The Effectiveness Of High Fidelity Simulation On Critical Thinking In Undergraduate Nursing Students: A Mixed Method Study In Saudi Arabia

The Effectiveness of High Fidelity Simulation (HFS) on the Critical Thinking of Undergraduate Nursing Students and to explore the role of nursing educators in the simulation lab at the nursing schools in Saudi Arabia.Mixed method design.

It has been demonstrated by Hall (2014) that one of the biggest concerns in nursing education is the poor opportunity to learn and occupy high-order thinking skills in clinical area. Especially, the clinical experience in hospitals do not provide adequate opportunities to the senior nursing students to utilise their critical thinking skill in providing care to the high risk patients. Hence, it becomes difficult for the student to learn about analysing a clinical situation and take effective decision during the time of crisis. Therefore, it has become one of the main concerns of the educators that whether the nursing students are learning about the essential skills such as critical thinking in order to adapt safe nursing practice in future. In this regards, high fidelity simulation has been found to be used widely in the recent years (Shoemaker, Riemersma and Perkins 2009). Simulation is considered as process of enhancing knowledge and skills in an interactive way and it is mainly associated with the level of fidelity (Alammary 2017). The process of high-fidelity simulation is associated with the use of mannequin connected computer and program which act like a real body and also responses to the life changes of physical world (Weaver 2011). SimMan, METI- man, and Noelle are considered as the exemplars of HFS (Maneval et al. 2012). HFS was introduced particularly for medical education and then it was recommended for nursing education as an effective tool, for knowledge acquisition and nursing skills development of undergraduate students (Alammary 2017). Shoemaker, Riemersma and Perkins (2009) have elaborated that, high-fidelity simulation in nursing education provides a learning environment which facilitate the development of non-technical nursing skills. Such learning environment allows the student to make mistakes, learn from the mistakes, fixed those mistakes in real time and improve practice without any hesitation and fear of compromising patient safety (van Vuuren et al 2018). Therefore, with high-fidelity simulation students could explore their knowledge and skills in an effective manner and learn from practical experiences. On the other hand, has reported that a session of high–fidelity simulation as laboratory activity has strong impact on the student’s perception and confidence before encountering acute clinical experience.

In addition, the perceptions of nursing educators and faculties have indicated that, the strategy of using high-fidelity simulation make it easy for the nursing students to understand the concept (Weaver 2011). The kinds of manikins used in high-fidelity simulation, are useful in increase the sense of reality among the nursing students, therefore they could effectively analyse and interpret difficult scenarios and introduce appropriate interventions according to a particular situation (Lasater 2007). Hence, it has been demonstrated that, using simulation based learning approach could effectively facilitate the knowledge acquisition of under graduate nursing students and support them to develop critical thinking and decision making skills. However, Maneval et al. (2012) have also conducted study a randomised control trial involving 80 nursing students in a clinical setting to identify the effectiveness of high-fidelity simulation in enhancing critical thinking and decision making skills of nursing students and the study was unable to identify any significance of high-fidelity simulation on these nursing skills, hence the impact of high-fidelity simulation has remained unclear. Furthermore, there are several obstacles such as budget, additional training for the staffs, limited time and fear of experimenting with new technology, which have restricted the faculties to utilise the strategy of high-fidelity simulation (Weaver 2011).According to van Vuuren et al (2018) nursing educators that are aware of the simulation based teaching approach still lack confidence and feel uncomfortable to use this pedagogical tool or lack the encouragement to learn about the new technology. The ageing population of the nurse cause anxiety and frustration and lack of properly trained nurses to handle these tools act as barriers to the use of such techniques.  Hence, it has been recommended to conduct further research in order to analyse the effectiveness of high-fidelity simulation on nursing education for developing various nursing skills. And minimize the limitations of using this technology in an effective manner.

High-fidelity simulation in Saudi Arabia

As defined earlier, high-fidelity simulation has been considered as one of the effective learning approaches and it has been found to simplify the learning process. High-fidelity simulation is also considered as human patient simulator. It has been found to be the most interesting and innovative pedagogical tool which has been developed in order to utilise in medical education, but now it has been highlighted as effective tool for utilising in nursing education as well (Kneebone et al 2005). In Saudi Arabia, there are a few nursing institution that have decided to use this innovative technology in order to facilitate the learning session of their nursing students and help the faculties with such resource to provide best education service. However, due to high cost and lack of experience regarding this technology, it is not admired or utilised in Saudi Arabia.

