuber who assisted me with setting up and organizing the study. Without all of them none of this would have been possible. Special thanks to Dr. Patricia Martin who encouraged me to apply to Case Western Reserve University. Her encouragement and support through a difficult time made it possible for me to complete my PhD in Nursing. I want to also thank all my colleagues at Wright State University for their support and encouragement over the years as this has been a long process and long time coming for me. A heartfelt thanks to my husband who support over the years through difficult times and sleepless nights was always there to assist me. His support with caring for our children assisted me with being successful in my journey. Thanks to my children for their tolerance of my absences as I have completed this process. Thanks for their support and kind words when I was tired and sometimes short with them. Your love and kindness is so appreciated. ix The Effect of Simulation on Knowledge, Self-Confidence, and Skill Performance Abstract by ANN MARIE BOWLING Current research supports that using simulation for nursing education will increase a student’s knowledge and self-confidence, but only a handful of research studies have looked at the effect of simulation on skill performance. The purpose of this study is to examine the effect of two educational interventions on measures of knowledge, self-confidence, and skill performance in junior level BSN nursing students. A nonequivalent control group pretest posttest design was used to examine and compare the effects of the two educational interventions, medium-fidelity simulation and low-fidelity simulation (paper/pencil case study). The student’s knowledge was measured using a multiple choice test, self-confidence was measured with the Self- Confidence in Learning Scale, and skill performance was measured using an objective structured clinical examination (OSCE). The OSCE has been routinely used in medicine to assess medical students’ clinical abilities and is just beginning to be used in nursing. A pilot study was conducted with a convenience sample of junior nursing students (n = 21) to determine the feasibility of the medium-fidelity and low-fidelity simulations, the