Abstract

Background: Simulation is an educational strategy that can be used to support the process of clinical education. It can help in improving students’ self-esteem through providing an opportunity to practice in a risk-free environment. Aim of the study: study effect of simulation on students' achievement in normal labor modules. Design: A Quasi experimental design. Setting: Maternity nursing lab & lecture class in the faculty of nursing Benha University. Sample: Purposive sample of 60 students were included for each study and control group. Tool: Self-administered questionnaire sheet, observational checklist, students’ satisfaction sheet. Result: There was an improvement in students’ both knowledge and practical skills during process of normal labor. Conclusion: Simulated delivery room classes were an effective training approach; they provide students with practices that result in a higher practical achievements and higher satisfaction scores compared to the conventional training. Recommendations: Maternity nursing students should be provided by variety of simulation-based education on maternity nursing skills to increase level of performance, satisfaction, and self-confidence.

1. Introduction

Traditional pedagogical techniques are still very much the norm within higher education. Student learning remains largely based upon extracting knowledge from texts and lectures. This style of teaching rarely gives students the opportunity to apply their newfound knowledge to actual situations, resulting in a serious time lag between students learning and applying new knowledge so, it attributed to simulations relates to the suggested improvements in overall student learning. Because much of the literature has stressed the increased levels of cognitive learning, it has the power to recreate complex, dynamic political processes in the lecture, allowing students to examine the motivations, behavioral Constraints, resources and interactions among institutional actors. ¹

Simulation is a potentially powerful teaching approach that engages nursing students and allows them to use critical thinking and clinical reasoning, and provides an opportunity for reflective learning and integration of the student’s knowledge. ² Simulation is an educational strategy that can be used to support the process of clinical education. It can help in improving students’ self-esteem through providing an opportunity to practice in a risk-free environment. ^{3, 4}

Simulation can take many forms, including human patient simulation manikins and/or standardized patients, Virtual and computer based simulations, simulation done to teach psychomotor skills, or role play. Simulation provides a rich learning opportunity for students to integrate theory with practice while making real-time clinical decisions in an environment that poses no risk to patients. Simulation creates transformational learning experience for all nursing students and provides diverse perspectives on caring for patients across the continuum of care. ⁵

Simulation is used in nursing education in the military, nuclear power, and aviation. It is also a recommended in teaching and learning strategy supported by several landmark studies. Although in the past 20 years simulation has become more integrated into the education of nurses and physicians, it has not been as well integrated into the development of skills for practicing nurses. Simulation has demonstrated benefits in nursing in preparation of newly graduated nurses for the practice environment. ⁶

Simulations as a strategy for clinical education promote student satisfaction with their learning and improve self-confidence. Simulations prepare the student to for real-life experience and speed the transition to professional career (Omer, (2016). It builds confidence and self-efficacy. Clinical simulation proves a vital role in the field of maternal- child health and allow nursing program to assess students’ competency. ⁷

Simulation application continues to expand in nursing education, specifically at the undergraduate level. Graduate nursing students’ can also benefit from simulation activities. Graduate nurse educator students’ exposure to clinical teaching issues may be limited; therefore, simulation provides a realistic, safe environment for students to practice the development of the teacher role. This manuscript provides ideas for planning, implementation, and suggestions for simulation technology use in the training of nurse educators for their role in clinical teaching. ⁸

Simulation models create further opportunities to transfer learning from fields outside health care. ⁹ Simulation removes the risk from these complex skills learning without stress of the real situation and help students acquire the teaching skills through the roll play in the classroom. ¹⁰ There is no previous study regarding simulation was conducted at obstetrics and gynecology department, faculty of nursing Benha university. So this study will be conducted to apply simulation for teaching the labor module and study its effect on student's achievement.

The current study was conducted to evaluate the effect of simulation on students' achievement in normal labor modules.

The students who learn the labor modules through simulation-based teaching will have significantly higher achievement scores and satisfaction level compared with those who learn through the traditional classroom-based teaching.

2. Subjects and Methods

Α Quasi-experimental study design.

The study was conducted at Maternity Nursing laboratory/classroom in the Faculty of Nursing Benhа University.

All nursing students', in the 2^nd semester of the academic year 2016-2017, enrolled in 3^rd year and in the obstetrics & gynecology department (120 students) were recruited for this study. The sample was divided into equal groups, study (60 students using simulation "Noelle mannequin & videos" method), and control group (60 students using the traditional method).

