The selection of tools within a study is a critical aspect. The primary means of designating effective tools for use in a study is through the use of validity and reliability. Look at the tools used in this study. Were the tools valid? How were they validated? If validated, is the validation a strong validation or not? Justify your answers. (Use two sources: journal for nurses in professional article below and introduction to nursing research incorporation evidence based practice boswell, c, and Cannon,S (2017) APA FORMAT ) Disher, J., Burgum,, A., Desai, A., Fallon, C., Hart, P., & Aduddell, K., (2014). The effect of unit-based simulation on nurses’ identification of deteriorating patients. Journal for Nurses in Professional Development, 30(1), 21-28. The Effect of Unit-Based Simulation on Nurses” Identification of Deteriorating Patients Abstract Patients are admitted to healthcare organizations with multiple, complex conditions that can lead to acute deterioration events. It is imperative that nurses are adequately trained to recognize and respond appropriately to these events to ensure positive patient outcomes. The purpose of this pilot research study was to examine the effects of a unit-based, high-fidelity simulation initiative on cardiovascular step-down unit registered nurses” identification and management of deteriorating patients. In today”s nursing practice environment, nurses are faced with patients with multiple, complex conditions that can change rapidly leading to an acute patient deterioration (APD) event (Bright, Walker, & Bion, 2004). Patients often exhibit early warning signs before APD events (Fuhrmann, Lippert, Perner, & Ostergard, 2008; Kause et al., 2004), but research supports that early warning signs are not always identified by healthcare providers and/or, if identified, are not addressed in an appropriate time frame (Hillman et al., 2005; Thompson et al., 2008). Multiple factors have been cited as reasons for failure to recognize and respond appropriately to APD events including lack of knowledge and skills, lack of confidence to handle APD events, not monitoring vital signs (VS) routinely, failure to seek assistance, communication failures, and confusion regarding role responsibilities (National Patient Safety Agency, 2007). As the acuity of patients increases, it becomes imperative that registered nurses (RNs) perform frequent assessments and intervene appropriately when patients” conditions began to deteriorate (Cooper et al., 2010). These interventions include providing appropriate care to stop the deterioration such as consultation with advanced practice nurses and/or physicians, ensuring/evaluating that the health plan is being implemented, and/or determining if transfer to critical care areas for higher level nursing care is required. The use of simulation as a teaching method assists nurses to improve their assessment skills and response to patient decline in a timely and knowledgeable manner (Cooper et al., 2010). The purpose of this pilot research study was to examine the effects of a unit-based, high-fidelity simulation initiative on cardiovascular step-down unit RNs” identification and management of deteriorating patients. LITERATURE REVIEW Patient Deterioration Patient deterioration is the failure to achieve an optimum patient outcome when an event is triggered (Lim, 2009). Studies document that incorrect identification and management of the deteriorating patient is a major health problem that often leads to life-threatening patient outcomes (Bright et al., 2004; Cioffi, Salter, Wilkes, Vonu-Boriceanu, & Scott, 2006; Peters & Boyde, 2007). RNs have been identified as the first-line professionals able to assess and determine patient deterioration (Tait, 2010). RNs” abilities to assess patient deterioration are affected by institutional support, confidence level, expertise, available deterioration tracking tools, and effective healthcare teamwork (Tait, 2010). Recent research documents that using simulation scenarios related to the deteriorating patient is a potential method for enhancing RNs” abilities to recognize signs and symptoms, intervene early, and seek appropriate assistance (Liaw, Rethans, Scherpbier, & Piyanee, 2011). Simulation High-fidelity simulation is the use of technology to create realistic patient situations with mannequins that respond and produce physiological changes to treatment interventions allowing healthcare providers to practice decision-making skills and procedures in a safe environment (Gordon, Oriol, & Cooper, 2004). On the other hand, low- to medium-fidelity simulation deals with task trainers that focus on specific anatomical areas that allow individuals to gain or validate psychomotor, assessment, or diagnostics skills by segmenting complex skills into smaller sections (Decker, Sportman, Puetz, & Billings, 2008). Simulation provides active learning that engages the learner emotionally, potentially stimulating a deeper cognition, and providing immediate feedback (LaVelle & McLaughlin, 2008). Gore, Hunt, and Raines (2008) indicated that simulation with predetermined scenarios allows for a safe, supportive learning environment for all knowledge and skill levels, without fear of mistakes that could cause negative outcomes or harm to patients. Various authors (Shapiro et al., 2004; Siassakos et al., 2009; Wallin, Meurling, Hedman, Hedegard, & Fellander-Tsai, 2007) have identified that simulation education in healthcare provides evidence of increased confidence and competence with improved team work skills. In addition, simulation education promotes critical thinking and a dramatic decrease in anxiety in selected patient scenarios (Cannon-Diehl, 2009; Gore et al., 2008; LaVelle & McLaughlin, 2008). In systematic reviews by Cant and Cooper (2010) and Harder (2010), the researchers reported that simulation is an effective method of teaching and learning with statistically significant improvements in nurses” knowledge, skills, critical thinking, and confidence levels Nursing professional specialists have incorporated the use of simulation in patient safety initiatives (Paparella, Mariani, Layton, & Carpenter, 2004), cardiac arrest training (Carpico & Jenkins, 2011; Huseman, 2012), rapid response team training (Kegler, Dale, & McCarthy, 2012), competency assessment (Landry, Oberleitner, Landry, & Borazjani, 2006; Lengetti, Monachino, & Schmoltz, 2011), teamwork and communication building (Kuehster & Hall, 2010; Merchant, 2012), and staff orientation (Ackermann, Kenny, & Walker, 2007; Beyea, Reyn, & Slattery, 2007). Positive outcomes have been shown in time to start chest compressions and defibrillation (Huseman, 2012), increased knowledge and comfort levels in activating rapid response teams (Kegler et al., 2012), improved teamwork and communication (Kuehster & Hall, 2010; Merchant, 2012), and improved skill competencies (Landry et al., 2006; Lengetti et al., 2011). In addition, simulation has been well received by nursing staff who enjoy hands-on, experiential learning in a safe, stimulating environment (Nickerson, Morrison, & Pollard, 2011). However, in a systematic review conducted by Hallenbeck (2012), little evidence exists that supports that the acquisition of skills, increased confidence, and increased knowledge obtained through simulation training translates into safer patient care and better patient outcomes. Further research is needed to investigate the effect of simulation training on actual patient care and patient outcomes. Unit-Based Simulation Most research studies (Cant & Cooper, 2010; Harder 2010) using high-fidelity simulation have been conducted in formal simulation centers. Because it is vital to provide realistic, meaningful, and informative educational programs that are cost-effective and focus on improving nursing skills and competences, unit-based simulation is a proven strategy. An example is the use of unit-based low- and high-fidelity simulation scenarios in teaching nursing staff skills, competencies, and roles in cardiac arrest situations (Baker & Tyler, 2011; Keys et al., 2009; Kilday, Spiva, Barnett, Parker, & Hart, 2013). Additional benefits of conducting unit-based simulation education includes teaching unit staff to reallocate unit resources to ensure coverage of all unit patients, improved communication among all unit personnel, and location of unit resources such as oxygen equipment and supplies (Baker & Tyler, 2011; Keys et al., 2009). THEORETICAL FRAMEWORK The framework for this study is based on Jeffries” (2007) Nursing Education Simulation Framework that includes five conceptual components: teacher, student, educational practices, simulation design, and expected outcomes. The model indicates that outcomes are directly related to the student/teacher characteristics and educational practices. The model also depicts that these outcomes are mediated by simulation design, which is defined in this study as the National League for Nursing simulation scenario with specific objectives and debriefing requirements. Jeffries proposed that participants not only learn using these five conceptual components but also retain knowledge creating self-satisfaction and confidence in their abilities. Thus, the premise is that participants taking part in this study will not only learn from the experience but will also become more confident, satisfied, and knowledgeable. RESEARCH QUESTIONS The following research questions were under investigation: 1. What is the effect of using unit-based, high-fidelity simulation as an educational tool on RNs” knowledge levels in handling acute respiratory deteriorating patients on step-down cardiovascular units in a community hospital? 