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Simmons College

School of Nursing and Health Sciences

VIRTUAL SIMULATION AND CONTENT MASTERY

by

JUDITH CULLINANE

Submitted in partial fulfillment of the requirements

for the degree of

Doctorate of Philosophy

Health Professions Education

August 2018

2018 Copyright Judith Cullinane

VIRTUAL SIMULATION AND CONTENT MASTERY ii

VIRTUAL SIMULATION AND CONTENT MASTERY iii

Abstract

Background

The changing landscape of healthcare and current focus on safe high quality care has prompted

close examination of teaching strategies by academic institutions (Hayden, Smiley, Alexander,

Kardon-Edgren & Jeffries, 2014). The use of simulation as a teaching strategy has increased in

popularity stemming from current evidence demonstrating positive results for meaningful

experiential learning, and for being an equitable alternative for clinical experiences due to

limited availability of clinical site placement (Adamson, 2015; Bogossian, Cooper, Cant, Porter

& Forbes, 2015; Hayden et al., 2014; National League for Nursing, 2015).

Purpose

The purpose of this study was 1). to evaluate the use of virtual simulation compared to concept

mapping for content mastery of a nursing topic and 2). to evaluate whether content mastery using

virtual simulation compared to concept mapping is transferable to a practice setting.

Methods

Twenty-eight undergraduate prelicensure nursing students were recruited to participate from two

colleges and randomly assigned to a control group using concept mapping and an experimental

group using virtual simulation. Each group completed a pre- post quiz on asthma prior to and

after the intervention. Following the post quiz, both groups completed the Healthcare

Professional Asthma Knowledge Questionnaire. Subjects in each group participated in a

standardized patient education simulation on the topic asthma and the use of the patient

education framework Teach-Back.

VIRTUAL SIMULATION AND CONTENT MASTERY iv

Results

The Healthcare Professional Asthma Knowledge Questionnaire was found to have a strong

reliability in nursing students as noted by the Cronbach’s alpha of 0.730. Findings revealed no

statistically significant difference in mean asthma knowledge scores between the control and

experimental groups. There was also no statistically significant difference between the mean

teach back score and the groups. A statistically significant difference in the change in mean CQ

correct scores were found to be higher in the concept map group, demonstrating a p = .05.

Conclusion

Both treatment groups demonstrated improvement in scores with almost identical means

observed between students in both groups. This finding suggests that virtual simulation may be

comparable to concept mapping as a teaching strategy for achieving student outcomes.

VIRTUAL SIMULATION AND CONTENT MASTERY v

Acknowledgements

There are a number of people to whom I am most grateful and wish to acknowledge for

their guidance and support throughout this experience. I give thanks to my family for being my

foundation throughout the journey. I was fortunate to have had a wonderful and experienced

dissertation chair and committee; Patricia Rissmiller, Margaret Costello and Robert Goldman.

Their expertise and dedication to my success was exceptional. I also express my gratitude to

Dean Judy Beal for her leadership coaching and support, to Susan Duty for the many years of

mentorship and friendship, and to my soul sister LaDonna Christian, whom I have had the

privilege of working with side by side and have gained much insight from all that can be. Lastly,

to my new found friends, Donna Pineau and Sheryl Cifrino. We vowed to complete this journey

together and to persevere using the power of positivity.

VIRTUAL SIMULATION AND CONTENT MASTERY vi

Dedication

This dissertation is dedicated to my loving family, Will, William, and Victoria and to my golden

girl sister, Anna Marie Matos. Their relentless love, support and inspiration fueled my

motivation to pursue and fulfill my dream.

