Evaluating the impact of high- and low-fidelity instruction in the development of auscultation skills

The efficacy of high-fidelity simulation on knowledge and performance in undergraduate nursing students: An umbrella review of systematic reviews and meta-analysis

OBJECTIVES

This umbrella review aimed to consolidate the evidence base on the impact of high-fidelity simulation on knowledge and performance among undergraduate nursing students.

DESIGN

Umbrella review with meta-analyses of pooled effect sizes, followed by an additional meta-analysis of primary studies from the included systematic reviews, excluding overlapping results.

DATA SOURCES

Systematic searches were performed up to August 2023 in PubMed, Embase, and Cochrane Library. We included reviews that compared high-fidelity simulation against other learning strategies.

REVIEW METHODS

The risk of bias was assessed for each included systematic review (ROBIS tool) and primary study (RoB 2 or ROBINS-I as appropriate). Random-effect meta-analyses of meta-analyses were performed to estimate the pooled effects of high-fidelity simulation on knowledge and performance. Further random-effect meta-analyses of primary studies were conducted, with overlapping studies excluded (12 %). Subgroup analyses were performed to provide a more comprehensive analysis of the findings. Trim-and-fill analyses were conducted to adjust for potential publication bias.

RESULTS

Six systematic reviews were included and encompassed 133 primary studies (2767 and 3231 participants concerning performance and knowledge, respectively). The adjusted pooled effects for knowledge (SMD = 0.877, 95 % CI: 0.182 to 1.572) and performance (SMD = 0.738, 95 % CI: 0.466 to 1.010) closely aligned with those obtained from meta-analyzing the primary studies for knowledge (SMD = 0.980) and performance (SMD = 0.540), both showing high statistical heterogeneity. Traditional lectures represented the more common comparison. The subgroup analysis revealed significant differences in effect sizes across geographic locations, topics, types of control, and how interventions were reported.

CONCLUSIONS

The results provide robust evidence supporting the integration of high-fidelity simulation into undergraduate nursing programs to enhance students' knowledge and performance. The high reported heterogeneity may be attributed to variations in study contexts or methodologies. Future research should explore the optimal use of high-fidelity simulation in different educational and cultural contexts.

An evaluation of nursing students' learning self-efficacy: A multi-dimensional instrument development and structural validation

BACKGROUND

Nursing learning self-efficacy (NLSE) is essential in nursing students' learning, and since it is a task-dependent construct, accurate measurements require a multidimensional instrument.

OBJECTIVE

This research aimed to develop and validate a multidimensional NLSE instrument to measure Taiwanese nursing students' views of nursing learning self-efficacy.

DESIGN

The cross-sectional study design was used for this investigation.

PARTICIPANTS

The study included 1143 nursing students from a nursing junior college.

METHODS

To assess the validity and reliability of the instrument's factors, exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were utilized. Conceptual understanding, higher-order cognitive skills, practical work, everyday application, and nursing communication were identified as five factors. A comparison of five proposed models was also conducted.

RESULTS

The study found that the correlated and one-factor second-order models were acceptable and provided a simple structure for evaluating nursing students' perceptions of NLSE. Furthermore, a specific model with two second-order scales (Cognition and Application) and one first-order scale (nursing communication) was identified, highlighting the crucial role of nursing communication in nursing students' self-efficacy.

CONCLUSIONS

Evaluating nursing students' learning self-efficacy using a valid and reliable instrument is crucial for understanding their learning confidence. The creation of such a scale constitutes the primary contribution of this study.

Exploring the effects of extended reality head-mounted display nervous system assessment training for nursing students: A pilot feasibility study

BACKGROUND

Health assessment is crucial for planning nursing interventions. Specifically, cerebrovascular diseases involve rapid neurological changes that necessitate precise hands-on assessment skills training.

OBJECTIVES

This study developed and implemented an extended reality head-mounted display (HMD) nervous system assessment training program for nursing students to identify the usability and effectiveness of the system by analyzing their experiences.

DESIGN

This was a mixed-methods study that combined the quantitative element of a one-group pre-post-test design with the qualitative element of qualitative content analysis.

SETTING

University in Korea.

PARTICIPANTS

The study involved 36 nursing students in their 4th year who completed classes in health assessments and adult nursing (nervous system).

METHODS

An extended reality nervous system assessment training program was developed using the National Institutes of Health Stroke Scale and limb strength assessment. The learners wore HMD and received training at their own pace. System usability, confidence in nervous system assessment, learning satisfaction, and performance ability were measured and analyzed using SPSS Windows software version 28.0. Descriptive data were used for qualitative content analysis of the training experience.

RESULTS

The usability of the extended-reality HMD nervous system assessment training received positive feedback and most participants (94.4 %) agreed with the system's consistency. Confidence in nervous system assessment significantly improved after the training (p < .001). After the training, learning satisfaction and performance ability were high. Furthermore, advantages of XR-based learning devices and positive learning were observed. Nonetheless, issues such as difficulties in operating the device, inconvenience, physical side effects of wearing the device, and technical limitations existed.

CONCLUSIONS

This study developed and implemented an extended-reality HMD nervous system assessment training program to confirm its feasibility. However, challenges regarding device utilization need to be resolved for its effective development as a learning tool.

Comparison of Cardiac Auscultation Features on Four Different Simulation Mannequins Performed by Pediatric Residents

INTRODUCTION

Cardiac murmurs are a common problem in pediatric clinical practice. Studies demonstrated low accuracy in detecting and diagnosing various cardiac murmurs at all levels of medical training. So, supplementary training methods started to evolve, including simulation for auscultation skills training. Over the years, mannequins have evolved with different types of technology. Therefore, we decided to compare cardiac auscultation accuracy among high-fidelity mannequins as the primary objective and compare the performance of various postgraduate-level residents as a secondary objective.

