CLINICAL SCHOLARSHIP
Case-Based Learning and Simulation: Useful Tools to Enhance Nurses’ Education? Nonrandomized Controlled Trial ` Marta Raurell-Torreda, Romero-Collado, PhD, RN, ` PhD, RN, Josep Olivet-Pujol, MSN, RN, Angel Maria Carmen Malagon-Aguilera, MSN, RN, Josefina Patino-Mas o, ˜ ´ PhD, RN, & Al´ıcia Baltasar-Bague, ´ PhD, RN Lecturer, School of Nursing, University of Girona, Girona, Spain
Key words Assessment, case-based learning, case method, case study, nontechnical skills, nurse education, nursing students, objective structured clinical examination, simulation Correspondence ` C/Emili Grahit, nº77 Dr. Marta Raurell-Torreda, Girona (Girona) 10071, Spain. E-mail: [email protected] Accepted: September 13, 2014 doi: 10.1111/jnu.12113
Abstract Purpose: To compare skills acquired by undergraduate nursing students enrolled in a medical-surgical course. To compare skills demonstrated by students with no previous clinical practice (undergraduates) and nurses with clinical experience enrolled in continuing professional education (CPE). Design: In a nonrandomized clinical trial, 101 undergraduates enrolled in the “Adult Patients 1” course were assigned to the traditional lecture and discussion (n = 66) or lecture and discussion plus case-based learning (n = 35) arm of the study; 59 CPE nurses constituted a comparison group to assess the effects of previous clinical experience on learning outcomes. Methods: Scores on an objective structured clinical examination (OSCE), using a human patient simulator and cases validated by the National League for Nursing, were compared for the undergraduate control and intervention groups, and for CPE nurses (Student’s t test). Findings: Controls scored lower than the intervention group on patient assessment (6.3 ± 2.3 vs 7.5 ± 1.4, p = .04, mean difference, -1.2 [95% confidence interval (CI) -2.4 to -0.03]) but the intervention group did not differ from CPE nurses (7.5 ± 1.4 vs 8.8 ± 1.5, p = .06, mean difference, -1.3 [95% CI -2.6 to 0.04]). The CPE nurses committed more “rules-based errors” than did undergraduates, specifically patient identifications (77.2% vs 55%, p = .7) and checking allergies before administering medication (68.2% vs 60%, p = .1). Conclusions: The intervention group developed better patient assessment skills than the control group. Case-based learning helps to standardize the process, which can contribute to quality and consistency in practice: It is essential to correctly identify a problem in order to treat it. Clinical experience of CPE nurses was not associated with better adherence to safety protocols. Clinical Relevance: Case-based learning improves the patient assessment skills of undergraduate nursing students, thereby preparing them for clinical practice.
Since it began in mid-1999, the Bologna Process led by the European Ministers of Education has worked to construct a European Higher Education Area (EHEA) that adapts higher education and research in Europe to the changing needs of society and to advances in scientific knowledge. As summarized in the Journal of the European Higher Education Area, “construction of the EHEA makes it 34
possible to strengthen the quality and international competitiveness of higher education in Europe, allowing an increase in mobility and in European university graduate employment” (Journal of the European Higher Education Area, 2011). According to Salminen et al. (2010), this initiative “has brought about a change in the concept of learning, from an emphasis on the student’s rote
Journal of Nursing Scholarship, 2015; 47:1, 34–42. C 2014 Sigma Theta Tau International
Raurell-Torreda` et al.
