Task-Evoked Pupillary Responses in Nursing Simulation as an Indicator of Stress and Cognitive Load

Effectiveness of Simulation-Based Education on Educational Practices of Communication Skills, Satisfaction, and Self-Confidence Among Undergraduate Nursing Students

Introduction: Simulation-based education is one of the important teaching and learning strategies that imitate real situations in a clinical environment of safety. Simulation-based education offers experiential, interactive, and collaborative learning opportunities, and hence can help improve students' communication skills and increase their satisfaction and self-confidence. Purpose: This study aimed to examine the effectiveness of simulation-based learning on the educational practice of communication skills, satisfaction, and self-confidence among undergraduate nursing students. Methods: An uncontrolled before-and-after study design among first-year nurse students (n = 112) used the Educational Practices Questionnaire and the Student Satisfaction and Self-Confidence in Learning instruments for data collection. Results: In total, 91.1% of participants reported high satisfaction with simulation-based education experiences. Mean scores for communication skills, student satisfaction, and self-confidence were higher on posttest. There was a suggestive correlation between simulation-based education and the practices of communication skills, satisfaction, and self-confidence. Conclusion: Simulation-based education is associated with improved communication, student satisfaction, confidence, and critical thinking among nursing students. This study is important for institutions because it demonstrates that simulation-based education enhances a safer and more effective learning environment to meet the demands of future health-care professionals by increasing their satisfaction and self-confidence and improving communication skills through increased collaboration in several real-life scenarios.

Surgical Sabermetrics: A Scoping Review of Technology-enhanced Assessment of Nontechnical Skills in the Operating Room

OBJECTIVE

To evaluate the current evidence for surgical sabermetrics: digital methods of assessing surgical nontechnical skills and investigate the implications for enhancing surgical performance.

BACKGROUND

Surgeons need high-quality, objective, and timely feedback to optimize performance and patient safety. Digital tools to assess nontechnical skills have the potential to reduce human bias and aid scalability. However, we do not fully understand which of the myriad of digital metrics of performance assessment have efficacy for surgeons.

METHODS

A systematic review was conducted by searching PubMed, EMBASE, CINAHL, and PSYCINFO databases following PRISMA-ScR guidelines. MeSH terms and keywords included "Assessment," "Surgeons," and "Technology". Eligible studies included a digital assessment of nontechnical skills for surgeons, residents, and/or medical students within an operative context.

RESULTS

From 19,229 articles screened, 81 articles met the inclusion criteria. The studies varied in surgical specialties, settings, and outcome measurements. A total of 122 distinct objective, digital metrics were utilized. Studies digitally measured at least 1 category of surgical nontechnical skill using a single (n=54) or multiple objective measures (n=27). The majority of studies utilized simulation (n=48) over live operative settings (n=32). Surgical Sabermetrics has been demonstrated to be beneficial in measuring cognitive load (n=57), situation awareness (n=24), communication (n=3), teamwork (n=13), and leadership (n=2). No studies measured intraoperative decision-making.

CONCLUSIONS

The literature detailing the intersection between surgical data science and operative nontechnical skills is diverse and growing rapidly. Surgical Sabermetrics may provide a promising modifiable technique to achieve desirable outcomes for both the surgeon and the patient. This study identifies a diverse array of measurements possible with sensor devices and highlights research gaps, including the need for objective assessment of decision-making. Future studies may advance the integration of physiological sensors to provide a holistic assessment of surgical performance.

Application of eye-tracking in nursing research: A scoping review

AIMS

To map the themes and methods of nursing researches involving eye-tracking as a measurement, and offer suggestion for future nursing research using eye-tracking.

DESIGN

We conducted a scoping review following the methodology outlined in the JBI Manual for Evidence Synthesis on scoping reviews.

METHODS

Eligibility criteria were established based on Population (involving nursing or nursing students), Concept (utilizing eye-tracking as a research method), and Context (in any setting). Articles were retrieved from the PubMed, Web of Science, Embase, CINAHL, APA PsycInfo, and Scopus databases, spanning from database inception to November 17, 2023. The included studies were analysed using descriptive statistics and content analysis.

