Clinical simulation is an effective teaching strategy that enhances student learning by decreasing anxiety (Hollenbach, 2016) and increasing satisfaction and confidence (Bambini, Washburn, & Perkins, 2009; Lewis & Ciak, 2011). Postpartum nursing can be sensitive in nature, and examination of the female breast, fundus (uterus), and lochia (vaginal discharge) may lead to feelings of inadequacy for nursing students. Simulation has been used successfully to prepare nursing students for other sensitive areas, for example, mental health nursing (Goh, Selvarajan, Chng, Tan, & Yobas, 2016). However, little research to date has examined the effects of simulation on the confidence levels of nursing students preparing for the sensitive and intimate care needs inherent to the maternity practicum.
Bambini et al. (2009) noted that confidence levels of 112 baccalaureate nursing students increased significantly after a 3-hour postpartum simulation workshop. Partin, Payne, and Slemmons (2011) qualitatively analyzed comments of 49 nursing students after a postpartum simulation experience with major themes including "feeling prepared for practice" and "enhancement of learning." These studies support the use of simulation in the maternity setting; however, lack of diversity in participant characteristics (race-ethnicity, gender) limits generalizability of the findings. Therefore, the purpose of this study was to evaluate the effect of simulation on confidence levels (with pre- and postpartum care tasks) of a group of diverse nursing students at a large public university in California.
METHOD
University institutional review board approval and participant consent were obtained prior to data collection. This study utilized a descriptive, quantitative pretest and posttest design. All junior-level baccalaureate students beginning their maternity rotation are required to take part in a maternity simulation in order to meet course requirements. In spring 2016, students were informed about the study by the primary investigator and were invited to participate.
Student confidence levels were assessed using a 6-item Likert-type questionnaire developed by Bambini et al. (2009). Scores range from 1 (not at all confident) to 10 (very confident), with higher scores indicating a greater level of self-efficacy. Content validity was established by obstetric nurses and nurse educators.
The posttest and follow-up surveys included open-ended questions, for example, "The things I learned during the postpartum simulation experience that I used on my first clinical days are[horizontal ellipsis]" and "For me, the most important aspect of the postpartum simulation experience in preparing for my first clinical days was[horizontal ellipsis]."
Nursing education is fast paced, requiring students to rotate through multiple clinical areas every three to four months and learn new nomenclature and clinical skills and procedures. Schumacher and Meleis's (1994) transition theory provided the framework for this study, as students entering into new clinical areas experience developmental (e.g., personal experience, cultural values) and situational (e.g., new environment) transitions as they learn new roles.
Prior to the simulation session, students were asked to complete a demographic questionnaire (age, gender, race-ethnicity) and a questionnaire rating their confidence level in performing specific maternal postpartum (breast, fundus, lochia) assessments. Next, groups of 8 to 10 students, led by their respective clinical instructors, participated in the four-hour simulation session designed to prepare students for postpartum-specific nursing care. The clinical faculty demonstrated breast, fundus, and lochia assessments on low-fidelity manikins and task trainers to their groups of students; then smaller groups of two or three students rotated through the stations to practice assessments on their own. Faculty provided guidance, reassurance, and clarification as needed. After completing all stations, students completed postsimulation confidence surveys and were given a follow-up survey to be completed after two full clinical days in their assigned postpartum or maternity unit.
RESULTS
Sixty-one of the 62 students in the maternity practicum took part in this study. The majority were female (n = 51, 84 percent), 20 to 25 years of age (n = 51, 84 percent), and self-identified as Asian (n = 42, 69 percent). Presimulation, postsimulation, and follow-up confidence level data were compared with paired t-tests using SPSS version 22. Paired t-tests were used instead of repeated-measures analysis of variance to include all data, rather than limiting the analysis to the 38 participants who completed the follow-up survey. Overall confidence level increased from presimulation to postsimulation, t(60) = -13.946, p < .001, and from postsimulation to follow-up, t(38) = -4.087, p < .001 (Table 1).
Confidence also increased over time for the individual assessments. For breast assessment, confidence increased between pre- and postsimulation, t(61) = -8.079, p < .001, but did not differ between postsimulation and follow-up, t(38) = -0.896, p = .376. On the other hand, confidence level in performing fundal assessment increased between pre- and postsimulation, t(61) = -13.320, p < .001, and between postsimulation and follow-up, t(38) = -2.304, p = .027. The same was noted for lochia assessment, with an increase from pre- to postsimulation, t(61) = -12.688, p < .001, and from postsimulation to follow-up, t(37) = -3.607, p = .001.
Narrative comments were reviewed by the research team to identity the most frequently used words: anxiety, confidence, and prepared. Comments included, "The simulation day lowered my anxiety and built my confidence level" and "I feel more prepared for the clinical setting, way more confident."
DISCUSSION / CONCLUSION
Study findings support the use of clinical simulation to enhance confidence levels among diverse nursing students as they transition into new areas of nursing and nursing care. In 2014, 6 percent of students enrolled in BSN nursing programs were of Asian descent and 15 percent were male (NLN, 2014). Asian cultures (Okazaki, 2002) and male students (Patterson & Morin, 2002) are often modest with intimate touch, which may contribute to anxiety when placed in uncomfortable nursing care situations (Hollenbach, 2016). Our sample was 68 percent Asian with 18 percent male students, significantly more than reported by the NLN (6 percent and 15 percent, respectively).
Limitations included the convenience sampling design and lack of debriefing sessions for student reflection (Lestander, Lehto, & Engstrom, 2016). The researchers were unable to maintain fidelity of the simulation between groups due to differing clinical faculty backgrounds and the delivery of simulation activities.
Similar to Bambini et al. (2009), the findings support the use of clinical simulation as a strategy to enhance confidence among students entering a postpartum clinical rotation. Intimate examinations are inherent to the postpartum setting; simulation experiences facilitated by faculty provide a safe, nonthreatening environment to practice uncomfortable nursing care, enhance learning, and prepare students for the transition to clinical practice (Partin et al., 2011).
This study supports the use of simulation to increase student confidence levels in uncomfortable nursing care situations, providing opportunities to enhance practice experiences and link them to real-life situations. Our findings indicate that simulation may increase confidence levels for students for whom intimate touch and sensitive assessments may be difficult based on gender or cultural differences. Future simulation research should strive to draw samples from diverse student populations.
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