The effectiveness of a high-fidelity teaching simulation based on an NLN/Jeffries simulation in the nursing education theoretical framework and its influencing factors☆

Fen-Fen Zhu,Li-Rong Wu

Suzhou Health College,Suzhou,Jiangsu 215009,China

Original Article

The effectiveness of a high-fidelity teaching simulation based on an NLN/Jeffries simulation in the nursing education theoretical framework and its influencing factors☆

Fen-Fen Zhu,Li-Rong Wu*

Suzhou Health College,Suzhou,Jiangsu 215009,China

A R T I C L E I N F O

Article history:

Received 9 July 2015

Received in revised form

15 December 2015

Accepted 17 June 2016

Available online 15 September 2016

Jeffries simulation in nursing education

High-fidelity simulation education

Teaching design

Teaching satisfaction

Self-efficacy

Objective:To investigate the effectiveness of a high-fidelity teaching simulation based on an NLN/Jeffries simulation in the nursing education theoretical framework and its influencing factors.

Methods:A high-fidelity teaching simulation on clinical nursing practices using intelligent human analogues was conducted with 200 students,and The Simulation Design Scale,and the Student Satisfaction and Self-Confidence in Learning Scale developed by the National League for Nursing were used to evaluate the training effectiveness and its influencing factors.

Results:For the high-fidelity teaching simulation,students gave scores of 4.36±0.54 points for satisfaction and 4.33±0.46 points for Self-Confidence.The students highly rated the five dimensions of teaching design,i.e.,teaching objectives/information,assistance/support for students,problem solving, guided feedback,and fidelity.The teaching design was closely correlated with the satisfaction of the high-fidelity teaching simulation and self-efficacy,and the dimensions of teaching objectives/information and assistance/support for students were particularly strong predictors of teaching effectiveness.

Conclusions:A high-fidelity teaching simulation based on Jeffries'theoretical framework improved student satisfaction with the simulation and their Self-Confidence.In planning simulations,teachers should take into account five characteristics,i.e.,teaching objectives/information on simulation education,assistance/support for students,problem solving,guided reflection,and fidelity,to achieve better teaching effectiveness.

?2016 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1.Introduction

A high-fidelity teaching simulation,characterized by in practice teaching,scene teaching,and individual teaching under the precondition of simulating realistic clinical scenarios,has the prominent advantage of having a medical environment without any health risks and has become a new trend in nursing education. Scientific and rational design of teaching is an important guarantee ofthe effectiveness ofhigh-fidelity teaching simulations.1Currently,it has been confirmed in countries outside of Chinathat clear and reasonable teaching goals and timely guided feedback are strong predictors of the effectiveness of high-fidelity teaching simulations.1,2However,studies in China have been mostly focused on confirming the effectiveness of the high-fidelity simulation teaching method,and the factors influencing teaching design have been rarely addressed.In addition,previous studies have mostly used homemade questionnaire scales to evaluate the effectiveness of simulations without validating the reliability and validity of the questionnaire,while the selected method is frequently arbitrary and without theory-based guidance.The Jeffries simulation education theoretical framework was developed by the American Nurses Association and has been widely used by countries such as the UK and the US to guide and evaluate teaching design,teaching practice,and teaching effectiveness and analyze their influencing factors.Recently,Franklin and Lafond et al further confirmed the rationality and practicality of the theoretical framework,which showed good reliability and validity as well.3,4Therefore,based on the Jeffries simulation education theoreticalframework,this study examined the comprehensive effectiveness of a high-fidelity teaching simulation and its influencing factors to provide a theoretical basis for better implementation of highfidelity teaching simulations in China.

2.Participants and methods

2.1.Subjects

Two hundred students(21-22 years in age)majoring in nursing were selected from four classes during 2013 at Suzhou Vocational and Technical College of Health,of which six were male and 194 were female.

2.2.Methods

The subjects had previously completed courses in basic medical concepts,basic theory and techniques of nursing,and health evaluation.Students in their third semester who were taking courses on internal medicine,surgery,gynecology,and pediatrics were enrolled in the training course used in this project.The specific training methods are as follows.

