The Use of Immersive Virtual Reality Training for Developing Nontechnical Skills Among Nursing Students: Multimethods Study

BACKGROUND

Immersive virtual reality (IVR) is a niche technology rising in popularity in nursing education. Although there is an abundance of evidence to demonstrate the effect of virtual reality (VR) on desired learning outcomes, this evidence is limited to technical or procedural skills or managing a single patient with clinical problems. Nontechnical skills (NTS), such as communication, decision-making, teamwork, situation awareness, and managerial skills, have not been explored using IVR technology.

OBJECTIVE

This study aimed to (1) investigate the potential efficacy of the IVR system virtual reality hospital (VR-Hospital, or VR-Hosp), a single-user game we developed, on nursing students' NTS, sense of presence in the virtual clinical environment, and satisfaction and self-confidence in learning; (2) identify variables that predict NTS; and (3) explore students' experience in using VR-Hosp.

METHODS

A multimethods design with a quantitative and qualitative approach was adopted. Participants were provided with VR-Hosp with 3 scenarios in training. VR-Hosp adopted a multibed, multipatient, multitask approach and was embedded with various clinical situations. Learning outcomes were measured after the training, followed by group interviews.

RESULTS

In total, 202 students joined the study. Results revealed high levels of satisfaction and self-confidence in learning. Significant achievement in NTS was perceived by the students. The levels of satisfaction and self-confidence in learning and the involvement and sensory fidelity domains in the sense of presence were positive predictors of NTS.

CONCLUSIONS

The promising results offer a basis for designing IVR activities for nursing education. Further investigations are imperative to determine the impact of IVR technology on learning outcomes in clinical practice.

Scaffolding safety in nursing simulation: A grounded theory

BACKGROUND

Simulation-based learning is a teaching technique that allows learners to apply theoretical knowledge to enhance patient safety. Despite limited evidence about the relationship between simulation and patient safety outcomes, nursing programs continue using simulation to improve student competencies.

PURPOSE

To explore the processes driving the actions of nursing students while providing care for a rapidly deteriorating patient during a simulation-based experience.

METHOD

Following the constructivist grounded theory method, the study recruited 32 undergraduate nursing students to explore their experiences during simulation-based experiences. Data were collected using semi-structured interviews over 12 months. Interviews were recorded, transcribed and analyzed using constant comparison and simultaneous data collection, coding, and analysis.

RESULTS

Two theoretical categories emerged from the data to explain the processes driving the students' actions during simulation-based experiences: Nurturing and contextualizing safety. The themes revolved around a core category of "Scaffolding Safety" in simulation.

CONCLUSION

Simulation facilitators can use the findings to build effective and targeted simulation scenarios. Scaffolding safety steers students' thinking and contextualizes patients' safety. It can be utilized as a lens to guide students and assist them with transferring skills from simulation to the clinical practice setting. Nurse educators should consider deliberately integrating the concepts of scaffolding safety into simulation-based experiences to connect theory and practice.

Evolving the Assessment of Clinical Judgment: An Individual or Collective Competency?

BACKGROUND

Nurses make decisions about care individually and as part of a team. Collective competence, the effective team management of patient care situations, is partially dependent on nurses' individual confidence and clinical judgment competence.

PURPOSE

To describe individual and team-based facilitators and barriers to collective competence in teams of senior baccalaureate-level prelicensure nursing students during a team-based simulation.

METHODS

With a cross-sectional design, the study used a 26-item survey based on the National Council of State Boards of Nursing (NCSBN)-Clinical Judgment Measurement Model (CJMM) (α= .86) to assess individual student confidence and perceptions of clinical judgment competence while observation of team dynamics and task completion assessed collective competence.

RESULTS

Closed-loop communication and role assignment were facilitators of collective competence when present and barriers when absent. Additional barriers were lack of student confidence and perceived competence with Layers 3 and 4 of the NCSBN-CJMM.

CONCLUSIONS

Team-based simulation strategies can be effectively used to assess collective clinical judgment competence.

Mental model for information processing and decision-making in emergency care

Background

Uncertainty and time pressure in emergency departments add a challenge to the rational decision-making process, specifically when encountering a critical patient who requires a prompt response. However, there has been little attempt to develop a mental structure model to understand the thought processes and identify cognitive weaknesses points in nurses’ decision-making. A better understanding can inform changes in both practice learning strategies and decision-making in emergency department. This study aims to better understand how newly employed nurses process information and initiate actions in emergency situations characterized by time constraints and uncertainty.