acquisition of knowledge to the acquisition of skills needed to exercise a chosen profession” (p. 5). As a result of the Bologna Process, the competencies required of a registered nurse can be grouped into the following categories: (a) professional values and nursing role; (b) nursing practice and clinical decision making; (c) nursing skills, interventions, and activities; (d) knowledge and cognitive competencies; (e) communication and interpersonal relationships; and (f) leadership, management, and team abilities. In addition to clinical practice in a healthcare organization (already an established part of the curriculum), university teaching and assessment methods have become much more diverse. These methods, designed to ensure that nursing students achieve the competencies required by the Bologna Process, include problem-based learning, cooperative learning, case-based learning, role-playing, and simulations (Rochmawati & Wiechula, 2010). Case-based learning is useful for various purposes, such as “illustrating principles of diagnostic process and outcomes, examining the relationship between cues and diagnosis, analysing diagnostic possibilities, and evaluating diagnostic expertise (Lunney, 1992, p. 23). In a more recent article (Lunney, 2008), the same author reported that case-based learning allows the nursing student to feel more connected to reality and decide how to plan and deliver patient care. It also promotes learner autonomy, decreases the theory–practice gap, and increases student motivation and interest (Gray & Aspland, 2011). The student develops five types of knowledge, skills, and abilities: theory, problem solving, critical thinking, clinical judgment, and communication skills (Hofsten, Gustafsson, & ¨ ¨ Haggstr om, 2010). As a “low-technology” (paper-andpencil) method, case-based learning helps to improve competency, defined as the ability of a student nurse to integrate and apply the knowledge, skills, judgment, and personal attributes required to practice safely and ethically in a designated role and setting (Scherer, Bruce, & Runkawatt, 2007; Tosterud, Hedelin, & Hall-Lord, 2013). Another learning methodology that gained importance as a result of the Bologna Process, and also serves as an evaluation method, is simulation, defined as activities that mimic the reality of a clinical environment and are designed to demonstrate procedures, decision making, and critical thinking required in routine patient care. Student interaction with high-technology human patient simulators (HPS) has the added advantages of presenting scenarios that are seldom found in clinical practice or that are highly variable, and allows students to concentrate their efforts on their own learning rather than on an individual patient’s needs. The goal is that students learn to apply classroom theory to clinical practice with no impact on actual patients (Cant & Cooper, 2010; Jeffries, 2005). Journal of Nursing Scholarship, 2015; 47:1, 34–42. C 2014 Sigma Theta Tau International
Simulation to Enhance Nurses’ Education
The National Council of State Boards of Nursing (2005) recommends the use of HPS because they help to prepare students to make accurate decisions (Wolf et al., 2011), work in teams, develop communication skills, observe the consequences of incorrect choices, and assess the effects of medication (Nehring & Lashley, 2004; Todd, Manz, Hawkins, Parsons, & Hercinger, 2008), all of which are basic nontechnical skills required of registered nurses (Pearson & McLafferty, 2011). Studies have shown that using HPS prepares students for clinical practice because of the opportunity for interactive learning in a risk-free environment, with immediate feedback from their professors (Radhakrishnan, Roche, & Cunningham, 2007). We identified no studies that assessed the transfer of HPS-acquired knowledge by implementing and who experiences different types of learning methods and compared students with no clinical practice with practicing professionals. Although individual educators tend to adopt a preferred style of teaching if the option exists, the Bologna Process demands a student-centered approach that encourages the development of collaboration, communication, and proactive group problem-solving skills among students. Part of the reason for undertaking the present study was the availability of faculty members with different beliefs about teaching approaches; two colleagues were interested in evidence about whether the new methodology would improve student outcomes and therefore the quality of nursing graduates of our program. Applied HPS technology was used in the present study to assess and compare the critical thinking and skills acquired by a group of undergraduates without clinical practice who had experienced case-based learning, a control group that followed traditional teaching and learning methods, and nurses with clinical experience enrolled in continuing professional education (CPE).
Methods The study was a nonrandomized clinical trial using an HPS in a simulated work environment to assess the communication and critical thinking skills of nursing students at the School of Nursing, based on type of learning experience acquired. The study population included second-year undergraduate students (study period: September 16, 2011 to June 20, 2012). The undergraduates were enrolled in a clinical core course, “Adult Patients 1,” but had not yet participated in any clinical practice in hospital settings. This course is assigned 12 European Credit Transfers System credits. Different professors teach the two sections of the “Adult Patients 1” course, morning and afternoon, but course content and 35
Raurell-Torreda` et al.
Simulation to Enhance Nurses’ Education
schedule is coordinated. The content includes the steps of the nursing process, in-depth discussion of the steps of nursing diagnosis, and care planning using the standard nursing language (Farren, 2010) developed by the North American Nursing Diagnosis Association (NANDA, 2009). Students become familiar with the Nursing Interventions Classification (NIC; Bulechek, Butcher, & Dochterman, 2008) and Nursing Outcomes Classification (NOC; Moorhead, Johnson, Maas, & Swanson, 2008) in care planning related to different clinical pathologies or syndromes and surgical procedures (Ackley & Ladwig, 2008).