2. What is the effect of using unit-based, high-fidelity simulation as an educational tool on RNs” self-confidence levels in handling acute respiratory deteriorating patients on step-down cardiovascular units in a community hospital? Method Design and Sample A pilot study using a quasi experimental design with an interventional preâ€“post method was used. The intervention consisted of a unit-based, high-fidelity simulation scenario depicting a patient with chronic obstructive pulmonary disease in respiratory distress followed by a debriefing session. Preintervention questionnaires were completed by participants to determine their baseline level of knowledge and self-confidence and, after the intervention, to determine the effectiveness of the unit-based, high-fidelity simulation intervention. The recruitment pool consisted of all nurses working on the step-down cardiovascular nursing units. Inclusion criteria included being a nurse working on one of the step-down cardiovascular units and being employed for at least 6 months. Participants completed the high-fidelity simulation intervention on a nursing unit to replicate a â€œrealâ€ experience within their normal work environment and depict a patient situation that was realistic for the types of patients cared for on their units. Scenario Development and Preparation The National League for Nursing (2009) simulation scenario, chronic obstructive pulmonary disease (COPD)â€”oxygen therapy, was chosen for the education intervention scenario. The scenario depicted a patient with COPD in moderate to severe respiratory distress. The expectations of the nurses participating in the scenario were as follows: (1) implements a focused respiratory assessment, (2) evaluates patient assessment information including VS, (3) recalls indications and contraindications for oxygen therapy, (4) recognizes signs and symptoms of respiratory distress, (5) shows effective teamwork, and (6) implements correct treatment for respiratory distress in a timely manner. To ensure consistency in conducting the simulation scenarios, the four NPD specialists attended a 4-hour simulation and debriefing workshop conducted by a simulation expert trained on the SimMan 3G simulator at a Laerdal training session. The purpose of the workshop was to prepare and educate the NPD specialists on the logics of the COPD scenario, functions of the SimMan 3G simulator, and the use of the SimMan â€œstudentâ€ computer. During the workshop, the NPD specialists developed a scripted orientation simulation document that outlined the purpose and procedures for conducting the simulation session. In addition, a scenario run-through was conducted on the nursing unit where the actual simulation education intervention was conducted. During the scenario run-through, the NPD specialists set up the simulation room with appropriate equipment, practiced the scenario script, confirmed computer settings for the simulator, reviewed assigned roles, and participated in an actual debriefing session. The four NPD specialists also did practice run-throughs with each other in the various roles of participant, facilitator, and simulation computer controller. Furthermore, the simulation expert attended the first simulation session to provide guidance and feedback on conducting the simulation scenario and debriefing session. Education Intervention Procedure A letter, as well as flyers, was distributed to RNs working on both step-down cardiovascular units explaining the purpose of the study. During March 2012, four 6-hour time segments were allocated to conduct the intervention. Two 6-hour segments occurred during the day shift, and two 6-hour segments occurred during the night shift. Nurses were asked to select and sign up for one of the sessions. The intervention consisted of a 15- to 20-minute scenario of a patient with COPD experiencing respiratory distress followed by a 20-minute debriefing session. The simulation and debriefing sessions were conducted on the nursing unit in an empty patient room. Groups of two step-down cardiovascular unit RNs participated in the simulation and debriefing sessions each time. The NPD specialists worked in groups of two. One specialist recorded interventions initiated by participants during the simulation on the instructor-controlled computer. The SimMan â€œstudentâ€ computer also recorded actions of the participants during the simulation. The second NPD specialist facilitated the simulation scenario. At the beginning of the simulation session, nurses were provided an intervention packet consisting of the informed consent, preassessment questionnaires, simulation patient information card, and postassessment questionnaires. The NPD specialists reviewed the informed consent with the participants and answered all questions before consent. Next, participants completed the preassessment questionnaires including the demographic, knowledge, and confidence questionnaires. Participants were provided an orientation to the simulation experience and were instructed on the functions of the SimMan 3G simulator. The NPD specialists then provided the participants with information about the patient”s history and presentation. The scenario was started at this point, and the simulator responded to the actions of the nurses. During the debriefing sessions, nurses