Lasater clinical judgment rubric reliability for scoring clinical judgment after observing asynchronous simulation and feasibility/usability with learners

BACKGROUND

There is strong evidence supporting using the Lasater Clinical Judgment Rubric (LCJR) for scoring learners' clinical judgment during in-person simulation performance and clinical experience reflections. However, a gap exists for using LCJR to evaluate clinical judgment after observing asynchronous simulation.

OBJECTIVE

We aimed to determine the reliability, feasibility, and usability of LCJR for scoring learners' written reflections after observing expert-modeled asynchronous simulation videos.

DESIGN/SETTING/PARTICIPANTS

We used a one-group, descriptive design and sampled pre-licensure, junior-level bachelor's learners from the Southwestern United States.

METHODS

Participants observed eight expert-modeled asynchronous simulation videos over one semester and provided written responses to clinical judgment prompts. We scored clinical judgment using LCJR. We studied reliability by measuring internal consistency of 11 clinical judgment prompts and interrater reliability with two raters. This study also investigated feasibility and usability of the asynchronous simulation learning activity using descriptive statistics. Feasibility included time learners spent completing written responses and time raters spent evaluating written responses. Learners reported usability perceptions using an instructor-developed survey.

RESULTS

Sixty-three learners completed 504 written responses to clinical judgment prompts. Cohen's kappa ranged from 0.34 to 0.86 with a cumulative κ = 0.58. Gwet's AC ranged from 0.48 to 0.90, with a cumulative AC = 0.74. Cronbach's alpha was from 0.51 to 0.72. Learners spent on average 28.32 ± 12.99 min per expert-modeling video observation. Raters spent on average 4.85 ± 1.34 min evaluating written responses for each participant. Learners reported the asynchronous learning activity was usable.

CONCLUSIONS

Nurse educators can reliably use LCJR for scoring learners' clinical judgment after observing asynchronous expert-modeled simulation. Logistically, learners complete the reflective learning activity and faculty use LCJR to measure clinical judgment in feasible time. Further, participants perceived the asynchronous learning activity usable. Nurse educators should utilize this learning activity for evaluating and tracking observer clinical judgment development.

Effect of Multiple-Patient Simulation on Baccalaureate Nursing Students' Anxiety and Self-confidence: A Pilot Study

BACKGROUND

Multiple-patient simulation (MPS) allows nursing students to develop leadership skills. Limited research examining student outcomes following MPS exists.

PURPOSE

This pilot study investigated the impact of MPS on (1) anxiety with transition to practice, (2) anxiety with clinical decision-making, (3) self-confidence with clinical decision-making, and (4) perceptions about MPS as a learning strategy.

METHODS

Twenty-two senior baccalaureate nursing students participated in this 2-group mixed-methods study. Data were collected before and after a leadership course using the State-Trait Anxiety Inventory, Nursing Anxiety and Self-Confidence with Clinical Decision-Making Scale, and a researcher-developed perceptions survey.

RESULTS

Self-confidence with clinical decision-making significantly increased for all participants regardless of group assignment. Anxiety and anxiety with clinical decision-making decreased without significant changes. No significant differences were found between groups. Qualitative findings yielded 3 themes: preparation for clinical practice, overcoming anxiety, and confidence.

CONCLUSION

Research investigating additional student outcomes after MPS with larger, more diverse samples is needed.

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.

Simulation in Undergraduate Education

Simulation is an integral component of undergraduate nursing education because it allows for a safe, timely, and prescriptive approach to meet learning objectives at the levels of individual simulations, courses, and academic programs. This review of the literature provides an overview of steps taken to move simulation forward in undergraduate nursing education, and it highlights educational theories, research, best practices, and policy statements underpinning modern nursing simulation. This chapter outlines simulation and curriculum integration approaches and provides examples of participant, course, and program outcomes.

TIDES: examining the influence of temporal individual differences on multitasking in educational simulation

BACKGROUND

The majority of tasks nurses complete in acute care settings are time-sensitive. Due to complex patient needs, nurses' multitasking behavior is of growing importance. Situations involving multitasking behavior typically require nurses to switch their attention among multiple tasks and patients in a rapid fashion. Research suggests temporal individual differences such as time urgency, polychronicity, and time perspective influence decision-making. The factors suggest that balanced time perspective may facilitate multitasking. Given novice nurses commit errors related to multitasking, we evaluated the relationship between temporal individual differences, cognitive workload, and multitasking behaviors in a simulation setting.