Alammary (2017) has aimed to conduct study among the population of Saudi Arabia. In this regards, the authors have recruited under graduated nursing students from Saudi Arabian cultural Mission and conducted a survey. Descriptive quantitative study method has been used over 3 months among 76 under graduate nursing students in Saudi Arabia. It has been found that high-fidelity simulation has positive impact on student satisfaction and improving their self-confidence, hence, it  might  help the nursing students to explore their critical thinking skill as well. The study has revealed that, high mean score has been achieved for the improvement in self-confidence and student satisfaction level with high-fidelity simulation in nursing education. Based on the statistical significance of the data, it can be said that high fidelity simulation can be useful increasing the self-confidence and satisfaction level among the students in Saudi Arabia. However, there are a few studies that have considered impact of high fidelity simulation on critical thinking of undergraduate students as their research topic, specifically in Saudi Arabia. Hence it is important to conduct further research in order to assess the effectiveness of this learning approach and explore its importance. In this regards this study will focus on elaborate the underpinning information about high-fidelity simulation and effectiveness on improving the critical thinking skill of nursing student. In addition, this study will explore the role of nursing educators in the simulation lab and their contribution in promoting the effectiveness of high-fidelity simulation through mixed method study design.

In order to search relevant literature different databases have been used such as, Google Shcolar, CINHAL, PubMed and Medline. Relevant key words associated with fidelity, simulation, high-fidelity simulation, nursing education, impact of simulation on critical thinking have been used for the purpose of this research. Articles that are published during 2005 to recent year has been selected for this study and only articles published in English language has been included based on their title, content, relevancy, methodology and result. In addition, Boolean search strategy has been used with conjunctions in order to find out the most relevant research articles. After following all search strategies 2 articles have been chosen and CASP tool has been used for the purpose of critical analysis of the selected articles (Casp-uk.net 2018)..

Search strategy

According to a study by Fero et al. ( 2010) to identify the relationship among the nursing student’s performance and critical thinking ability metrics by availing the learning which is simulation based. This was executed by using the high fidelity human simulation (HFHS), videotaped vignettes (VTV) and also by using two critical thinking measurement score that are California Critical Thinking Skills Test (CCTST) and Thinking Deposition Inventory (CCTDI). In this study, a quasi-experimental, cross over design was used and almost 36 nursing students were used as sample. The nursing students were from different levels: associate (n=:12), diploma (n=14), baccalaureate (n=10). According to the exclusion and inclusion criteria set by the author, the sample size were grouped into two teams and they were given HFHS and VTV alternatively in a particular time. Students filled the CCTST and CCTDI and the obtained result was compiled between the used metrics and assessment method.  After analysing the HFS score and critical thinking scores, it was seen that the result was significant (Cramer’s V =0 .413, P =0 .047).

Therefore, the findings should be observed carefully as the small size of the sample can alter the generalizability of this study. Along with this,there were several factors that may cause biasness of the participants as the subject population were not attached involuntarily. In addition, the anxiety of the students while performing the HFHS scenario lonely, may alter the performance of the students. The very short timing (10 minutes) allowed to perform the and the grading process may hamper the result.  In addition, the different background of the subject population with different clinical and experiences can also affect the study result. The strengths of this study were the equal treatment for both groups, using reliable and valid tools, properly maintained ethical guidelines. Moreover the researcher were unbiased to the groups and the answers from the students were compared without biasness and that had enhanced the quality of the work.

Goodstone et al. (2013) conducted another quasi experimental study to find the effectivity of the HFPS to observe any kind of progress on critical thinking of the students who are who were  pursuing associate degree course in Health assessment course. In this study , the total number of subject population was 42 (n=42). However, there was no inclusion and exclusion criteria and along with this no power calculation has been affirmed that may alter the external validness of the study and the generalizability. The total sample group of divided into two groups and among them , the first group ( n=20) received the HFS and the other group (n=22) received the low fidelity simulation through case studies and this process was continued once per week. Moreover, there was selection bias due to the lack of randomization of the samples.  The ethical consideration, consent from the participants, and the drop out participants were justified and explicated. However, the blindness of the experimenters and the secrecy to team allocation were not definite that hamper the quality of the study. The obtained data were analysed by using proper statistical tools. From the analysed result, it is seen that, the case study group and the HFS group has improved critical thinking scores after Health Studies Reasoning Test ( HFRT) that is proven as reliable tools. Although the results were not conclusive statistically (p= 0.09). To enhance the study rigor, the results were tallied with the results of previous studies. Researcher found that , the small sample size and time for the study were the main weakness of this study and further study is required.

