护理仿真模拟学习的设计特征及其与学生信心和满意度的关系

袁浩斌，Beverly A.Williams（Macao Polytechnic Institute，Macao 999078China）

For addressing the increasingly complex health care needs，nurses are expected to use their knowledge to transform health care delivery.Clinical education should focus on enhancing knowledge application and developing nursing technical skills.Increased attention to patient safety and technological advances has prompted rapid integration of human patient simulation into nursing education［1］.Simulation has been proposed as a learner－centered method to transfer students’clinical competence and self－confidence from the classroom to the real clinical environment［2］.A high degree of realism can be facilitated by the use of a high－fidelity simulator to increase applicability to real clinical practice.A human patient simulator can mimic real symptoms and signs and provide physiological responses to interventions.The simulated scenarios can be run to have different outcomes depending on the students’performances.Sometimes students may make some mistakes，but they get opportunities to detect and correct their errors without any negative consequence.Although students may feel disappointed when the expected outcome is not achieved，they are efforts to try again and again until it succeeds.Such kind of experience can assist the students to enhance their cognitive abilities as well as offer students the opportunity to practice their assessment and organizational skills［3］.Learning actually occurs in a complex and interactive environment and focuses on transferring the knowledge into practice.Students should be educated in safety practices and collaborative care.They should learn how to solve problems and practice over and over in each trial until they become skilled.Active learning strategies，such as experience learning or“learning by doing”should be promoted in Chinese clinical nursing education.Supportive environments can enhance students’learning and confidence with clinical skills.Simulation has been shown to increase the confidence of students in a lowanxiety setting［4，5］.However，Blum et al.（2010）［6］and Brannan et al.（2008）［7］demonstrated that the confidence in the high－fidelity simulation group was similar with that of students in the control group.Barbara et al.（2012）［8］suggested that tutors should ensure that simulation experiences are well planned and rigorous in order to assist students to improve their self－confidence.Teachers need to think about how to design the situations using a human patient simulator for promoting students’confidence and satisfaction with learning.The research question of this study was how design features related students＇confidence and satisfaction with learning？

1 Research objectives

The research objectives of this study were：to describe the design features of simulation；to describe student confidence and satisfaction with learning；to examine the correlations between design features and student confidence and satisfaction with learning.

2 Methods

2.1 Design A descriptive study was conducted at one nursing school in Macao.

2.2 Participants Purposive sampling was used.85 baccalaureate nursing students（17in male，68in female）who completed the 36－hours of simulation were voluntary to participant in this study.The average age of students was 20.24years old（S.D.1.46，range 19～26）.

2.3 Simulation design The scenarios were designed by two qualified tutors using a human patient simulator（the SimMan）which is a computer－controlled full－body manikin with a realistic upper airway，chest movement，variable cardiac and breath sounds and a palpable pulse.Some specific trigger questions were prepared for each scenario in order to stimulate the students’thinking broadly and critically.The trigger questions were：Why does the client have such uncomfortable？；What would happen to the client at this moment？；What are the meanings of laboratory tests？；What kinds of physical examination should be performed？；What additional data would you collect？Why？；How can the client be managed once she／he is admitted？

Five or six students worked as one group.They took care of the simulated patient with appendicitis，chronic obstructive pulmonary disease，gastrointestinal bleeding，myocardial infarction or critical trauma.Students acted as registered nurses，patients，family members or friends.The tutor acted as a facilitator and controlled the sequence of events.

Students were given a brief amount of time to review the scenarios and discuss the approaches to care，and then they performed assessments.They explored the main symptoms and the provoking and relieving factors.They had to manage any complaint of the SimMan，such as pain，shortness of breath，vomiting，nausea，cough，thirst and hunger.They also should conduct the physical examination and take the history of disease，medication，allergies，operations and special dietary.Then they gave an appropriate explanation of abnormal signs and symptoms.Based on the results of health assessment and laboratory examination，students should define the problems which required nursing care and set the priorities of problems，and give nursing interventions for the SimMan，such as blood transfusion，wound care，urethral catheterization，oxygen therapy or electrocardiogram monitoring meanwhile they should assess physiological responses of the SimMan.The SimMan may be set in a critical situation，such as having severe arrhythmia，bleeding，cardiac arrest or dyspnoea.Students were asked to give timely detection and make correct judgment for managing the emergencies.If they did not recognize the severity of situation，the SimMan can be set to death.Students were guided to reflect on their decision and performance until they realized their mistake and understand how to manage the emergencies correctly.Debriefing was conducted following each scenario in the simulation laboratory.It focused on the team care of the patients in terms of clinical judgment，safety practices，continuous assessment and group collaboration.Students learned from their mistakes and thought about what need to be improved in further scenarios.

