Ảnh hưởng trải nghiệm mô phỏng điều dưỡng và trình tổ chức nâng cao đến hiệu suất lâm sàng

THE EFFECTS OF NURSING PROGRAM SIMULATION EXPERIENCE LEVEL AND TYPE OF ADVANCED ORGANIZER ON CLINICAL JUDGMENT PERFORMANCE, SATISFACTION, SELF-CONFIDENCE, AND PERCEIVED COGNITIVE LOAD OF PRE-LICENSURE NURSING STUDENTS IN SIMULATION BASED LEARNING A Dissertation Submitted to the Graduate Faculty of the University of South Alabama in partial fulfillment of the requirements for the degree of Doctor in Philosophy in Instructional Design and Development by Tina D. in Nursing, Bishop State Community College, 1995 B. in Nursing, University of Mobile, 2004 M. in Nursing, University of Mobile, 2008 May, 2018 I dedicate this dissertation to my husband, Steve, and son, Josh, for always providing their love and encouraging me to dream big.

To my Mom (who did not live to see me complete this journey) and to my Dad, who always believed in me and instilled in me a passion for learning. ii ACKNOWLEDGEMENTS This dissertation could not have been completed without the great support I have received from many individuals over the years. First and foremost, I would like to thank God, for giving me the perseverance through many life challenges to complete this degree. I could not have accomplished it without His guidance, grace and mercy in my life.

To my committee chair and devoted advisor, Dr. James Van Haneghan, thank you for the expert advice and constant encouragement to explore on my own and for providing the guidance to recover when my steps faltered. I am forever grateful. To my committee members: Dr.

Burke Johnson for always having an open door and offering words of encouragement along the way, Dr. Daniel Surry for sending words of wisdom over a distance and providing practical guidance when needed, and to Dr. Lisa Carwie, my mentor, for your inspiration, guidance, and constant support. You always understood my thought process and assisted in enriching my ideas.

Thank you all for your advice, wisdom, and encouragement through this journey. Gail McLean for your support and endless hours spent keeping me on the right path. You are an inspiration. To the faculty and staff at the University of South Alabama Instructional Design and Development program for your guidance and support throughout my educational journey.

iii To President Cole, my work family, and students in Pensacola, Florida, for allowing me the opportunity to broaden my horizons. Your support, smiling faces, and guidance have brightened this journey. William Bryce Evans and Mrs. Jo for believing in a small town “bayou girl” and always giving your love, support, and unrelenting encouragement through the years.

David Williams and LeAnn Bullock, my fellow cohort and dear friends. Thank you for being my sounding board, providing words of encouragement, and “swift kicks” when needed. I am grateful for your kindness and support. Personally, to my parents, Edward and Kathleen Barbour, for all of the years of love and encouragement.

It is because of their guidance that I have a passion for learning and am who I am today. To Melvin and Beatrice Taylor, for your continued support and love along the way. To my brothers, sisters, and family for always having faith I could do this. To my son, Joshua, the light of my life, I could not have done this without all of the hours you spent reading and editing my southern “twang”.

Your love and hugs kept me going. And lastly, to my wonderful husband, Steven, you are my rock. Without you I am incomplete. I could not have done this without your love and support.

You were always there for me. This accomplishment is as much yours as it is mine. I am deeply appreciative of all of the individuals who have supported my work and blessed my journey along the way. iv TABLE OF CONTENTS LIST OF TABLES.

