Research design
This study used a non-equivalent control group pretest-posttest design to verify the effect of a practical training program using the OPT model and SBAR protocol on communication clarity, communication confidence, problem-solving process, and team efficacy with a quasi-experimental research design (Figure 1).
Study participants
Participants were recruited from the nursing departments of two universities located in Gyeonggi-do and Chungcheong-do, and after posting a recruitment notice on the nursing notice board and community explaining the purpose and contents of the research. All participants who agreed to participate in the study were selected from among those who understood the purpose of the study, provided written consent, and met the study selection criteria. The inclusion criteria were as follows: (1) completed the fundamentals of nursing and health assessment within the department of nursing science, (2) had no previous experience with the OPT model and SBAR protocol education, and (3) the students who participated in adult nursing clinical practice as a third-year nursing student.
The sample size was calculated as 20 for each group by setting the number of groups = 2 (u = 1), significance level (α) = .05, power (1-β) = .70, and effect size (d) = .40 as per Cohen's table (Cohen, 1988). This study recruited a total of 75 subjects - 43 in the experimental group and 30 in the control group, considering the drop-out rate; two subjects in the control group were excluded due to late attending. Thus, the final number of participants was 73 (43 for the experiment group and 30 for the control group). The experimental group was assigned to an in-school practice group using case-study, whereas the control group was assigned to students participating in the internal medicine ward of adult nursing during clinical practice (Table 1). However, the study participants were not provided with information about the group to which they belonged.
Research tools
Demographic characteristics
The demographic characteristics of the participants included sex, age, grade point average (GPA), major satisfaction, and clinical practice satisfaction. The scores on the major satisfaction and clinical practice satisfaction measurement tools ranged from 5 (‘very satisfied') to 1 (‘very dissatisfied’). The higher the score, the higher the satisfaction with the major and clinical practice.
Communication clarity measurement tool
The communication clarity measurement tool developed by Marshall et al. [26] and modified and supplemented by Cho [27] was used in this study. This tool consists of a total of 14 items that employs a Likert scale from 1 (‘not at all’) to 5 (‘strongly agree’), with the total possible points ranging from 14 to 70. The higher scores indicating higher communication clarity. The tool reliability at the time of development was Cronbach's α .77 [27] and Cronbach's α was .95 in this study.
Communication confidence measurement tool
The communication confidence measurement tool refers to the level of confidence in reporting the clinical situation to medical staff according to the standardized SBAR protocol (situation, background, evaluation, and recommendation). The tool used in this study is a score measured on a 10-point numeric rating scale developed by Kim [28], with 0 at the left end being 'not at all confident' and 10 at the right end being 'very confident’, with the total possible points ranging from 0 to 50. The higher the score, the more confident the user is in communicating. The reliability at the time of development of this tool was Cronbach's α .95 [28], and Cronbach's α was .98 in this study.
Problem Solving Process Measurement Tool
The problem-solving process measurement tool developed by Lee [29] and modified and supplemented by Woo [30] was used in this study. This tool consists of a total of 25 items: 'discovery of problems (5 items), problem definition (5 items), problem solution design (5 items), problem implementation (5 items), and problem-solving review (5 items). Each item was measured on a Likert scale ranging from 1 point for 'not at all' to 5 points for 'almost always', with the total possible points ranging from 25 to 125. The higher the score, a higher problem-solving ability. The reliability at the time of development of this tool was Cronbach's α .89 [30] and Cronbach's α was .98 in this study.
Team efficacy measurement tool
The team efficacy measurement tool developed by Marshall [26] and modified and supplemented by Kwon [31] was used in this study. This tool consists of a total of eight items and a 5-point Likert scale, The score ranges from a minimum of eight points to a maximum of 40 points, with a higher score indicating a higher sense of team efficacy. The reliability at the time of development of this tool was Cronbach's α .97 [31], and Cronbach's α was .92 in this study.
Experimental situation and data collection
The experimental treatment in this study was carried out for 2 weeks over 2 sessions from April 25 to May 20, 2022. As shown in Table 2, the experimental and control groups consisted of the same learning content and instructor guidance times for each session. The program education applied to the experimental group consisted of a total of 80 hours (including 15 hours of instructor guidance) for two weeks and was conducted as a classroom practice at Y University. The control group participated in clinical practice for a total of 80 hours (including 15 hours of instructor guidance), similar to the experimental group.
Experimental treatment
Pre-Education and Pre-Survey: On April 18, 2022, 43 people in the experimental group and 30 in the control group were given a program orientation (experimental group) and a clinical practice orientation (control group) for 60 minutes each. Regarding the contents of the pre-orientation, a pre-investigation was conducted after explaining the introduction of practice education for each group, the pre-learning method, and the practical operation method. The experimental group consisted of a smaller group of fewer than five students who participated in discussion, cooperative learning, and self-directed learning. The program for experimental group was provided two patient cases. One was related to the basic stage respiratory disease and the second was related to advanced stage cardiovascular disease, similar to the clinical practice in the adult nursing internal medicine ward for the control group. As for the procedure for each session, as shown in Table 2, the experimental and control groups had the same practice time, a total of 80 hours for 2 weeks, including a total of 15 hours of the instructor’s guidance time for 2 weeks.