RESULTS

After duplicates were removed, 815 citations were identified from searches of electronic databases and other resources, and 66 met the inclusion criteria finally. Thirty-eight studies were conducted in a simulated environment. Five application domains were identified, and most of the studies (N = 50) were observational. The domains found in our review did not cover all topics of nursing research in the same depth. Additionally, 39 studies did not solely explicate eye-tracking data but instead integrated behavioural measures, scales/questionnaires, or other physiological data.

CONCLUSIONS

Eye-tracking emerges as a significant research tool in uncovering visual behaviour, particularly in nursing research focused on nursing education. This study not only summarized the application and interpretation of eye-tracking data but also recognized its potential in advancing clinical nursing research and practice. To effectively harness the capabilities of eye-tracking in elucidating cognitive processes, future research should aim for a clearer grasp of the theoretical underpinnings of the addressed research problems and methodological choices. It is crucial to emphasize the standardization of eye-tracking method reporting and ensuring data quality. No Patient or Public Contribution.

Evaluating Medic Performance in Combat Casualty Care Simulation and Training: A Scoping Review of Prospective Research

INTRODUCTION

Combat medics are required to perform highly technical medical procedures in austere environments with minimal error. Effective means to quantify medic performance in field and simulated environments are critical to optimize medic training procedures as well as to evaluate the influence of medical equipment and other supportive technologies on medic performance. Human performance evaluation in combat casualty care presents many unique challenges due to the unique environment (battlefields) and population (medics) that must be represented. Recent advances in simulation and measurement technology have presented opportunities to improve simulation fidelity and measurement quality; however, it is currently unclear to what extent these advances have been adopted in this domain.

METHODOLOGY

In this work, a scoping review of recent (2011-2021) prospective research on Army medic (68 W and Special Operations) performance is presented. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines served as the framework for the review. The goal of this work was to summarize recent trends and practices and to illuminate opportunities for future work. Two human factors experts performed an exhaustive review of relevant, peer-reviewed literature and systematically identified articles for inclusion in the final analysis. The articles were examined in detail, and data elements of interest were extracted.

RESULTS

Forty-eight articles were identified based on the defined inclusion criteria. Thirty three of the articles focused on technological evaluation, 25 focused on medic training procedures, and 5 focused on evaluating medical techniques. Study contributions were predominantly related to medic training materials/procedures and simulator technology. Supportive medical technologies, including telemedical systems, hemorrhage control devices, and ultrasound devices, also received significant attention. Timing was the most common metric used to quantify medic performance, followed by skill pass/fail ratings. There was a notable lack of neurophysiological data used to examine medic physical/cognitive workload during procedures, a growing practice in many other related domains. The most commonly simulated procedures were hemorrhage control, airway management, and thoracostomy. Notable limitations cited across articles were insufficient simulation fidelity, inadequate sample size or sample representativeness, and poor study design.

CONCLUSIONS

This work provided a summary of recent peer-reviewed research related to medic simulation and training, and performance evaluation. This article should be used to contextualize existing research and inspire new research questions. Expanding and advancing research on medic simulation and training will help to ensure optimal casualty care at the front lines.

Cognitive Load Assessment Scales in Simulation: Validity Evidence for a Novel Measure of Cognitive Load Types

INTRODUCTION

Cognitive load (CL) theory provides a framework to inform simulation instructional design. Reliable measures of CL types (intrinsic [IL], extraneous [EL], and germane load [GL]) in simulation are lacking. We developed the novel Cognitive Load Assessment Scales in Simulation (CLAS-Sim) and report validity evidence using Kane's framework.

METHODS

This quasi-experimental study tested the effect of a segmented/pause-and-debrief or standard/end-of-case-debrief intervention on pediatric residents' performance and self-rated CL in 2 complex- and simple-case simulations. After each simulation, participants completed 22 items measuring CL types. Three validity inferences were examined: scoring (instrument development and principal component analysis); generalization (internal consistency reliability of CL-component items across cases); and extrapolation [CLAS-Sim correlations with the single-item Paas scale, which measures overall CL; differences in primary task performance (high vs low); and discriminant validity of IL under different instructional-design conditions].