METHOD

Pediatric residents at King Abdulaziz University Hospital were given a lecture on the basics of cardiac auscultation and then requested to auscultate four mannequins, namely SimJumior® (Laerdal Medical, Stavanger, Norway), SimBaby™ (Laerdal Medical), Pediatric HAL® (Gaumard Scientific, Miami, FL, USA), and Cardiac Patient Simulator K-Plus (Kyoto Kagaku Co. Ltd., Kyoto, Japan). The accuracies of murmur type, diagnosis, and auscultation time were compared.  Results: A total of 56 pediatric residents were enrolled. Median murmur accuracy ranged from 50% to 53% (p-value 0.79), and median diagnosis accuracy ranged from 33% to 36% (p-value 0.77), with a nonsignificant difference between mannequins. Comparing resident levels in all mannequins, median murmur accuracy ranged from 49% to 56% (p-value 0.70), and median diagnosis accuracy ranged from 29% to 41% (p-value 0.09). While the median average auscultation time was between 41 and 50 seconds (p-value 0.34).

CONCLUSION

Auscultation skills can be taught through simulation on any mannequin used in this comparison, not necessarily the cardiac one. For better accuracy, future comparisons might include more advanced cardiac mannequins based on cardiac auscultation expertise (i.e., consultant level). The introduction of an auscultation program from the undergraduate level throughout the training process and monitoring of these skills are mandated.

Task complexity and cognitive load in simulation-based education: A randomised trial

INTRODUCTION

When designing simulation for novices, educators aim to design tasks and environments that are complex enough to promote learning but not too complex to compromise task performance and cause cognitive overload. This study aimed to determine the impact of modulating task and environment complexity on novices' performance and cognitive load during simulation.

METHODS

Second-year pharmacy students (N = 162) were randomly assigned to one of four conditions (2 × 2 factorial design) in simulation: simple task in simple environment, complex task in simple environment, simple task in complex environment and complex task in complex environment. Using video recordings, two raters assessed students' performance during the simulation. We measured intrinsic cognitive load (ICL) and extraneous cognitive load (ECL) with questionnaires after the task and tested knowledge after task and debriefing.

RESULTS

Mean performance scores in simple environment were 28.2/32 (SD = 3.8) for simple task and 25.8/32 (SD = 4.2) for complex task. In complex environment, mean performance scores were 24.6/32 (SD = 5.2) for simple task and 25.6/32 (SD = 5.3) for complex task. We found significant interaction effects between task and environment complexity for performance. In simple environment, mean ICL scores were 4.2/10 (SD = 2.2) for simple task and 5.7/10 (SD = 1.5) for complex task. In complex environment, mean ICL scores were 4.9/10 (SD = 1.8) for simple task and 5.1/10 (SD = 1.9) for complex task. There was a main effect of task complexity on ICL. For ECL, we found neither an interaction effect nor main effects of task and environment complexity. There was a main effect of task complexity on knowledge test after task and main effects of both task and environment complexity on knowledge after debriefing.

CONCLUSIONS

Performance was good, and cognitive load remained reasonable in all conditions, which suggests that, despite increased complexity, students seemed to strategically manage their own cognitive load and learn from the simulations. Our findings also indicate that environmental complexity contributes to ICL.

Learning practical nursing skills in simulation centers - A narrative review

Background

Practical skills are complex procedures integrating communication and caring, as well as technical and manual aspects. Simulation at a simulation/skills center offers a wide range of learning activities and aims to imitate patient situations.

Objectives

To investigate the international research literature on practical skills learning in simulation/skills centers in nursing education. Research questions: 1. What are the range and type of practical skills studied? 2. What learning activities are focused on in the studies included in the review? 3. What are the learning outcomes and how are they assessed?

Design

Narrative review.

Methods

We searched electronically and included studies from Medline Ovid, CINAHL, Eric, Embase, Academic Search Premiere, and Cochrane. Unique indexing terms and search strategies were developed for each database. The criteria for inclusion were bachelor nursing students as the study population and practical nursing skills learning in simulation/skills centers. We used Rayyan QCRIt for the initial screening and the Mixed Method Appraisal Tool for quality assessment. We used a narrative approach to synthesize the diverse range of studies.

Findings

One hundred and twenty-one studies from 26 countries published between January 2013 and March 2022 were included. The amount of quantitative research was overwhelming (n = 108). A total of 50 different practical skills were represented. The studies focused on which learning modalities resulted in the best learning outcomes. Only 8.5% (n = 7) of the included studies concerned students' learning processes. Skill performance (n = 101), knowledge (n = 57), confidence (n = 34), and satisfaction (n = 32) were the main learning outcomes measured.

Discussion

The quality assessment indicated that 10 of the studies achieved 100% on the mixed method appraisal tool criteria. In many of the studies with quasi-experimental and randomized controlled trial designs, the intervention group received some form of educational treatment while the control group received no treatment. The choice of no treatment for the control group in pedagogical research seems to disregard the inherent purpose and effect of teaching and learning.

Conclusion

Heterogeneity in the use of learning modalities and measuring instruments precludes the possibility of building on other research. Technical skills were the preferred choice of skill, while skills that involved a fair measure of communication and collaboration were only sparingly studied. Students' learning processes were barely touched on in the included studies. More focus should be placed on this area in further research, since the choice of learning modalities may affect the students' learning processes in significant ways.

Feasibility and effectiveness of cardiac auscultation training with a cardiology patient simulator for first-year medical students

BACKGROUND

The effectiveness of cardiac auscultation training with a cardiology patient simulator for medical students is still unclear. Starting such training earlier may help students improve their proficiency. We investigated whether cardiac auscultation training using a simulator for first-year students is feasible and effective.

METHODS

A total of 43 first-year medical students (5-12 in each year, 2015-2019) participated in three 1.5-hour extra-curricular classes comprising mini-lectures, facilitated training, two different auscultation tests (the second test closer to clinical setting than the first), and a questionnaire. The test results were compared with those of 556 fourth-year medical students who participated in a compulsory 3-hour cardiac auscultation class in 2016-2019.