were asked to discuss what went well and to identify areas for improvement in the future. The debriefing discussion focused on the recognition of signs and symptoms of patient deterioration by physical assessment, interpretation of VS, prompt interventions to avoid further deterioration, and evaluation of interventions based on participants” performance. Once the debriefing session was completed, the participants completed the postassessment questionnaires. PROTECTION OF HUMAN PARTICIPANTS Approval was obtained from the hospital”s Nursing Research Committee and Institutional Review Board for the Protection of Human Subjects. Before the beginning of data collection, written informed consent was obtained from each participant. Participants were provided with a $10.00 gift card for participation in the research study. This small honorarium was provided to acknowledge participants” time and effort as a form of respect for their willingness to participate in the study (Groth, 2010). DATA COLLECTION PROCEDURE Instruments A demographic questionnaire, knowledge instrument, and self-confidence scale comprised the instruments for the study. The demographic questionnaire included questions related to academic preparation, certification, and years of practice. Instruments A demographic questionnaire, knowledge instrument, and self-confidence scale comprised the instruments for the study. The demographic questionnaire included questions related to academic preparation, certification, and years of practice. Self-confidence scale The 12-item self-confidence scale (Hicks, Coke, & Li, 2009) measures self-confidence in caring for patients in acute deterioration. The questionnaire measures four dimensions: (a) accurately recognizing a change in patient”s condition, (b) performing basic physical assessments, (c) identifying basic nursing interventions, and (d) evaluating the effectiveness of interventions during acute deterioration. The items are rated on a Likert response scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating greater self-confidence. Internal consistency reliability has been shown in previous studies with Cronbach”s alphas at 0.93 and 0.96. The responses to all items on the questionnaire were averaged to obtain a mean score. Permission to use the instrument was obtained. DATA ANALYSIS Data were analyzed with descriptive and inferential statistics using SPSS for Windows Release 18.0. Preanalysis data screening was conducted before statistical analysis. Dependent t tests were conducted to examine participants” knowledge and self-confidence levels before and after the intervention. RESULTS Sample Twenty-three cardiovascular step-down unit nurses participated in the pilot study. Years experienced as a nurse ranged from 1 to 34 years (M = 11.88 years, SD = 11.21 years; see Table 2). Most participants held a baccalaureate degree (60.9%). A little over half (52.2%) were certified by a national organization, and 56.5% were members of a professional organization. Gender and ethnic background data were not collected. Knowledge The mean preintervention knowledge score was 72.73 (SD = 13.52), and the mean postintervention knowledge score was 81.82 (SD = 11.81; see Table 3). Postintervention knowledge levels were significantly higher compared with preintervention knowledge levels (t(22) = -3.097, p < .01). Self-confidence The mean preintervention self-confidence score was 4.40 (SD = 0.42), and the mean postintervention self-confidence score was 4.59 (SD = 0.39; see Table 3). Postintervention self-confidence levels were significantly higher compared with pre intervention self-confidence levels (t(22) = -3.172, p < .01). DISCUSSION The findings of this pilot study support the use of unit-based, high-fidelity simulation as an effective training approach for bedside nurses. As in other research, knowledge scores improved significantly after training compared with before training (Alinier, Hunt, Gordon, & Harwood, 2006; Brannan, White, & Benzanson, 2008; Kilday et al., 2013; Linden, 2008). During debriefing sessions, nurses were able to review their performance and identify key learning opportunities. One key learning opportunity was the identification of early warning signs/symptoms instead of waiting for late signs/symptoms of deterioration. Education focused on establishing trends in the changes in respiratory and heart rates to identify patients in the early stages of deterioration and to act quickly in seeking assistance to prevent further deterioration. Another key learning opportunity was the consequences of using high-flow oxygen in patients with COPD. Education focused on the importance of conducting physical assessments, evaluating vital sign changes such as pulse oximetry readings, and understanding the role of oxygen and carbon dioxide levels in making appropriate decisions for oxygen therapy in patients with COPD. Engaging in active, experiential learning versus a lecture/didactic format provided an environment for learning that was