METHODS

A one-group repeated measures design was used to evaluate the relationship between multitasking, demographic factors, cognitive workload, and temporal individual differences. One hundred sixty fourth-year, prelicensure nursing students independently completed two 45-min multiple patients simulations involving care of three interactive patient simulators. Participants completed the Multitasking Preference Inventory, Time Perspective Inventory, Experiences of Time survey, and Time Urgency Scale before simulation. A summary Creighton Simulation Evaluation Instrument score was used to represent multitasking. Participants completed the Task Load Index to represent cognitive workload. We calculated deviation from balanced time perspective and measured its correlation with multitasking. Regression models calculated how much variance deviation from balanced time perspective, demographic factors, and cognitive workload contributed to multitasking.

RESULTS

Standardized test scores were more predictive of multitasking than deviation from balanced time perspective (β = 0.19, t = 2.48, p = 0.0142). As deviation from balanced time perspective increased, multitasking behaviors decreased (r = - 0.17), participants reported a higher sense of urgency (r = 0.39), and they had more frustration after simulation (r = 0.22). Deviation from balanced time perspective did not influence cognitive workload.

CONCLUSIONS

Nursing students who demonstrate multitasking behaviors tend to have a more balanced time perspective. Knowing students' deviation from balanced time perspective may help educators anticipate who will need more assistance with multitasking in simulation. Nursing students frequently wait until just before graduation to provide care for multiple patients; including mention of deviation from balanced time perspective in simulation preparation may help senior nursing students become more self-aware and ultimately improve behavioral performance.

A Randomized Trial of Multiple-Patient Simulation Preparation to Improve Novice Nurses' Competence and Self-Efficacy

AIM

The purpose of the study was to determine best practices for multiple-patient simulation (MPS) preparation and frequency to improve behavioral performance in nursing students.

BACKGROUND

MPS provides a safe environment for novice nurses to practice priority setting, delegation, and multitasking, but evidence for best practices is needed.

METHOD

A multisite, blinded, randomized trial was conducted to evaluate the effect of three simulation preparation methods (expert modeling, voice-over PowerPoint, and reading assignments) on students' competence and self-efficacy for providing care to multiple patients in the simulation lab. Participants (n = 73) were enrolled in capstone clinical courses at two schools of nursing.

RESULTS

Though there was no difference in raw change in competence score among the study groups, there was a statistically significant difference in pretest and posttest scores. The change in self-efficacy did not correlate with the change in competence.

CONCLUSION

These findings will help educators understand how novice nurses benefit from repeated MPS activities.

Effectiveness of Simulation Preparation on Novice Nurses' Competence and Self-Efficacy in a Multiple-Patient Simulation

This study examined the influence of three simulation preparation methods (expert modeling/intervention, voice-over PowerPoint/active control, and reading assignments/passive control) on improving novice nurses' competence and self-efficacy for providing care to multiple simulated patients. Both competence and self-efficacy were measured at baseline and following a five-week intervention. Twenty senior pre-licensure nursing students participated in the trial. One-way ANOVAs and parametric/nonparametric correlations were used. Voice-over PowerPoint and expert modeling resulted in greater improvements in self-efficacy compared with traditional reading assignments as simulation preparation. However, there was no relationship between change in competence and self-efficacy over time.

Comparison of expert modeling versus voice-over PowerPoint lecture and presimulation readings on novice nurses' competence of providing care to multiple patients

Due to today's complex needs of hospitalized patients, nurses' competence and strategies to improve competence are of growing importance. Simulation is commonly used to influence competence, but little evidence exists for comparing how presimulation assignments influence competence. A randomized control trial was used to compare the efficacy of three simulation preparation methods (expert modeling/intervention, voice-over PowerPoint/active control, and reading assignments/passive control) on improving competence for providing care to multiple patients among senior undergraduate novice nurses. Competence was measured at two time points (baseline and following a 5-week intervention) by two blinded raters using the Creighton Simulation Evaluation Instrument. Twenty novice nurses participated in the trial. No significant differences were noted in raw improvements in competence among the three groups, but the expert modeling (Cohen's d=0.413) and voice-over PowerPoint methods (Cohen's d=0.226) resulted in greater improvements in competence, compared with the passive control.

