Near the start of the fall 2015 semester, an opportunity to replace live clinical hours with simulation occurred due to changes at a live clinical site. One clinical day was replaced with a one-on-one instructor-to-student simulation for a cohort of 37 nursing students. The simulation was developed to introduce students to technology and equipment common in the critical care setting and to help students appreciate how nursing theory can be used in critical care.

Simulation has been shown to be an effective strategy to replace live clinical experiences (Harder, 2010; Lapkin, Levett-Jones, Bellchambers, & Fernandez, 2010). A recent study (Hayden, Smiley, Alexander, Kardong-Edren, & Jefferies, 2014) supported the use of simulation experiences for up to 50 percent of clinical time with no negative effect on National Council Licensure Examination-Registered Nurse (NCLEX-RN(R)) pass rates. The process of student assessment in this simulation was intended to evaluate if the continuation of this activity was acceptable as a replacement for live clinical time.

BACKGROUND

Nursing knowledge, theory, and research are cornerstones of nursing practice; they help shape professional identity and guide the thinking, being, and doing of nursing (Smith & Parker, 2015). Locsin's (2015) technology competency as caring in nursing theory was chosen to guide practice in this simulation because it offers a unique perspective on caring with technology. The theory focuses on the use of technology to know the wholeness of a person. In the critical care setting, monitoring technology and medical equipment is an extension of a person and also requires care.

Simulation is a good way to develop confidence before students enter live clinical practice experiences (Nevin, Neill, & Mulkerrins, 2014; Palmer & Ham, 2017). For this reason, a simulation to practice theory use, as well as familiarize students with life-sustaining equipment, was developed. The intent was to give students an opportunity to explore and gather data from medical equipment while simultaneously being available for a mother to ask questions regarding the care of a child. The purpose of this article is to report students' perceived confidence using the theory as a guide for practice and in describing the monitoring of technology and equipment in the critical care area.

METHOD

Thirty-seven nursing students completing the last semester of a baccalaureate program were assigned a simulation experience to replace one clinical day in critical care. All students enrolled in a university nursing program in the Midwest participated as part of their clinical coursework; specific demographic data were not collected. Students were given the assignment details (purpose, objectives, background reading, and evaluation material) prior to the required simulation experience. Use of aggregated assessment data was approved by the university's institutional review board.

Procedure

Students scheduled a 60-minute video-recorded simulation with the simulation coordinator and a one-on-one debriefing session using SIMview (http://www.laerdal.com/us/SimView) with the course didactic faculty member. The simulated experience included a human patient simulator and an actor playing the part of the manikin's mother. The human patient simulator depicted a patient in critical care intubated on a ventilator with an intracranial pressure monitor, chest tube, pulmonary artery catheter, Foley catheter, and arterial line.

Students were directed to prepare the mother to see her child hooked to several pieces of life-sustaining equipment for the first time and to answer her questions. The actor used a script of questions to encourage the student to describe the equipment and the possibility of surgery for a tracheotomy. For example, the actor might ask, "What is that thing sticking out of her head?"; "Why is there blood leaking out of her chest?"; or "What is that long tube coming out of her mouth hooked to that machine?"

Video-taped simulation sessions were uploaded to the Blackboard learning management system to be reviewed in a 30-minute debriefing session between the student and didactic faculty member. Prior to the video review, the didactic faculty asked the student: "Tell me how you used ideas from the technology competency as caring in nursing theory during this experience." Semistructured questions developed using strategies to guide reflection (Jeffries, 2007, pp. 79-82) were used by didactic faculty during the debriefing: "Tell me what you were thinking at this point"; "What more would you add, now that you have had time to think about the experience"; and "What questions do you have about this experience?"

Data Overview

Three faculty-developed questions were asked before the simulation and after the debriefing to evaluate the effectiveness and continued use of this activity as a clinical replacement. The questions employed a simple visual analog scale (VAS) with a horizontal 10-inch line using the number descriptor 0 on the left and 100 on the right placed under each question. The VAS method is quick to administer and relatively sensitive for scoring (Wagner & Christensen, 2015). Prior to beginning the simulation, the coordinator directed students to make a hash mark on the line between 0 and 100 that represented their answer to the following questions: 1) How confident are you describing technology used in the critical care area? 2) How confident are you describing equipment used in the critical care area? 3) How confident are you describing the technology competency as caring in nursing theory by Locsin? At the conclusion of the debriefing, the didactic faculty member directed students to use a new sheet of paper to make a hash mark that represented their answer to the same questions, without looking at their earlier marks.

Descriptive statistics and t-tests were calculated using SPSS 22. A computer-generated 10-inch ruler, with 100 equally spaced marks, was used to manually measure units from the left-hand end of the line to the point marked by the student. The presimulation VAS score was subtracted from the postdebriefing score to determine the student-perceived change in confidence for each question. A dependent t-test was used to compare differences between the scores.

RESULTS

Student confidence in all areas was significantly higher after the simulation experience. On average, students' confidence describing technology (M = 73.02, SE = 1.88) and equipment (M = 72.35, SE = 2.15) improved by 17 units on the VAS (technology: M = 56.08, SE = 2.21, t(36) = -8.04, p < .00, r = .80; equipment: M = 55.18, SE = 2.44, t(36)= -8.04, p < .00, r = .80). A larger difference, 30 units, was seen in students' confidence describing the technology competency as caring in nursing theory (after the simulation, M = 73.91, SE = 2.61 vs. before the simulation, M = 43.37, SE = 3.89), t(36)= -8.33, p < .00, r = .81.

LESSONS LEARNED AND IMPLICATIONS

The questions used for this simulation were deliberately broad in scope and intended to evaluate the continuation of this activity as a replacement for live clinical time. In the future, questions should be developed to ask specific details of Locsin's (2015) theory. A second limitation was the use of the VAS as a rating scale to compute differences. The VAS may not have interpretable meaning as it is not based on mathematical properties of well-defined size (Svensson, 2001). Timing of the simulation in the course sequence could be another limitation. Students self-scheduled the simulation, which may or may not have coincided with their critical care clinical experience. Future studies could compare outcomes for those with and without this as a simulation experience before a live critical care clinical.

Limitations notwithstanding, intentional development of a simulation focused on nursing theory with a subsequent one-on-one debriefing session can provide an opportunity to discuss technology competency as a way of caring (Locsin, 2015). The use of technologies of care and equipment as tools to know more about a person is higher in the critical care area, which was why the technology competency as caring in nursing was a good fit to guide this simulation. Palmer and Ham (2017) also found simulation can promote confidence, which was true in this experience, suggesting that the simulated experience was successful in helping students see the use of theory in practice.

In addition to the above results, some students voiced that the simulated experience forced them to perform alone for the first time in this particular program. The simulation provided the students an opportunity to explain life-sustaining equipment and to communicate with family members (actors) without support from clinical instructors, staff, or peers. In reflection, simulations at the end of a nursing program may be an opportunity for dialogue about transitioning as students near independent practice.

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