2.2.1.Determination of the training programs and design of case scenarios

A teaching team consisting of nursing teachers and part-time hospital teachers created the tasks by preparing the course in groups before the training.First,investigations on hospital procedures were conducted,in which the training programs were determined based on the relatedness of tasks and processes of professional clinical nurses and the key cases that must be mastered as required by the curriculum;the case materials were based on patients from the college-affiliated hospital and were standardized after revisions.The training programs included nursing for patients with asthma,heart failure,or ruptured spleen. Each case was used as a training session,which lasted for three hours and was divided into three phases,i.e.,admission assessment and care,assessment of changes in condition and care,and health education.

2.2.2.Pre-training preparation and presentation of cases and objectives

Teachers performing the background maintenance input the case information into a computer to create human analogues with various diseases,and the objectives were proposed based on different stages of disease and condition changes of the human analogues.One week in advance,teachers assigned the cases,tasks,and questions to the students and familiarized the students with the function and use of the high-end human analogues while providing homemade videos on the cases as reference material.

2.2.3.Training phase

Clinical scenarios were presented in a stage-wise manner, and students performed clinical nursing training according to their respective roles.The disease progressed according to the preset trend;if the measures applied by the student were appropriate and effective,the simulated patient's condition would improve;if the judgment and the measures taken by the student were invalid,the disease condition would deteriorate, ultimately leading to death.Each phase consisted of four steps, i.e.,assessment and judgment,implementation,evaluation,and reflection.

2.2.4.Guided feedback

Reflection included an evaluation of the phase,determination of whether correct measures have been taken,and the reasons for these actions;the participants in the reflection phase consisted of role-playing students,the audience,and instructors.

2.3.Evaluation tool

A series of scales developed by the American Nurses Association were adopted,translated into Chinese by teachers and graduate students of nursing,and tested for validity and reliability of the content by five experts in nursing education prior to the surveys.5All scales were scored using a five-point scale that corresponded to the agreement level.The simulation education design scale contained 20 items in five dimensions,i.e.,teaching objectives/information,assistance/support for students,problem solving,feedback/guided reflection,and fidelity,and these items had a content validity of 0.88 and a Cronbach'sαcoefficient of 0.89.The simulation education satisfaction scale reflected the students'satisfaction with the overall high-fidelity teaching simulation and contained five items.The scale had a content validity of 0.86 and a Cronbach's αcoefficient of 0.94.The simulation education self-efficacy scale reflected the students'confidence in clinical nursing practice after completing the simulation education and contained eight items;it exhibited a content validity of 0.78 and a Cronbach'sαcoefficient of 0.82.

2.4.Statistical method

SPSS17.0 statistical software was used for data processing. Values ofwere used to describe measurement data,and factors that affected the satisfaction and self-confidence of the highfidelity teaching simulation were analyzed using stepwise multivariate regression.The Spearman method was used for correlation analysis.

3.Results

3.1.Evaluation of student satisfaction and self-confidence after the high-fidelity teaching simulation

In this study,the average score for student satisfaction after the teaching simulation was 4.36±0.54 points;164 students(82%) gave the simulation a score of≥4 points,and only one student gave a score of＜3 points.The average score of student self-efficacy was 4.33±0.46 points;160 students(80%)gave a score of≥4 points, and no student gave a score of＜3 points.

3.2.Student evaluation of the design of the high-fidelity teaching simulation

The students highly rated the five dimensions of the teaching design;the highest rating was given to the dimension of guided feedback,and the lowest rated dimension was assistance/support for students.Specifically,the scores for teaching objectives/information,assistance/support for students,problem solving,guided feedback,and simulation degree were 4.25±0.49,4.16±0.56, 4.26±0.51,4.52±0.49,and 4.38±0.56,respectively.

