Effects of different education methods in peritoneal dialysis application training on psychomotor skills and self-efficacy of nursing students

Abstract

BACKGROUND:

Applying the proper technique for connections in Peritoneal Dialysis (PD) is crucial in preventing potential infectious complications.

OBJECTIVES:

The aim of this study is to investigate the effects of different education methods in PD application training on the psychomotor skills and self-efficacy of nursing students.

METHODS:

The randomized controlled and experimental study was conducted with a total of 28 nursing student participants. The PD training was provided theoretically and by using a PD simulator for the experimental group and by using videos for the control group. At the end of the training, each student who was included in the experimental and control group were asked to perform PD on the PD simulator one by one. Psychomotor skills were evaluated according to the PD application skill evaluation criteria. Self-efficacy of the students before and after the application was also measured.

RESULTS:

Psychomotor skill scores of the students were found to be significantly higher in the experimental group, and there was no significant difference between the experimental and control groups in terms of self-efficacy scores. No statistically significant difference was detected between the self-efficacy scores of the experimental group regarding pre-test and post-test results.

CONCLUSION:

This technique can be used to improve the development of psychomotor skills, since the demonstration of the PD application with the simulation technique is effective in the development of psychomotor skills.

Keywords

Nursing students self-efficacy peritoneal dialysis psychomotor skills simulation

1. Introduction

Peritoneal dialysis (PD) is based on the delivery of a physiological solution to the peritoneal cavity through a peritoneal dialysis catheter [1]. Peritoneal dialysis treatment can provide independence, self-efficacy, and control over feelings for individuals [2]. Over 90% of patients perform PD application by themselves. For this reason, PD is a good example of treatments through which dealing with and managing the chronic illness situations can be taught [1].

Educational practice plays a key role in enabling individuals to successfully and actively perform their own treatment and provide their own care. Peritoneal dialysis is a home-based self-care method that provides independence for individuals. However, management of the disease, PD therapy, and the training of the patient is a complex process involving many factors that need to be carefully considered [3]. On the other hand, it also includes specific educational challenges like the presence of an abdominal catheter for PD, protection of the catheter, and carefully following the steps of PD process [4]. In the light of these observations, PD educators should have the customized teaching skills and experience necessary to train PD practitioners.

Self-efficacy is defined as a person’s reliance on their own capabilities [5] and is a quality which can be improved by learning [6]. Self-efficacy is considered to be an important concept for health care. Health professionals who feel inadequate have a higher risk of making mistakes and it is considered that this can lead to increased healthcare costs [7]. Therefore, especially in recent years, it has been observed that simulation-based trainings have seen more application than the pre-clinical applications in nursing education [8].

It is known that there is a statistically significant increase in the knowledge level, psychomotor skills and the self-confidence of the students after simulation-based learning [9, 10, 11, 12]; and simulation-based education increases the self-efficacy of the nursing students [13, 14].

For this reason, it may be appropriate to provide PD application training in conjunction with simulations in undergraduate nursing education curricula. In literature, the lack of studies evaluating the PD practice training based on the simulations given to the students constitutes the starting point of our research. From this point of view, this study was conducted to determine the effects of simulated peritoneal dialysis on psychomotor skills and self-efficacy of students.

2. Methods

2.1 Aim and design of the study

The aim of this study, which is randomized, controlled, experimental research, is to investigate the effects of a PD simulator and video display methods on the psychomotor skills and self-efficacy of the nursing students in peritoneal dialysis application training.

2.2 Hypothesis

H0: There isn’t a statistically significant difference between the effects of the PD simulator and video display method on the nursing students’ psychomotor skills and self-efficacy levels in peritoneal dialysis application training.

H1: There is a statistically significant difference between the effects of PD simulator and video display method on the nursing students’ psychomotor skills and self-efficacy levels in peritoneal dialysis application training.

2.3 Universe and sample of the research

The universe of the study consists of third-year students ( $N=$ 40) in a nursing department of the health college of a university. The study was conducted in May, 2017 during out-of-class hours. Participation criteria for inclusion in research are: having succeeded medical and surgical nursing courses and volunteering to participate in the research. A simple random number table was used to determine the experimental and control groups, which consisted of students who met the criteria to be included in the study. The randomized study was finalized with a total of 28 students.