Intervention Group (Undergraduate, No Clinical Experience) Students in the afternoon sections course constituted the intervention group. Case-based learning was used extensively throughout the “Adult Patients 1” course. During each of the 32 class sessions, the professor provided content material (lecture and discussion) for not more than 50 min and small groups worked on casebased learning for the remaining 30 min.
Control Group (Undergraduate, No Clinical Experience) Students in the morning sections course constituted the control group. Traditional teaching methods were used in the “Adult Patients 1” course, lecture and discussion, consisting of 80-min lectures in each of the 32 class sessions.
CPE Group (Clinical Experience) Registered nurses with clinical experience, at minimum the practical experience within the undergraduate curriculum, who were enrolled in CPE were not included in the trial but participated in the HPS exercise; this allowed a comparison of their skills with the communication and critical thinking skills of the two groups of undergraduate students. This was the final portion of the study.
Ethical Considerations Before beginning data collection and analysis, the study was approved under all applicable university policies and provisions. All student volunteers submitted a signed consent form to participate in this study. 36
Intervention Protocol Cases used in the intervention group were developed by a professor who was not teaching in the simulation scenario. He constructed his own cases following the instructions in Lunney (2009, 2010) and based on his years of clinical nursing experience, documented according to the content and structure of cases specified in the references cited about critical thinking processes. The instructor who used case-based learning did not receive additional training. The control group’s instructor chose not to apply case-based learning because of his experience and comfort with traditional teaching methods. Thirty minutes of each class period was devoted to the analysis of fictitious cases illustrating the eight areas of nursing knowledge (Lunney, 2010): regular medication, current medical diagnosis, medical history, information on current disease, nursing diagnostics, nursing interventions and physicians’ orders, outcome objectives of the nursing diagnostics, and laboratory data and additional tests. Self-selected groups of three to five students, generally based on seating proximity on any given day, worked together on the problem identification and nursing care planning steps, using the NANDA NIC-NOC taxonomy. The students were required to develop a care plan, noting the information relevant to the diagnostics, NIC, and NOC. The rest of the needed information was presented in the written case (Supplement 1, available with the online version of this article). In each session, students worked on a specific case; the lecture portion of the next class session addressed the care plan that resulted from the case analysis. Students could consult their pharmacology textbooks, laboratory tests, nursing diagnostics, etc. This helped to strengthen their information search skills, similar to what they would need to do as practicing nurses (Lunney, 2010).
Objectives Based on the hypothesis that case-based learning strengthens student acquisition of clinical judgment skills, the study had the following objectives: 1. To compare the communication and critical thinking skills of undergraduate students in the control group with the intervention group. 2. To compare the communication and critical thinking skills of undergraduate and CPE nurses.
Assessment Tools Student learning was assessed using a scenario-based objective structured clinical examination (OSCE), “an Journal of Nursing Scholarship, 2015; 47:1, 34–42. C 2014 Sigma Theta Tau International
Raurell-Torreda` et al.
approach to the assessment of competence in which the components of competence are assessed in a wellplanned or structured way with attention being paid to objectivity” (Mitchell, Henderson, Groves, Dalton, & Nulty, 2009, p. 399). This extra-credit activity in the School of Nursing’s simulation laboratory, with HPS in a simulated work environment, was offered to those students who passed the course and wanted to improve their score or further test their skills. OSCE uses a checklist based on an objective marking scheme for evaluating students’ skills and behaviors. The OSCE used was validated by Henneman, Cunningham, Roche, and Curnin (2007), with a reported interrater reliability of 95%, and was later used by Wolf et al. (2011) specifically to evaluate nontechnical skills. The OSCE content permits evaluation of student competency in the following categories: patient safety and communication, patient assessment, recognition of signs and symptoms, problem identification, and nursing diagnostics and interventions used to address the problem. To guarantee maximum objectivity, each section was scored with a simple dichotomous point system. If the behavior is observed, the student is awarded 1 point for that item; otherwise, the score for that behavior is 0. For each category, the points were totaled and a score calculated from the total possible points. A professor unfamiliar with the students and blinded to which students were in the control and intervention groups evaluated their competency on the scenario-based OSCE. Results were compared between the control and intervention groups and also with the CPE nurses. All groups of students (intervention, control, CPE) were evaluated in the same manner at the end of their course: r In laboratory simulations, students worked together on the scenario in randomly assigned groups of two or three using a computer-generated list. r Five medical-surgical scenarios were purchased from the National League for Nursing and randomly assigned to student teams; each simulation represented a highly prevalent patient problem in nursing practice and was related to lecture content presented to both sections of the undergraduate “Adult Patients 1” course. Before the evaluation, all students had used the R , Laerdal, Wappingers Falls, NY, HPS (SIM MAN 2G USA) to practice patient assessment and fundamental management skills such as administering medications.