3.3.Correlation of teaching satisfaction with self-confidence and teaching design

Student satisfaction and self-efficacy after the simulation were positively correlated with the five dimensions of teaching design (P＜0.01). The correlations between teaching objectives/information and satisfaction and between objectives/information and clinical self-efficacy had the highest correlation coefficients,as shown in Table 1.

3.4.Regression equation for satisfaction and teaching design of the teaching simulation

A stepwise regression analysis was performed using satisfaction as the dependent variable and factors of teaching design as independent variables,and the values ofαfor including and excluding a factor in the regression equation were set to 0.05 and 0.10, respectively.Two factors affected satisfaction in the following order:teaching objectives and assistance/support for students,which explained 34.3%of the total variance,as shown in Table 2.

3.5.The regression equation of student self-confidence and teaching design

A stepwise regression analysis was performed using self-efficacy as the dependent variable and factors of teaching design as independent variables,and the values ofαfor including and excluding a factor in the regression equation were set to 0.05 and 0.10,respectively.Two factors affected the self-confidence in the following order:teaching objectives and assistance/support for students, which explained 35.5%of the total variance,as shown in Table 3.

4.Discussion

4.1.Evaluation of student satisfaction and self-confidence in a highfidelity teaching simulation

Jeffries simulation framework is a theoretical framework that has continuity and empirical support and in recent years has been recommended to guide the design,implementation,and evaluation of teaching effectiveness for nursing teaching simulations by International Nursing Association for Clinical Simulation and Learning.1The satisfaction and self-confidence factors in Jeffries simulation education framework are used by students to comprehensively evaluate high-fidelity teaching simulations.5,6Satisfaction with teaching includes the evaluation of the overall teaching effectiveness,teaching methods,teaching content,and learning motivation;in this study,the average score for student satisfaction was 4.36±0.54 points,and only one student gave a score＜3 points,indicating that this simulationwaswellreceived by the students.In interviews,the students mentioned that they were eager to gain clinical experience to clinical practice.However,in the previous approach,the students were required to memorize a large amount of material.A high-fidelity simulation reproduces actual clinical situations,provides the students with a risk-free learning condition and environment to learn clinical skills and knowledge, enhances their learning motivation,promotes the development of knowledge,attitudes,emotions,skills,and techniques,and seamlessly maximizes the application of knowledge to clinical practice.7

Table 1Correlations of the high-fidelity simulation design with satisfaction and selfconfidence.

Qualitative studies have shown that the self-efficacy of nurses is a key factor for clinical decision-making and responding to emergencies and a strong predictor of clinical competence and performance.8New nurses or students generally have lower self-efficacy, believe that they are not ready,lack confidence,and do not know how to effectively communicate with patients and their family members;therefore,it is imperative to nurture the self-efficacy of nurses.9In this study,the students gave a scoreof 4.33±0.46 points for self-efficacy,and all students gave scores greater than 3 points. One student said:“I am about to start clinical practice,but I have been very worried about how to communicate with patients,not to mention the specific workflow.The high-fidelity teaching simulation gives me a rather realistic scenario of the clinical experience so that I will not be as nervous and as helpless as I was before the simulation when I begin clinical practice.”Bandura believed that the direct experience gained by individuals through personal involvement and operations was the most important factor that affected self-efficacy.9The students obtained real experience in the high-fidelity teaching simulation,and they used the knowledge they had learned to address clinical problems;this knowledge was converted into abilities,which improved their self-efficacy.