2.4 Data collection tools and the simulator used

2.4.1 Peritoneal Dialysis Application Skill Assessment Checklist (PDASAC)

The PD application steps are included in the checklist prepared by the researchers in light of the relevant literature and in line with the international PD application guide [1]. In this form consisting of a total of 20 items each item is scored as “sufficient (3 points), partially sufficient (2 points), needs improvement (1 point).” The highest score that can be taken from the form is 60 and the lowest is 20 points. This list was given to all students in the experimental and control group immediately after the theoretical training and before the application as a PD practice guide. The form includes the steps of the PD application process such as hand washing, preparation of the materials, insertion and removal techniques of the PD solution set to the catheter, and the refuse disposal.

2.4.2 General Self-Efficacy Scale (GSES)

The General Self-Efficacy Scale (GSES) was developed by Jeruselam and Schawazzer [15] in 1979. Yeşilbalkan et al. [16] applied PD to the Turkish population by performing a validity and reliability study. There are 10 items in the Turkish form and each one is scored ranging from 1 to 4. The highest score that can be obtained from the scale is 40 and the lowest is 10. The self-efficacy score increases as the scale score increases. As a result of the validity reliability study, the test-retest reliability was found to be 0.80 and the internal consistency was found to be 0.88 [16]. This scale was applied to all students in the experimental and control group before and after the simulated PD application.

2.5 PD simulator

The PD simulator is a half-body model with a fixed PD catheter and transfer set placed on. Peritoneal dialysis solution can be transferred in and out of it.

2.6 The process of the research

The research was carried out in two stages.

2.6.1 First stage

All students who participated in the study (experiment and control) were provided with theoretical training supported by pictures about the PD by the power point method in the classroom environment. Theoretical training consisted of learning: the purpose of PD, the patient selection criteria for PD, the insertion method of a PD catheter, characteristics of the PD application room, correct application technique, the materials used in PD application, steps of the PD application, disposal of PD refuse, as well as the points to be considered before, during, and after PD application.

Advice from the Nursing Association for Clinical Simulation and Learning Board (INACLS) Crite- ria were completely applied, including: identification of the requirements, measurable aims, the type of simulation, clinical scenario or situation, authenticity, moderator/facilitator approach to be used in the simulation, prebriefing, debriefing and evaluation steps [17]. The step of testing the design was not conducted and the step of the preparation of the participants were performed by theoretical training and PDASAC form for both groups, by videos for the control group and by demonstration for the experimental group. Learning objectives for theoretical education for the student include: can prepare materials for PD application completely, can start and terminate the PD application with the correct technique, can destroy the refuse with the correct technique. The self-efficacy scale was applied to both groups and the list of PD application steps prepared by the researchers was given to participants at the end of the training. Afterwards, students were randomly divided into control and experimental groups. The experimental and control groups were kept in two different classes so that they would not interact with each other.

2.6.2 Second stage

All students in the experimental group were taken to the waiting room reserved for them. Students were called to the simulation laboratory one by one and the scenario of the patient who came to the emergency unit with metabolic problems and could not perform dialysis by himself were explained to the student. Each student performed the dialysis process on the patient by using PD process steps. Steps of PD application process were demonstrated to the students in the experimental group on the PD simulator in the simulation laboratory. Promotive messages such as “do not touch the head of the catheter,” “make sure that your fingers stay at the line below,” and “be careful where you place your finger,” as well as warning messages such as “this kind of mistake may cause peritonitis” were displayed on the PD simulator during the demonstration.

During the briefing, each student was called from the waiting room and informed about items used for PD such as the clamp, dialysis solution, heating bag of the dialysis solution, weighing scale, IV holder, PD simulator, mini cap, transfer set, handwashing soap, hand disinfectant, paper towel, the surface disinfectant, and the table where the materials would be placed on. The clinical scenario of the patient was explained, and was followed by the skill application. The steps of the process performed by the student during the application were monitored by two observers who were in the same room with the student. The observers obtained the psychomotor skill scores by filling out the PDUBDKL form and the average of the scores given by the two observers was taken.

Debriefing was performed by the students after the application to evaluate their own performances. During this session, students were asked to evaluate their performances during PD application by using a plus/delta method and by answering questions such as “How did you feel during this case?” and “What do you think you did well?” and “What could you make better if you face with such a case again?” The duration of the debriefing was twice as long as the duration of the application. Students who completed the application were asked to fill out a self-efficacy scale in a separate room inside the simulation laboratory. Since the debriefings were performed one-to-one with the students right after the application, no video recordings were performed for the debriefing.