VIRTUAL SIMULATION AND CONTENT MASTERY vii

Table of Content

Approval..........................................................................................................................................ii

Abstract..........................................................................................................................................iii

Background..............................................................................................................................................iii

Purpose..................................................................................................................................................... iii

Methods.................................................................................................................................................... iii

Results...................................................................................................................................................... iv

Conclusion................................................................................................................................................ iv

Acknowledgements..........................................................................................................................v

Dedication.......................................................................................................................................vi

Chapter 1........................................................................................................................................10

Research Question.........................................................................................................................11

Definition of Terms.......................................................................................................................11

Conceptual Terms....................................................................................................................................11

Operational..............................................................................................................................................12

Significance...................................................................................................................................13

Theoretical Framework..................................................................................................................15

Chapter 2........................................................................................................................................19

Literature Review..........................................................................................................................19

History of Simulation..............................................................................................................................19

Evolution of Simulation..........................................................................................................................19

Types of Simulation................................................................................................................................23

VIRTUAL SIMULATION AND CONTENT MASTERY viii

Concept Mapping....................................................................................................................................28

Content Mastery......................................................................................................................................31

Asthma Diagnosis....................................................................................................................................32

Teach-Back Method................................................................................................................................34

Summary of the Literature.......................................................................................................................38

Chapter 3........................................................................................................................................40

Methods.........................................................................................................................................40

Design......................................................................................................................................................40

Sample.....................................................................................................................................................40

Setting......................................................................................................................................................40

Procedures...............................................................................................................................................41

Intervention..............................................................................................................................................46

Data Analysis...........................................................................................................................................50

Human Protection....................................................................................................................................53

Chapter 4........................................................................................................................................54

Results............................................................................................................................................54

Summary..................................................................................................................................................59

Chapter 5........................................................................................................................................61

Discussion......................................................................................................................................61

Limitations...............................................................................................................................................67

Conclusion...............................................................................................................................................67

Future Educational Recommendations and Research.............................................................................69

References......................................................................................................................................72

VIRTUAL SIMULATION AND CONTENT MASTERY ix

Tables and Graphs.........................................................................................................................87

Appendix A....................................................................................................................................90

Appendix B....................................................................................................................................95

Appendix C....................................................................................................................................96

Appendix D....................................................................................................................................97

Appendix E....................................................................................................................................98

Appendix F....................................................................................................................................99

Appendix G..................................................................................................................................100

Appendix H..................................................................................................................................101

Appendix I...................................................................................................................................103

Appendix J...................................................................................................................................104

Appendix K..................................................................................................................................105

Appendix L..................................................................................................................................106

VIRTUAL SIMULATION AND CONTENT MASTERY 10

Chapter 1

The changing landscape of healthcare and the focus on patient safety and quality of care

has prompted academic institutions preparing health professionals to look closely at the teaching

strategies they use (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). Patient

acuity continues to increase across all healthcare settings and patient populations. These dynamic

changes in healthcare emphasize the importance of having a well prepared healthcare workforce

capable of caring for complex patients (Institute of Medicine [IOM], 2003). Critical thinking,

reflective practice, and sound decision making are pivotal skills needed at the point of care where

the health professional meets the patient (Bogossian, Cooper, Cant, Porter, & Forbes, 2015;

Broussard, Meyers, & Lemoine, 2009; Gore & Thomson, 2016; Kilmon, Brown, Ghosh, &

Mikitiuk, 2010; Shin, Sok, Hyunk, & Kim, 2015). Nurses, as key stakeholders for promoting

patient safety and quality care, are at the center of care delivery and are an integral part of the

care team. Appropriate education and the ability to transfer knowledge and skills about nursing

care to the patient care environment are essential from the onset of a nurse’s career (Tschannen,

Aebersold, McLaughlin, Bowen, & Fairchild, 2012).

The use of simulation as a teaching strategy has grown in healthcare settings and

academic institutions. The popularity stems from current evidence that demonstrates

positive results for meaningful experiential learning, as well as being an equitable

alternative to clinical experiences in the absence and decrease of clinical site placements

(Adamson, 2015; Bogossian et al., 2015; Hayden et al., 2014; National League for

Nursing [NLN], 2015). However, there is limited empirical evidence about how

simulation improves student learning outcomes, how it facilitates transferability of

content mastery from the classroom into practice, and what impact it has on patient


outcomes (Adamson, 2015; Aebersold & Tschannen, 2013; Cantrell, Franklin, Leighton