Independent Variables Primary: group membership (control, intervention, CPE). Secondary: sociodemographic variables (age, sex), Journal of Nursing Scholarship, 2015; 47:1, 34–42. C 2014 Sigma Theta Tau International
Simulation to Enhance Nurses’ Education
previous university study, previous university study in health sciences, healthcare work experience, and path to university admission (standard admissions testing, postsecondary training module, or older student [>25 years old]).
Dependent Variable The score was obtained by the student on the OSCE simulation by study group (control, intervention, CPE).
Sample Size and Group Assignment The study population was a convenience sample of all students enrolled in the “Adult Patients 1” course in 2011–2012. Students could not be randomized to control or intervention groups because exposure to case-based learning was based on their course schedule (morning, control group; afternoon, intervention). Therefore, we controlled for potential confounding variables, which were considered independent variables: previous university study, previous university study in health sciences, health-related work experience, and path to university admission. All of these characteristics could confer some advantage to certain groups because their knowledge of the work environment and experience interacting with patients could help them handle the simulation more proficiently.
Statistical Methods Categorical variables are expressed as frequency and percentage, using chi-square or Fisher’s exact test for comparison between groups. The results for quantitative variables were expressed as a mean and standard deviation (SD) or median and interquartile range (P25–P75), depending on the normality of distribution, and groups were compared using Student’s t or Mann-Whitney U test, respectively. The comparison of HPS evaluation results between the undergraduate and CPE groups used an analysis of variance test; post hoc analysis was done with Dunnett’s test. A p value of
Case-Based Learning and Simulation: Useful Tools to Enhance Nurses’ Education? Nonrandomized Controlled Trial ` Marta Raurell-Torreda, Romero-Collado, PhD, RN, ` PhD, RN, Josep Olivet-Pujol, MSN, RN, Angel Maria Carmen Malagon-Aguilera, MSN, RN, Josefina Patino-Mas o, ˜ ´ PhD, RN, & Al´ıcia Baltasar-Bague, ´ PhD, RN Lecturer, School of Nursing, University of Girona, Girona, Spain
Key words Assessment, case-based learning, case method, case study, nontechnical skills, nurse education, nursing students, objective structured clinical examination, simulation Correspondence ` C/Emili Grahit, nº77 Dr. Marta Raurell-Torreda, Girona (Girona) 10071, Spain. E-mail: [email protected] Accepted: September 13, 2014 doi: 10.1111/jnu.12113
Abstract Purpose: To compare skills acquired by undergraduate nursing students enrolled in a medical-surgical course. To compare skills demonstrated by students with no previous clinical practice (undergraduates) and nurses with clinical experience enrolled in continuing professional education (CPE). Design: In a nonrandomized clinical trial, 101 undergraduates enrolled in the “Adult Patients 1” course were assigned to the traditional lecture and discussion (n = 66) or lecture and discussion plus case-based learning (n = 35) arm of the study; 59 CPE nurses constituted a comparison group to assess the effects of previous clinical experience on learning outcomes. Methods: Scores on an objective structured clinical examination (OSCE), using a human patient simulator and cases validated by the National League for Nursing, were compared for the undergraduate control and intervention groups, and for CPE nurses (Student’s t test). Findings: Controls scored lower than the intervention group on patient assessment (6.3 ± 2.3 vs 7.5 ± 1.4, p = .04, mean difference, -1.2 [95% confidence interval (CI) -2.4 to -0.03]) but the intervention group did not differ from CPE nurses (7.5 ± 1.4 vs 8.8 ± 1.5, p = .06, mean difference, -1.3 [95% CI -2.6 to 0.04]). The CPE nurses committed more “rules-based errors” than did undergraduates, specifically patient identifications (77.2% vs 55%, p = .7) and checking allergies before administering medication (68.2% vs 60%, p = .1). Conclusions: The intervention group developed better patient assessment skills than the control group. Case-based learning helps to standardize the process, which can contribute to quality and consistency in practice: It is essential to correctly identify a problem in order to treat it. Clinical experience of CPE nurses was not associated with better adherence to safety protocols. Clinical Relevance: Case-based learning improves the patient assessment skills of undergraduate nursing students, thereby preparing them for clinical practice.