Critical appraisal

A systematic review study was conducted by Mok et al. (2016) to obdserve the effect of HFS in critical thinking. They studied the impact of teaching clinical reasoning along with critical thinking and high fidelity patient simulation. In this review, 11 studies, which are quasi experimental or randomized, were included. In this study, there three main area of concern that were critical thinking, knowledge acquisition, skill performance. Only 2 out of 11 studies were related to the investigation of the critical thinking ( (Ravert 2008; Brown and Chronister 2009). According to a study by Ravert (2008) , there was no statistical differences in the results of the three groups that were HFPS, CG and non HFPS, although, there was enhanced critical thinking ability among the students.  However, in the critical thinking group large effect size was noticed. The non- significant result may be due to the limitation of the sample size with a particular age group ( 21-25 years) and high grade point ( over 3.65) and also due to homogeneity of the sample. The result would be more significant, if the author can use large and heterogeneous sample population. Brown and Chronister (2009) also failed find any significance in the result while performing the same experience by using Elsevier’s Evolve Electrocardiogram Custom Exam.

Shin et al. (2015) conducted a multi-site, pre-test and post-test in order to evaluate the impact of paediatric simulation integration in the nursing practice of paediatric nursing and also the its impact on the ungraduated student’s critical thinking. In this study, almost 237 sample from three different school was chosen with considering the exclusion and inclusion criteria. In spite of having a large sample size, there was no calculation to achieve the 80% of power calculation. Along with this, there was selection bias as recruitment procedure was not referred. There was clear explanation and well maintained ethical guidelines in the research method,that helped to increase the reliability of the research. The used tool was also valid and reliable as per the previous studies. The number of students in each group was 15 and 10 where pre-test have been allotted. The participants of the three school got the same treatment in terms of utilizing HFS and also uses same orientation and scenario about the courseware simulation. The first group completed their session within the first week, the second group executed two sessions of HFS ,whereas the third one performed for three seasons of HFS by 1^st day of three weeks. The result after the post-test showed that there was significant improvement of the critical score among the groups who were exposed three times than that of the group which was exposed once and twice to HFS (p = 0.02, 0.287, 0.088 respectively). The results were tallied with previous studies and the dissimilarities in the results were explained and that enhanced the quality of the study. Statistical Package of Social Sciences (SPSS) was used to perform the statistical analysis and paired t-test was used for analysis. Lastly, the study limitations and recommendations were suggested by the researcher in order to increase the research quality.

This study aims to investigate the effect of high-fidelity simulation on critical thinking of undergraduate nursing students in comparison with another group of undergraduate nursing students that are involved in traditional learning approach such as classroom lectures in Saudi Arabia and also explore the perception of the nurse educators towards HFS.

• Does high-fidelity simulation effective in increasing developingcritical thinking of undergraduate nursing students as compare to traditional learning method at a nursing education institution in Saudi Arabia?

PICO format has been utilised in order to structure and answer the research question.

This study aims to prove the hypothesis that, there is a cabalistic dissimilation in the critical thinking score of the undergraduate students that have used high-fidelity simulation as compare to the student that have used traditional learning method.

• To explore the effectiveness of high-fidelity simulation in improving critical thinking skill of undergraduate nursing students who have been involved in HFS as compare to the students who have been involved in traditional learning method.
• To explore further study associated with HFS in acquisition of nursing knowledge and critical thinking skill and facilitate nursing education in an effective manner,
• To implement HFS as an effective pedagogical tool for teaching undergraduate nursing students in Saudi Arabia.
• To explore the role of nursing educators in the simulation lab and their contribution in promoting the effectiveness of HFS teaching strategy.