2.4 Instruments

2.4.1 The Simulation Design Scale（the SDS student version）The National League for Nursing（NLN）developed the 20－item SDS to elicit student preferences regarding simulation.A five－point scale was designed for evaluating design features including learning information，learning support，problem solving，guided reflection and fidelity.The scale measures the existence（1strongly disagree，2disagree，3undecided，4agree，5strongly agree）and importance（1not important somewhat important，3neutral，4important，5very important）of each design feature［9］.With approval from the NLN，we translated the SDS into Chinese through a back－translation technique.In this study，the reliability of internal consistency（Cronbach＇s alpha）was found to be 0.832for the existence and 0.896for the importance.

2.4.2 Student Satisfaction and Self－Confidence in Learning（the SSSCLS）The National League for Nursing（NLN）designed the 13－item SSSCLS to measure learner satisfaction with current learning（items 1to 5）and self－confidence in learning（items 6 to 13）using a five－point response（1strongly disagree，2disagree，3undecided，4agree，5strongly agree）［9］.With approval from the NLN，we translated the SDS into Chinese by a back－translation technique.The reliability of internal consistency（Cronbach’s alpha）was reported as 0.814.

2.5 Data collection and analysis Participants were invited to complete the SDS and the SSSCLS after they completed the 36－hours of simulation experience.Statistical analyses were conducted with SPSS 17.0（Software package，Chicago，Illinois，USA）.Descriptive analyses were performed to describe the central tendency and dispersion for the scores on the SDS and the SSSCL.Pearson＇s Product Moment Correlation analysis was conducted to examine the relationships between the mean scores on the SDS and the SSSCLS.A multiple linear regression analysis was run to determine design features which might explain the variability in confidence and satisfaction.

2.6 Ethical considerations This study was approved by the Research Committee in the Macao Polytechnic Institute.The Dean of School of Health Sciences gave the permission to access students for data collection.A complete explanation about the nature of the study was provided for all participants.The confidentiality and autonomy of the participants were assured in whole study.It was informed that only aggregate data would be reported.All participants signed the written consent inform.

3 Results

Students considered fidelity and guided reflection were more important design features；especially guided reflection was designed well in the simulation（see Table 1）.The item of“I was supported in the learning process”received the highest score in both’existence’（mean 4.39，S.D.＝0.58）and＇importance＇（mean 4.36，S.D.＝0.67）subscales.It meant that students were involved in a supportive learning environment.Simulation allowed students to analyze their own behavior and actions（mean 4.36，S.D＝0.67）and provided them with the opportunity to obtain guidance／feedback from the teacher（mean 4.36，S.D.＝0.59），and it was more important that the scenario resembled a real－life situation（mean 4.34，S.D.＝0.66）.

Table 1 The mean scores of existence and importance of design features

Students were satisfied with this learning method（item mean 4.14，S.D.＝0.44）Students enjoyed how their teachers taught the simulation（mean 4.41，S.D.＝0.64）and considered the teaching methods used in this simulation were helpful and effective（mean 4.11，S.D.＝0.58）.In addition，students felt self－confident in learning（item mean 3.96，S.D.＝0.34）.They perceived high self－confident in their own responsibility for learning（mean 4.28，S.D.＝0.67），and indicated that the resources used in simulation were helpful（mean 4.12，S.D.＝0.63）.They felt confident in obtaining clinical knowledge（mean 4.08，S.D.＝0.49）and critical aspects of clinical skills（mean 3.96，S.D.＝0.52）.

The positive correlations were found between design features and students’confidence and satisfaction’s significantly.This suggests that well designed simulation is associated with the higher students’confidence and satisfaction in learning.Feedback and guided reflection were highly corre lated with student confidence and satisfaction（see Table 2）.

Table 2 Correlations between existence of designfeatures and satisfaction／self－confidence（n＝85）

The results of regression analysis indicated that 36.3%of the variance in student satisfaction was explained by all design features（P＝0.000）.Feedback／reflection，fidelity and learning information contributed to 31.3%（P＝0.006），29.4%（P＝0.008）and 24.8%（P＝0.027）of variance in students’satisfaction respectively.Regarding to students’confidence，38.2%of the variance was explained by the five design features combined（P＝0.000）.Feedback／reflection and fidelity contributed to 40.5%（P＝0.000）and 22.5%（P＝0.038）of variance in students’confidence.