& Carlson, 2017; Tschannen et al., 2012). In addition, the National League for Nursing

(NLN) (2015) reports the need for further research about how using simulation as a

teaching strategy can enhance learning outcomes (Tschannen et al., 2012). The evolution

of technology has also facilitated the development of virtual simulation. However, there

is limited evidence supporting virtual simulation as a pedagogy for enhancing learning in

nursing education and

2). explore whether students can transfer the asthma content using virtual simulation

compared to concept mapping to a simulated patient education session that encompassed

the teach-back method as a framework.

facilitating the transferability of knowledge to the clinical setting (Cantrell, Franklin,

Leighton, & Carlson, 2017).

The purpose of this quantitative study was to:

1). explore the effect of virtual simulation compared to concept mapping instruction for

content mastery using the subject of asthma.

Research Question

The following question guided the study: how does content mastery on asthma differ

using virtual simulation compared to using concept mapping instruction among nursing students

in a prelicensure baccalaureate program?

Definition of Terms

Conceptual Terms

For the purpose of this study the following terms are defined:

Competence: The performance of nursing students at an expected


level of knowledge, skills and abilities in nursing (American Nurses

Association, 2013).

Concept mapping: A method for creating maps that accommodate

inputs, outputs and relationships of concepts for problem solving

and critical thinking (Noonan, 2011).

Content mastery: The ability of nursing students in a

baccalaureate nursing program to reach a level of understanding

about content and the ability for the students to respond to a series

of skills and tasks measured against specific criteria that is

predetermined (Guskey & Anderman, 2014).

NLN Jeffries Simulation Theory: A framework for designing,

implementing, and evaluating simulations used as teaching

strategies in nursing (Jeffries, Rodgers & Adamson, 2015).

Teach-Back Method: A method used by healthcare professionals

to confirm a patient and family’s understanding of a health care

plan by asking them to explain and demonstrate the learning in

their own words (Agency for Healthcare Research and Quality

[AHRQ], 2014).

Operational

For the purpose of this study the following terms are defined:

Consumer Asthma Knowledge Questionnaire: A validated

asthma knowledge questionnaire for adult consumers (Kritikos,

Krass, Chan, & Bosnic-Anticevich, 2005).


Fidelity: The degree to which a simulation replicates reality (Lewis,

Strachan, & Smith, 2012).

Healthcare Professional Asthma Knowledge Questionnaire: A

validated asthma knowledge questionnaire for healthcare

professionals (Kritikos et al., 2005).

Simulation: A technique for providing experiences that resembles

realistic aspects of care delivery in an interactive manner

(Alexander, Dryham, Hooper, & Jeffries et al., 2015)

Virtual simulation: A form of high fidelity simulation that is

computerized and enables the user to manipulate and interact with

the environment (Bai, Duncan, Horowitz, & Graffeo, 2012)

Significance

The main goal of simulation experiences is to help close the gap between the classroom

and the patient care setting (Bai et al., 2012). While the use of simulation has increased in

healthcare education, there continues to be a lack of consensus on how the method of instruction

is provided and implemented (Adamson, 2015). In a systematic review completed by Adamson

(2015) on simulation, recurring gaps and key issues were identified as cost, need for faculty

development, and consensus on methods for implementation of simulation instruction. In

addition, there is limited empirical evidence on the effects of simulation on patient and systems

outcomes (Adamson, 2015; Broussard et al., 2009). The body of evidence that primarily exists

on simulation focuses on improvement of self-confidence and self-efficacy for nursing students,

and the outcomes are considered lower levels of evaluations (Adamson, 2015; Bai & Lavin,

2016; Franklin & Lee, 2014).


The NLN (2015) report, A Vision for Teaching Simulation: A Living Document from the

National League for Nursing, endorsed the findings of the study conducted by Hayden et al.

(2014), noting that there is sufficient evidence to support simulation as a substitute for 50% of

traditional clinical experience in nursing. The study was a comprehensive longitudinal

randomized trial with over eight hundred student participants from different schools of nursing.

