Implementing simulation in oncology emergencies education: A quasi- experimental design

Abstract

BACKGROUND:

High-fidelity simulation (HFS) as a teaching-learning method has increased, especially in medical programs.

OBJECTIVE:

This study was conducted to assess the effectiveness of using HFS on the satisfaction, self-confidence, self-efficacy, and knowledge of undergraduate students in oncology care.

METHODS:

A pre-test post-test quasi-experimental design was utilized. Random sampling technique was used to recruit the participants. The scenarios including septic shock and infusion reaction were implemented. The training program including lectures and the simulation was run in a high fidelity simulation lab.

RESULTS:

There was a significant difference ( $t=-$ 5.95, $p=$ 0.001) between the experimental group ( $M=$ 13.95, $SD=$ 3.35) and the control group ( $M=$ 6.25, $SD=$ 2.65) regarding knowledge, confidence ( $t=-$ 22.75, $p=$ 0.001) between the experimental group ( $M=$ 61.25, $SD=$ 12.10) and the control group ( $M=$ 38.50, $SD=$ 6.20), satisfaction level $t=-$ 18.25, $p=$ 0.001; experimental group – $M=$ 42.25, $SD=$ 4.25; and control group – $M=$ 28.50, $SD=$ 3.15), and there was a significant difference between the experimental group ( $M=$ 35.50, $SD=$ 3.25) and control group ( $M=$ 24.25, $SD=$ 2.85) regarding self-efficacy ( $t=-$ 13.25, $p=$ 0.001).

CONCLUSIONS:

High-fidelity simulation in nursing increased student knowledge, self-confidence, satisfaction, and self-efficacy in managing septic shock and infusion reaction as common oncology emergencies.

Keywords

Clinical simulation confidence satisfaction knowledge self-efficacy

1. Introduction

Nursing education is considered a practice-based profession. Having qualified graduates depends on the quality of their clinical training and level of competencies they achieve [1]. Undergraduate nursing education has been facing numerous challenges due to shortage of academic and clinical staff compared to the increased number of students, limited clinical placements, and use of highly developed technology in the clinical field [2, 3, 4].

Recently, using HFS as a teaching-learning method has increased, especially in medical programs. It enhances and increases the students’ chances to practice their skills with no direct harm to real patients, it shows reality, increases clinical competencies, promotes inter-professional communication, increases clinical standardisations, improves clinical judgment skills, and encourages beneficial feedback [5, 6, 7, 8]. It has been identified as a pivotal method in nursing programs worldwide and should account for approximately 20% of the total learning methods [9].

Considerable number of literature exists regarding the utilization of simulation in nursing education. However, limited literature related to use of simulation in oncology education [10]. Importantly, cancer remains a leading cause of death worldwide, it is the second highest cause of mortality after cardiovascular disorders, and one of the most common disorders among adults [11]. Accordingly, as the number of cancer patients increases, the need for qualified professionals, particularly nurses, is increasing as well. In general, nursing schools are preparing students to be general nurses with no specialised training on cancer management, whereas this could include a wide scope of oncology fields. Therefore, students graduate unprepared to manage the common emergencies of cancer patients [11]. Consequently, nurse educators must utilize simulation to prepare the graduate nurse with essential knowledge, confidence, and competencies to manage oncology patients effectively [10].

Managing patients with cancer can be a challenge for nurses due to the nature of the disease and complications of the treatment modalities [12]. Oncology patients were being admitted to the hospital for management of the different oncology emergencies such as septic shock, infusion reaction, tumor lysis syndrome, and spinal cord compression [13]. Importantly, since nurses are primary care provider, their knowledge, self-confidence, and efficacy are vital in providing patients with the optimal care and enhance the prognosis [14].

Hospital administration face a huge challenge with newly employed nurses in oncology units, as they need to ensure that the staff has the required competencies to provide optimal and safe care. Thus, nurses require continuous training programs to shape and enrich their competencies and skills. Preparing undergraduate nursing students with such essential skills will help them to advance their competencies and skills [15, 16].

Intensive research has been conducted regarding use of simulation in nursing education, the majority of them in critical care units. These studies highlighted the advantages and positive impact on advancing nursing knowledge, skills, critical thinking approaches, and improving competencies [17, 18, 19]. Despite the previous advantages of using HFS in nursing education, there is a substantial need for evidence from Middle-East countries as the majority of these studies were conducted in Western countries. In fact, there is a difference in the education system between the western system and the system implementing in the Middle-East countries. In the western system, the students are expected to be independent, informal way of communication, students are more initiatives, and learning is student-centered approach. In the other site, the education system in Middle-East, the teachers take control of the teaching, using formal way of communication, students usually do not question or challenge their instructors, and learning is teacher-centered approach [20]. Thus, it is necessary to evaluate the effectiveness of using HFS in a different education system such as in the Middle-East countries.