Since it began in mid-1999, the Bologna Process led by the European Ministers of Education has worked to construct a European Higher Education Area (EHEA) that adapts higher education and research in Europe to the changing needs of society and to advances in scientific knowledge. As summarized in the Journal of the European Higher Education Area, “construction of the EHEA makes it 34
possible to strengthen the quality and international competitiveness of higher education in Europe, allowing an increase in mobility and in European university graduate employment” (Journal of the European Higher Education Area, 2011). According to Salminen et al. (2010), this initiative “has brought about a change in the concept of learning, from an emphasis on the student’s rote
Journal of Nursing Scholarship, 2015; 47:1, 34–42. C 2014 Sigma Theta Tau International
Raurell-Torreda` et al.
acquisition of knowledge to the acquisition of skills needed to exercise a chosen profession” (p. 5). As a result of the Bologna Process, the competencies required of a registered nurse can be grouped into the following categories: (a) professional values and nursing role; (b) nursing practice and clinical decision making; (c) nursing skills, interventions, and activities; (d) knowledge and cognitive competencies; (e) communication and interpersonal relationships; and (f) leadership, management, and team abilities. In addition to clinical practice in a healthcare organization (already an established part of the curriculum), university teaching and assessment methods have become much more diverse. These methods, designed to ensure that nursing students achieve the competencies required by the Bologna Process, include problem-based learning, cooperative learning, case-based learning, role-playing, and simulations (Rochmawati & Wiechula, 2010). Case-based learning is useful for various purposes, such as “illustrating principles of diagnostic process and outcomes, examining the relationship between cues and diagnosis, analysing diagnostic possibilities, and evaluating diagnostic expertise (Lunney, 1992, p. 23). In a more recent article (Lunney, 2008), the same author reported that case-based learning allows the nursing student to feel more connected to reality and decide how to plan and deliver patient care. It also promotes learner autonomy, decreases the theory–practice gap, and increases student motivation and interest (Gray & Aspland, 2011). The student develops five types of knowledge, skills, and abilities: theory, problem solving, critical thinking, clinical judgment, and communication skills (Hofsten, Gustafsson, & ¨ ¨ Haggstr om, 2010). As a “low-technology” (paper-andpencil) method, case-based learning helps to improve competency, defined as the ability of a student nurse to integrate and apply the knowledge, skills, judgment, and personal attributes required to practice safely and ethically in a designated role and setting (Scherer, Bruce, & Runkawatt, 2007; Tosterud, Hedelin, & Hall-Lord, 2013). Another learning methodology that gained importance as a result of the Bologna Process, and also serves as an evaluation method, is simulation, defined as activities that mimic the reality of a clinical environment and are designed to demonstrate procedures, decision making, and critical thinking required in routine patient care. Student interaction with high-technology human patient simulators (HPS) has the added advantages of presenting scenarios that are seldom found in clinical practice or that are highly variable, and allows students to concentrate their efforts on their own learning rather than on an individual patient’s needs. The goal is that students learn to apply classroom theory to clinical practice with no impact on actual patients (Cant & Cooper, 2010; Jeffries, 2005). Journal of Nursing Scholarship, 2015; 47:1, 34–42. C 2014 Sigma Theta Tau International
Simulation to Enhance Nurses’ Education
The National Council of State Boards of Nursing (2005) recommends the use of HPS because they help to prepare students to make accurate decisions (Wolf et al., 2011), work in teams, develop communication skills, observe the consequences of incorrect choices, and assess the effects of medication (Nehring & Lashley, 2004; Todd, Manz, Hawkins, Parsons, & Hercinger, 2008), all of which are basic nontechnical skills required of registered nurses (Pearson & McLafferty, 2011). Studies have shown that using HPS prepares students for clinical practice because of the opportunity for interactive learning in a risk-free environment, with immediate feedback from their professors (Radhakrishnan, Roche, & Cunningham, 2007). We identified no studies that assessed the transfer of HPS-acquired knowledge by implementing and who experiences different types of learning methods and compared students with no clinical practice with practicing professionals. Although individual educators tend to adopt a preferred style of teaching if the option exists, the Bologna Process demands a student-centered approach that encourages the development of collaboration, communication, and proactive group problem-solving skills among students. Part of the reason for undertaking the present study was the availability of faculty members with different beliefs about teaching approaches; two colleagues were interested in evidence about whether the new methodology would improve student outcomes and therefore the quality of nursing graduates of our program. Applied HPS technology was used in the present study to assess and compare the critical thinking and skills acquired by a group of undergraduates without clinical practice who had experienced case-based learning, a control group that followed traditional teaching and learning methods, and nurses with clinical experience enrolled in continuing professional education (CPE).