RESULTS

The accuracy rate of all heart sounds and murmurs was higher in the first-year students than in the fourth-year students in both the first (85.8 vs. 79.4 %, p = 0.001) and second (71.3 vs. 61.2 %, p = 0.02) tests. That of second/third/fourth sounds was also higher in the first-year students than in the fourth-year students in both the first (86.0 vs. 79.7 %, p = 0.01) and second (70.9 vs. 53.9 %, p = 0.002) tests. The accuracy rate of murmurs was higher in the first-year students than in the fourth-year students in the first test (85.5 vs. 78.9 %, p = 0.04), but not in the second test (72.1 vs. 75.7 %, p = 0.58). All the first-year students and 65 % of them agreed that they had received sufficient knowledge and built sufficient skills, respectively. All the first-year students and 93 % of them agreed that they were satisfied with the program, and that the program was suitable for first-year students, respectively.

CONCLUSIONS

Although training time was different between the two groups and it is possible that only motivated first-year students participated in the program, these results suggest that our cardiac auscultation training is feasible and effective for first-year medical students.

Effectiveness of high- and low-fidelity simulation-based medical education in teaching cardiac auscultation: a systematic review and meta-analysis

Simulation-based medical education (SBME) is an evolving method of teaching cardiac examination skills to healthcare learners. It has been deliberated how effective this teaching modality is and whether high-fidelity methods are more effective than low-fidelity methods. This systematic review aimed to assess the effectiveness of high-fidelity SBME in teaching cardiac auscultation compared with no intervention or another active teaching intervention (low-fidelity SBME) using evidence from randomized controlled trials (RCTs).

Literature searches were performed on Medline, Embase, PsychInfo and Cinahl. RCTs that compared the effectiveness of high-fidelity simulation against no intervention or high-fidelity simulation against low-fidelity simulation in teaching cardiac auscultation to healthcare learners were included. Outcomes were knowledge, skills and satisfaction relating to cardiac auscultation education. Data were analyzed using Review Manager 5.3 software.

Seventeen RCTs (n = 1055) were included. Twelve RCTs (n = 692) compared high-fidelity simulation with no intervention. The pooled effect sizes for knowledge and skills were 1.39 (95% confidence interval [CI], 0.39–2.38;

This review’s findings suggest that high-fidelity SBME is an effective teaching method for cardiac auscultation education. Interestingly, there was no significant difference in knowledge or skills among learners when comparing high-fidelity simulation with low-fidelity simulation. Further research is needed to establish the effectiveness of different forms of SBME as educational interventions.

Exploring Visualisation for Embryology Education: A Twenty-First-Century Perspective

Embryology and congenital malformations play a key role in multiple medical specialties including obstetrics and paediatrics. The process of learning clinical embryology involves two basic principles; firstly, understanding time-sensitive morphological changes that happen in the developing embryo and, secondly, appreciating the clinical implications of congenital conditions when development varies from the norm. Visualising the sequence of dynamic events in embryonic development is likely to be challenging for students, as these processes occur not only in three dimensions but also in the fourth dimensions of time. Consequently, features identified at any one timepoint can subsequently undergo morphological transitions into distinct structures or may degenerate and disappear. When studying embryology, learners face significant challenges in understanding complex, multiple and simultaneous events which are likely to increase student cognitive load. Moreover, the embryology content is very nonlinear. This nonlinear content presentation makes embryology teaching challenging for educators. Embryology is typically taught in large groups, via didactic lecture presentations that incorporate two-dimensional diagrams or foetal ultrasound images. This approach is limited by incomplete or insufficient visualisation and lack of interactivity.It is recommended that the focus of embryology teaching should instill an understanding of embryological processes and emphasise conceptualising the potential congenital conditions that can occur, linking pre-clinical and clinical disciplines together. A variety of teaching methods within case-based and problem-based curricula are commonly used to teach embryology. Additional and supplementary resources including animations and videos are also typically utilised to demonstrate complex embryological processes such as septation, rotation and folding.We propose that there is a need for embryology teaching in the twenty-first century to evolve. This is particularly required in terms of appropriate visualisation resources and teaching methodologies which can ensure embryology learning is relevant to real-world scenarios. Here we explore embryology teaching resources and methodologies and review existing evidence-based studies on their implementation and impact on student learning. In doing so, we aim to inform and support the practice of embryology educators and the learning of their students.

Employment of color Doppler echocardiographic video clips in a cardiac auscultation class with a cardiology patient simulator: discrepancy between students' satisfaction and learning

BACKGROUND

We have provided fourth-year medical students with a three-hour cardiac auscultation class using a cardiology patient simulator since 2010. The test results of 2010-2012 revealed that as compared with aortic stenosis murmur, students correctly identified murmurs of other valvular diseases less often. We investigated whether employment of color Doppler echocardiographic video clips would improve proficiency in identifying murmurs of aortic regurgitation and mitral regurgitation, and whether students' favorable responses to a questionnaire were associated with improved proficiency.

METHODS

A total of 250 fourth-year medical students were divided into groups of 7-9 students in 2014 and 2015. Each group attended a three-hour cardiac auscultation class comprising a mini-lecture, facilitated training, two different auscultation tests (the second test being closer to clinical setting than the first) and a questionnaire. We provided each student with color Doppler echocardiographic videos of aortic regurgitation and mitral regurgitation using a tablet computer, which they freely referred to before and after listening to corresponding murmurs. The test results were compared with those in 2010-2012. The students had already completed the course of cardiovascular medicine, comprising lectures including those of physical examination, echocardiography, and valvular heart diseases, before participating in this auscultation training class.