Method

Participants worked under time pressure and uncertainty to solve a simulated shock case by establishing an assumption of what type of shock the simulated patient might have and its cause. An 8-minute window was available to initiate action. Following the simulation, a retrospective think-aloud interview was conducted.

Findings

Participants’ ability to identify the category of shock was better than their ability to identify the underlaying cause of the shock. This influenced their ability to intervene correctly. Participants’ thinking process in an emergency situation can be organized using ABCDE acronym as follows: (1) awareness of the situation, followed by, an instant (2) generation of beliefs (presumption), (3) controlling the consequence (first-line management action), (4) involvement in deliberate thinking and, finally (5) execution, actions (second-line management action). The cognitive weakness was mainly noticed during the first-line management action when participants were involved in immediate lifesaving activities.

Conclusion

Classification of the steps involved in decision-making when encountering emergency situations may provide insight into the strengths and weaknesses of the thought process at different stages. Further studies are required.

Nursing students' development of using physical assessment in clinical rotation-a stimulated recall study

Background

The overall aim of this study was to explore third-year bachelor nursing students’ stimulated recall reflections on their physical assessment competence development. The choice of learning strategies in nursing education seems to have great impact on nursing students’ use of physical assessment skills while in clinical rotation. There is a need to explore nursing students’ learning processes related to the use of physical assessments.

Methods

Explorative qualitative design using a triangulation of data collection methods. Nine final-year nursing students’ physical assessment performances during patient encounters were audio-taped and observed. Shortly after, an individual stimulated recall interview based on the audio-recorded patient encounter and observation notes was conducted. A two-fold analysis was conducted: 1) analysis of students’ performed assessments, and 2) phenomenological hermeneutical analysis of the stimulated recall interviews.

Results

Nursing students assessments shifted from a checklist approach to a symptom-based, more holistic and person-centred approach, emphasizing conversation as part of their assessments. The nursing students also reported that a safe and stimulating learning environment was a prominent feature for their continuing development. Learning from skilled role models with expectations to them using physical assessment skills facilitated their continuing skills appliance, interprofessional communication and reflective practice.

Conclusions

This study contribute with a novel, comprehensive and in-depth description of what influenced nursing students’ learning processes experiences of using physical assessment skills during clinical rotation. The results reveal the need for targeted course designs by implementing scaffolded learning activities in practical and theoretical courses aimed at strengthening students’ learning of physical assessment skills—building upon and emphasizing their prior knowledge and competence, which may lead to more confident registered nurses and promote patient safety in different health care contexts. We propose using stimulated recall systematically as a novel reflective learning activity in nursing education to foster clinical reasoning and metacognition skills and achieve deep learning.

Effects of patient deterioration simulation using inattentional blindness for final year nursing students: A randomized controlled trial

BACKGROUND

Patient deterioration should be detected early and responded appropriately for patient safety. It is necessary to strengthen situational awareness regarding patient deterioration. Inattentional blindness is a major factor that hinders situational awareness about patient deterioration in the clinical setting.

OBJECTIVES

To analyze the impact of patient deterioration simulation using inattentional blindness (PDS-IB) on situational awareness and patient safety competency-attitude among final year nursing students.

DESIGN

A randomized controlled trial.

PARTICIPANTS

Final year nursing students at a university in South Korea.

METHODS

Students were randomly assigned to an experimental or control group. The experimental group (n = 47) was given a PDS-IB. The control group (n = 44) received a simple patient deterioration simulation. Situational awareness and patient safety competency-attitude were measured at baseline, post intervention, and at 2 weeks follow-up. Data were analyzed using a two-way repeated measures ANOVA.

RESULTS

There were statistically significant group effects, time effects, and group and time interaction effects in situational awareness and patient safety competency-attitude.

CONCLUSION

PDS-IB is an effective educational strategy that increases situational awareness and patient safety competency-attitude in final year nursing students.

The Lasater Clinical Judgment Rubric: Implications for Evaluating Teaching Effectiveness

BACKGROUND

Concern with patient safety necessitates valid and reliable measures to evaluate clinical judgment. The purpose of this article is to describe how the Lasater Clinical Judgment Rubric (LCJR) has been used to evaluate the effectiveness of educational interventions to promote clinical judgment and its psychometric properties.