Students in the control group waited in a different room accompanied by a researcher until the end of the application of the experimental group. Students watched videos about PD application while they were waiting. Participants in the control group were taken into the laboratory one by one after the application of the experimental group ended. Students were informed about the scenario of the PD patients who came to the emergency service with metabolic problems and could not perform dialysis on their own. After that, students were asked to perform the dialysis process on the patients by following the PD process steps. The students in the control group were not asked to evaluate themselves through debriefing. Instead, they were told by researchers about the points they should develop themselves.

2.7 Ethical considerations

Ethics approval for this research was obtained from Amasya University, Scientific Ethics Committee in a written manner (no: 15386878-044). Additionally, verbal permission was given by the students who participated in the study in accordance with the principle of willingness.

2.8 Data analysis

The data were uploaded onto the IBM SPSS Statistics version 21.0 (IBM Co., Armonk, NY, USA) software program, and analyzed using the Independent T Test. Statistical significance was set at the level of $p<$ 0.05.

2.9 Limitations of research

The limitations of the research were the inability to simultaneously conduct the application on both the experimental and control groups due to an inadequate number of instructors and PD simulators for the simulated PD application. Furthermore, the “pilot test” step of the INACSL criteria could not be performed since the application was also performed the same day. Theoretical training was provided for the preparation of the participants in both groups. Sources such as books, articles, and Internet resources which would help students to be prepared for the simulation training were not used for this step.

3. Results

When the total scores of psychomotor skills of the students in the experimental and control groups related to PD application were examined, a statistically significant difference was found between the experimental and control groups’ total scores of psychomotor skills related to PD application ( $p<$ 0.01). However, no statistically significant difference was detected between the experimental and control groups in terms of self-efficacy scores ( $p>$ 0.05) (Table 1).

Table 1
Comparison of the total average scores of psychomotor skills and self-efficacy levels of experimental and control group ( $n=$ 28)

Group	$n$	Mean	Median	Minimum	Maximum	SD	$t$	$p^{*}$
PD application psychomotor skill total score
Control	14	41.14	41.00	26.00	52.00	7.78	$-$ 5.3	0.0001
Experimental	14	54.57	55.50	45.00	60.00	5.32
Total self-efficacy score before the PD application
Control	14	30.43	30.00	19.00	38.00	4.57	0.103	0.919
Experimental	14	30.21	30.50	18.00	43.00	6.34
Total self-efficacy score after the PD application
Control	14	32.57	34.50	18.00	40.00	6.94	0.335	0.741
Experimental	14	31.79	33.00	14.00	37.00	5.39

${}^{*}$ T test on independent groups.

When the self-efficacy total average scores of students in the experimental group before and after PD application were compared, ( $p>$ 0.05), the mean scores of self-efficacies after PD were higher than those of PD before application although it was not statistically significant (Table 2).

4. Discussion

Although peritoneal dialysis is a process that allows individuals to be sufficient and independent to self-practice in the home environment, it requires experience and skill since it includes complex processes including the application method, the steps in the application, the application environment, points to be considered before, during, and after the procedure, and so on [1]. Nurses play a major role in providing individuals with the necessary skills and experience about PD [4]. PD nurses need to constantly improve their education methods while considering that the group of patients receiving PD therapy is composed of uremic individuals, and that there may be various learning difficulties of these individuals.

In recent years, simulation training has become increasingly widespread in laboratory applications, and these are indispensable for nursing educations to provide psychomotor skills and experience [18]. Simulation training is an effective teaching method for the transfer of theoretical knowledge to practice, the development of individual skills of students, professional awareness, and skill acquisition [19].

In addition, simulation training is also noteworthy in terms of enabling students to repeat the applications while providing a risk-free and safe environment [20]. In our study on the effects of simulated peritoneal dialysis on the psychomotor skills and self-efficacy of the students, the students in the experimental group were found to have a higher mean score of psychomotor skills than those in the control group.

Table 2
Comparison of the total average self-efficacy scores of the students in the experimental group before and after PD application ( $n=$ 28)

	Experimental group
	$n$	Mean	Median	Minimum	Maximum	SD	$t$	$p^{**}$
Total self-efficacy score before the PD application	14	30.21	30.50	18.00	43.00	6.34	$-$ 0.841	0.416
Total self-efficacy score after the PD application	14	31.79	33.00	14.00	37.00	5.39

${}^{**}$ T test on paired group.