RESULTS

Most students indicated that the videos were useful or somewhat useful regarding aortic regurgitation (86.3%) and mitral regurgitation (85.7%). The accuracy rates were 78.4% (81.2% in 2010-2012) in aortic regurgitation and 76.0% (77.8%) in mitral regurgitation in the first test, and 83.3% (71.4%) in aortic regurgitation and 77.1% (77.6%) in mitral regurgitation in the second test, showing no significant differences as compared to 2010-2012. Overall accuracy rate of all heart sounds and murmurs in the first test and that of second/third/fourth sounds in the first and second tests were significantly lower in 2014-2015 than in 2010-2012.

CONCLUSIONS

Referring to color Doppler echocardiographic video clips in the way employed in the present study, which most students regarded as useful, did not improve their proficiency in identifying the two important regurgitant murmurs, revealing a discrepancy between students' satisfaction and learning. Video clips synchronized with their corresponding murmurs may contribute toward improving students' proficiency.

Effect of simulation-based teaching on nursing skill performance: a systematic review and meta-analysis

Objective

To summarize and produce aggregated evidence on the effect of simulation-based teaching on skill performance in the nursing profession. Simulation is an active learning strategy involving the use of various resources to assimilate the real situation. It enables learners to improve their skills and knowledge in a coordinated environment.

Methods

Systematic literature search of original research articles was carried out through Google Scholar, Medline, and Cochrane Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Studies conducted on simulation-based teaching and skill performance among nursing students or clinical nursing staff from 2010 to 2019, and published in the English language, were included in this study. Methodological quality was assessed by Joanna Briggs Institute, and the risk of bias was also assessed by Cochrane risk of bias and the risk of bias assessment tool for non-randomized studies (ROBINS-I) checklists.

Results

Initially, 638 titles were obtained from 3 sources, and 24 original studies with 2209 study participants were taken for the final analysis. Of the total studies, 14 (58.3%) used single group prep post design, 7 (29.1%) used high fidelity simulator (HFS), and 7 (29.1%) used a virtual simulator (VS). Twenty (83.3%) studies reported improved skill performance following simulation-based teaching. Simulation-based teaching improves skill performance among types of groups (single or double), study regions, high fidelity (HF), low fidelity (LF), and standard patient (SP) users. But the effect over virtual and medium fidelity simulators was not statistically significant. Overall, simulation-based teaching improves the skill performance score among the experimental group (d = 1.01, 95% confidence interval [CI] [0.69–1.33], Z = 6.18, P < 0.01, 93.9%). Significant heterogeneity and publication bias were observed during the pooled analysis.

Conclusions

Simulation did improve skill performance among the intervention groups, but the conclusion is uncertain due to the significant heterogeneity. The large extent of difference among original research has necessitated the development of well-defined assessment methods for skills and standardized simulation set-up for proper assessment of their effects.

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.

The role of manikins in nursing students' learning: A systematic review and thematic metasynthesis

OBJECTIVES

To summarise and synthesise findings from qualitative primary research studies of nursing students' experiences from educational activities using manikins to gain a deeper understanding of the role these manikins play in the students' learning.

DESIGN AND DATA SOURCES

A systematic review and thematic metasynthesis were conducted. Cinahl+, Ovid Medline, ERIC and Embase were searched systematically.

REVIEW METHODS

Sandelowski and Barroso's framework guided the review process. A comprehensive search to identify qualitative studies of nursing students' experiences from learning with manikins was performed in January 2019 and updated in April 2020. Study selection was guided by six screening questions derived from these inclusion criteria: qualitative primary studies, published from 2008, in English or Scandinavian, presenting findings of undergraduate nursing students' experiences with manikins at all fidelity levels. Thomas and Harden's method for thematic synthesis was followed.

RESULTS

Twenty-eight articles of twenty-seven studies were included. We identified three synthesised analytic themes: Seeing the manikin as a doll or a patient, Experiencing yourself as a nurse caring for a patient, and Being a team member.

CONCLUSIONS

When it is perceived as a patient, a manikin can give students a realistic experience of what it means to behave like nurses. Consequently, this realism lets students practice and acquire relational, communicative, and collaborative nursing skills. Using a manikin can facilitate the development of students' professional identity.

Examining Knowledge, Skill, Stress, Satisfaction, and Self-Confidence Levels of Nursing Students in Three Different Simulation Modalities

PURPOSE

The aim of this study was to compare the effect of different simulation modalities on knowledge, skill, stress, satisfaction, and self-confidence levels of students receiving undergraduate education in three nursing schools.

METHOD

This was an experimental study. Students applied the scenario of "Respiratory Sounds Assessment" which was prepared according to three different simulation modalities. In the study, the standardized patient, high-fidelity simulation, and partial task trainer were used as simulation modalities.

RESULTS

An increase was observed in postpractice knowledge levels of the three groups which had similar knowledge levels before the practice. Virtual Analog Scale stress levels of the students in the standardized patient group were higher than those of others. The students' mean scores of satisfaction in learning were higher in the standardized patient group. The students in the partial task trainer group had lower scores of self-confidence in learning. Skill scores of the students were lower in the standardized patient practice than those in others.

CONCLUSION

Simulation-based experiences give students the opportunity of experiencing situations they may experience in the actual practice beforehand. Therefore, this may increase their performance in real practices, as reality increases in the standardized patient group.

Developing and Evaluating a Simulator for Complex IVC Filter Retrieval

RATIONALE AND OBJECTIVES

Simulation models allow trainees to acquire and develop procedural skills without compromising patient safety. Complex inferior vena cava (IVC) filter retrieval requires the operator to be proficient at using devices, such as endobronchial forceps, and advanced techniques to carefully dissect free embedded filter tips encased in fibrous tissue adherent to the IVC. Therefore, it is important to develop an effective, inexpensive model to simulate tip-embedded IVC filter retrieval.