Increasing demand for qualified nurses with safe practice in clinical settings forces researchers to conduct experimental studies to assess the effectiveness of using HFS among nursing students. Additionally, limited literature exists related to using simulation in training of oncology nurses.

1.1 Conceptual framework

Kolb’s Experiential Learning Theory (1984) supported this study to evaluate the effectiveness this study was conducted to assess the effectiveness of using HFS on the satisfaction, self-confidence, self-efficacy, and knowledge of undergraduate students in oncology care. In his theory, balanced learning among students can be achieved through providing different experiences within the learning environments [21]. Using HFS in education promotes students’ cognitive, affective, and psychomotor skills, resulting deeper understanding and learning [21].

2. Aim

This study was conducted to assess the effectiveness of using HFS on the satisfaction, self-confidence, self-efficacy, and knowledge of Middle-East undergraduate nursing students.

3. Methods

3.1 Design

A pretest-posttest quasi-experimental design was used to assess the effectiveness of using HFS on the satisfaction, self-confidence, self-efficacy, and knowledge of undergraduate students in oncology emergencies care.

3.2 Data collection and analysis

3.2.1 Sampling and participants

A simple random sampling technique was used to recruit the participants from the fourth year nursing students. A computer list of all students enrolled in the fourth year courses from all sections was generated. Students enrolled in the critical care nursing course were admitted to the College of Nursing and had successfully completed a physical assessment course, fundamentals of nursing course, and adult I and adult II nursing courses were eligible to participate. A list of 95 students was generated. Then, the sample was selected randomly to participate. The inclusion criteria were all students in the critical care nursing course were included in the study. The students who missed one of the previous nursing courses were excluded.

A power analysis for $t$ -test was calculated to determine the estimated sample size [22]. Sample of 60 students (30 students per group) was estimated with an effect size of 0.5, alpha at 0.05, and a power of 0.80. Thirty-five students participated as the experimental group and 35 students participated as the control group.

3.2.2 Instruments

Demographic data including students’ gender, age, and GPA were collected in the current study. Students’ knowledge was assessed by using a knowledge test. Twenty multiple choice questions were developed by the researcher to test the students’ knowledge level pre- and post-intervention. The test included comprehension, application, and analysis level questions. The questions emerged from the related text book and literature. Questions for the test were developed and accompanies with Mosby’s oncology nursing advisor: A comprehensive Guide to clinical practice [23]. This is the required textbook for the oncology nursing course. Face and content validity were measured by the researcher with consultation with three experts in the field in both clinical and academic fields of oncology nursing [24].

Students’ self-confidence was assessed by using the self-confidence scale. The instrument developed by Hicks (2006) was used in the current study. The scale consists of 13 items with a five points Likert scale (1 $=$ strongly agree, 5 $=$ strongly disagree) measuring the students’ self-confidence. The scale was valid and reliable per Cronbach’s alpha, 0.96 [5].

Furthermore, students’ satisfaction was measured. The scale consisted of 23 items was used. It was developed by NLN (2006). This scale was valid and reliable with Cronbach’s alpha of 0.94 [25].

Finally, self-efficacy was assessed. A 10 items scale developed by Schwarzer and Jerusalem was used to measure the students’ self-efficacy. The scale was reliable and valid with Cronbach’s alpha of 0.80 [26].

3.2.3 Intervention and scenarios development

The current study was conducted in the simulation laboratory at the School of Nursing between January and March 2018. The unit has an advanced simulator. The simulator is high-fidelity with all necessary features such as hemodynamic status monitor to measure blood pressure, heart rate, ECG rhythm, respiratory features, and simulator voice.

The scenarios were developed by the researcher based on the real patient situations and accompanies with algorithms used by Kuhrik et al. [15]. Once the algorithms were draw up, they were evaluated by a panel of experts (holding PhD and Masters in Nursing); in addition, they have good experience in both academic and clinical fields of nursing. Furthermore, the scenarios were piloted on 10 students for the applicability and relevancy. The scenarios covered the septic shock management and chemotherapy infusion reaction. The two simulation scenarios were carefully chosen based on the previous literature. The literature indicated that sepsis and infusion reaction are the most common emergencies among cancer patients, and require complex treatment and care from nurses [27, 28, 29].