Methods The study was a nonrandomized clinical trial using an HPS in a simulated work environment to assess the communication and critical thinking skills of nursing students at the School of Nursing, based on type of learning experience acquired. The study population included second-year undergraduate students (study period: September 16, 2011 to June 20, 2012). The undergraduates were enrolled in a clinical core course, “Adult Patients 1,” but had not yet participated in any clinical practice in hospital settings. This course is assigned 12 European Credit Transfers System credits. Different professors teach the two sections of the “Adult Patients 1” course, morning and afternoon, but course content and 35
Raurell-Torreda` et al.
Simulation to Enhance Nurses’ Education
schedule is coordinated. The content includes the steps of the nursing process, in-depth discussion of the steps of nursing diagnosis, and care planning using the standard nursing language (Farren, 2010) developed by the North American Nursing Diagnosis Association (NANDA, 2009). Students become familiar with the Nursing Interventions Classification (NIC; Bulechek, Butcher, & Dochterman, 2008) and Nursing Outcomes Classification (NOC; Moorhead, Johnson, Maas, & Swanson, 2008) in care planning related to different clinical pathologies or syndromes and surgical procedures (Ackley & Ladwig, 2008).
Intervention Group (Undergraduate, No Clinical Experience) Students in the afternoon sections course constituted the intervention group. Case-based learning was used extensively throughout the “Adult Patients 1” course. During each of the 32 class sessions, the professor provided content material (lecture and discussion) for not more than 50 min and small groups worked on casebased learning for the remaining 30 min.
Control Group (Undergraduate, No Clinical Experience) Students in the morning sections course constituted the control group. Traditional teaching methods were used in the “Adult Patients 1” course, lecture and discussion, consisting of 80-min lectures in each of the 32 class sessions.
CPE Group (Clinical Experience) Registered nurses with clinical experience, at minimum the practical experience within the undergraduate curriculum, who were enrolled in CPE were not included in the trial but participated in the HPS exercise; this allowed a comparison of their skills with the communication and critical thinking skills of the two groups of undergraduate students. This was the final portion of the study.
Ethical Considerations Before beginning data collection and analysis, the study was approved under all applicable university policies and provisions. All student volunteers submitted a signed consent form to participate in this study. 36
Intervention Protocol Cases used in the intervention group were developed by a professor who was not teaching in the simulation scenario. He constructed his own cases following the instructions in Lunney (2009, 2010) and based on his years of clinical nursing experience, documented according to the content and structure of cases specified in the references cited about critical thinking processes. The instructor who used case-based learning did not receive additional training. The control group’s instructor chose not to apply case-based learning because of his experience and comfort with traditional teaching methods. Thirty minutes of each class period was devoted to the analysis of fictitious cases illustrating the eight areas of nursing knowledge (Lunney, 2010): regular medication, current medical diagnosis, medical history, information on current disease, nursing diagnostics, nursing interventions and physicians’ orders, outcome objectives of the nursing diagnostics, and laboratory data and additional tests. Self-selected groups of three to five students, generally based on seating proximity on any given day, worked together on the problem identification and nursing care planning steps, using the NANDA NIC-NOC taxonomy. The students were required to develop a care plan, noting the information relevant to the diagnostics, NIC, and NOC. The rest of the needed information was presented in the written case (Supplement 1, available with the online version of this article). In each session, students worked on a specific case; the lecture portion of the next class session addressed the care plan that resulted from the case analysis. Students could consult their pharmacology textbooks, laboratory tests, nursing diagnostics, etc. This helped to strengthen their information search skills, similar to what they would need to do as practicing nurses (Lunney, 2010).