Psychometric testing on the NLN Student Satisfaction and Self-Confidence in Learning, Simulation Design Scale, and Educational Practices Questionnaire using a sample of pre-licensure novice nurses

BACKGROUND

In 2006, the National League for Nursing published three measures related to novice nurses' beliefs about self-confidence, scenario design, and educational practices associated with simulation. Despite the extensive use of these measures, little is known about their reliability and validity.

METHODS

The psychometric properties of the Student Satisfaction and Self-Confidence in Learning Scale, Simulation Design Scale, and Educational Practices Questionnaire were studied among a sample of 2200 surveys completed by novice nurses from a liberal arts university in the southern United States. Psychometric tests included item analysis, confirmatory and exploratory factor analyses in randomly-split subsamples, concordant and discordant validity, and internal consistency.

RESULTS

All three measures have sufficient reliability and validity to be used in education research. There is room for improvement in content validity with the Student Satisfaction and Self-Confidence in Learning and Simulation Design Scale.

CONCLUSION

This work provides robust evidence to ensure that judgments made about self-confidence after simulation, simulation design and educational practices are valid and reliable.

Three-dimensional microscopy of the Rad51 recombination protein during meiotic prophase

An open question in meiosis is whether the Rad51 recombination protein functions solely in meiotic recombination or whether it is also involved in the chromosome homology search. To address this question, we have performed three-dimensional high-resolution immunofluorescence microscopy to visualize native Rad51 structures in maize male meiocytes. Maize has two closely related RAD51 genes that are expressed at low levels in differentiated tissues and at higher levels in mitotic and meiotic tissues. Cells and nuclei were specially fixed and embedded in polyacrylamide to maintain both native chromosome structure and the three dimensionality of the specimens. Analysis of Rad51 in maize meiocytes revealed that when chromosomes condense during leptotene, Rad51 is diffuse within the nucleus. Rad51 foci form on the chromosomes at the beginning of zygotene and rise to approximately 500 per nucleus by mid-zygotene when chromosomes are pairing and synapsing. During chromosome pairing, we consistently found two contiguous Rad51 foci on paired chromosomes. These paired foci may identify the sites where DNA sequence homology is being compared. During pachytene, the number of Rad51 foci drops to seven to 22 per nucleus. This higher number corresponds approximately to the number of chiasmata in maize meiosis. These observations are consistent with a role for Rad51 in the homology search phase of chromosome pairing in addition to its known role in meiotic recombination.

Evidence for a stromal GTP requirement for the integration of a chlorophyll a/b-binding polypeptide into thylakoid membranes

The integration of chlorophyll a/b-binding (LHCP) polypeptides and the translocation of the 33-kD oxygen-evolving enhancer protein (OEE33) have been previously shown to occur in chloroplast extracts containing stroma, thylakoids, ATP, and MgCl2. We have re-examined the nucleotide requirement for these two reactions using stromal extract and translation products depleted of low molecular weight compounds. LHCP integration activity was up to 10-fold higher when assayed with GTP compared with ATP, CTP, or UTP. A combination of ATP and GTP supported less LHCP integration activity than GTP alone, suggesting that GTP meets the entire nucleotide requirement. Nonhydrolyzable analogs of GTP were inhibitory, consistent with the idea that GTP hydrolysis is required for integration activity. Periodate-oxidized GTP (GTPox) also inhibited the integration reaction when present during the assay. Pretreatment of stroma with GTPox followed by GTPox removal inhibited integration activity, whereas pretreatment of thylakoids had no effect. We interpret this to mean that a GTP-binding protein involved in integration is localized in the stroma. Translocation of OEE33 was more efficient with ATP than with GTP, and the combination of both nucleotides was not additive. Our data implicate the involvement of a GTPase in LHCP integration but not in the translocation of OEE33.