4 Discussion

Simulation is a hypothetical experience that involves the learners in realistic learning environment.Learners engage in the meaningful learning activities and deal with complex problems meanwhile they construct new knowledge and nursing technical skills without any risk－taking consequence［10］.Students considered fidelity and guided reflection to be important design features of simulation.Fidelity refers to the extent to which the appearance of the simulators or simulated scenarios reproduces the real－world situation.The closer a learning experience resembles a real situation，the easier it is for students to transfer gained knowledge and skills to the real－world nursing care placements［2］.Faculty developed authentic scenarios relevant to usual clinical work settings and suitable to the students’level of learning.Smith and Roehrs（2009）reported that guided reflection had the highest mean score on the simulation design scale［11］.Reflection is the process of looking back on an experience to discover how knowing－in－action links theory and practice，and leads to self awareness and empowerment［12］.Students and tutors engaged in a reflective thinking session to examine what happened and what was learned.The guided reflection focused on students’primary misconceptions or anything they missed in report［13］.Reflective learning helps students to clarify their thinking，release any emotional tension，and link the simulation to real life while reinforcing specific knowledge，gaining insight and promoting clinical reasoning skills to advance their practice［3］.

Students were most satisfied with the tutor’s guidance and displayed high self－confidence in responsibility for learning and patient care.This could be explained by the interactive learning that occurred during simulation.Learners often learn most effectively when they can participate in interactive environments.Concrete applications increase learner engagement in learning and retention of knowledge.Students learn from their mistakes which can be allowed during simulation and lead to natural consequences without harming actual patients.The experiential learning in simulation consists of the clinical experience with reflection，cognitive conceptualization of knowledge，and active experimentation with the simulators［14］.Simulation fosters cognitive／behaviororiented skills including teamwork，decision making，resource handling，and situation awareness when an urgent or high－risk situation can be successfully organized or controlled.Simulation is an integrative approach to increase confidence in patient care when students understand the risks or potential risks to pa－tient safety and the effectiveness of nursing interventions［15］.High－fidelity simulation enhanced student confidence in performing the procedures of nursing skills and deepened their knowledge internalization.Students were satisfied with the learning process［16］.The interactive learning helps students to maintain engagement in the learning process and take responsibility for ensuring patient safety［3］.Most participants report that their confidence in identifying the critical patient conditions，correction of airway obstruction or altered circulation and collaboration with others during an emergency has increased as the simulation learning［17］.Kaddoura（2010）interviewed 10new graduate nurses who experienced 8－day simulation using a human patient simulator in critical care training，and reported that participants had more confidence in taking care of critical patients or dealing with critical events［5］.However，the results of a comparison study among 107junior nursing students indicated that there were no significant differences in cognitive skills and confidence construction of learning about acute myocardial infarction between the high－fidelity simulation group and the lecture group［7］.Zulkosky（2012）reported a statistically significant higher level of students’confidence and satisfaction with the lecture and case study teaching strategy than with the prerecorded simulation scenarios strategy and explained that lack of student preparation made it difficult to facilitate a debriefing session and may have caused the decreased satisfaction and self－confidence［18］.In this case，the question arises about whether the guided reflection，rather than the realism of the simulators，enhanced learning，and suggests that more studies need to be conducted to explore this issue.

Furthermore，this study revealed that learning information，reflection and fidelity significantly contributed to student satisfaction meanwhile reflection and fidelity also contributed to student confidence.But the other two features（support and problem solving）did not show significant contribution to satisfaction or confidence.The findings are somewhat difference with the results of Smith and Roehrs（2009）’s study.Smith and Roehrs（2009）reported that having clearly designed learning information and an appropriate problem to solve were significantly related to student confidence and satisfaction with learning in the western United States［11］.These diversities required more studies with a variety of students in different programs and different levels of simulation to determine whether the amount of variation in student confidence and satisfaction is associated with specific design features.It should be emphasized that design features need special consideration for optimizing student engagement and achievement of learning objectives.Scenarios should be designed based on students’current knowledge and readiness to learn.Tutors should create simulation orientation guidelines and keys to successful simulation.Prompting and providing opportunities for students to ask for help should be provided to encourage critical thinking and clinical reasoning.

5 Limitations

The limitations of a single site，small sample size and a purposive sampling method may limit the applicability to other nursing students in other types of simulation programs.There is a need for additional investigation with larger samples.Additionally，short timeframe of simulation and the response bias caused by using self－report technique may affect the accuracy of outcome measures.

6 Recommendations

A longitudinal follow－up study is needed to reveal whether student confidence gained in the simulation laboratory is transferred to real clinical practice.Further comparative studies need to determine whether length of simulation experience，fidelity of the simulator，or debriefing methods affect student confidence and satisfaction with learning.

7 Conclusions

This study demonstrated that simulation using a human patient simulator could be designed to meet the students’needs for clinical skill learning.The findings highlight the value of simulation design in predicting student satisfaction and confidence.Learning information，reflection and fidelity can significantly explain the variation in student confidence and satisfaction.Appropriate learning information，guided reflection and interactive learning are key strategies for improving student confidence and satisfaction.

（Acknowledgements We wish to acknowledge the Macao Polytechnic Institute （code RP／ESS－01／2012）for providing funding for this research.）

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