The researcher developed and delivered the lectures and demonstrated the nursing care plan for the participants. The content covered the essential and required knowledge regarding advanced nursing interventions to manage the proposed scenarios. The content of the current program was developed based on valid literature, text books in oncology care nursing, and reviewed by the panel of experts in oncology care nursing [23]. The scenarios lasted about twenty minutes and the debriefing about thirty minutes. The control group was taught in a traditional face-to-face setting, and demonstration and re-demonstration approach.

3.2.4 Data analysis

Collected data was analyzed using SPSS version 23. Descriptive analyses were used to describe the sample characteristics of the nursing students. An independent $t$ test was used to examine the difference between the students’ knowledge scores before and after the interventional session. In addition, paired $t$ test was run to examine if there were significant differences between the mean pretest and posttest scores in knowledge, self-efficacy, satisfaction, and self-confidence.

4. Results

4.1 Sample characteristics

Seventy nursing students participated in the current study (50 females and 20 males). Mean age was 21.3 years ( $SD=$ 0.95), the mean GPA was 70.2 ( $SD=$ 6.31) (Table 1).

Table 1
Sample characteristics and pretest for experimental and control groups ( $N=$ 70)

Variable	Mean and standard deviation (pretest):	Mean and standard deviation (pretest):
	experimental group ( $N=$ 35)	control group ( $N=$ 35)
Age (year)	21.3 (1.80)	21.5 (1.90)
Gender
Male	8	9
Female	27	26
GPA	70.2 (6.10)	69.8 (5.85)

4.2 Reliability coefficients for study instruments

The knowledge instrument, self-confidence in learning, and overall OSCE score were assessed for internal consistency, using Cronbach’s alpha. The results show that the instruments were reliable (Table 2).

Table 2
Reliability coefficients for study instruments ( $N=$ 70)

Instrument	Number of items	Cronbach’s alpha
Knowledge test	20	0.82
Self-confidence	13	0.88
Satisfaction	23	0.85
Self-efficacy	10	0.91

4.3 Homogeneity of the participants from both groups

An independent $t$ test was conducted to assess the homogeneity of the participants from both groups. The results showed no significant differences in terms of age, gender, GPA, pretest knowledge, self-efficacy, satisfaction, and self-confidence between the participants (Table 3).

Table 3
Homogeneity of the participants characteristics and pretest for experimental and control groups ( $N=$ 70)

Variable	Mean and standard deviation (pretest):	Mean and standard deviation (pretest):	$p$ value
	experimental group ( $N=$ 35)	control group ( $N=$ 35)
Age (year)	21.3 (1.80)	21.5 (1.90)	0.71
Gender			0.62
Male	8	9
Female	27	26
GPA	70.2 (6.10)	69.8 (5.85)	0.58
Knowledge	6.50 (1.85)	5.96 (1.75)	0.42
Self-confidence	22.5 (2.52)	21.8 (2.15)	0.35
Satisfaction	28.5 (3.25)	27.6 (3.10)	0.56
Self-efficacy	23.2 (2.31)	22.8 (2.21)	0.86

4.4 Knowledge, self-confidence, satisfaction, and self-efficacy post the intervention

Table 4 shows the research outcomes. Following the educational simulation interventional program, the difference in knowledge, self-confidence, satisfaction, and self-efficacy was significant between the experimental and control groups.

There was a significant difference ( $t=-$ 5.95, $p=$ 0.001) between the experimental group ( $M=$ 13.95, $SD=$ 3.35) and the control group ( $M=$ 6.25, $SD=$ 2.65) regarding knowledge. Furthermore, the results showed a significant difference ( $t=-$ 22.75, $p=$ 0.001) between the experimental group ( $M=$ 61.25, $SD=$ 12.10) and the control group ( $M=$ 38.50, $SD=$ 6.20) regarding confidence in managing cancer patients with sepsis and infusion reaction. In addition, an independent $t$ test showed a significant difference between the two groups regarding satisfaction level ( $t=-$ 18.25, $p=$ 0.001; experimental group – $M=$ 42.25, $SD=$ 4.25; and control group – $M=$ 28.50, $SD=$ 3.15). Finally, there was a significant difference between the experimental group ( $M=$ 35.50, $SD=$ 3.25) and control group ( $M=$ 24.25, $SD=$ 2.85) regarding self-efficacy ( $t=-$ 13.25, $p=$ 0.001) (Table 4). In summary, the results showed that student knowledge, self-confidence, satisfaction, and self-efficacy were high at the posttest phase after the educational program compared with the pretest results. In addition, the results of the experimental group were higher than the results of the control group. This strongly indicates the positive impact of the educational program using simulation strategies.