Objectives Based on the hypothesis that case-based learning strengthens student acquisition of clinical judgment skills, the study had the following objectives: 1. To compare the communication and critical thinking skills of undergraduate students in the control group with the intervention group. 2. To compare the communication and critical thinking skills of undergraduate and CPE nurses.
Assessment Tools Student learning was assessed using a scenario-based objective structured clinical examination (OSCE), “an Journal of Nursing Scholarship, 2015; 47:1, 34–42. C 2014 Sigma Theta Tau International
Raurell-Torreda` et al.
approach to the assessment of competence in which the components of competence are assessed in a wellplanned or structured way with attention being paid to objectivity” (Mitchell, Henderson, Groves, Dalton, & Nulty, 2009, p. 399). This extra-credit activity in the School of Nursing’s simulation laboratory, with HPS in a simulated work environment, was offered to those students who passed the course and wanted to improve their score or further test their skills. OSCE uses a checklist based on an objective marking scheme for evaluating students’ skills and behaviors. The OSCE used was validated by Henneman, Cunningham, Roche, and Curnin (2007), with a reported interrater reliability of 95%, and was later used by Wolf et al. (2011) specifically to evaluate nontechnical skills. The OSCE content permits evaluation of student competency in the following categories: patient safety and communication, patient assessment, recognition of signs and symptoms, problem identification, and nursing diagnostics and interventions used to address the problem. To guarantee maximum objectivity, each section was scored with a simple dichotomous point system. If the behavior is observed, the student is awarded 1 point for that item; otherwise, the score for that behavior is 0. For each category, the points were totaled and a score calculated from the total possible points. A professor unfamiliar with the students and blinded to which students were in the control and intervention groups evaluated their competency on the scenario-based OSCE. Results were compared between the control and intervention groups and also with the CPE nurses. All groups of students (intervention, control, CPE) were evaluated in the same manner at the end of their course: r In laboratory simulations, students worked together on the scenario in randomly assigned groups of two or three using a computer-generated list. r Five medical-surgical scenarios were purchased from the National League for Nursing and randomly assigned to student teams; each simulation represented a highly prevalent patient problem in nursing practice and was related to lecture content presented to both sections of the undergraduate “Adult Patients 1” course. Before the evaluation, all students had used the R , Laerdal, Wappingers Falls, NY, HPS (SIM MAN 2G USA) to practice patient assessment and fundamental management skills such as administering medications.
Independent Variables Primary: group membership (control, intervention, CPE). Secondary: sociodemographic variables (age, sex), Journal of Nursing Scholarship, 2015; 47:1, 34–42. C 2014 Sigma Theta Tau International
Simulation to Enhance Nurses’ Education
previous university study, previous university study in health sciences, healthcare work experience, and path to university admission (standard admissions testing, postsecondary training module, or older student [>25 years old]).
Dependent Variable The score was obtained by the student on the OSCE simulation by study group (control, intervention, CPE).
Sample Size and Group Assignment The study population was a convenience sample of all students enrolled in the “Adult Patients 1” course in 2011–2012. Students could not be randomized to control or intervention groups because exposure to case-based learning was based on their course schedule (morning, control group; afternoon, intervention). Therefore, we controlled for potential confounding variables, which were considered independent variables: previous university study, previous university study in health sciences, health-related work experience, and path to university admission. All of these characteristics could confer some advantage to certain groups because their knowledge of the work environment and experience interacting with patients could help them handle the simulation more proficiently.
Statistical Methods Categorical variables are expressed as frequency and percentage, using chi-square or Fisher’s exact test for comparison between groups. The results for quantitative variables were expressed as a mean and standard deviation (SD) or median and interquartile range (P25–P75), depending on the normality of distribution, and groups were compared using Student’s t or Mann-Whitney U test, respectively. The comparison of HPS evaluation results between the undergraduate and CPE groups used an analysis of variance test; post hoc analysis was done with Dunnett’s test. A p value of