Displaying videos and supporting the narration with pictures besides the theoretical education was not enough for the students to acquire skills. Skill training should be improved by using simulations and models related to the given training. In the literature, while there is no research evaluating simulation trainings related to PD application on nursing students, there are studies which evaluate the effectiveness of simulation in different samples or in different applications [18, 19, 21, 22]. In Fukasawa’s study of hybrid simulation with inexperienced physicians on PD catheter insertion [21], physicians are reported to be 2–4 times more successful in the PD catheter placement procedure with this simulation method. In a study conducted by Sarmasoğlu et al. [18] by using various simulation models, it is stated that the average academic success was similar in the experimental and control groups and the simulation method provided for the students in the experimental group has fostered students’ interest and curiosity in the clinical skill trainings, and contributed to them in terms of learning occupational responsibilities and preparation for the clinical education.

Simulation provides many advantages to the students learning psychomotor skills. These advantages include progressing from simple to complex within the scope of individual limitations without the fear of harming the patient, and providing a safe and controlled environment [23]. Therefore, the students gain experience before meeting with real patients in the clinic by strengthening the skills they learn in such an environment. When the self-efficacy total point averages of the students in this study were examined, it was determined that there was no statistically significant difference between the groups. In a study in which students’ opinions about the simulation method were questioned, it is stated that the subjects used in the simulation training of the students do not react like real patients, and they see themselves as inadequate in pre-clinical skill development areas [24].

In another study on blood pressure measurement, one of the basic nursing skill training lessons, it is stated that the students who are studying the simulation feel more effective in practice [21]. Although our study did contribute to the development of psychomotor skills of students with simulated PD, there was no difference in pre- and post-application self-efficacy perceptions. This can be attributed to the fact that: the evaluation of the student is done by the two observers during the application, the training and evaluation are done on the same day, time is needed for the development of the self-efficacy perception, and that there was a small number of subjects. In the curricula of nursing education in our country, PD is examined in more detail only in elective courses called “dialysis nursing”. In clinical practice students are not allowed to have direct PD connection techniques on patients, preventing students from gaining experience. For this reason, psychomotor skills of students should be developed by using PD simulators in nursing curriculum programs.

In this study, when the self-efficacy total average points of the students in the experimental group were compared before and after PD application; although not statistically significant, it was determined that post-PD average scores were higher than pre-PD scores. It can be said that although the PD application involves complex processes, the simulated training method contributes to the improvement of the students’ self-efficacy for this application. This result may be due to low numbers of subjects.

Simulation models can be effective in the PD connection technique and other topics involved in PD training. That is because simulation training makes it possible to implement environmental controls and standard procedures, and helps the student to practice and correct mistakes without harming the patient. Simulation training includes simulated case studies, analysis of the main causes of adverse outcomes, and continuous updating and improvement of procedures [25]. For this reason, it is important that simulated PD application trainings are not only included in nursing education at undergraduate level but also in certificated PD trainings for clinic nurses, and during in service and orientation trainings. We believe that the nurse who is trained with this model would be more willing to use the same model in patient education or to try new training methods.

5. Conclusion

The demonstration of the PD application with the simulation technique is effective in the development of psychomotor skills. Nurses that practice applications that require very rigorous work, such as PD practice, are recommended to work on PD simulators before working with real patient subjects. Supporting narration with video and pictures alone is not enough. The PD application technique should be taught by simulation to all students in the nursing undergraduate curriculum, not only to dialysis nurses. That is because all nurses have the responsibility to provide education. In future studies, it is suggested to use the simulation training method by screening other topics in PD education content.

5.1 Implications for clinical practice

No matter which clinic nurses work in, there is always the possibility to meet and give care to a PD patient. If PD can be applied with the right technique, infection and complications that can occur during application can be avoided. Simulation PD training methods can be widely used in the certification program of PD nurses to improve practice and technique.

Footnotes

Conflict of interest

None to report.

References

Schaepe

Bergjan

. Educational interventions in peritoneal dialysis: a narrative review of the literature. Int J Nurs Stud. 2015; 52: 882–898.

Tong

Lesmana

Johnson

Wong

Campbell

Craig

. The perspectives of adults living with peritoneal dialysis: thematic synthesis of qualitative studies. Am J Kidney Dis. 2013; 61(6): 873–888.

Finkelstein

Ezekiel

Raducu

. Development of a peritoneal dialysis program. Blood Purif. 2011; 31(1-3): 121–124.

Kalirao

Pederson

Foley

Kolste

Tupper

Zaun

, et al. Cognitive impairment in peritoneal dialysis patients. Am J Kidney Dis. 2011; 57(4): 612–620.

Yıldırım

İlhan

İ"O

. Genel Öz Yeterlilik Ölçeği Türkçe formunun geçerlilik ve güvenilirlik çalışması. Türk Psikiyatri Dergisi. 2010; 21(4): 301–308.

