Development of clinical competence by undergraduate students in simulation-based teaching: quasi-experimental study

ORIGINAL

Ana Cândida Martins Grossi Moreira1, Thaísa Mariela Nascimento de Oliveira2, Maria Gorete Nicolette Pereira2, Caroline Lourenço Almeida Pincerati2, Gisele Andrade Menolli2, Eleine Aparecida Penha Martins2

1State University of Northern Paraná, Bandeirantes, PR, Brazil

2State University of Londrina, Londrina, PR, Brazil

ABSTRACT

Objective: To evaluate simulation-based teaching in the development of students' clinical competence. Method: Quasi-experimental study carried out at a public university with the participation of 62 students. A Knowledge Test and a Checklist were used for data collection. Data were presented as percentages and compared using ANOVA. Results: The average percentage of knowledge, before, during and after the theoretical strategies (case study and dialogued theoretical class), was 67.6%, 76.7% and 88.1% respectively and 87.6% after 30 days. In the simulation, the skill “communicated with clear speech and controlled tone of voice” obtained 93.5% of correct answers; “attached pulse oximeter” and “administered platelet antiaggregant” 100%; 75% of the students classified the patient in one of the three groups of coronary syndrome and 83.7% related it to the best treatment. Conclusion: Simulation-based teaching enabled the development of students' clinical competence in treating coronary syndromes.

Descriptors: Simulation; Clinical Competence; Education.

INTRODUCTION

In recent decades, health education has changed a lot around the world. Active methodologies arise in the context of education, in which the student becomes the protagonist of his/her learning, with autonomy to think about their actions and choices, which favors the development of competencies for care practice(1).

A way of understanding the formation of competences had already been presented in 1990 in Miller's pyramid, which demonstrated that learning for adults went through different levels, from the acquisition of theoretical knowledge to its integration with practice, going through the levels of knowledge, knowing how, showing how and doing(2).

Simulation-Based Teaching (SBT) can contribute to the development of nursing students' clinical competence(3). Simulation is seen as an important active teaching methodology that helps in critical-reflective training and in skill acquisition through integration of theory with practice, identification of errors, recognition of failures and motivation to evolve in the teaching-learning process, which contributes to the decision-making process(4).

In order to obtain clinical competence, which involves knowledge, skill and attitude, simulations can be developed in diverse clinical scenarios such as Acute Coronary Syndrome (ACS). Faced with the current reality of this pathology as one of the main causes of death of the Brazilian population and that the rapid care of patients is essential for better survival(5), it is intended to invest in the training of competent students, future professionals responsible for the care of these patients.

To assess the effect of teaching on students' knowledge, the comparison of knowledge before and after the experience of an educational event can be used. However, it is essential to analyze its retention after a period of time(6), especially in ACS, in which the scientific basis becomes relevant to act quickly and safely, in which every second is important for the patient's prognosis.

The simulation can also contribute to the evaluation of the student's development, which analyzes whether he is able to work safely in his professional life. The skills that need to be improved can be identified during the evaluation of the care simulation, as there is a demonstration of how the actions are carried out, reflecting the mastery of the acquired cognitive, attitudinal and procedural skills(6).

Thus, the objective was to evaluate simulation-based teaching in the development of clinical competence of nursing students for the care of patients with coronary syndrome.

METHOD

This is a quasi-experimental before-and-after study, known as a non-randomized trial or experiment. The research was a single arm, in which all participants were part of the experimental group, developed in the period between February 2019 and February 2020, in which 62 students participated.

The experiment consisted of applying SBT to nursing students at a public university in southern Brazil, in the critical patient module (divided into four groups). The nursing course has been offered by the university for 50 years, and currently has approximately 54 professors and 240 students. Despite the course being organized in an integrated curriculum, in which the professor and the student must be involved in the teaching-learning process in an active and contextualized way, this was the students' first experience with teaching based on simulation. The inclusion criteria in the study was to be enrolled in the fourth year of the nursing course, in the critical patient module, as it is in this period and module that the coronary syndrome class, the subject of the research, is taught. The exclusion criterion was the student having another degree in the health area with competence in caring for patients with ACS, as this could favor their performance in the simulation scenario. The development of the study protocol occurred in three stages and the Model The National League Nursing (NLN) /Jeffries Simulation Theory was used as a methodological theoretical framework(7), which has five components, namely the characteristics of the facilitator; knowledge about the participants; the characteristics of the simulation design; educational practices and the result regarding the skills performed, critical thinking, self-confidence and the contributions of simulation as a teaching-learning method.

The first stage consisted of the construction of a simulation scenario that considered five variables(7), learning objectives, fidelity, problem solving, student support and debriefing, the scenario was also based on a bibliographic review and on the guidelines of the American Heart Association (AHA)(8) on ACS.

A high-fidelity simulation was carried out with an actor patient (student of the nursing residency), in the nursing skills laboratory organized for the service, which aimed to provide assistance to the patient with coronary syndrome by undergraduate nursing students, lasting 40 minutes. Behaviors expected by the participants included, identifying vital signs and intervening, requesting an electrocardiogram, performing a physical examination and anamnesis, administering medication according to the protocol/medical prescription, interpreting an electrocardiogram and classifying the patient into one of the three groups of coronary syndrome. The scenario was validated by the students using the Simulation Design Scale.