Table 4
Mean difference in the posttest for knowledge, satisfaction, self-efficacy, and self-confidence ( $N=$ 70) in experimental and control groups

Variable	Mean and standard deviation (posttest):	Mean and standard deviation (posttest):	$t$	$p$ value
	experimental group ( $N=$ 35)	control group ( $N=$ 35)
Knowledge	13.95 (3.35)	6.25 (2.65)	$-$ 5.95	0.001
Self-confidence	61.25 (12.10)	38.50 (6.20)	$-$ 22.75	0.001
Satisfaction	42.25 (4.25)	28.50 (3.15)	$-$ 18.25	0.001
Self-efficacy	35.50 (3.25)	24.25 (2.85)	$-$ 13.25	0.001

5. Discussion

Future nurses require advanced training as the number of patients with chronic illness such as cancer is increasing. Oncology nurses require advanced knowledge and competencies in order to provide patients with optimal care [30]. Oncology nurses face challenges during their intervention due to the characteristics of cancer and the related complications [31]. However, as nurses’ knowledge and competencies have increased, more oncology patients are receiving better care [31]. Since nurses are the primary bedside care providers, continued education regarding patient’s management is highly important. Gordon and Buckley stated that using HFS in clinical training for nurses developed their skills and competencies in early assessment, prioritises nursing actions, and implements immediate interventions, and this improves patient care and prevents deterioration [32].

This study was conducted to assess the effectiveness of using HFS on the satisfaction, self-confidence, self-efficacy, and knowledge of undergraduate students in oncology care. The results of the current study demonstrated that nursing students who participated in the simulation program showed improvement in their knowledge, satisfaction, self-confidence, and self-efficacy compared with students from the control group.

To the author’s knowledge, limited research has been conducted to assess the impact of using simulation teaching techniques on undergraduate nursing students’ knowledge, confidence, satisfaction, and self-efficacy, particularly regarding oncology care. Indeed, the need for qualified nurses able to care for cancer patients is increasing as the number of cancer patients is increasing worldwide. Thus, this study showed a positive impact on students’ performances when using simulation as a teaching method.

The findings from the current study supporting previous studies conducted to assess the impact of using simulation in teaching on nursing students, mainly in nursing critical care patients, and showed a positive effect of using simulation methods in nursing education [33] and encourages knowledge acquisition and critical thinking for nursing students learning critical care [17, 34]. Using simulation increasing the students’ knowledge compared with the face-to-face method of teaching, this might be related to the realistic learning environment, which increases cognitive ability of the students, the interactive learning sphere, active engagement in patient care, and using visual, auditory, and tangible learning methods [6, 8, 35].

Patients feel secure and safe when being cared for by knowledgeable nurses [36]. Cancer patients suffer from physical and psychosocial difficulties during their treatment. Previous studies indicated that patients with cancer stated that nurses’ knowledge and skills was the greatest indicator for better care [36]. In addition, patients defined nurses as health professionals; professional was defined as standard nurses’ knowledge, skills, and behaviours [37]. However, general nursing staff reported a lack of knowledge and skills regarding cancer care and treatment modalities, this affected their care for cancer patients and families [38]. Thus, enriching undergraduate nursing students’ knowledge and advancing their skills will improve their care for cancer patients. The results of the current study showed that students’ knowledge improved after the intervention. Thus, improvement in future nurses’ knowledge will improve their care for cancer patients.

Moreover, the results of the current study demonstrated increases in students’ self-confidence levels after using simulation. Regardless of the different competencies and different fields of care, the results of this study support previous studies conducted to assess the confidence level during caring of critical care patients [6, 8, 9, 17]. Using simulation in teaching strengthens students’ fundamental skills, creates a safe environment for practice, and increases opportunities to repeat the procedures; thus, it will increase self-confidence [1, 6, 39].

In the current study, students’ confidence was improved. They felt more confident that they are able to take care of cancer patients, asses them, and implement appropriate interventions. Being able to address physical and emotional demands of cancer patients is considered a challenge for inexperienced, new nurses [11]. Thus, it’s highly important to increase students’ confidence, this will contribute positively to the quality of care [11]. Willingness and motivation to deal, care, and manage cancer patients requires not only knowledge, but confidence also.