Both qualitative and quantitative approach should be taken for this study for getting an in-depth understanding of the effectiveness HFS in nursing in developing the critical thinking skills. The qualitative approach will mainly be used to understand the perception of the nurse educators about HFS. A mixed method is generally used in studies to enhance the validity of the result as the researcher gets to use both the strengths of the quantitative and a qualitative study (Morse 2016).  Due to the allied range of complexities in the theoretical concepts in nursing, many clinical questions cannot be answered by using only one approach. However, since both the methods are used, much effort has to be given on the data collection and the analysis process (Miles, Huberman and Saldana 2013).

As mentioned mixed method including both the qualitative and quantitative data will be used in order to identify the difference between the critical thinking score of the nursing students receiving high-fidelity simulation and the nursing students receiving traditional teaching method such as class lecture and lab. This study design will help to the difference in the development of critical thinking skills of undergraduate nursing students’ pre and post period of receiving high-fidelity simulation and traditional learning method, hence, will allow elaborating the effectiveness of high-fidelity simulation in developing critical thinking skill among undergraduate nursing students. The research will be conducted within two different nursing education facilities in Saudi Arabia and quantitative data will be collected and analysed in order to derive the result. On the other hand, an interview will be conducted with faculty members in order to understand their perception about the nurses.  

For the qualitative approach an interview of the faculty members of the Prince Nora nursing education facility has been taken. Interview is an effective tool for exploring the human views and the experiences (Miles, Huberman and Saldana 2013). Semi structured questions will be used for the interview as it allows flexibility to the participants to explore their viewpoints. Open ended questions like- 1. Their viewpoints about HFS.

2. Whether they have sufficient knowledge about the use of HFS. 3) What changes has to be made in the curriculum to implement HFS in nursing studies. However, adequate time will be considered for asking other questions that might be arise during the interview.  

The interview will be conducted in English as the staff of the institution used this language. A private room will be used for the interview for ensuring privacy and confidentiality. The interview will be conducted for 6 days and two participants will be selected for each day. Information about the demographic background of the participants will be collected before the interview and data collection will be continued until saturation is reached. Saturation is considered as the point at which further data regarding the phenomenon cannot be collected or same information is repeated by the participants. 6-7 interviewee would be adequate for this research to reach the level of data saturation within 60 to 90 minutes. Hence, the participants will be informed that the interview will be last for one to one and a half hour. An audio tape recorder should be used for recording the interview for analytic purpose.

For the purpose of quantitative data collection difference in critical thinking score will be measured among the student of two different nursing education facilities such as Prince Nora and King Abdulaiz University. One group will be provided high-fidelity simulation and another group will be provided traditional teaching method such as class lectures and case based scenario. The assessment will be done after 16 weeks, as the timeline for this study will be set for 16 weeks, because the module will be continued for one semester which takes 16 weeks. Reliable tool such as California Critical Thinking Disposition Inventory (CCTDI) will be used in order to explore the critical thinking score of these two groups. The independent variable will be the teaching approaches such as high-fidelity simulation and traditional teaching method and dependent variable will be the critical thinking score of the undergraduate nursing students. The collected data will be analysed in an effective manner in order to derive the expected result.

In this study, sample will be recruited with the help of course coordinator. None of the participants will be forced to participate in the study. In this regards, a thorough description about the research question, aim and objectives will be provided to the students both verbally and through written information sheet. The researchers will not be allowed to involve in the process of data collection in order to increase the rigour of this study. Random sample will be recruited from the above mentioned nursing education institution of Saudi Arabia. The nursing students will be asked to participate voluntarily through an email sent through the official site of the particular university. The interested students will be asked to reply to the mail and will be requested to sign the consent form before participating in the study. The students will be recruited according to the following inclusion and exclusion criteria-

Inclusion criteria-

• Both the female and male undergraduate nursing students that are enrolled as BSN in Prince Nora and King Abdulaiz University will be eligible for the study.
• Undergraduate fourth year students.
• Nursing students that have undertaken community nursing module in their first semester.

Exclusion criteria-

• Students that are experienced in high-fidelity simulation.
• Students that are transferred from other nursing universities with the associate degree.

The study will be conducted in two different nursing institutes in Saudi Arabia, Prince Nora nursing institute which have already implemented high-fidelity simulation technique in order to promote simulation based learning approach and King Abdulaiz University which is using the traditional teaching method till now.