In the second stage of the study, the data collection instruments (Knowledge Test and Checklist) were developed by the researchers, based on a bibliographic review through specific books on the subject, scientific articles and the AHA guidelines regarding ACS patient care(8). For the review, the descriptors Patient Simulation, Acute Coronary Syndrome, Clinical Competence and Nursing Students were used, and scientific articles from the last five years were used as inclusion criteria. The Knowledge Test was composed of sociodemographic data and 20 closed theoretical questions, of the true or false type, which aimed to evaluate the students' knowledge regarding ACS. A Checklist for the evaluation of skills and attitudes performed in care simulation, consisting of four indicators and 31 items, developed by the authors and validated through the Delphi technique and expert judges on the subject. Attitudes were demonstrated through assertive decision-making.

In this study, the Checklist indicators were understood as competences to be developed by the students, and the items as technical and non-technical skills, actions to be performed correctly during care simulation. According to the authors, although there are divergences in the literature about the concept of clinical competence, there is a consensus on its elements, composed of knowledge (acquired and accumulated knowledge), skills (knowing how to do specific to the profession) and attitudes (knowing how to act, evaluate and decide(9-10).

SBT implementation occurred during the third stage, and included the application of three teaching strategies, case study, classroom dialogued theoretical class and simulation practice. In the first strategy, the researcher delivered a case study, on the day of the opening of the module, with questions about ACS. The participants were instructed to study and return the questions answered individually, five days later, before starting the previously scheduled dialogued theoretical class.

The theoretical dialogued class lasted 3 hours, using multimedia resources such as Microsoft Power Point, which, associated with the case study, provided a theoretical basis for simulation, according to the objectives of the lesson plan. The students completed the Knowledge Test in four moments, at the opening of the module, after delivering the case study, after the theoretical class and 30 days after the simulation.

The third teaching strategy regarding to care simulation was divided into three phases, as presented below(7). In the pre-briefing and briefing, the students learned about the objectives of the scenario, the physical structure and materials available for use during the activity and asked the students to divide into pairs, lasting 10 minutes. Next, the clinical case was presented to the first pair, randomly chosen, with a request by one of the team members to evaluate a patient with chest pain in the emergency room.

The simulation experience began, simultaneously, with the receipt of the clinical case and the displacement of the pair of nursing students to the emergency room, organized in the nursing skills laboratory, for evaluation and care of the patient actor in 15 minutes. The four observers (evaluators) were positioned behind cardboard screens with glass and one-way film, which allowed the assessment of skills and attitudes, without being viewed by the students. The evaluators were intentionally invited two nursing professors, who work in the fourth year nursing critical patient module, in which the Checklist was applied, and two nursing residents, all with experience in assisting patients with ACS for at least six months.

After the end of the simulation, the facilitator (PhD student in charge of the research) conducted the debriefing with good judgment in pairs, in 15 minutes. All phases were filmed, with the consent of the participants.

Each pair performed the scenario only once, in all, 23 pairs performed the scenario. The time allocated for this practice was 3 days, with an average of eight pairs per day. At each simulation, only the pair, the facilitator and the evaluators remained in the environment, the others were waiting in another room far from the laboratory. After practice, the pair waited in another environment reserved especially for students who had already finished, at the en a general feedback was given to all pairs.

To verify learning retention, the Knowledge Test was reapplied after 30 days, the SBT, as recommended(11).

All the steps and activities developed in this study are described in Figura 1:

Source: Prepared by authors, 2019.

Figure 1 - Search flow. Londrina, PR, Brazil, 2019

In care simulation evaluation, the students' skills and attitudes are presented according to the four competencies (communication, patient evaluation, immediate treatment and interpretation of the ECG), which express the performance of the pairs of students and the judgment of four observers. The performance results of 16 students who constituted the first SBT group served as adjustments in the scenario (pre-test for scenario validation) and were not included in the Checklist analysis, thus considering the performance of 46 students, organized in 23 pairs, during care simulation. However, the results of the students' correct answers in the Knowledge Test were counted from the four groups (62 students), because there was no need to change the instrument after the first group.

Regarding data analysis, the information was double-typed in excel spreadsheet and later checked (Exact Formula). Statistical analyses were carried out in the Statistical Package for the Social Sciences® (SPSS) version 20. The categorical data presented in absolute number and percentage, and numerical variables, in mean and standard deviation. The results of the dependent variables were presented with confidence interval (CI) of 95%.

Comparison of the means of the percentage of correct answers, over the four moments in the Knowledge Test, was performed using the ANOVA test for repeated measures. The difference between means, p value < 0.05 was adopted for statistical decision.

This study was approved by the Research Ethics Committee (CEP) in 2018, considering the recommendations of Resolution nº 466/2012 of the National Health Council, with opinion nº 3.093.034, subject to the signature of the Free and Informed Consent Form (TCLE) by the participants.

RESULTS

According to the sociodemographic characterization of the participants, the mean age was 21.44 years (SD±1.49), 57 (91.9%) were women and 5 (8.1%) men, no student had a completed degree course at the time and only one (1.6%) had a technical nursing course.

The average percentage of correct answers in the Knowledge Test by the students, over the three moments of the research, is shown in Figure 2.