RESULTS

Seventy-four residents completed both simulations and postcase CLAS-Sim measures. The principal component analysis yielded 3 components: 4-item IL, 4-item EL, and 3-item GL scales (Cronbach's α, 0.68-0.77). The Paas scores correlated with CLAS-Sim IL and total CL scores in both cases ( rs range, 0.39-0.70; P ≤ 0.001). High complex-case performers reported lower IL and total CL (analyses of variance, each P < 0.001). In multivariate analyses of variance, CLAS-Sim IL, GL, and total CL varied across both cases by arm (each P ≤ 0.018); the segmented-debrief arm reported lower IL than the standard-debrief arm in both cases (each P ≤ 0.01).

CONCLUSIONS

The CLAS-Sim demonstrates preliminary validity evidence for distinguishing 3 CL types but requires further study to evaluate the impact of simulation-design elements on CL and learning.

Factors Associated with Student Satisfaction and Self-Confidence in Simulation Learning among Nursing Students in Korea

This study aimed to examine the relationships between student satisfaction and self-confidence in learning (SCLS), the simulation design scale (SDS), and educational practices in simulation (EPSS) and to identify the influencing factors on SCLS in nursing students undergoing simulation learning. Of the fourth-year nursing students, 71 who were taking a medical-surgical nursing simulation course and voluntarily provided informed consent to participate in the study were enrolled. Data on SCLS, SDS, and EPSS were collected via an online survey after the simulation, from 1 October 2019 to 11 October 2019. The mean SCLS score was 56.31 ± 7.26, the mean SDS score was 86.82 ± 10.19 (range: 64~100), and the mean EPSS score was 70.87 ± 7.66 (range: 53~80). SCLS was positively correlated with SDS (r = 0.74, p < 0.001) and EPSS (r = 0.75, p < 0.001). The regression model for SCLS in nursing students revealed that SCLS increased with increasing EPSS and SDS, and that SDS and EPSS explained 58.7% of the variance in SCLS (F = 50.83, p < 0.001). Therefore, to improve the learning satisfaction and learning confidence of nursing students in simulation classes, it is necessary to consider simulation design and practice considering educational factors.

Using Task-Evoked Pupillary Response to Predict Clinical Performance during a Simulation Training

Training in healthcare skills can be affected by trainees' workload when completing a task. Due to cognitive processing demands being negatively correlated to clinical performance, assessing mental workload through objective measures is crucial. This study aimed to investigate task-evoked changes in pupil size as reliable markers of mental workload and clinical performance. A sample of 49 nursing students participated in a cardiac arrest simulation-based practice. Measurements of cognitive demands (NASA-Task Load Index), physiological parameters (blood pressure, oxygen saturation, and heart rate), and pupil responses (minimum, maximum, and difference diameters) throughout revealed statistically significant differences according to performance scores. The analysis of a multiple regression model produced a statistically significant pattern between pupil diameter differences and heart rate, systolic blood pressure, workload, and performance (R² = 0.280; F (6, 41) = 2.660; p < 0.028; d = 2.042). Findings suggest that pupil variations are promising markers to complement physiological metrics for predicting mental workload and clinical performance in medical practice.

Gender Differences in Psychological Safety, Academic Safety, Cognitive Load, and Debriefing Satisfaction in Simulation-Based Learning

BACKGROUND

As there is an increasing trend in the number of male-identifying learners in undergraduate nursing education, a need exists to identify the gender differences in learners' perceptions regarding simulation-based learning.

PURPOSE

This study aimed to identify the gender differences in psychological safety, academic safety, cognitive load, and debriefing satisfaction in simulation-based nursing education.

METHODS

A cross-sectional descriptive survey was implemented with 97 female and 95 male nursing students. Data were analyzed using Mann-Whitney U tests or independent-samples t tests.

RESULTS

Female nursing students reported a lower academic safety and higher intrinsic load than male nursing students. Male nursing students perceived a higher germane load than female nursing students.

CONCLUSIONS

The significance of the present study was the identification of gender differences in participant perception of the simulation learning experience for effective simulation design.

Using Mean Pupil Diameter Change to Analyze Behavioral Performance in Multitasking Training Game

To explore the actual behavioral performance of subjects in multitasking training games, we designed a VR game including a Target-tracking task (TTT) of continuously moving "Player" to track "Targets" and a randomly appearing Color-discrimination task (CDT) requiring discriminating whether "Player" and "Monster" have the same color, and recorded subjects' pupillary changes to reflect mental effort. By analyzing the mean pupil diameter change (MPDC) of different groups, we found that the high group presented pupil dilation during the post-event stage, reflecting that they engaged in psychological processing of CDT during the event, whereas the low group had no pupil dilation during part of the post-event stage, reflecting the possibility of ignoring the appearance of CDT, and such behaviors hardly raise good expectations for training effect. Our study suggests that MPDC mirrors not only the actual behavior of the different groups treating the multitasking paradigm, but also the influence of game design.