Students’ satisfaction increased after using the simulation session. The current results indicated increased student satisfaction with their leaning method, particularity using simulation. This might be related to the effective and interactive approach, which gives them clear explanations, ideas, and competencies they should achieve. These results are congruent and support other findings showing that regardless of different competencies that had been achieved, the principles of using simulations are similar [40].

Self-efficacy was defined as ability of people to accomplish their tasks successfully and competently. In addition, an enhanced ability to control complex situations was revealed. The learner feels control over the learning outcomes and objectives. Most of the previous studies assessed self-efficacy related to chronic illness and health promotion behaviours such as smoking cessation. Limited studies were conducted to investigate this concept in nursing education. The results of the current study indicate that using simulation in nursing education increases students’ self-efficacy. These findings add to the existing knowledge regarding the positive impact of using simulation in nursing education. These findings support the recent study examining self-efficacy in nursing education [39]. Saied conducted a study to investigate the impact of simulation on paediatric nursing students’ self-efficacy. The students showed higher levels of self-efficacy after the simulation session [39].

Increasing nurses’ self-efficacy will improve the quality of care provided to cancer patients. Increasing self-efficacy will increase nurses’ ability to provide care needs, structure a positive energy environment, and make patients comfortable, all enhancing patients’ quality of life. Furthermore, it will encourage nurses to develop their skills and knowledge to meet patients’ demands and provide better care [41]. The effect of nurses’ attitude and behaviours has great influence on patient outcomes. The previous literature showed that if nurses’ attitude towards cancer patients was negative, patient outcomes will be negatively affected [11].

This study addressed the effectiveness of using HFS to improve care for cancer patients by improving undergraduate nursing students’ knowledge, self-confidence, satisfaction, and self-efficacy. Because the number of patients with cancer is increasing, it is necessary for nurses to equip themselves with the necessary skills and knowledge to provide cancer patients with optimal care. Enhancing nurses’ self-efficacy and satisfaction is related to cancer care. According to social cognitive theory, nurses having a high level of self-efficacy will provide patients with better care [41]. Proving continued cancer education leads to enhances nurses’ knowledge, satisfaction, self-confidence, and self-efficacy, and this will improve the quality of care and positively influence cancer patient outcomes.

6. Conclusion

Oncology nursing is a challenging profession due the nature of cancer and its related complications and impact on patients and their families. It’s highly important to prepare competent nurses able to provide care to all patients with cancer.

Improving nursing students’ knowledge, self-confidence, satisfaction, and self-efficacy will influence the patient outcomes and improve quality of care. The results of the current study indicate that using HFS in nursing education is an effective teaching and learning modality that increases these variables. These results will open the eyes of nursing educators and stakeholders to increase use of such modalities in all nursing courses, and it should be integrated in the nursing curriculum and continue education for new graduate nurses specially in managing oncology emergencies.

However, the current study has some limitations including the small sample size, single institution, and it focused only on fourth year nursing students. Further researches with large sample sizes and multi-institutions from different years will enrich our understanding of the effectiveness of using HFS in nursing education.

6.1 Summary statement

What is already known about this topic:

Undergraduate nursing education has been facing numbers of challenges due to shortage of academic and clinical staff.

Utilization of simulation in nursing education has been increased. However, limited literature related to use of simulation in oncology education.

Sepsis and infusion reaction are the most common emergencies among cancer patients, and require complex treatment.

What this paper adds:

Using High-fidelity simulation (HFS) increasing the nursing students’ readiness for managing cancer patients with septic shock and infusion reaction complications.

Using High-fidelity simulation (HFS) increasing the nursing students’ knowledge, self-confidence, satisfaction, and self-efficacy in managing patients with oncology emergencies.

Increasing nurses’ knowledge, self-confidence, satisfaction, and self-efficacy can improve the quality of care provided to cancer patients.

The implications of this paper:

Nursing educators and stakeholders to increase use of such modalities in all nursing course.

Further research with further scenarios such as chemotherapy spill and extravasation has been recommended.

Using simulation in nursing education should be adopted in the hospitals also.

Footnotes

Acknowledgments

The author would like to thank the participants for their effort and time. This research was carried out by the principle investigator while on sabbatical leave from AL Zaytoonah University of Jordan for the academic year (2017/2018).

Conflict of interest

None to report.

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