It is important to recruit appropriate sample size in order to reduce the biasness of the study and make the findings of the study more valuable. In this regards G* power calculator will be used in this study in order to ensure that an acceptable sample size has been recruited. In addition independent t-test will be utilised in order to evaluate the difference among the two groups. 0.5 will be used as the medium effect size. (Rutterford, Copas and Eldridge 2015) has indicated that proper effect size helps to prove or disprove the association between independent and dependent variable. Further, minimal value (0.5) of alpha level for type 1 error will be set for the sample size. Power will be conventionally set at 0.80. From the total population of 224 undergraduate fourth year nursing students eligible students will be selected following all inclusion and exclusion criteria. Equal number of students will be distributed in the two groups and the sample size will be increased by 20% in order to increase the validity and generalizability of the result.

Lecturer containing similar background in community nursing module will be involved in this study. Group 1 will receive high-fidelity simulation at Prince Nora institution and group 2 will receive traditional learning method at King Abdulaiz University. Each group will be provided 2 hours for 2 laboratory session on adult health nursing for 16 weeks. Advance teaching plan with case scenario and high-fidelity simulation will be arranged during the laboratory session with the help of module coordinator. Critical thinking score of each participant will be measured before the intervention and after the completion of the module.

In order to measure the critical thinking score of the undergraduate nursing students, California Critical Thinking Disposition Inventory (CCTDI) will be used. This tool has been developed by Facione and Facione in the year 1992 (Facione, Facione and Giancarlo 2001) for the purpose of measuring critical thinking ability of the students. The tool contains 7 dimensions such as, open-mindedness, truth seeking, analyticity, inquisitiveness, systematicity, maturity of judgment and confidence in reasoning and the tool is consisted of 75 questions along with 9 to 12 items for each subscale. Students require 15 to 20 minutes in order to complete the answers and rank in 6 point Likert scale from strongly disagree to strongly agree. American Philosophical Association (APA) has validated this tool with 0.91 Cronbach alpha internal consistency coefficients (Facione, Facione and Giancarlo 2001). Due to such significance this scale has been chosen for the purpose of this study.

In order to derive appropriate result it is essential to analyse the collected data in an effective manner. In this regards, SPSS tool will be used for the purpose of data analysis. In order to test the assumption of normal distribution, the variables will be measured with the use of kurtosis and skewness and values will be divided by standard error. Skewness value less than +/- 2.00 will be indicated that the distribution cannot be skewed. Kurtosis value less than +/- 2.00 will be considered as normal distribution. P value >0.05 will be considered as normal distribution (Crowder 2017). T-test will be done as well. Parametric value will be indicated normal distribution and for non-parametric value Mann Whitney U test will be done (Little and Rubin 2014). A thematic analysis should be used for the qualitative study. The transcripts of the interviews should be sorted out in to themes and patterns. NVivo, which is a software package should be used for analysing the data by coding (Sgier 2012). The themes should finally be reviewed, defined and then named.

This proposal will be submitted to the ethics committee of Saudi Arabia and Cardiff University Research Review Ethics Committee for approval and ensure that whether the study is able to comply with the ethical standard. Approval will be taken from the Ministry of Health of Saudi Arabia. Participant’s right will be maintained through confidentiality and anonymity. The purpose of the research will be informed to all participants and consent form will be signed by each participant. The student will be provided coded serial numbers instead of names. Power gradient between the students and the esearchesr might be created through voluntariness of the participants, in contrast, they might feel obliged for being a part of this research. Hence, it will be ensured that this research wil not affect their grades or performance. The collected data will be exported and stored in Microsoft excel and specific code or password will be provided to the researchers. It will be ensured that the data will be used only for the purpose of this research and result will be disseminated through the official site of the institutions. For the audio recording, data will be erased when transcription into paper is finished, following the University guidelines, health board policy and Data Protection Act. The hard copies of data will be secured in locked cupboard as per the institution policy. Another risk is associated with inequivalent randomization of intervention for the control group as compare to the exposure of intervention group. In order to eliminate this, the participants will be offered schedule time for self-study to experience the learning trials of HFS. Further, the result of this research will be disseminated through the official site of the institutions.

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