4.2.Student evaluation of the design of the high-fidelity teaching simulation

Teaching design can be evaluated by five aspects:whether the objectives of high-fidelity teaching simulations are clear,assistance/support for students,problem solving,feedback/guided reflection,and simulation of cases.In this study,the scores of the five dimensions were all higher than 4 points,indicating that the teaching design was rational and reasonable.The score of the feedback/guided reflection dimension was slightly higher than that in other reports,2,10,11indicating that the simulation achieved good results.Guided reflection provides students with the experience of reflection and a platform that allows them to learn from their own mistakes;it is therefore a core aspect of simulated teaching,directly influencing the effectiveness of simulation education.Shinnick et al12believed that a teaching simulations without retrospective discussions had no effect on enhancing student knowledge.12In this study,students who were involved in the role-playing exercises were first asked to discuss their training experiences,which were evaluated by the attending students. Then,the teacher played back the video and made comments on the accuracy,rationality,and logic of the care at each stage. Measures that reflect the concept of care and solved practical problems of patients were encouraged and recognized,while students were guided to present reasonable solutions for existing problems in a timely manner.Lastly,the teacher created a new scenario and facilitated student discussion so that knowledge was flexibly applied to different clinical situations,and students were encouraged to observe and solve problems in a diversified and multi-faceted manner.

4.3.Relationships between the design of the high-fidelity teaching simulation and teaching satisfaction and clinical self-confidence of the students

In this study,which was based on Jeffries theoretical framework of simulation education,the relationships between the design of the high-fidelity teaching simulation and teaching satisfaction and clinical self-confidence of the students were analyzed.The results showed that all five dimensions of teaching design were positively correlated with student satisfaction and clinical self-confidence,and the highest correlations were found for the items related to providing clear objectives,support andassistance for students.Further regression analyses showed that teaching objectives/information was always the first item to be included in the equation and a strong predictor of satisfaction with the high-fidelity teaching simulation and clinical selfefficacy of students,which is consistent with the findings of Smith et al.2This suggests that providing students with clear teaching objectives and sufficient information before a highfidelity teaching simulation has a great impact on its effectiveness.Qualitative studies have shown that students were not concerned that they had to actively search for information and prepare for the class,but they were concerned about unclear teaching objectives or incomplete data and information presented by the teacher,which causes the student to lack adequate preparation and directly influences the effectiveness of teaching.13Therefore,in the teaching process,clear and realistic learning objectives and adequate information,including the content of the scenario,process,time required,role requirements,and expectations,must be provided to the students.In addition,assistance/ support for students was also included in the equation and was an important factor that influenced the teaching effect.Due to limitations of student knowledge and the inability to determine whether they can perform the simulation training completely independently,the teacher should provide timely assistance to students throughout the process to generate an autonomous, exploratory,and synergistic learning atmosphere.

Table 2The stepwise regression of dependent variables for nursing student satisfaction with the high-fidelity teaching simulation and its design.

Table 3The stepwise regression of dependent variables for nursing student self-efficacy in the teaching design of a high-fidelity teaching simulation.

5.Conclusions

High-fidelity teaching simulations highlight the dominant position of students in learning.These simulations are important for mastering of knowledge and skills by students as well as nurturing student self-efficacy;thus,these simulations are very popular among the students.Teaching programs should be carefully designed to take into account five features,i.e.,the teaching objectives/information,assistance/support for students, problem solving,guided reflection,and simulation degree.Clear goals should be developed,and assistance and support should be provided for the students to achieve better teaching results.

Conflicts of interest

All contributing authors declare no conflicts of interest.

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How to cite this article:Zhu F-F,Wu L-R.The effectiveness of a high-fidelity teaching simulation based on an NLN/Jeffries simulation in the nursing education theoretical framework and its influencing factors.Chin Nurs Res.2016;3:129-132.http:// dx.doi.org/10.1016/j.cnre.2016.06.016

☆This project was supported by Jiangsu Province Health Vocational and Technical Education Research Grants Program(No.201402);Jiangsu Province College“Qing Lan Project”[Su Teacher No.2014(23)];The Science and Technology Innovation Team Project of Suzhou Health College(No.szwzytd 201304).

*Corresponding author.

E-mail address:shengwu01@163.com(L.-R.Wu).

Peer review under responsibility of Shanxi Medical Periodical Press.

http://dx.doi.org/10.1016/j.cnre.2016.06.016

2095-7718/?2016 Shanxi Medical Periodical Press.Publishing services by Elsevier B.V.This is an open access article under the CC BY-NC-ND license(http://creativecommons. org/licenses/by-nc-nd/4.0/).