Study design and participants
The present quasi-experimental study was conducted during May-July 2020 at Larestan University of Medical Sciences. The research goals were investigating the effects of medium- and high-fidelity simulations in preparing Undergraduate Nursing and operating room (OR) students for clinical activities. In this regard, students’ knowledge, skills and attitudes were evaluated.
Sampling: The statistical populations of the study were nursing and OR students of Larestan University of Medical Sciences who were selected using census method. Inclusion criteria included passing the theory lesson of nursing principles and skills for nursing students and passing the theory lesson of principles and techniques of clinical skills for OR students, and of course willingness to participate in the study. For each field, students enrolled in two specific academic year were consider as control group and students enrolled on other two academic year were consider as experimental group. A total of 192 students participated in this study, which 96 students were in the control group and 96 students were in the experimental group.
Data Collection instruments: 4 instruments were used for data collection.
Demographic information form which included student’s personal profile such as gender and age, field and year of entry to university. A questionnaire containing 27 questions to assess students’ attitude, which is based on the Likert scale, and there are five options for each question: strongly agree, agree, undecided, disagree, strongly disagree; that a score of 1 to 5 is awarded to them. For the validity and reliability of this questionnaire: first the English questionnaire was translated into Persian by 2 English language experts. Then the Persian version was translated into English by 2 other person and the original English questionnaire was matched with the questionnaire translated from the Persian version to confirm the accuracy of the translation. It was also culturally adapted. Then, the validity of the questionnaire was confirmed by five experts. The English questionnaire was provided to us by McCaughey Caroline S., the author of the article “The role of simulation in nurse education” (19). Student Knowledge Assessment Questionnaire, which consisted of 20 four-choice questions, which were assigned one point to the correct answer and zero point to wrong answer or no answer. Check list of objective structured clinical examination (OSCE) stations to assess students’ skills, which included 5 stations. Station No 1. (Peripheral intravenous cannulation), Station No 2. (Nasogastric tube insertion), Station No 3. (Urinary catheter insertion), Station No 4. (Endotracheal intubation), Station No 5. (Cardiopulmonary resuscitation). The test score ranged from zero to 128. Finally, the score obtained from the knowledge assessment questionnaire was added to the score obtained from the OSCE and then the score was calculated based on 20.
Procedure
For each field, students enrolled in two specific academic year were consider as control group and students enrolled on other two academic year were consider as experimental group. A total of 192 students participated in this study, which 96 students were in the control group and 96 students were in the experimental group. The students were verbally informed of the purpose, context, and method of the research. Because of the special circumstances due to the prevalence of Corona virus (Covid-19), all the points of health protocols and physical distancing also were explained to the students. Written informed consent was obtained from the participants. The participants were assured that the information they provide to the research will be used only for the purpose of this research and their privacy will be protected. At the beginning of the study, students of both groups participated in the pre-test by implementing health protocols and physical distancing. In this way, first the demographic information forms were filled in by students and then the attitude questionnaires were given to them. After that, knowledge assessment questionnaires were given to students. Then, an OSCE was held to assess students’ skill, which included 5 stations. Before entering the test site, students rested in a separate hall, and after explaining how to hold the test, 5 students were selected in each turn and each student entered a room (a station). After the specified time has elapsed, they left the station with the sound of the alarm clock and went to the next station in a clockwise direction, so that each student passed 5 stations and then they left the test site. Training started the day after the pre-test. In such a way that the students of both control and experimental groups were divided into smaller groups and two sessions were held every week for each small group lasting 2 hour, which trainings were conducted by several instructors in separate rooms and finally the total training lasted 8 weeks. In the control group, teaching the clinical skills of nursing and OR was done traditionally by presenting a lecture, Power Point presentation and using low-fidelity mannequins that had no the capability for providing feedback. In the experimental group, in addition to lectures and Power Point presentations, clinical skills training for nursing and OR student’s was conducted at the clinical skills center and by using medium- and high-fidelity mannequins and models that had the capability for providing feedback.
The clinical skills center, which was recently opened in Larestan University of Medical Sciences, consists of 12 rooms and has units of nursing, midwifery, operating room, anesthesia, medical emergencies, physical exam, conference room, practice room and locker room. Mannequins and models in the nursing unit: Advanced nursing mannequin, child nursing mannequin, blood pressure manual training model, nasal feeding training model, NG TUBE tracheostomy training model, bed wound care training model, female catheterized training model, arm model for veins extraction, Enema training model, surgical dressing torso model, arm for training IM and SQ injections, forearm model for intra-skin injections, pad for teaching cannulation, injection training pad (two veins), DC shock. Models in the emergency medical and anesthesia unit: ALS adult MEGA CODE mannequin with VITAL SIM, CPR child training mannequin with QCPR device, CPR adult training mannequin with intubation and shock capability, CHEST TUBE training model, choking training model, Top and lower body models for bandage training, seat belt, safety necklace, backpack, suction training model, 25 kg injured transport and rescue mannequin. Models in the OR and anesthesia unit: Adult intubation model with laryngeal spasm and suction capability, child intubation model, spinal injection training model, baby head model for vein training, arm model for suturing training, suture practice kit, Anesthesia machines, various kinds of surgical instruments. Models in the midwifery unit: maternal and neonatal simulation with cyanosis and CPR capability, Leopold maneuvering mannequin, measuring engagement of the fetal head model, cervical effacement and dilatation measurement training model, episiotomy training model, Ob/Gyn training model, family planning training model, IUD placement training model, child nursing mannequin (male and female), infant model for intubation and CPR with the umbilical catheter, delivery instrument set and episiotomy set, Doppler fetal monitor. In this center, clinical skills training for experimental group was done according to the purpose of the study and by using the relevant mannequins and models. Then students of the experimental group practiced on these mannequins and models. The practice method was such that while performing the technique by each member of the group, the other members evaluated her/his technique and discussed about it after completing and presented the necessary feedback to each other. Instructor monitored the students’ performance at all stages and provided them with the necessary feedback. The book Clinical Skills Center, written and published by the first author of this article, was given to the students of the experimental group, in which purpose of establishing the clinical skills center, center’s mannequins and models and how to work with them are explained. Throughout the study, necessary health protocols and physical distancing were fully observed and both groups passed the post-test after completing the trainings. The pre-test and post-test conditions were the same in different ways for students of both groups.