conducive to real-time feedback about performance and identification of teachable moments that focused on knowledge deficits. Self-confidence levels were significantly higher after the simulation training compared with self-confidence levels before the training. This finding is also consistent with the literature (Brown & Chronister, 2009; Jeffries & Rizzolo, 2006). Nurses participating in the simulation training were able to engage in â€œhands-onâ€ care to practice and critique their assessment skills and intervention strategies leading to a greater comfort in caring for actual patients experiencing acute deterioration. Participating in a safe, simulated environment allowed nurses to practice their decision-making and technical skills without fear of harming patients to hone their skills and build their self-confidence in handling APD situations. In addition, benefits and challenges in conducting unit-based, high-fidelity simulations were identified. A benefit in conducting unit-based, high-fidelity simulation training was that the education training occurred in an actual work environment allowing nurses to learn in a â€œreal lifeâ€ setting instead of an artificial laboratory environment. This strategy provided access to familiar equipment and work flow that depicted a realistic environment in which nurses routinely practice. In contrast, some challenges included scheduling of relief nurses to care for patients during the training as well as finding the most appropriate time during the shift for the training. Overall, the unit-based, high-fidelity simulation training was perceived by bedside nurses as an acceptable teaching and learning strategy. LIMITATIONS A convenience sample of nurses from two specifically chosen acute care nursing units was recruited for the study. This limited the sample size and diversity of daily experience and practice to the nurses who participated. The finding may not represent the general population of acute care nurses. The Hawthorn effect (Polit & Beck, 2012) may have influenced the results whereby participants changed their behavior during the scenarios knowing they were being observed and tested. In addition, despite the request to keep the simulation experience confidential, the possibility of discussion about the scenario and test questions between the volunteers may have occurred, which threatens the validity of the study”s test results. Finally, another limitation of the study is the preâ€“post research design. Participants” knowledge and self-confidence levels were measured immediately after the unit-based simulation intervention. Conducting a third measurement at 3 months or 6 months after the intervention could provide information about whether the nurses retained their knowledge and self-confidence levels over time. IMPLICATIONS FOR NPD The results of this study revealed that more unit-based, high-fidelity simulation and debriefing should be included in the continuing education curriculum. Unit-based, high-fidelity simulation and debriefing could be an effective teaching method for NPD specialists to use to meet unit-specific educational needs. This educational strategy allows for the NPD specialist to incorporate a â€œhigh techâ€ continuing education opportunity for RNs with relative ease and cost. The opportunity is tailored to RNs” learning needs and is a systematic, measurable, and realistic strategy that would meet The Joint Commission (2009) requirement of evaluating RNs” clinical competencies. This study documented the value and importance of scenario development and design to fit the learning situation and ensure the best educational experience. The researchers found the use of established scenarios to be useful, reliable, and valid for this study design. In addition, the study documented that it does take time to establish appropriate facilitators, which can be achieved through partnership with area universities or other educational units in the community. These partnerships allow the necessary facilitator training and the appropriate staff to run the simulations and maintain the simulators to ensure the best educational experience (Hallenbeck, 2012). By connecting the process with research, the systems barriers were easier to overcome. As Hallenbeck (2012) indicated in a systematic review of the literature on high-fidelity simulation, the financial issues must be addressed because the manikins can cost from $20,000 to $60,000 with accessories. The implications for this study document how the use of personnel from area academic settings allows for updated training without the cost of having a coordinator at the facility (Broussard, 2008; Leigh, 2011; Hallenbeck, 2012). Thus, the partnerships allow for a collaborative, evenly distributed cost in running the laboratories. The key to cost-effective use of simulation involves partnerships, using established scenarios, and integrating the process with research and evidence-based practice.
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