MATERIALS AND METHODS

Silicone tubes (Flexi-Seal SIGNAL, ConvaTec Inc., Skilman, NJ), IVC filters (Cook Günther Tulip Vena Cava Filter, Cook Medical, Bloomington, IN), and endobronchial forceps (Lymol Medical, Woburn, MA) were obtained to assemble the model. A total of 12 combinations of adhesive binding methods were used to adhere IVC filter fragments to the silicone tubes, and these were blind tested. A single operator with over 10 years of experience using forceps scored the adhesives subjectively on a three-point scale for adherence, elasticity, and tactile feel. The adhesive most similar to IVC fibrous tissue was selected to assemble the final tip-embedded IVC filter model. 20 trainees were then assigned to practice on the model. A 3-point scale scoring metric objectively measured confidence before and after training on the model.

RESULTS

Sil-poxy Silicone Adhesive (Smooth-On, Macungie, PA) was found to be the most similar to human IVC fibrous tissue with an average score of 3 of 3 on all metrics. Comparing scores from before and after use of the model, trainee confidence improved significantly (p < 0.1) in all three categories from 1.20 to 2.10 (handling forceps), 1.05 to 2.15 (understanding tactile feel of fibrous tissue), and 1.05 to 1.70 (overall confidence).

CONCLUSION

The development of a low-cost simulator for embedded IVC filters is feasible and can be used to improve trainee confidence and skill for complex IVC filter retrieval.

The effects of training with simulation on knowledge, skill and anxiety levels of the nursing students in terms of cardiac auscultation: A randomized controlled study

BACKGROUND

The use of simulation methods in nursing education is important in terms of decreasing anxiety of students in a safe and realistic environment due to the improvement of knowledge and skills of students in terms of cardiac auscultation and their attitudes to prepare for clinical applications.

OBJECTIVES

The aim of this study is to compare the effectiveness of high-fidelity simulator and traditional teaching method on nursing students' knowledge and skill development in terms of cardiac auscultation and their anxiety levels.

DESIGN

Randomized controlled study.

SETTING

The study was conducted in the simulation laboratory of the Nursing Department in the Health College and in the inpatient clinics of the Medicine Faculty Hospital.

PARTICIPANTS

72 first-year nursing students (simulation group = 36, control group = 36).

METHODS

The students were randomly distributed to the simulation and control groups. The students in the simulation group received a cardiac auscultation training by using a high-fidelity simulator while the students in the control group received training with the traditional teaching method. After the training sessions, all students practiced their skills in the laboratory and on real patients in clinical setting under the supervision of the researcher. The data were collected by using the Demographic Information Form, Knowledge Assessment Form for Cardiac Auscultation, Skill Evaluation Form for Cardiac Auscultation and State Anxiety Inventory (SAI).

RESULTS

High-fidelity simulators and traditional teaching method were found to be effective in increasing the students' knowledge and skill levels in terms of cardiac auscultation. However, it was found that the high-fidelity simulator method was more effective than the traditional teaching method to increase the students' knowledge (p = 0.001) and skill (p < 0.001) levels; this increase was significant. In addition, it was found that the students in the high-fidelity simulator group showed a significant decrease in anxiety scores compared to the students who were trained with traditional education method (p < 0.001).

CONCLUSIONS

The results showed that the use of high-fidelity simulator in nursing education was more effective than traditional method in terms of improving the students' knowledge, skill levels for cardiac auscultation and reducing their anxiety.

The effect of high- and low-fidelity simulators in learning heart and lung sounds by undergraduate nurses: a randomized controlled trial

Aim: To determine the effects of high- and low-fidelity simulators on student nurses' learning of heart and lung sounds.Background: Simulation is an important part of nursing education because it helps to improve patient care and provides patient security.Method: The sample consisted of 3rd and 4th year students who studied at a nursing faculty in Istanbul between April and June 2017. In this randomized controlled experimental study, students were randomly divided into 2 groups, the high-fidelity simulator group (HFS group, n = 36), and the low-fidelity simulator group (LFS group, n = 35).Results: The auscultation skill levels of the HFS group were significantly higher post-training in comparison to the pre-training measurement (P < .05). There were no significant differences in the auscultation skill levels of the LFS group between the pretest and posttest measurements.Conclusion: The use of high-fidelity simulators is more effective in the learning of heart and lung sounds by student nurses than low-fidelity simulators.

Expert opinions on the authenticity of moulage in simulation: a Delphi study

BACKGROUND

Moulage is a technique in which special effects makeup is used to create wounds and other effects in simulation to add context and create realism in an otherwise fabricated environment. The degree to which moulage is used in the simulated environment is varied; that is, there is no guide for how authentic it is required to be. To objectively assess whether a higher level of authenticity in moulage influences engagement and better outcomes, a common model to assess authenticity is required. The aim of this study was to explore expert opinions on moulage in simulation and develop an instrument for the classification of moulage in simulation.

METHODS

The instrument was developed in 3 phases: expert panellist recruitment, domain identification, and consensus rounds. A Delphi technique was used to explore themes of authenticity using Dieckmann's Theory of Realism as a frame of reference. An initial list of elements was raised by a panel of international experts. The experts participated in a further four rounds of questioning, identifying and then ranking and/or rating elements of authenticity in moulage. A priori consensus threshold was set at 80%.

RESULTS

In round 1, 18 of 31 invited panellists participated, and a total of 10 completed round 5 (attrition 44%). As a result of the Delphi, the Moulage Authenticity Rating Scale was developed. Under the three domains of realism, 60 elements were identified by experts. A total of 13 elements reached the consensus threshold, whilst tensions regarding the necessity for authentic moulage were identified throughout the rounds.

CONCLUSION

This study demonstrates the complexity of moulage in simulation, with particular challenges surrounding the experts' views on authenticity. A prototype instrument for measuring moulage authenticity is presented in the form of the Moulage Authenticity Rating Scale (MARS) to further aid progress in understanding the role of authentic moulage in simulation.

Effect of Psychoacoustic Learning on Cardiac Auscultation Proficiency in Nurse Practitioner Students

BACKGROUND

Assessment is a vital role of all nurses, yet cardiac murmur identification remains difficult for students. Cardiac auscultation is a technical, not intellectual, skill, and a psychoacoustic approach to learning is recommended. A psychoacoustic approach involves repetition of cardiac sounds to facilitate auditory perceptual learning.