Four tools were used for data collection:

Structured interview questionnaire sheet was designed to assess

• Students’ demographic characteristic

• Students’ knowledge regarding normal labor. Total scoring of the students’ knowledge regarding normal labor was equal (20); Adequate knowledge ≥75%, = (15 to 20 marks). While inadequate knowledge <75%, = (0 to 14 marks).

• Students’ knowledge regarding practical skills and procedures at labor stages. Total scoring of the students’ knowledge regarding the practical skills of labor stages was equal (7); adequate knowledge ≥75%, = (5 to 7 marks), while inadequate knowledge <75%, (0 to 4 marks).

Students practices observational checklist.

It contains the procedures that were done for the women such as perineal care, abdominal examination, vaginal examination, and handling, assessments of fundus, placental examination and newborn physical assessment. Total scoring of the students' practices were highly satisfactory practice (≥85%), and satisfactory practice (75%-85%).

Media for modules of labor (Noelle mannequin & Video).

This tools used for training students about simulated videos about labor procedures.

Students’ satisfaction with the learning method (simulation) structured interview questioner.

It was developed to assess students’ satisfaction with modules. Total scoring of the students’ satisfaction with the learning method was equal (7); Satisfactory > 75%, (5 to 7 marks); Uncertain 60%-75%, (4 marks); Unsatisfactory <60%, (0 to 3 marks).

The developed tools were reviewed for content validity by a jury consisting of a group of 5 experts specialized in the obstetric nursing field. The reliability of the tools was tested using Cronbach’s Alpha test. Ethical and administrative procedures took into researchers' considerations. Α pilot study was carried out on 12 students. All phases of the data collection; assessment phase, planning phase, implementing phase, and evaluation phase took 4 months (from February 1, 2017 to May 31, 2017).

(1): Assessment and planning phase

The researcher interviewed both study and control groups using tools of data collection. Students in the control group receive the routine of training in the lab (demonstration) by using traditional mannequin and allow them to do re-demonstration (this training phase). While students in the study group received simulated delivery classroom by the researcher using simulated parturient women mannequin (Noelle Simulator) and videos.

(2): Implementation phase

The Program implementation is carried through theoretical and practical sessions. The theoretical session was discuss normal labor, including definition, terms, stages, sign & symptoms and mechanism of labor; sign and symptoms of placental separation, mechanism of placental delivery and care during the 4^th stage of labor. The practical session was concerned with abdominal examination, vaginal examination, and perianal care, assessment of fundus, handling, placental examination, and newborn physical assessment. It conducted in the affiliated laboratory of the department including demonstration, videos, and re-demonstration. Implementation phase for each group of study took about two weeks.

(3): Evaluation phase

During this period the researcher observes the students’ practice for normal labor through an observational checklist and assessed their knowledge through nursing students’ self-administered questionnaire sheet. Comparison between both groups was done using the same tools. Pre-post knowledge tool was utilized to evaluate knowledge. Pre-post-test performance checklist was used to evaluate student practical skills.

Data analysis was performed using IBM SPSS statistical software version 22. Mean and standard deviation were done for quantitative data frequency distribution was done; (t) test was used for qualitative data (X²). Α correlation coefficient (г) was used to evaluate the relationship between the study variable. Α statistical significant difference was considered if p-value ≤ 0.05 and a highly statistical significance was considered when p-value ≤ 0.001.

3. Results

Figure 1 shows that 53.3% & 56.7% and 71.7% & 70.0%, of the study and control group, respectively, had technical nursing institute. Moreover, 71.7% and 70.0% were from rural areas, respectively.

Figure 2 indicates improvement and а high progression of correct theoretical knowledge for both study and control group, about all item of normal labor, after intervention phases compared to pre-intervention phase. However, the improvement was higher and more significant in the study group.

Figure 3 portrays а high progression of total adequate knowledge of the study group after intervention phases, associated with high regression of inadequate one, compared to the control group.

Table 1 reveals a highly statistically significant difference, between study and control group, regarding students’ practical skills of stages of labor at pre/post-intervention phases (p< 0.001).

Figure 4 portrays а high progression of total adequate practical skills of stages of labor for the study group after intervention phases, associated with high regression of inadequate one, compared to the control group.

