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Online Journal of Nursing Informatics (OJNI) Spring 2008 Volume 12, Number 1
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Bremner, M., Aduddell, K. & Amason, J. (February, 2008). Evidence-Based Practices Related to the Human Patient Simulator and First -Year Baccalaureate Nursing Students' Anxiety. Online Journal of Nursing Informatics (OJNI), 12, (1) [Online]. http://ojni.org/12_1/bremner.html


Evidence-Based Practices Related to the Human Patient Simulator and First Year Baccalaureate Nursing Students' Anxiety

By Marie N. Bremner DSN, RN, Kathie F. Aduddell, Ed.D, RN and Janeen S. Amason, MSN, RN


HPS The use the Human Patient Simulator (HPS) as the state-of-the-art educational technology has been documented in nursing literature (Gaba, et al, 1998; Good, et al,, 1992; Chopra, et al., 1994; Issenber, et al., 1999; Farnsworth, et al., 2000; Haskvitz & Koop, 2004; Feingold, et al., 2004; Bremner, et al., 2006). The next step is to establish evidence-based practices related to this unique form of educational technology. In particular, this project investigated the impact of this type of education technology on the perception of confidence and comfort levels of nursing students entering their first clinical experience as evidenced by their anxiety level. The study provided an opportunity to further explore assumptions and findings from a previous study related to the use of HPS in promoting confidence in first level baccalaureate nursing students (Bremner, et al., 2006). The previous study documented that a majority (61%, N = 55) of the students agreed or strongly agreed that using the HPS gave them confidence with physical assessment skills. Many of the students (68%, N = 55) also felt the experience with the HPS should become a mandatory component of the nursing curriculum. This second study had three major objectives: 1) to examine specific demographic information of first year baccalaureate nursing students participating in a study using the HPS; 2) to examine the effects on a HPS session on the level of anxiety of these students as they enter their first clinical experience; and, 3) to explore the relationship of learning styles, coping styles, and anxiety levels of students using this form of educational technology

Operational Definitions

Four major variables identified in this research study include the human patient simulator (HPS), anxiety, learning styles, and coping styles. The HPS represents the latest in the state of the art simulation technology for educating and training health care clinicians to experience various patient scenarios involving pathologies and responses to a variety of treatments. It is a mannequin that represents the physical characteristics of an adult male/female with sophisticated, pre-programmed human physiology and pharmacological responses to simulate a patient's condition and response to clinician's actions and interventions in a variety of scenarios. This simulator allows students to experience rare and life threatening situations over and over again making them confident and prepared for a real life crisis without any risk to a real patient. Previous research identifies best practices in using the HPS in nursing education (Bremner, et al., 2006). Students appear to embrace this form of interactive learning even though they feel some anxiety (Nehring & Lashely, 2004).

A second variable involves the level of anxiety of nursing students and their description of comfort they may experience in starting their first clinical experience. In this particular study, anxiety is defined as a transitory emotional state that varies in intensity and fluctuates over time and is characterized by subjective consciously perceived feelings of tension and apprehension (Speilberger, Gorsuch, & Lushene, 1983). Individuals also have various levels of anxiety proneness which identify differences in how one may respond to situations perceived as threatening (Speilberger, et al., 1983). According to Rhodes and Curran (2005), nursing students develop fear and anxiety due to the lack of experience in a clinical setting. As indicated by these authors, high anxiety leads to decreased student learning. Completing nursing skills for the first time in a clinical setting can be overwhelming for the student, especially the student who may already be anxious. Begat, Ellefsen, and Severinsson (2005) discussed the importance of nurses empowering themselves by knowing why they think and act as they do, so that this knowledge may decrease the stress in the clinical work environment.

The third variable in this study involved the measurement of the students' learning styles. Learning styles are the modality by which an individual synthesizes, assimilates, or internalizes information. In particular, five specific learning styles are utilized in this study as identified by the Self Assessment Inventory from the Assessment Technologies Institute (ATI). These five styles include visual, auditory, tactile, group and individual. Numerous research instruments, such as the Kolb, Felder and Soloman instrument, have been used in identifying students' learning styles; each discussing a variety of ways that an individual learns information (Caanagh, Hogan, & Ramgopal, 1995; Dunn, et al, 1986; Billings & Halstead, 1998; Entwistle, 2001; Koob & Fund, 2002; & Utley-Smith, 2004). In addition, instruction is typically focused on the majority of the group rather than according to the individual needs of students (Griggs, Dunn, & Ingham, 1994). However, Kelly (1997) described the need for a variety of instructional methods in meeting the learning needs of baccalaureate nursing students. She also described the importance of adapting the methodology as a result of the shift to a more diverse student population. For example, the shift of an older, second career student verses the traditional younger student entering nursing school or simply the variety of ages seen in many nursing schools today (Linares, 1999; Clausing, Kurtz, Prendeville, & Walt, 2003).