The program provided to the experimental group was advanced according to knowledge work, self-talk, pattern recognition, juxtaposing, reframing, and reflection checks, based on the thinking strategy for mastery of clinical reasoning [10].
Step 1 Knowledge work: On the first day of the experimental treatment, it is very difficult to infer nursing problems for a patient case without knowing the definition and classification of disease states or the area of nursing knowledge that provides the basis of academic knowledge for nursing providers [10]. Specifically, on the first day of the experimental treatment, 60 minutes of training was provided on the preparation of the OPT model clinical reasoning web worksheet showing the basic patient assessment method, OPT model, and causal relationship to the nursing problem. In addition, for a basic understanding of the patient's disease, a lecture related to respiratory diseases was provided for 60 minutes, and then through self-directed learning, the participants were asked to study to find detailed evidence about symptoms and signs, treatment and nursing intervention based on given respiratory cases by using various references such as books, internet and so on.
Step 2 Self-talk: On the second day of the experimental treatment, 'self-talk' was conducted to express thoughts through self-directed learning. In other words, self-talk or think-loudness is useful for weaving clinical reasoning webs [10]. Using the provided respiratory disease cases, each individual wrote OPT models and clinical reasoning web worksheets to speak aloud about meaningful nursing problem clues, infer causal relationships, and connect diagnostic hypotheses and their links. During the instruction time of 60 minutes, the instructor encouraged the participant to think like a nurse using guideline-based Q&A after identifying whether the participant could recognize appropriate clues to deduce the clues about key nursing problem.
Step 3 Pattern recognition and juxtaposing: On the third day of the experimental treatment, a major part of clinical reasoning is to link pattern recognition between what has been known and experienced, and what has been observed and assessed [10]. Step 3 concentrated on peer-feedback time with only team activities learning without instruction time to improve the participant’ clinical reasoning ability. Participants were asked to perform team discussions and cooperative learning activities to whether they wrote the OPT model and clinical reasoning web worksheet correctly or not through self-directed learning on the Step 2. During team discussions and cooperative learning activities were induced by focusing on the theoretical basis for deriving nursing problems and whether the assessment was made in accordance with the theoretical basis. Through this course, we provided the opportunity to revise the OPT model and clinical reasoning web worksheet by self-discovering errors in nursing problems derived during self-directed learning. In addition, the participants participated in the nursing skill lab and practiced for three hours to nursing intervention and core fundamental nursing skills to solve the respiration patient's priority nursing problems. In other words, by directly performing the nursing intervention learned through the theory, significant patient status change patterns and changes between the subject's current status and outcome status were recognized.
Step 4 Reframing and reflection check: On the 4th day of the experimental treatment, Frame reconstruction is a thinking strategy that gives different meanings to content and context through a series of clues, decisions, and judgments. On the step 4, the instructor held a conference for 90 minutes and gave feedback on the results of writing on the OPT model and clinical reasoning web. The instructor held the conference sequentially according to the flow chart of the nine steps of the OPT model (client in context, cue logic, keystone issue, framing, testing, present state, outcome state, decision-making–intervention, judgment), and by analyzing the patient’s situation and context according to each step, the patient’s condition was comprehensively identified, and the opportunity was given to revised. Through reflection on the integrated process, self-correction becomes possible, and as a prospective nurse, this helps improve clinical reasoning competency and professionalism.
Step 5 Handover: On the 5th day of the experimental treatment, after 60 minutes of training on the purpose and method of using the SBAR protocol, the nursing problems and priorities of patients with respiratory disease at the basic level were identified and written on the SBAR protocol worksheet for each individual. In addition, through role-play with peers were asked to perform handover practice on the patient's situation, and then the instructor provided direct feedback for 60 minutes.
The applying of advanced cases with complex patient’s condition promotes the development of clinical confidence and competency and fosters sensitivity to patterns of changes in patient status [10]. On the 6th to 10th days of the experimental treatment, cardiovascular disease patient’s cases were provided as advanced cases, which is recognized to be most difficult by nursing students. The process method was the same as in Days 1–5. As a total of five steps–knowledge work, self-talk, pattern recognition and parallelization, reframe and reflection check, and handover–were repeated to promote critical and simultaneous thinking, which Nursing students’ clinical reasoning competency was also strengthened.
Control group
The control group participated in 80 hours of clinical practice for two weeks (10 days) in the internal medicine ward of adult nursing at Hospital Y in Gyeonggi-do and Hospital H in Chungcheong-do in Korea. The nursing students assessed one of their patients with respiration and cardiovascular diseases and identifying the nursing problems as usual. During clinical practice, the control group comprised less than five individuals in each team and the instructor gave a total of 15 hours of instruction for two weeks, including a meeting, similar to the experimental group (Table 2).
Ethical considerations
This study was conducted after obtaining ethical approval from the Institutional Review Board of the researcher’s affiliated university (IRB No. 1041078-202201-HR-031).
Data Analysis
The collected data were analyzed using SPSS statistics (version 25.0; Chicago, USA).
1) The general characteristics of the participants were analyzed as real numbers, percentages, means, and standard deviation.
2) To verify the homogeneity of the experimental group and the control group, χ²-test and t-test were performed.
3) Differences in communication clarity, communication confidence, problem-solving process, and team efficacy between the experimental and control groups were analyzed using a paired t-test.