PURPOSE

The purpose of this study was to determine the effectiveness of a psychoacoustic learning modality for identification of cardiac murmurs by nurse practitioner (NP) students.

METHODS

A repeated-measures design was used. Following a pretest, NP students listened to repetitions of heart sounds, then took a posttest. Students were instructed to listen to the heart sounds weekly, then given posttests at 1 and 3 months.

RESULTS

All posttest scores were higher than pretest scores; no significant difference in scores was noted between posttests.

CONCLUSIONS

Psychoacoustic learning may improve cardiac assessment. Further research is recommended with prelicensure nursing and NP students.

Cognitive load theory for training health professionals in the workplace: A BEME review of studies among diverse professions: BEME Guide No. 53

AIM

Cognitive load theory (CLT) is of increasing interest to health professions education researchers. CLT has intuitive applicability to workplace settings, yet how CLT should inform teaching, learning, and research in health professions workplaces is unclear.

METHOD

To map the existing literature, we performed a scoping review of studies involving cognitive load, mental effort and/or mental workload in professional workplace settings within and outside of the health professions. We included actual and simulated workplaces and workplace tasks.

RESULT

Searching eight databases, we identified 4571 citations, of which 116 met inclusion criteria. Studies were most often quantitative. Methods to measure cognitive load included psychometric, physiologic, and secondary task approaches. Few covariates of cognitive load or performance were studied. Overall cognitive load and intrinsic load were consistently negatively associated with the level of experience and performance. Studies consistently found distractions and other aspects of workplace environments as contributing to extraneous load. Studies outside the health professions documented similar findings to those within the health professions, supporting relevance of CLT to workplace learning.

CONCLUSION

The authors discuss implications for workplace teaching, curricular design, learning environment, and metacognition. To advance workplace learning, the authors suggest future CLT research should address higher-level questions and integrate other learning frameworks.

Effects of high-fidelity simulation based on life-threatening clinical condition scenarios on learning outcomes of undergraduate and postgraduate nursing students: a systematic review and meta-analysis

OBJECTIVE

The purpose was to analyse the effectiveness of high-fidelity patient simulation (HFPS) based on life-threatening clinical condition scenarios on undergraduate and postgraduate nursing students' learning outcomes.

DESIGN

A systematic review and meta-analysis were conducted based on the Cochrane Handbook for Systematic Reviews of Interventions and its reporting was checked against the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist.

DATA SOURCES

PubMed, Scopus, CINAHL with Full Text, Wiley Online Library and Web of Science were searched until July 2017. Author contact, reference and citation lists were checked to obtain additional references.

STUDY SELECTION

To be included, available full-texts had to be published in English, French, Spanish or Italian and (a) involved undergraduate or postgraduate nursing students performing HFPS based on life-threatening clinical condition scenarios, (b) contained control groups not tested on the HFPS before the intervention, (c) contained data measuring learning outcomes such as performance, knowledge, self-confidence, self-efficacy or satisfaction measured just after the simulation session and (d) reported data for meta-analytic synthesis.

REVIEW METHOD

Three independent raters screened the retrieved studies using a coding protocol to extract data in accordance with inclusion criteria.

SYNTHESIS METHOD

For each study, outcome data were synthesised using meta-analytic procedures based on random-effect model and computing effect sizes by Cohen's d with a 95% CI.

RESULTS

Thirty-three studies were included. HFPS sessions showed significantly larger effects sizes for knowledge (d=0.49, 95% CI [0.17 to 0.81]) and performance (d=0.50, 95% CI [0.19 to 0.81]) when compared with any other teaching method. Significant heterogeneity among studies was detected.

CONCLUSIONS

Compared with other teaching methods, HFPS revealed higher effects sizes on nursing students' knowledge and performance. Further studies are required to explore its effectiveness in improving nursing students' competence and patient outcomes.

High-fidelity is not superior to low-fidelity simulation but leads to overconfidence in medical students

BACKGROUND

Simulation has become integral to the training of both undergraduate medical students and medical professionals. Due to the increasing degree of realism and range of features, the latest mannequins are referred to as high-fidelity simulators. Whether increased realism leads to a general improvement in trainees' outcomes is currently controversial and there are few data on the effects of these simulators on participants' personal confidence and self-assessment.

METHODS

One-hundred-and-thirty-five fourth-year medical students were randomly allocated to participate in either a high- or a low-fidelity simulated Advanced Life Support training session. Theoretical knowledge and self-assessment pre- and post-tests were completed. Students' performance in simulated scenarios was recorded and rated by experts.

RESULTS

Participants in both groups showed a significant improvement in theoretical knowledge in the post-test as compared to the pre-test, without significant intergroup differences. Performance, as assessed by video analysis, was comparable between groups, but, unexpectedly, the low-fidelity group had significantly better results in several sub-items. Irrespective of the findings, participants of the high-fidelity group considered themselves to be advantaged, solely based on their group allocation, compared with those in the low-fidelity group, at both pre- and post-self-assessments. Self-rated confidence regarding their individual performance was also significantly overrated.

CONCLUSION

The use of high-fidelity simulation led to equal or even worse performance and growth in knowledge as compared to low-fidelity simulation, while also inducing undesirable effects such as overconfidence. Hence, in this study, it was not beneficial compared to low-fidelity, but rather proved to be an adverse learning tool.

Designing for online computer-based clinical simulations: Evaluation of instructional approaches

BACKGROUND

Online computer-based simulations are becoming more widespread in nursing education. Therefore, an understanding of when and how to implement the variety of instructional strategies related to these simulations is fundamental.

OBJECTIVES

This study compares the effectiveness of online computer-based simulations designed using two alternative instructional approaches-Productive Failure and Simple-to-Complex sequencing-on learning of clinical reasoning skills.