Exploring Finger Digit Ratios (2D:4D) in Surgeons, Professional Rugby Players, and Political Journalists to Form a Directional Hypothesis: Could Finger Length Predict Attention and Focus?

In this short report we explore the predictive nature of finger digit ratio (i.e., second/index finger length divided by fourth/ring finger length; 2D:4D) and achievement. This research, with niche and specialized populations, was intended to support and grow on knowledge obtained from other large population 2D:4D studies and help form a directional hypothesis for future work exploring finger digit ratio and “success.” Twenty-nine professional rugby players aged 25.1 ± 4.2 years, height 185.2 ± 6.3 cm and weight 101.9 ± 11.8 kg; n = 16 orthopedic surgeons aged 55.3 ± 9.3 years with height 183.8 ± 10.2 cm and weight 90.8 ± 14.0 kg; and n = 18 political journalists with age, height and weight of 38.8 ± 7.3 years, 182.8 ± 7.8 cm, and 84.4 ± 11.4 kg, respectively, were recruited. Three experiments were conducted where we (1) explored relationships for 2D:4D with testosterone and cortisol responsiveness to low stress exercise, (2) explored relationships for 2D:4D with pupil constriction and pupil constriction latency (pupillometry measures related to testosterone and cortisol responsiveness and to attentiveness), and (3) compared 2D:4D between rugby players, surgeons, and journalists. Our results revealed 2D:4D was not predictive of testosterone and cortisol responsiveness to low-level exercise stress. However, relationships exist for 2D:4D and pupillometry measures (p < 0.05). Journalists right minus left 2D:4D difference was significantly different to rugby players’ and surgeons (p < 0.05). We argue 2D:4D is likely predictive of testosterone sensitivity and associated ability to focus attention; a skill important to high achievement in various contexts.

Effect of Psychophysiological Stress and Socio-Emotional Competencies on the Clinical Performance of Nursing Students during a Simulation Practice

Psychophysiological stress can affect the cognitive response and effective learning of students during medical simulation practices. This study aimed to explore the effect of psychophysiological stress and socio-emotional competencies on clinical performance during a simulation experience. A pre-test/post-test design was used to assess physiological (blood pressure, heart rate and blood oxygen saturation) and psychological parameters (stress and anxiety) as well as socio-emotional skills (cognitive load, self-efficacy and motivation) in nursing students (n = 40) before and after the simulation of a cardiopulmonary resuscitation practice. Physiological responses showed statistically significant differences between pre-test and post-test conditions for blood pressure and heart rate (p < 0.0001). Moderate and significant correlations were also observed when comparing self-efficacy with stress (r = −0.445, p = 0.004), anxiety (r = −0.467, p = 0.002) and motivation (r = −0.406, p = 0.009) measures. Similarly, cognitive-load dimensions were significantly associated with either physiological (r = −0.335, p = 0.034) or psychological (r = −0.448, p = 0.004) indicators. The analysis of multiple regression models revealed a relationship between the effectiveness of the simulated experience, post-test blood oxygen saturation, heart rate, workload and self-efficacy (R² = 0.490; F (3, 39) = 8.305; p < 0.0001; d = 1.663). Therefore, the evaluation of psychophysiological parameters and socio-emotional skills seems to provide a promising framework for predicting the quality of simulated clinical practices.

Cognitive load experienced by nurses in simulation-based learning experiences: An integrative review

BACKGROUND

Simulation based learning experiences help nurses gain skills necessary for independent practice. However, increased cognitive load placed on learners in simulation may affect learning outcomes.

OBJECTIVES

The purpose of this integrative review was to synthesize what is known about nurses' cognitive load in simulation and summarize measurement approaches.

DATA SOURCES

A search of CINAHL, Medline, ProQuest Nursing and Allied Health, and ERIC databases was limited to peer-reviewed studies published after 2006 in the English language, using the key words nurse, simulation, and cognitive load.