Hsu

Chang

Hsieh

. The effects of scenario-based simulation course training on nurses’ communication competence and self-efficacy: a randomized controlled trial. J Prof Nurs. 2015; 31(1): 37–49.

Mercan

Özcan

Aydın

. Psikiyatride ve iletişim eğitiminde simüle hasta uygulamaları. Psikiyatride Güncel Yaklaşımlar Current Approaches in Psychiatry. 2018; 10(3): 292–30.

Şendir

Doğan

. Hemşirelik eğitiminde simülasyonun kullanımı: sistematik inceleme. FN Hem Derg. 2015; 23(1): 49–56.

Bornais

Janet

Ryan

El-Masri

. Evaluating undergraudate nursing students’ learning using standardized patients. Journal of Professional Nursing. 2012; 28(5): 291–296.

10.

Reid-Searl

Happell

Vieth

Eaton

. High fidelity patient silicone simulation: a qualitative evaluation of nursing students’ experiences. Collegian. 2012; 19(2): 77–83.

11.

Kim-Godwin

Livsey

Ezzell

Highsmith

Winslow

Aikman

. Students like peer evaluation during home visit simulation experiences. Clinical Simulation in Nursing. 2013; 9(11): 535–542.

12.

Tosterud

Hedelin

Hall-Lord

. Nursing students’ perceptions of high- and low-fi delity simulation used as learning methods. Nurse Education in Practice. 2013; 13: 262–270.

13.

Bambini

Washburn

Perkins

. Outcomes of clinical simulation for novice nursing students: communication, confi-dence, clinical judgment. Nursing Education Perspectives. 2009; 30(2): 79–82.

14.

Roh

Lee

Chung

Park

. The effects of simulation based resuscitation training on nurses’ self-efficacy and satisfaction. Nurse Education Today. 2013; 33(2): 123–8.

15.

Jerusalem

Schwarzer

. Self-efficacy as a resource factor in stress appraisal processes. In: Schwarzer

. (ed.). Thought control of action. DC: Hemisphere. 2.nd edn, Washington, USA, 1992; pp. 195-213.33.

16.

Yeşibalkan

Karadakovan

Ünal

. General self efficacy of peritoneal dialysis patients. Nefroloji Hemşireliği Dergisi. 2005; 39–44. in Turkish.

17.

INACSL Standards Committee, INACSL Standards of Best Practice: Simulation

{}^{\text{SM}}

Simulation Design, Clinical Simulation in Nursing 2016; 12: 5–12 http://www.nursingsimulation.org/article/S1876-1399(16)30126-8/fulltext.

18.

Sarmasoğlu

Dinç

Elçin

. Nursing students’ opinions about the standardized patients and part task trainers used in the clinical skills training. Hemşirelikte Eğitim ve Araştırma Dergisi. 2016; 13(2): 107–115. in Turkish.

19.

Erkalp

Çokay Abut

Kitapçıoğlu

Aşık Eren

Aksoy

Yumru

, et al. Simulation education of anaesthesiology and reanimation residents: simmerk® experience of the four years. Göğüs-Kalp-Damar Anestezi ve Yoğun Bakım Derneği Dergisi. 2013; 19(1): 23–30. in Turkish.

20.

Gürol

Balcı Akpınar

Ejder Apay

. The effect of simulation applications on the skill levels of students. Kocatepe Medical Journal. 2016; 17: 99–104. in Turkish.

21.

Karadağ

Çalışkan

Korkut

Göçmen Baykara

Özturk

. The effect of simulation training on the learning of some psychomotor skills by first year nursing students: the case of Turkey. Procedia-Social and Behavioral Sciences. 2012; 47: 781–785.

22.

Fukasawa

. Practice of peritoneal dialysis access education using the new hybrid simulator in Japan. J Vasc Access. 2015; 16(Suppl. 10): 5–8.

23.

Gunberg Ross

. Simulation and psychomotor skill acquisition: a review of the literature. Clinical Simulation in Nursing. 2012; 8: e429–e435.

24.

Terzioğlu

Kapucu

Özdemir

Boztepe

Duygulu

Tuna

, et al. Nursing students’ opinions about simulation method, Hacettepe Üniversitesi Sağlık Bilimleri Fakültesi Hemşirelik Dergisi. 2012: 16–23. in Turkish.

25.

Davidson

Lok

Dolmatch

Gallieni

Nolen

Pittiruti

, et al. Virtual reality: emerging role of simulation training in vascular access. Semin Nephrol. 2012; 32(6): 572–581.