Nursing schools and colleges with large numbers of students find it logistically difficult to allow all students to be in the active role in clinical simulation for every lesson plan. As a result, students are often assigned to either an active role or passive (observation) role during the clinical simulation, leading to different learning experiences. One issue arising from the difference in student roles is the level of anxiety experienced by the students.
The use of clinical simulation to decrease anxiety in the clinical setting is an important topic. Clinical simulation has also been linked to enhancing critical thinking skills in a safe environment (Szpak & Kameg, 2013). A study performed by Megel et al. (2012) compared anxiety in two groups of prelicensure nursing students, one that participated in clinical simulation prior to a clinical experience and one that observed the other group and also had psychomotor skill practice without a manikin. The group that practiced with manikins in the clinical simulation rated less anxiety on their first clinical rotation. The study concluded that students in the observer/passive role valued the experience and were able to learn by watching others. Although these findings support the use of the observer/passive role, there is no mention of how the experience affected anxiety levels in either group at the time of the simulation.
Nielsen and Harder (2013) conducted a literature review on causes of anxiety in nursing students and noted that anxiety experienced by students in the active role is often related to being observed by classmates. Although some level of anxiety can facilitate learning, an overwhelming increase in anxiety can have a negative effect on learning outcomes. Findings from the literature review indicated that it is the educator's responsibility to be aware of and address causes of increased anxiety during simulation. The purpose of the current study was to determine if students in the active role during a clinical simulation have a higher or lower level of anxiety before and after the simulation when compared to students in the passive role.
THEORETICAL FRAMEWORK
The Yerkes-Dodson model of arousal and performance (learning) was used as the theoretical framework to guide this study. The model states that if one is not aroused or too aroused in a particular task, such as clinical simulation, these arousal extremes can impair learning and performance (Keeley, Zayac, & Correia, 2008; Vance, Bail, Enah, Palmer, & Hoenig, 2016). In this study, anxiety served as a proxy for arousal as it relates to participating in the clinical simulation. Yet, as students generally try to perform in a socially desirable way in front of their instructors, they will have high arousal that may increase their anxiety level if unsuccessful, which could interfere with their ability to learn.
In essence, performance and learning outcomes are better when participants are a little or moderately nervous. When that increase in arousal (anxiety) becomes excessive, there can also be a decrease in learning. An optimal level of anxiety can elevate the learner's arousal, but too little or too much negatively impacts the learner's arousal and ability to focus and perform (Keeley et al., 2008).
METHOD
A two-group pretest-posttest experimental educational pilot study was conducted with a convenience sample of 97 second-year baccalaureate nursing students. Students were randomly assigned to either an active role or a passive role. The active role group participated in the clinical simulation; the passive role group watches and observed the clinical simulation via a webcam.
Anxiety was assessed using the familiar 40-item Spielberger State-Trait Anxiety Inventory (STAI), completed before and after the clinical simulation experience (Spielberger, 1989). To assess trait anxiety, participants were asked how they "generally feel" on 20 items (e.g., "I feel nervous and restless") on a 4-point Likert-type scale (1 = almost never, 4 = almost always). A composite score was created by summing these items; higher scores indicated more trait anxiety (range, 20 to 80). To assess state anxiety, participants were asked how they "feel right now, that is, at this moment" on 20 items (e.g., "I am tense") on a different 4-point Likert-type scale (1 = not at all, 4 = very much so). A composite score was created by summing these items; higher scores indicated more state anxiety (range, 20 to 80).
Trait anxiety, which refers to how frequently the person feels anxious, is considered stable over time; state anxiety, which refers to the intensity of anxiety the person is currently experiencing, is subject to immediate change in response to environmental interactions. The STAI has been well studied and has excellent Cronbach's alphas, which range from .73 to .86 (Spielberger, 1989).
The clinical simulation scenarios were based on patient cases that students were typically unable to encounter in the clinical setting. Students in both groups were prebriefed on the manikin functions and given a brief description of the case. They were also briefed on the fiction contract; by signing this contract, students agreed to engage in the clinical simulation as if the manikins were real-life patients. Each simulated scenario lasted approximately 10 to 15 minutes. Once the case was complete, the two groups participated in a 15-minute debriefing.
There were a total of four consecutive clinical simulation scenarios. Participants completed the pretest documents at the beginning of the first scenario and completed the posttest documents after the fourth scenario. Basic descriptive statistics, independent sample t-tests, and analyses of covariance were conducted using SPSS version 24.
The university's institutional review board conducted an expedited review and approved the study as data were collected confidentially but were then analyzed anonymously. Students enrolled in a required maternal-child health course participated in the simulation as part of a normal course assignment. Students participated voluntarily and were aware that no credit would be given for participating; they were notified of their right to opt out of the study at any point during data collection and analysis. The principal investigator, who was not a faculty member assigned to the course, performed the data collection.
RESULTS
Of 140 students in the class, 97 (69 percent) participated in the study. The sample consisted of two groups: the active role group (n = 29) and the passive role group (n = 64). Analyses of data only included participants with completed information; as appropriate, list-wise deletion was used when cases were missing data. Participants' ages ranged from 20 to 41 years (M = 21.6 years); the majority were women (80 percent).
Trait anxiety, as measured by the STAI, showed no significant difference between the active role group (M = 40.93) and the passive role group at pretest (M = 41.94, t = 0.40, df = 91, p = .69), and there was no significant change between the two groups at posttest (M = 40.93 compared to 41.94, respectively, t = 0.90, df = 93, p = .34). The findings indicate that both groups had similar levels of trait anxiety at the beginning and end of the study. As trait anxiety is a stable psychological disposition, this result was expected.
State anxiety, as measured by the STAI, also showed no significant difference between the active role group (M = 39.83) and the passive role group at pretest (M = 41.83, t = 0.56, df = 94, p = .56) but began to trend toward a significant difference at posttest (M = 33.44 compared to 37.70, respectively, t = 1.68, df = 91, p = .097). Controlling for pretest state anxiety, an analysis of covariance was performed between the two groups. The active role group (Madj = 34.13) experienced significantly less state anxiety at posttest compared to the passive role group (Madj = 37.39, F = 4.75 (2, 93), p = .032).
DISCUSSION AND IMPLICATIONS
Study results validate that students in the active role group had less anxiety than those in the passive role group. A small, convenience sample of 97 nursing students was reasonable; however, a larger sample size could impart more widespread, generalizable findings. Another limitation of this study is that participants were not queried regarding a previous diagnosis of anxiety. Data were collected at the end of the simulation day instead of after each scenario, which could have impacted the anxiety rating. If collected after each simulation scenario, study findings would provide more accurate data.
As enrollment increases in nursing programs, student participation in course-related clinical simulation assignments is necessary. To plan more valuable experiences, it is imperative that nurse educators understand the effects of clinical simulation on anxiety and desired objectives. Clinical experiences are different than clinical simulation, and as such, these data may not reflect actual clinical application; thus, more studies on clinical simulation are needed. Compared to the passive role group, students in the active role group experienced less state anxiety after the experience, which theoretically can facilitate learning according to the Yerkes-Dodson model (Keeley et al., 2008; Vance et al., 2016).
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