Characterization of a gene encoding a Ca(2+)-ATPase-like protein in the plastid envelope

By screening an Arabidopsis expression library with an antiserum against chloroplast envelope proteins, we have isolated a partial cDNA with an open reading frame that encodes a polypeptide similar to P-type cation-transporting ATPases. The corresponding genomic clone was isolated and the complete coding sequence was deduced after identification and mapping of introns. The gene has been designated PEA1 (plastid envelope ATPase) and the predicted polypeptide PEA1p. PEA1p has 946 amino acids and a molecular mass of 104 kDa. This protein is 40-44% identical to various mammalian plasma membrane Ca(2+)-ATPases but lacks the C-terminal calmodulin binding domain present in the mammalian polypeptides. When aligned with mammalian plasma membrane Ca(2+)-ATPases, PEA1p has a 70- to 80-amino acid N-terminal region that extends beyond the N terminus of these enzymes. This extension has some similarity to the transit peptide of the plastid envelope phosphate translocator and may function to target the protein to the plastid. Antibodies raised against a portion of PEA1p recognize a single 90- to 95-kDa polypeptide in chloroplast inner envelope preparations. Transcript abundance as determined by RNase protection was found to be 7- to 9-fold higher in roots than in leaves. Possible roles for a plastid envelope calcium pump are suggested.

Characterization of a chloroplast homologue of the 54-kDa subunit of the signal recognition particle

Proteins and RNAs homologous to components of the eukaryotic signal recognition particle (SRP) have been identified in a number of prokaryotic organisms. Here we report the isolation of an Arabidopsis thaliana cDNA, FFC (fifty-four chloroplast homologue), that encodes a chloroplast protein (54CP) homologous to the 54-kDa subunit of the signal recognition particle. 54CP shares 27% identity with mammalian SRP54 and 44% identity with the Escherichia coli ffh gene product suggesting a prokaryotic origin for this gene. FFC is a nuclear gene encoding a 62-kDa cytoplasmically synthesized precursor that is capable of being imported into isolated chloroplasts and processed to a 53-kDa stromal polypeptide. Antibodies generated against a portion of 54CP recognize an endogenous 53-kDa chloroplast protein that sediments at 4 S and 70 S, the latter form may be associated with ribosomes. The FFC transcript is most abundant in green shoot tissue whereas etiolated buds and roots have transcript levels about 30 and 10%, respectively, relative to light grown green shoots. By analogy with the eukaryotic signal recognition particle which targets secretory proteins to the endoplasmic reticulum, it is speculated that 54CP may target chloroplast proteins to either the thylakoid or envelope membranes.

Primary structure and characterization of an Arabidopsis thaliana calnexin-like protein

A cDNA clone (pTE-83) encoding a protein (CNX1p) related to the microsomal Ca(2+)-binding protein, calnexin, was isolated from an Arabidopsis thaliana expression library. Southern and Northern hybridization indicated that CNX1 is a single-copy gene encoding a message of 1900 nucleotides. The open reading frame encodes a polypeptide with 530 amino acids, a molecular mass of 60.5 kDa, and overall 48% identity to dog calnexin. Both animal calnexin and CNX1p contain a large luminal domain followed by a single potential membrane-spanning domain near the C terminus and a small C-terminal domain exposed to the cytoplasm. The in vitro translation product from the cloned cDNA yielded a polypeptide of 67 kDa that was co-translationally imported into dog microsomes and processed to a 64-kDa product. Antibodies generated against the C-terminal half of the protein cross-react with an identically sized protein present in the microsomal fraction from Arabidopsis. Both the imported and native proteins are cleaved by trypsin to a 59-kDa product indicating that the gene product was indeed correctly processed and translocated into dog microsomes and that the membrane topology of CNX1p resembles that of dog calnexin. The presence of a calnexin-like protein within the plant kingdom indicates that this protein is widespread and involved in processes fundamental to all eukaryotes.

Viral plasmacytosis (Aleutian disease) of mink resembling human collagen disease

A disease in mink has been discovered that has many of the features of collagen diseases in man. Affected animals suffer from wasting with leukopenia and thrombocytopenia as well as plasma cell infiltration, hypergammaglobulinemia, glomerulonephritis, arteritis and amyloidosis. Cell-free filtrates and ultracentrifugates from diseased animals induced the disease in normal mink, and aleutian genotypes were unusually susceptible to infection. This genotype was characterized by abnormal lysosomal structures in all the granule-forming cells, resembling the Chediak-Higashi syndrome of man. Anti-gamma-globulin factors similar to human rheumatoid factors were reported, although tests for antibodies such as ANF and LE factors have been negative. Arteritis and glomerulonephritis lesions stained positively for gamma-globulin, and Coombs-type sensitized red cells have been detected in the majority of affected mink. Some mink develop a monodispersion of hypergammaglobulinemia resembling the serum protein changes in human myeloma. These studies highlight genetic, immunological and microbiological causative factors in a mink disorder resembling human collagen disease.