Simulation can be utilized to enhance the education of students in many levels of nursing education. Through simulation, students have opportunities to practice nursing skills such as assessment, invasive procedures, evaluation, and communication. Practicing these skills can have many positive outcomes on student performances and increase confidence in the clinical setting.

This article reports on a pilot study conducted to validate the effectiveness of a simulation experience in a junior-level eight-week obstetrical rotation in a baccalaureate nursing program. The decision was made to study self-confidence levels related to the experience. It was hypothesized that the use of simulation would enhance the educational experience of students and increase their confidence levels. Studies have shown simulation to increase students' confidence and that "self-confidence has a significant impact on[horizontal ellipsis]understanding and feeling of success in their clinical practices" (Valizadeh, Amini, Fathi-Azar, Ghiasvandian, & Arkbarzadeh, 2013, p. 158).

A postpartum hemorrhage (PPH) scenario was chosen for the simulation experience as opportunities to see this emergent situation clinically are unlikely. PPH accounts for approximately 30 percent of all maternal deaths worldwide (Fawole, Awolude, Adeniji, & Onafowokan, 2010), with the majority of deaths happening in the first four hours after birth (Ricci, Kyle, & Carmen, 2013). The most likely cause of PPH is uterine atony, the etiology incorporated into the scenario.

BACKGROUND

There is overwhelming support in the nursing literature for the use of simulation to facilitate learning. Self-confidence has been linked to simulation as well. The National Council of State Boards of Nursing National Simulation Study (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014) showed that groups with the most simulation experience demonstrated the highest levels of self-confidence.

Studies have shown simulation to be effective in improving communication skills, team collaboration, clinical judgment, and problem solving (Yuan, Williams, & Fang, 2012). It is an excellent way to give students the opportunity to learn and apply emergency management skills and concepts (Bradshaw & Lowenstein, 2011), allowing students to participate in life-threatening scenarios that encourage the practice of skills and procedures in a nonintimidating environment. "Faculty members have the opportunity to observe students more closely and to allow students to demonstrate their potential" (Billings & Halstead, 2012, p. 358).

METHOD

This pilot study used a quasiexperimental design. Institutional review board approval was obtained from the university.

The sample consisted of 24 students in two cohorts. The first cohort had 15 students; the second had 9 students. Written informed consent to participate in the study portion was obtained from each student; participation in the surveys and evaluation forms was anonymous.

Procedure

Students in the first cohort were randomly assigned to three groups of four students and one group of three students; the second cohort included three groups of three students. Students were randomly assigned to the following roles: team leader, skills nurse 1, skills nurse 2, and communicator/documenter.

Each group was oriented to the simulation room and supplies and received the following report: "M.L. was a gravida four, para three postpartum patient who just delivered a 9-pound baby boy. She has a history of postpartum hemorrhage after her last delivery. She had an epidural during her delivery and did not have a laceration or episiotomy." A high-fidelity Gaumard(R) simulator, Noelle, with the capability to have a PPH, was programmed to exhibit signs of hypotension and tachycardia, which normally follow a hemorrhagic episode.

The students worked in teams to assess the patient, identify problems, notify the physician if needed, perform procedures and interventions, communicate effectively, and document correctly. The physician who gave orders using a prepared script was played by a faculty member. During the simulation, a checklist was used to evaluate the students. At completion, each class met for a debriefing session to allow reflection on the experience, to discuss errors, and to obtain feedback.

Instruments

Three instruments were developed for the study: a pre/post simulation survey to measure student confidence, an evaluation form to gather student feedback on the effectiveness of the simulation, and a checklist to evaluate student performance and competency. The pre/post survey consisted of five items ranked on a 5-point Likert-type scale; scores ranged from "not at all confident" to "very confident." Perceived confidence levels were measured in the areas of assessment, intervention, and patient evaluation.

The checklist consisted of 26 items representing actions and behaviors expected for the treatment and evaluation of PPH. They included continual bedside evaluation, administration of uterotonic drugs, intravenous access, and frequent assessment of vital signs (Belfort, 2013). One point was given for each item that demonstrated competency; zero was given for actions that did not demonstrate competency.

The effectiveness evaluation survey consisted of six items: increasing knowledge of assessment of PPH, timing of the simulation (end of rotation), challenging critical thinking skills, providing a variety of learning experiences, and providing an appropriate experience with a high level of realism. A 5-point Likert-type scale was used with scores ranging from "not at all effective" to "extremely effective." Students were asked to provide suggestions for improvement.

RESULTS

Confidence Level

A breakdown of the results showed an increase in confidence in each category following the simulation (pre, M = 2.91; post, M = 3.86). The highest level of confidence prior to the simulation was for performing a postpartum assessment (M = 3.08); postsimulation confidence levels increased more for when to notify the physician (from M = 2.83 to M = 3.91) than for all other areas on the survey.

The highest reported confidence level, both pre- and postsimulation, was for monitoring responses to nursing interventions (pre, M = 3.29; post, M = 4.13). According to Newberry (2014), increased self-confidence levels are associated with the ability to understand more complex clinical situations and better recognize patients' decline.

Performance Checklist

Overall group performance on the performance checklist ranged from 75 percent to 100 percent; the average total score for the entire group was 92 percent. Strong performances from individual groups included performing procedures correctly (IV and Foley, 100 percent), medication administration (92.8 percent), and collaboration (95 percent). The category with the worst overall performance was documentation (42.8 percent). Other weak performances included assessment of the bladder and the use of standard precautions (each received overall scores of 71 percent).

Effectiveness Survey

The results of this six-question survey were positive. Students reported an overall effectiveness rating of "very effective" (M = 4.15). The results revealed that the simulation experience was most effective in providing a variety of learning experiences and providing an experience appropriate to the students' level of learning (M = 4.39). The least effective point was the timing of the simulation training, which occurred after completion of the course and the clinical rotation (M = 3.91); no students provided suggestions for better placement. Suggestions for improvement from the students primarily included improving mechanical issues with the manikin and increasing the level of realism.

The findings tend to correlate with results from other studies regarding outcomes on students' performances and confidence levels. For example, Hall (2015) stated that high-fidelity simulation "enhanced their confidence in their ability to perform appropriate patient care techniques, promoting persistence and ultimately contributing to improvement in skills and cognitive competencies" (p. 125).

CONCLUSION

The integration of simulation into this course was successful, as it allowed students a hands-on experience during an obstetrical emergent situation not often seen in clinical settings. It enhanced education by providing an opportunity for students to improve skills performance, increase self-confidence in the clinical setting, and experience an emergent situation that is infrequently witnessed. The results demonstrated that students' confidence levels can be increased by using this simulation. Nursing faculty can utilize the processes used in the development of this simulation to build and promote positive curriculum changes.

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