Participants were divided into three groups. Group one received 25% of the clinical practicum

hours by simulation. A second group received 50% of the clinical practicum hours by simulation

and the control group had traditional clinical hours and no simulation. Outcomes were measured

by evaluating students’ knowledge, competency, critical thinking and perceptions on learning

needs met. The results demonstrated no statistically significant difference between the three

randomized groups.

Several areas of focus were identified and summarized by the NLN for future research in

simulation. The recommendations emphasized the need for research in contextual experiential

learning opportunities using simulation. Other suggestions for research included evaluating

purposeful integration of simulation with connection to student learning outcomes, and using

valid and reliable measurements to increase the body of knowledge on simulation (NLN, 2015).

This research study investigates virtual simulation as a teaching strategy for content mastery of

the topic asthma using a validated asthma knowledge questionnaire for health care providers.

Advancements in technology have allowed simulation to evolve into the virtual space of

the digital world (Bai et al., 2012). The evolution began in the 1980’s and favorable outcomes

have been incrementally noted (Smith & Hamilton, 2015). The unprecedented changes occurring

in healthcare today and the demand for high quality care have become key focus points for

nursing academia to expand innovative teaching strategies (Hayden et al., 2014). Melynk and


Fineout-Overholt (2011) have proposed that virtual simulation can be used in nursing education

and that the strategy offers a different strategy to connect theory to practice. However, there is

different technology used to deliver virtual simulation as a teaching strategy and there is limited

research on how best virtual simulation can enhance student learning outcomes (Aebersole et al.,

2012; Bai et al., 2012; Jenson & Forsyth, 2012). The goal of this research study is to add to the

body of knowledge on virtual simulation. The study will evaluate the effects of virtual simulation

on student mastery of content and its effects for transferability knowledge using the teaching

strategy concept mapping as a comparison.

Theoretical Framework

The NLN Jeffries Simulation Theory was the theoretical framework used

for this study. The theory was previously called the Nursing Education

Framework and was developed for designing, implementing and evaluating

simulation instruction conducted in nursing education (Jeffries, 2005). The

original framework was composed of the elements teacher, student,

educational practices, simulation, design, and outcomes (Jeffries, 2005). The

original model was adapted from a framework to a mid-range theory after

changes were recommended by LaFond & Van Hulle Vincent (2012) and a

synthesis of the literature was conducted by Adamson (2015). Figure 1

demonstrates a schematic design of the theory.


Figure 1. NLN Jeffries Simulation Theory

The concepts of the theory were then revised to include context,

background, design, simulation experience, facilitator, educational

strategies, participant, and outcomes (Haerling & Prion, 2017; Jeffries et al.,

2015).

In the theory, context is described as circumstances and the setting in which a simulation

resembles reality (Jeffries et al., 2015). Within the context, there is an emphasis on fidelity or the

realistic feel of the simulation (LaFond & Van Hulle Vincent, 2012). The concepts of

background and design are described in relation to the specific learning objectives and

expectations that guide the development of the simulation scenario, critical thinking, and the

learner satisfaction within the simulation (Jeffries et al., 2015). Context, background and design

are components of the theory necessary to produce the synergy of a simulation experience and

together they facilitate experiential, interactive, active, and collaborative learning (Kelly, 2015).


Developing interactivity in a simulation and noting its effects on the environment are relevant in

establishing trust between the participant and the facilitator (Wilson & Klein, 2012). The

relationship enables engagement by both the facilitator and participant and authenticates the

experience and the ability to suspend disbelief during a simulation instruction (Jeffries et al.,

2015; Wilson & Klein, 2012).

The relationship established between the facilitator and the participant

is also enhanced by the facilitator’s knowledge, skills, and attributes, as well

as, by the participant characteristics. The facilitator provides support using

cues, directions, and guided reflection during a simulation and during a

debriefing session after a simulation. The characteristics of the participants,

such as age, gender, learning needs, and self-confidence are factors that are

taken into consideration in the development of a simulation and during a

simulation experience. These characteristics emphasize the importance of

purposeful design when creating a simulation instruction in order to best

meet the participants’ capabilities for successful performance in the

simulation experience (Adamson, 2015; Fisher & King, 2013; Jeffries, 2005;

Jeffries et al., 2015; LaFond & Van Hulle Vincent, 2012).