PARTICIPANTS

Participants in this study were undergraduate nursing students (n = 103, mean age = 23.4 ± 2.1) enrolled at a university in Israel.

METHODS

Participants completed two online simulations designed using Productive Failure approach (emergency medicine, mental health) and two online simulations using Simple-to-Complex approach (cardiovascular health, pediatrics). Pre- and post-test clinical reasoning evaluations were administered prior to and immediately following each simulation.

RESULTS

Clinical reasoning learning gains were significantly higher for online simulations designed with the Simple-to-Complex approach than simulations designed with Productive Failure approach (F (3, 288) = 9.656, P < 0.001). Students devoted significantly more time (F (1, 102) = 260.15, P < 0.001) and more attempts (F (1, 102) = 167.39, P < 0.001) in learning with Simple-to-Complex simulations than they did with Productive Failure simulations. The amount of time that students were engaged in learning with simulations was significantly associated with learning gains scores.

CONCLUSIONS

This study proposes that well-designed online simulations can improve nursing students' clinical reasoning. The Simple-to-Complex approach was found to be more efficient than Productive Failure for online learning. Learning with Simple-to-Complex approach was behaviorally more engaging and students' achievements were higher, which implies that instructional process facilitates learning, and therefore have to be taken in consideration by nurse educators. Integration of computerized educational modalities within nursing education is discussed.

The value proposition of simulation-based education

Simulation has become an integral part of physician education, and abundant evidence confirms that simulation-based education improves learners' skills and behaviors and is associated with improved patient outcomes. The resources required to implement simulation-based education, however, have led some stakeholders to question the overall value proposition of simulation-based education. This paper summarizes the information from a special panel on this topic and defines research priorities for the field. Future work should focus on both outcomes and costs, with robust measurement of resource investments, provider performance (in both simulation and real settings), patient outcomes, and impact on the health care organization. Increased attention to training practicing clinicians and health care teams is also essential. Clarifying the value proposition of simulation-based education will require a major national effort with funding from multiple sponsors and active engagement of a variety of stakeholders.

Varying levels of fidelity on psychomotor skill attainment: a CORTRAK product assessment

Background

A task trainer is defined as a model that represents a part or region of the human body such as an arm and an abdomen… generally used to support procedural skills training. Concepts for consideration when selecting a task trainer include fidelity and cognitive load. Insertion of small - bore FTs in acutely ill patients continues to be a high - risk skill. The most frequent complication is insertion of the F T into the pulmonary system, which can lead to pneumothorax, pneumonitis and death. Training consists of placing the FT under electromagnetic visual assistance in a task trainer.

Objective

This study describes assessment of two task trainers that are used to simulate assisted feeding tube (FT) insertion. Simulation is an excellent approach to close the learning gap and ensure competency. Study selection: This study used a prospective observational design. Participants (n=20) were registered nurses considered to be superusers. They were randomly assigned to order of the task trainer.

Findings and conclusions

The findings suggest the learners preferred the low-fidelity task trainer. The clear Anatomical Box scored higher overall (18.35/21) when compared with the human-like task trainer (16.5/21). A higher fidelity task trainer may seem attractive; however, with a lens to cognitive load theory, it may hinder the early learning process. Fidelity requirements vary depending on the training task. Recommendations from this study include: initial instruction should focus on the psychomotor steps for the FT insertion process. The high-fidelity human torso is recommended for performance, final competency and ongoing competency maintenance.

Does Appearance Matter? Current Issues and Formulation of a Research Agenda for Moulage in Simulation

STATEMENT

The use of moulage is assumed to add realism and authentic context in simulation. Despite the expense required to utilize moulage effectively, there is little exploration in the literature as to both its necessity and its accuracy of portrayal. We explore engagement, authenticity, and realism theories in the context of moulage and highlight the need for more evidence on moulage in simulation-based education, including suggestions for future research. In particular, we urge the simulation community to move beyond descriptive papers to investigate moulage in terms of justification and clarification.

The contributions of digital technologies in the teaching of nursing skills: an integrative review

Objective

To analyze the contributions of digital educational technologies used in teaching nursing skills.

Method

Integrative literature review, search in five databases, from 2006 to 2015 combining the descriptors 'education, nursing', 'educational technology', 'computer-assisted instruction' or related terms in English.

Results

Sample of 30 articles grouped in the thematic categories 'technology in the simulation with manikin', 'incentive to learning' and 'teaching of nursing skills'. It was identified different formats of digital educational technologies used in teaching Nursing skills such as videos, learning management system, applications, hypertext, games, virtual reality simulators.

Conclusions

These digital materials collaborated in the acquisition of theoretical references that subsidize the practices, enhancing the teaching and enable the use of active learning methods, breaking with the traditional teaching of demonstrating and repeating procedures.

Variation in effectiveness of a cardiac auscultation training class with a cardiology patient simulator among heart sounds and murmurs

BACKGROUND

Effectiveness of simulation-based education in cardiac auscultation training is controversial, and may vary among a variety of heart sounds and murmurs. We investigated whether a single auscultation training class using a cardiology patient simulator for medical students provides competence required for clinical clerkship, and whether students' proficiency after the training differs among heart sounds and murmurs.

METHODS

A total of 324 fourth-year medical students (93-117/year for 3 years) were divided into groups of 6-8 students; each group participated in a three-hour training session using a cardiology patient simulator. After a mini-lecture and facilitated training, each student took two different tests. In the first test, they tried to identify three sounds of Category A (non-split, respiratory split, and abnormally wide split S2s) in random order, after being informed that they were from Category A. They then did the same with sounds of Category B (S3, S4, and S3+S4) and Category C (four heart murmurs). In the second test, they tried to identify only one from each of the three categories in random order without any category information.