ix LIST OF FIGURES .x LIST OF ABBREVIATIONS. xiii CHAPTER I - INTRODUCTION .1 Background for the Study .15 Purpose of the Study and Research Questions .16 Importance of the Study .17 Definition of Key Terms .18 Chapter Summary and Organization .21 CHAPTER II - LITERATURE REVIEW .22 Clinical Judgment and Competency in Nursing .22 Benner’s Novice to Expert Nurse Theory.26 Deliberate Practice and Expertise in Nursing .28 Tanner’s Model of Clinical Judgment .31 v Nursing Education Simulation Framework (NESF) .34 Nursing Education Simulation Process .36 SBL Student Self-confidence and Satisfaction .37 Cognitive Load Theory and Memory .39 Impacts to Extraneous Cognitive Load .43 Impacts to Intrinsic Cognitive Load .44 Impacts to Germane Cognitive Load .44 CLT in Nursing .49 Four Component Instructional Design Model (4C/ID) .54 Types of Advanced Organizers .55 Organizers in Education .58 Organizers in Computer-based Instruction .58 Organizers in SBL and Healthcare .61 Reflection-on-action .65 Pilot Study Research Questions .69 Procedures for the Pilot Study .76 vi CHAPTER III - METHODOLOGY .80 Research Questions, Hypotheses, and Expectations .80 Research Question One .80 Research Question Two .82 Research Question Three .86 Protection of Human Rights.91 Facilities and Equipment.92 Variables of the Study.96 Procedures for the Study .101 CHAPTER IV - RESULTS .120 Summary of the Study .120 Discussion of Quantitative Findings .121 Discussion of Qualitative Findings .129 vii Implications for Instructional Design .130 Limitations of the Study.131 Strengths of the Study .133 Recommendations for Future Research .166 Appendix B DASH©SV .167 Appendix C Reflective Debriefing Script .169 Appendix D Pilot Study Permission Letter .170 Appendix E Pilot Study IRB Approval .171 Appendix F Pilot Study Consent Form .172 Appendix G NLN-SSLS and Permission .175 Appendix H LCJR Permission, Rubric, and Scoring Scale .177 Appendix I Cognitive Load Assessment Survey – Mnemonic .181 Appendix J Cognitive Load Assessment Survey – Concept Map .182 Appendix K Debrief Session Interview Questions .183 Appendix L Study IRB Approval .184 Appendix M Study Permission Letter .185 Appendix N Study Consent Form .186 Appendix O Study Demographic Survey .188 viii LIST OF TABLES Table Page 1. Application of AO and CLT to SBL. Cognitive Load and Causes.

Means and Standard Deviations of DASH©SV Elements by Group. Post Intervention Scoring on C-CEI®. Post Intervention Scoring on C-CEI® - Blind Rating. Factorial Comparison Group Research Design.

Power Analysis to Determine Sample Size for ANOVA. Demographic Profile of Participants. Clinical Judgment Performance Scores for NPS Experience Level. Clinical Judgment Performance Scores for NPS Experience Level and Type of AO.

Pretest-Posttest Differences for Type of AO and NPS Experience Level. AO Perceived Load for NPS Experience Level. SBL Perceived Load for NPS Experience Level. Perceived Load for Type of AO.

Participants’ Responses to Focus Interview by Theme. Satisfaction and Self-confidence by NPS Experience Level and Type of AO. 126 ix LIST OF FIGURES Figure Page 1. Nursing Education Simulation Framework (adapted from Jeffries, P.

Tanner’s Model of Clinical Judgment (adapted from Tanner, C. Mnemonic of the Nursing Assessment Process forms an analogy of the nursing process to stimulate recall. Concept Map of the Nursing Assessment Process provides a template to assist in information organization. 94 x LIST OF ABBREVIATIONS 4C/ID Four Component Instructional Design Model AACN American Association of Colleges of Nursing ANCOVA Analysis of Covariance AO Advanced Organizer(s) CBI Computer-based Instruction C-CEI® Creighton Competency Evaluation Instrument CE Central Executive CL Cognitive Load CLT Cognitive Load Theory CMS Center for Medicare and Medicaid Services DASH©SV Debriefing Assessment for Simulation in Healthcare Student Version ECL Extraneous Cognitive Load EMT Emergency Medical Technician GCL Germane Cognitive Load GPA Grade Point Average IRB Institutional Review Board ICL Intrinsic Cognitive Load LCJR Lasater Clinical Judgment Rubric xi LPN Licensed Practical Nurse LTM Long Term Memory NACNEP National Advisory Council on Nurse Education and Practice NCLEX-RN® National Council Licensure Examination – Registered Nurse NESF Nursing Education Simulation Framework NLN National League for Nursing NLN-SSLS National League for Nursing Student Satisfaction and Self-confidence in Learning Scale NPS Nursing Program Simulation PL Phonological Loop RDS Reflective Debriefing Script SBL Simulation Based Learning SPSS Statistical Package of the Social Sciences TSDS Traditional Standardized Debriefing Script WM Working Memory xii ABSTRACT Taylor, Tina D., University of South Alabama, May 2018.