METHOD

Search terms included nurse, student, clinical judgment, and Lasater Clinical Judgment Rubric in Scopus, ERIC, and CINAHL with EBSCOhost databases. The final review included 20 studies.

RESULTS

Researchers reported alphas for total scales as .80 to .97, subscales as .89 to .93, and students' self-scored as .81 to .82. Themes were: Individual Versus Group Evaluations, Clinical Judgment Scenarios, and Adaptation for Nonobservation Activities.

CONCLUSION

Results of this review indicate that the LCJR can be used to evaluate clinical judgment, but educators need to consider inter- and intrarater reliability, individual versus group evaluation, clinical judgment scenarios, and adapting the rubric for nondirect observation activities. [J Nurs Educ. 2021;60(2):67-73.].

Reflection on actions: Identifying facilitators of and barriers to using physical assessment in clinical practice

Current research suggests that nursing students do not apply all sets of physical assessment skills (PAS) learned in their nursing education. The aim of this study was to evaluate third-year nursing students' process of clinical judgment using PAS in clinical rotation. Specific focus was on how the process of clinical judgment affected when the nursing students performed physical assessment, and which types of knowledge were implied in their practice. Ten nursing students performed PAS independently while in clinical rotation; these performances were audiotaped and observed. Shortly after, individual semi-structured stimulated recall interviews (SRI) took place. Regardless of the nursing students' stated level of PAS utilization, self-efficacy or scientific knowledge, clinical judgment was primarily based on contextual factors and personal prerequisites. This study contributes to in-depth knowledge about how nursing students perform physical assessment, how they describe their clinical judgment process and their strategies towards systematically and confidently using PAS. We conclude the paper with pedagogical strategies and learning activities that can facilitate reflection-in-action and reflection-on-action.

Situation awareness and the decision-making processes of final-year nursing students

AIMS AND OBJECTIVES

To investigate final-year nursing students' use of situation awareness when making clinical decisions about patients' progress postsurgery.

BACKGROUND

Making clinical decisions about patient care is a generic nursing competence, developed in preregistration nursing programmes and critical to providing safe patient care. Situation awareness is an important precursor to making decisions and is linked to improved clinical outcomes. However, there is evidence to suggest that nursing students feel inadequately prepared to make clinical decisions.

DESIGN

Endsley's (Situation awareness analysis and measurement. Hillsdale, NJ: Lawrence Erlbaum Associates, 2000) 3-level situation awareness framework was used to guide the study. Level 1 situation awareness is perception of information required to make a decision. Level 2 relates to comprehending the information. Level 3 situation awareness is projecting how this information will inform the future. Twelve final-year nursing students were recruited to participate. Think-aloud research method was used to capture students' decision-making, followed by semi-structured interviews. Data were analysed using an adapted protocol analysis and were encoded inductively. The COREQ checklist has been used in reporting the study.

RESULTS

Students demonstrated level 1, 2 and 3 situation awareness when making clinical decisions. However, it was not demonstrated consistently and at times subsequent decision-making was inappropriate. Three themes emerged: "systems approach to assessment of postoperative patients"; "policy drives practice"; and "deferring decisions to registered nurses". Within the themes, students demonstrated differing levels of situation awareness.

CONCLUSION

Making safe clinical decisions is a paramount skill for nurses; however, student nurses are ill-equipped to undertake this skill. Situation awareness is important in informing safe decision-making, but students' use of situation awareness is variable. Cognitive apprenticeship, applied to supporting development of situation awareness, affords the opportunity to develop students' decision-making.

RELEVANCE TO CLINICAL PRACTICE

Clinical decision-making is a generic competence for all registered nurses and imperative for safe practice. However, student nurses are unprepared to undertake this skill once registered.

Inattentional blindness and pattern-matching failure: The case of failure to recognize clinical cues

Eye-tracking methodology was used to investigate lapses in the appropriate treatment of ward patients due to not noticing critical cues of deterioration. Forty nursing participants with different levels of experience participated in an interactive screen-based simulation of hypovolemic shock. The results show that 65% of the participants exhibited at least one episode of non-fixation on clinically relevant, fully visible cues that were in plain sight. Thirty-five percent of participants dwelt for sufficient time (>200 ms) on important cues for perception to take place, but no action followed, indicating they had pattern-matching failure. When participants fail to notice what, they should notice in patient status until it is too late, this can have serious consequences. Much work needs to be done, since these human perceptual limitations can affect patient safety in general wards.