A final variable of this study involves coping styles which results from the psychological and emotional effects produced by a circumstance or situation. The result, dependent upon the duration of the stressor and the positive or negative nonspecific response from the body, leads to varied levels of physiological or psycho/emotional adaptations. Stress is a part of everyday life, but how the individual handles stress can lead to specific situations or conditions. Stress levels that are mild can actually help students strive and learn in clinical areas, but excessive levels of stress can hinder the clinical performance (Lincoln, Adamson, & Covic, 2004). Strategies to cope with stress may involve cognitive and behavioral abilities such as problem-solving or cognitive restructuring as well as disengagement strategies such as problem avoidance or wishful thinking. Wong, et al (2005) evaluated students who utilized a variety of resources to cope with stress. Learning to cope with stress in the nursing profession in a positive manner is imperative. Thomas (2005) identified that recognizing stress and dealing with the stress in a positive manner are basic coping mechanisms used by successful nurses. Shaikh et al (2004) identified that females and males used different coping skills. The females would study and sleep to cope with existing stress, while the males played sports and interacted with friends.


The research methodology for this study consisted of an experimental design using randomized intervention groups over the duration of two consecutive college semesters. A simulator program and module at a nursing school in the southeastern United States was utilized in developing this educational intervention study. Written informed consent was obtained from all participants as well as approval from the university institutional review board prior to the study. One group participated in a hands-on HPS session that incorporated the use of the patient simulator one week prior to their first clinical day. Students were instructed to communicate with and assess the simulator as they would a real patient. The second group of students received the usual skills lab practice session without the use of the patient simulator one week prior to their first clinical experience. These skills included vital signs, basic physical assessment skills and safety. Skills were taught with demonstration, video, and return demonstration. During this session the students were given the opportunity to review all the newly learned psychomotor skills that had been demonstrated to them during the semester. Both groups of students had a debriefing session after the end of the educational intervention. This session allowed the students to indicate what they learned, how they felt, and how they would apply what they learned during their first clinical day.

Population/Sampling Size

The target population consisted of a convenience sample of nursing students in their sophomore level of a large baccalaureate nursing program in southeastern United States. The sophomore nursing students (N = 149) were randomly divided into two intervention groups over two consecutive semesters. One group (N = 71) received the educational session using the HPS. The other group (N = 78) did not receive the training. Table I displays the educational intervention for the two groups.

Table 1

Instruments Used In Study

The students also completed three instruments to evaluate the experience, identify their learning style and coping styles, as well as measure anxiety levels. The first instrument was a self-designed questionnaire and consisted of items to collect demographic information as well as evaluation of the content. The demographic information included age, gender, employment status (to note previous experience in health care), and educational level (identified as holding a previous educational degree). The evaluation of the content was designed as a pre and post test with twenty (20) items to determine information as to the use and value of the intervention strategy. Specific evaluation and analysis of this information with one semester of students was presented in a previous article (Bremner, et al., 2006).

The Self Assessment Inventory from the Assessment Technologies Institute (ATI) measured the students learning style and coping styles. The inventory is a Likert-type assessment designed to be administered to adult nursing program populations. There are forty-five (45) specific questions to obtain information about the student's learning style. In addition, the inventory assesses personal characteristics with eighteen (18) questions specific to stress and coping. This particular inventory has been reviewed by content experts and evaluated for relevance and content validity of material to the identified constructs (ATI, 2000). Reliability of the assessment inventory was found to be .9144 using coefficient alpha (ATI, 2000).

The researchers utilized the State-Trait Anxiety Inventory (STAI) to measure the students' anxiety. The STAI is comprised of self-report scales for measuring two distinct anxiety concepts. The STAI-A Trait scale consists of 20 statements that assess how people generally feel and indicates a stable dimension of personality (Speilberger, et al., 1983). The A-State scale also consists of 20 statements but identifies how people feel at a particular moment of time with each scale allowing a minimum score of 20 and a maximum score of 80 (Speilberger, et al., 1983). Both of these instruments allowed the researchers to examine students' normal state of anxiety versus the anxiety related to their first clinical experience. The essential qualities evaluated by the A-State scale according to Speilberger, et al., (1983) involve feelings of tension, nervousness, worry, and apprehension. The validity and reliability has been documented in the literature (Speilberger, et al., 1983).

Analysis and Results

The data was encoded and analyzed using SpSS network version 13.0. Missing responses from specific questions were incorporated into the data analysis. The data was analyzed to answer the research questions and is presented descriptively such as percentages of responses or frequency distributions. Further exploration was accomplished using statistics such as cross tabulation and Chi square. In general, there were no significant difference between the experimental and control groups in terms of age, gender, education, and employment status. Ninety-three (93 %) percent of the participants were female. The average age of the student was 28 years with a range between 20 to 52 years old. The majority (57 %) of students were employed with approximately one third of these students employed in health care settings. Table II presents a summary of some findings from the self-design questionnaire given to the students who had the HPS intervention. When both the control and intervention groups answered the question about their comfort level in starting clinical, there does appear to be statistical significance between the two groups.

Table 2

The students also identified specific advantages and disadvantages when working with the HPS as listed in Table III. In general, the qualitative comments indicate a successful HPS session with major themes of involving preparation, collaboration, sense of humor and reflection.