REVIEW METHODS

Whittemore and Knafl's (2005) integrative review method was used. Studies investigating advanced practice nurses or interprofessional teams were excluded.

RESULTS

Database and reference lists searches identified a total of 3077 records, and 20 met inclusion criteria. Simulation fidelity, time pressure, dual-tasking, interruptions, task complexity, distractions, and mismatched simulation objectives to learner ability increase nurses' cognitive load. However, past experience, pre-briefing, repeated scenarios, and worked-out modeling optimize cognitive load. Subjective and objective cognitive load measures help researchers understand cognitive load and define its relationship with other variables.

CONCLUSIONS

Simulation impacts nurses' cognitive load. Varying simulation designs to optimize cognitive load will improve learning outcomes. Future nursing simulation research should utilize well-validated cognitive load measures and measure cognitive load alongside other variables to further understand how cognitive load affects simulation outcomes.

Predictors of Nursing Clinical Judgment in Simulation

ABSTRACT

This was a pilot study of novice and expert nurses participating in a simulation to determine the predictors of clinical judgment. Covariates included age, nursing experience, simulation experience, and six measures of pupil dilation as a measure of stress with scores on the Lasater Clinical Judgment Rubric as the dependent variable. A stepwise linear regression found years of RN experience was the only predictor of better clinical judgment. Despite evidence of stress, only years as a nurse was a statistically significant predictor.

Is There a Link between Stress and Cognition, and Capacity to Execute Motor Skill?

PURPOSE

This study aimed to examine the link between stress (measured via salivary cortisol and testosterone), cognition (measured via pupillometry, with greater pupil constriction and reduced pupil constriction latency associated with increased attention and improved information processing), and motor skill capacity (measured via somatosensory processing).

METHODS

Twenty-five professional rugby players participated in this study. Saliva samples were collected upon waking, before pupillometry and somatosensory processing testing, and after testing. Testing times varied for participants; however, it was always in the morning, and the order of testing was randomized.

RESULTS

Very small differences in hormone concentrations were seen across the morning (effect size = 0.01). Moderate to large differences in left eye pupil constriction for direct (left eye) versus consensual (right eye) stimulus were also seen (P < 0.01; effect size = 0.51 to 1.04). No differences for pupil constriction latency were seen for direct versus consensual stimulus. Some positive weak to moderate relationships were seen for testosterone and pupil constriction latency (r = 0.37 to 0.39, P < 0.05). Moderate to strong inverse relationships were seen for hormones with left eye pupil constriction difference between direct and consensual stimulus, and for pre- to posttest testosterone-to-cortisol ratio decline with left eye pupil constriction for direct and consensual stimulus (r = 0.41 to 0.52, P < 0.05). Weak to moderate inverse relationships for testosterone-to-cortisol ratio decline and somatosensory processing were seen (r = 0.36 to 0.47, P < 0.05).

CONCLUSION

Stress may affect ability to receive information and ability to execute motor tasks. Thus, stress may compromise ability to make appropriate objective decisions and consequently execute skill/task behavior. Strategies to help mitigate negative stress responses are noted.

Effect of Facial Skin Temperature on the Perception of Anxiety: A Pilot Study

The extent of anxiety and psychological stress can impact upon the optimal performance of simulation-based practices. The current study investigates the association between differences in skin temperature and perceived anxiety by under- (n = 21) and post-graduate (n = 19) nursing students undertaking a cardiopulmonary resuscitation (CPR) training. Thermal facial gradients from selected facial regions were correlated with the scores assessed by the State-Trait Anxiety Inventory (STAI) and the chest compression quality parameters measured using mannequin-integrated accelerometer sensors. A specific temperature profile was obtained depending on thermal facial variations before and after the simulation event. Statistically significant correlations were found between STAI scale scores and the temperature facial recordings in the forehead (r = 0.579; p < 0.000), periorbital (r = 0.394; p < 0.006), maxillary (r = 0.328; p < 0.019) and neck areas (r = 0.284; p < 0.038). Significant associations were also observed by correlating CPR performance parameters with the facial temperature values in the forehead (r = 0.447; p < 0.002), periorbital (r = 0.446; p < 0.002) and maxillary areas (r = 0.422; p < 0.003). These preliminary findings suggest that higher anxiety levels result in poorer clinical performance and can be correlated to temperature variations in certain facial regions.