The effects of nursing program simulation experience level and type of advanced organizer on clinical judgment performance, satisfaction, self-confidence, and perceived cognitive load of pre-licensure nursing students in simulation based learning. Chair of Committee: James P. Van Haneghan, Ph. Nursing education programs face many challenges with training students to become professional nurses who will practice safely in an evolving and complex healthcare system.

Nurse educators are obliged to prepare students to meet these challenges, with clinical experience being a key aspect of training. However, limited availability of clinical sites restricts adequate training. Simulation based learning (SBL) activities that mimic real world environments are now transforming the clinical experience, however, research is limited and additional research is needed. By understanding the demand of cognitive load during SBL, nurse educators can design simulation activities that promote positive outcomes.

Advanced organizers (AO) are one way of assisting students to retain information and aid recall. Therefore, this study focused on the effects of AO and participant Nursing Program Simulation (NPS) experience level on clinical judgment performance, satisfaction and self-confidence, and perception of CL during SBL. This study used a mixed methods sequential research design and examined 99 students enrolled in an associate degree nursing program. Participants were enrolled in xiii one of three courses which used SBL.

Students were assigned to comparison groups based on their course level and assigned clinical instructor. Participants were given a mnemonic or a concept map during the SBL pre-briefing phase. A pretest simulation was completed followed by a posttest simulation within a 12-week period to assess for differences in clinical judgment performance. Students were given questionnaires post simulation to determine perception of satisfaction and self-confidence, as well as determine their perceived cognitive load.

A focus group interview was conducted post simulation to identify additional emerging themes. Quantitative analysis showed NPS experienced students had higher clinical judgment performance pretest-posttest scores than NPS novice students. There was an interaction between the combined effects of NPS experience level and type of AO showed NPS experienced students had higher scores with the use of a concept map over a mnemonic, whereas the NPS novice group showed no difference. The analysis found NPS novice group participants had higher perceived satisfaction and self-confidence with the use of a mnemonic, whereas the NPS experienced students had higher perceived satisfaction and self-confidence with a concept map.

NPS novice group students had a higher perceived cognitive load with the use of a concept map compared to a mnemonic, but the NPS experienced group showed no differences. Qualitative results showed NPS novice participants seemed to feel more comfortable and satisfied with the use of the mnemonic as a memory aid. Conversely the NPS experienced group seemed more self- confident with the use of a concept map. Therefore, the selection of instructional strategies are important for educators to consider when developing SBL experiences.

xiv CHAPTER I INTRODUCTION Background for the Study Current nursing practice faces many challenges including a growing population of acutely ill hospitalized patients, increasing healthcare costs, rapidly advancing technology, and the need to stay current with evolving medical knowledge (The National Advisory Council on Nurse Education and Practice [NACNEP], 2010). The medical knowledge base, currently doubling every 5 to 8 years, is reliably predicted to begin doubling every year; medical schools, healthcare institutions, practitioners, and students will need to develop strategies for coping with the sheer volume of information, concepts, and skills (Distlehorst, Dunnington, & Folse, 2000). To ensure the delivery of high quality, safe and effective care, the nursing profession must keep pace with this ever- changing healthcare environment (Dreifuerst, 2015). Traditional nursing education practices and rote memorization are no longer an adequate option for today’s nursing students (Lasater & Nielsen, 2009).

Nurse educators are under continuous pressure to prepare and graduate highly skilled, critically thinking nurses; often leaving them toiling over how to best prepare pre- licensure nursing students for practice in the increasingly complex healthcare environment (White, Brannan, Long & Kruszka, 2013).