Table 3

No significance was noted related to the students' learning and coping styles and anxiety levels. An example of the ATI learning styles for one group of students is shown in Table IV. The learning styles indicate a majority of the students preferred visual and tactile learning and were group learners which demonstrate the use of HPS to be an appropriate educational strategy.

Table 4

Table V displays the group mean scores for the anxiety state (pre-test) and anxiety trait (post test #1) for the intervention versus the nonintervention groups as well as the anxiety trait (post test #2) one week after their first clinical experience in a hospital setting. The variance between the groups' means is evident between the pre and post test with a difference noted between the intervention and non-intervention groups. However, the Control Group who did not have the HPS intervention exhibits a higher level of anxiety in general. A cut-point of 39-40 is normally used for clinically significant symptoms of a state of anxiety (Knight, et al., 1983; Forsberg & Bjorvell, 1993; Addolorato et al., 1999). In addition, Figures I and 2 provide the reader with graphs of the mean scores from the students' responses to the twenty questions on the anxiety instruments for both groups. Analysis indicates some variance in specific questions.

Table 5

Figure 1
Figure I: Mean Score of the Twenty Questions - Control Group without HPS intervention

Figure 2
Figure II: Mean Score of the Twenty Questions - Experimental Group with HPS

Implications and Recommendations

The evidence from this study confirms some of the information established from earlier self-reports from students indicating that this form of educational technology assisted them in decreasing their stress level related to first-time clinical experiences. This study also confirms the authors' identification of specific criteria for success when working with the first-year baccalaureate nursing student while using the HPS as an educational strategy. This criteria includes having well-articulated learner outcomes which have a clear connection to course and clinical objectives, student involvement for session planning, implementation, and evaluation, as well as time for reflection during and after the HPS session. The aim of this study was to provide an analysis of the impact on the use of HPS as a teaching strategy for the first-year baccalaureate nursing student in relation to their clinical experience and the effects on their anxiety levels as well as to exploration of relationships to learning and coping styles. This study assists in establishing evidence-base educational practice in using HPS to assist students with their anxiety level.

Although this research endeavor concentrated on the experience of first year nursing students, the patient simulator can be utilized with other levels of students throughout the curriculum. For example, senior nursing students needing to become proficient in competencies in emergency decision making would benefit by learning with simulated emergency situations in a non-threatening environment. The less threatening environment would allow errors to be made without the detrimental effects, thus giving the senior level student the opportunity to apply critical thinking skills in an emergency situation.

Some other recommendations in using a patient simulator with this level of student includes to turn the monitor off since it makes the students nervous, use small groups of students when working with the patient simulator so they can gain confidence and have individual time to work with the HPS, and have someone designated to coordinate and facilitate usage of the simulator because of the sophistication and maintenance of the equipment. Continued efforts should be directed to compare and evaluate the effectiveness of the simulated experience with a variety of learning styles. A suggested topic for further study is to identify student learning styles that would not be suited to this style of learning. Further recommendations for research include the investigation of potential benefits that simulation can play to improve the safe delivery of quality health, especially with the current emphasis on patient safety. For example, there needs to be a scientific base established in how this educational simulation technology can reduce medication errors. Future studies should be designed to determine the impact of simulations on nurse competencies and patient safety outcomes in settings to include emergency, critical, ambulatory care. Best practice guidelines related to patient safety outcomes can then be incorporated into nursing education and staff development as well as explore the use of this form of education simulation in different health care settings.


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Authors' Bios

Marie N. Bremner DSN, RN
Professor, WellStar School of Nursing
Kennesaw State University

Dr. Bremner has been employed in nursing education and consultation for the past 23 years. Dr. Bremner's research interests include innovations in teaching/learning and technology with particular emphasis on NCLEX-RN success, human patient simulations and clinical competencies of nursing students.

Kathie A. Aduddell, EdD, RN
Associate Professor, Director Community Health Clinic Program
WellStar College of Health & Human Services
Kennesaw State University

Dr. Aduddell has extensive experience in administration and nursing education. Her clinical background is in pediatrics/child nursing. She is currently president of Mu Phi Chapter, Sigma Theta Tau International Nursing Honor Society. In addition, her research interest is in program assessment and evaluation, outcome research, learning styles and instructional technology, and the new "chronic illnesses" in children such as obesity, Type 2 diabetes, and health disparities. Dr. Aduddell has extensive experience in administration and nursing education. Her clinical background is in pediatrics/child nursing. She is currently president of Mu Phi Chapter, Sigma Theta Tau International Nursing Honor Society. In addition, her research interest is in program assessment and evaluation, outcome research, learning styles and instructional technology, and the new "chronic illnesses" in children such as obesity, Type 2 diabetes, and health disparities.

Janeen Amason MSN, RN
Lecturer, WellStar School of Nursing
Kennesaw State University

Janeen Amason has been a Lecturer of Nursing at Kennesaw State University for the past 3 years. She has been employed in nursing education full time for 9 years in ADN and BSN nursing programs. Mrs. Amason's interests include creative teaching strategies for the classroom and clinical and obstetrical nursing.