Figure 5 illustrated students’ satisfaction with learning by simulation modules. It shows that 78.3% of the studied sample agree that “simulation provides students with a variety of learning materials and activities to promote the learning curriculum”, 73.3% agree that “the teaching methods used in this simulation were helpful and effective”. Additionally, while 65.0% of students agreed as the simulation can help in understanding the concepts which will be covered by it, only 3.3% of them disagreed.

4. Discussion

Simulation is taking an important place in training and education of healthcare professionals. ^{11, 12} Several factors drive the increase of using simulation in nursing and health professional education. ¹³ The present study is significantly supported through research hypothesis, which directs our attention to stress the importance and utilization of simulation in the education for improving students' achievement, performance, and satisfaction regarding labor process and enhancement of the students' clinical skills.

Pre-intervention, it was not surprise to find that the majority of participant students had incorrect and inadequate theoretical knowledge, regarding process & physiology of labor. This result is in accordance with Hаssan et al (2015). ¹⁴ Otherwise, in post-intervention, improvement for students' knowledge was observed. The present study indicated that studied groups achieved their theoretical knowledge regarding all item of normal labor. This result was matched with Omer (2016), who reported improvement of knowledge because methods used in the simulation were effective and gave them clear ideas of what is expected from them. These knowledge acquisition abilities improve their self-confidence. ¹⁵ This reflects the effect of the simulation model of teaching.

The results of the present study revealed а great difference between study & control groups regarding their total knowledge pre/post-intervention. It isn’t surprising to find the majority of both study (86.7%) and control (84.3%) group had inadequate knowledge regarding the process of labor in pre-intervention phase. Otherwise, post-intervention, our results illustrate а progression of total adequate knowledge of both study (94.3%) and control (50.0%) group. The achievement in both groups can be declared by even traditional methods of teaching will get knowledge for students. However, achievement was а highly satisfactory score in the study group; а high progression of total adequate knowledge of the study group (94.3%) after intervention phases, associated with high regression of inadequate one (5.7%), compared to control group (50.0% & 50.0%, respectively). Of course, it attributes to the effect of intervention with simulation. This result agrees with Simko, et al, (2014) who reported that scores were significantly higher in the post-test than the pre-test overall, for the traditional undergraduate & second degree students. The simulation experience is truly а safe environment for the nursing student to learn the nursing interventions needed during а real code situation. This finding may be due to the increase of retained students' information and skills from study course. ¹⁶

The results of the present study revealed that the mean score of studied sample regarding average practice score about labor procedures of both phases of assessment revealed the achievement was better in the study group than control one. Α statistically differences found (p≤0.001). Moreover, the results present study revealed a highly statistically significant difference between study and control groups regarding their total practices pre/post-intervention phase (р≤0.001). Our results revealed that the majority of both study (86.7%) & control (83.3%) group had inadequate & unsatisfactory practical skills regarding stages of labor in the pre-intervention phase. Otherwise, post-intervention, our results illustrate а progression of total adequate practices of both study (93.3%) and control (50.0%) group. However, achievement was а highly satisfactory score in the study group; a high progression of total adequate practices of the study group (93.3%) after intervention phases, associated with highly regression of inadequate one (6.7%), compared to control group (50.0% & 50.0%, respectively). This is supported by Bezyack (2007) who mentioned that simulation is potential tools that help the nursing students to practice in a real environment. ¹⁷

Regarding student’s satisfaction about simulation method, the result of this study showed that slightly more than three-quarter of students of the studied sample agree with "the simulation provide student with а variety of learning materials & activities to promote the learning curriculum". While а minority of them disagree with "help in understanding the concepts converted in the simulation. This may be attributed to the students in the simulation sessions take an opportunity for performing procedures on mannequins in а simulation lab and seeing videos about labor procedures. The result of this study was congruent with Mould, et al, (2011) who reported that а higher learner satisfaction with learning by clinical simulation and the learner confidence in their skills. ¹⁸ Hаll, (2013) supporting the present study finding, by evaluating the effect of simulation-based education on baccalaureate nursing students’ satisfaction and reporting that the students were very satisfied with the simulation learning activity. ¹⁹

5. Conclusion

Simulated delivery room classes were an effective training approach; they provide students with practices that result in higher practical achievements and higher satisfaction scores compared to the conventional training.

6. Recommendation

• Nursing staff should work to improve and streamline processes in the nursing simulation Lab.

• Simulation-based teaching should be integrated into the practical training for students before their contact with actual woman in the labor units with clear connections toward achievement of student learning outcomes.

References