RESULTS

The overall accuracy rate declined from 80.4% in the first test to 62.0% in the second test (p<0.0001). The accuracy rate of all the heart murmurs was similar in the first (81.3%) and second tests (77.5%). That of all the heart sounds (S2/S3/S4) decreased from 79.9% to 54.3% in the second test (p<0.0001). The individual accuracy rate decreased in the second test as compared with the first test in all three S2s, S3, and S3+S4 (p<0.0001).

CONCLUSIONS

Medical students may be less likely to correctly identify S2/S3/S4 as compared with heart murmurs in a situation close to clinical setting even immediately after training. We may have to consider such a characteristic of students when we provide them with cardiac auscultation training.

Thrive or overload? The effect of task complexity on novices' simulation-based learning

CONTEXT

Fidelity is widely viewed as an important element of simulation instructional design based on its purported relationship with transfer of learning. However, higher levels of fidelity may increase task complexity to a point at which novices' cognitive resources become overloaded.

OBJECTIVES

In this experiment, we investigate the effects of variations in task complexity on novices' cognitive load and learning during simulation-based procedural skills training.

METHODS

Thirty-eight medical students were randomly assigned to simulation training on a simple or complex lumbar puncture (LP) task. Participants completed four practice trials on this task (skill acquisition). After 10 days of rest, all participants completed one additional trial on their assigned task (retention) and one trial on a 'very complex' simulation designed to be similar to the complex task (transfer). We assessed LP performance and cognitive load on each trial using multiple measures.

RESULTS

In both groups, LP performance improved significantly during skill acquisition (p ≤ 0.047, f = 0.29-0.96) and was maintained at retention. The simple task group demonstrated superior performance compared with the complex task group throughout these phases (p ≤ 0.002, d = 1.13-2.31). Cognitive load declined significantly in the simple task group (p < 0.009, f = 0.48-0.76), but not in the complex task group during skill acquisition, and remained lower at retention (p ≤ 0.024, d = 0.78-1.39). Between retention and transfer, LP performance declined and cognitive load increased in the simple task group, whereas both remained stable in the complex task group. At transfer, no group differences were observed in LP performance and cognitive load, except that the simple task group made significantly fewer breaches of sterility (p = 0.023, d = 0.80).

CONCLUSIONS

Reduced task complexity was associated with superior LP performance and lower cognitive load during skill acquisition and retention, but mixed results on transfer to a more complex task. These results indicate that task complexity is an important factor that may mediate (via cognitive overload) the relationship between instructional design elements (e.g. fidelity) and simulation-based learning outcomes.

Simulation-based education: understanding the socio-cultural complexity of a surgical training 'boot camp'

OBJECTIVE

The focus of simulation-based education (SBE) research has been limited to outcome and effectiveness studies. The effect of social and cultural influences on SBE is unclear and empirical work is lacking. Our objective in this study was to explore and understand the complexity of context and social factors at a surgical boot camp (BC).

METHODS

A rapid ethnographic study, employing the theoretical lenses of complexity and activity theory and Bourdieu's concept of 'capital', to better understand the socio-cultural influences acting upon, and during, two surgical BCs, and their implications for SBE. Over two 4-day BCs held in Scotland, UK, an observer and two preceptors conducted 81 hours of observations, 14 field interviews and 11 formal interviews with faculty members (n = 10, including the lead faculty member, session leaders and junior faculty members) and participants (n = 19 core surgical trainees and early-stage residents).

RESULTS

Data collection and inductive analysis for emergent themes proceeded iteratively. This paper focuses on three analytical themes. First, the complexity of the surgical training system and wider health care education context, and how this influenced the development of the BC. Second, participants' views of the BC as a vehicle not just for learning skills but for gaining 'insider information' on how best to progress in surgical training. Finally, the explicit aim of faculty members to use the Scottish Surgical Bootcamp to welcome trainees and residents into the world of surgery, and how this occurred.

CONCLUSIONS

To the best of our knowledge, this is the first empirical study of a surgical BC that takes a socio-cultural approach to exploring and understanding context, complexities, uncertainties and learning associated with one example of SBE. Our findings suggest that a BC is as much about social and cultural processes as it is about individual, cognitive and acquisitive learning. Acknowledging this explicitly will help those planning similar enterprises and open up a new perspective on SBE research.

Is a picture worth a thousand words: an analysis of the difficulty and discrimination parameters of illustrated vs. text-alone vignettes in histology multiple choice questions

BACKGROUND

Advances in cognitive load theory have led to greater understanding of how we process verbal and visual material during learning, but the evidence base with regard to the use of images within written assessments is still sparse. This study examines whether the inclusion of images within the stimulus format of multiple choice questions (MCQs) has a predictable or consistent influence on psychometric item properties, such as difficulty or discrimination.

METHODS

Item analysis data from three consecutive years of histology multiple choice examinations were included in this study. All items were reviewed and categorised according to whether their stem, or stimulus format, was purely textual or included an associated image.

RESULTS

A total of 195 MCQs were identified for inclusion and analysed using classical test theory; 95 used text alone and 100 included an image within the question stem. The number of students per examination ranged from 277 to 347, with a total of 60,850 student-question interactions. We initially examined whether the inclusion of an image within the item stem altered the item difficulty using Mann-Whitney U. The median item difficulty for images with purely textual stems was 0.77, while that for items incorporating an appropriate image was 0.80; this difference was not significant (0.77 vs. 0.80; p = 0.862, Mann-Whitney-U = 4818.5). Mean values showed that the Item Discrimination Index appeared unaffected by the inclusion of an image within the stem, and Item point biserial correlation also showed no difference in means between these two groups (Independent samples t-test; 2-tailed).

CONCLUSION

We demonstrate that the addition of illustrations within undergraduate histology Multiple Choice Question stems has no overall influence on item difficulty, or measures of item discrimination. We conclude that the use of images in this context is statistically uncritical, and suggest that their inclusion within item stems should be based upon the principles of constructive alignment. However, further research with respect to the effect of images within item stems on cognitive processing, particularly with regard to image complexity or type, would enable the development of more informed guidelines for their use.