Five outcome variables of the NLN Jeffries Simulation Theory have been identified:

learning, skill, performance, learner satisfaction, critical thinking, and self-confidence (LaFond

& Van Hulle Vincent, 2012). The newly revised theory separates the variables into three

categories and are described as participant, patient (or care recipient), and systems outcomes

(Jeffries et al., 2015). There have been numerous studies that have reported the significance that

simulation instruction contributes to a participant’s self-confidence and self -efficacy when the


NLN Jeffries Simulation Model is used to develop them (Adamson, 2015; Bai & Lavin, 2016;

Cantrell et al., 2017; Franklin and Lee, 2014).

In an integrative review of twenty-four studies by Weaver (2011), the author reported the

majority of the findings from the studies noted student reports of an increase in confidence and

knowledge after completing simulation experiences. Foronda, Liu, and Bauman (2013) reported

similar results after conducting an integrative literature review of one hundred studies on

simulation. The findings from the review noted an emergence of five themes: an increase in self-

confidence and self-efficacy, an increase in satisfaction with the simulation experience, a

decrease in anxiety and stress, an increase in gained knowledge acquisition and an improvement

in interprofessional communications. In the study done by Walter, Potetz and Fedesco (2017),

the use of simulation during lectures was examined with fifty nursing student. Subjects were

randomized between a traditional lecture course and a course with simulation integrated into it.

The simulation experiences were held during class time and all students were invited to attend.

Groups placed into the simulation experience participated in a scenario for approximately twenty

to thirty minutes. Measures consisted of evaluating knowledge gained and perceptions of the

learning environment. Statistically significant differences were found in the quiz performance in

favor of the simulation group (M = 89.84, SD = 9.69) in comparison to the non-simulation group

(M= 81.57, SD = 12.43). Students’ perceptions were positive for the learning environment. The

limitation of the study was that it was a small sample size and the inability to generalize findings.

The NLN Jeffries Simulation Theory facilitates the opportunity to explore the effects of a

simulation instruction on student learning outcomes by the nature of its design. Simulation is

complex and takes into account several different facets that connect learning. The concepts in the

NLN Jeffries Simulation Model provide a directional link to connect learning outcomes while


encompassing other learning theories such as the experiential learning theory (Haerling & Prion,

2017). The NLN Jeffries Simulation theory also helps to prevent a research study on simulation

from being lost or linked to technology alone (Haerling & Prion). Applying the concepts of the

model to the design of this research study on simulation helped to maintain the integrity and

consistency of the study across groups, as well as, to investigate the effects in the outcomes

(Haerling & Prion). The model was used in this study to ensure the environment was conducive

for learning and to develop effective interventions across two groups.


Chapter 2

Literature Review

A literature review was conducted using EBSCOhost, OVID, the Cumulative Index for

Nursing and Allied Health Literature (CINAHL), and PubMed. Key words used in the search

were virtual simulation, virtual 3D simulation, simulation, healthcare, concept mapping, content

mastery, asthma, competency, teach-back, and, pre-licensure nursing student. The literature used

for the study focused on studies that evaluated the effects and outcomes of different simulation

techniques, theory frameworks used in simulation, the teaching instructions concept mapping

and the teach-back method.

History of Simulation

Simulation has been used as a teaching instruction in nursing education as early as 1911

when the “Mrs. Chase” doll was used for practicing nursing skills (NLN, 2015; Stokowski,

2013). Other examples of the early use of simulation in nursing education include chicken bones

and lamb’s jaw to learn how to apply traction for orthopedic fractures, the use of rag dolls

without the stuffing to learn how to give enemas, and the use of Resusci Anne to learn

emergency nursing skills (Chee, 2013; Stokowski, 2013). Simulation is also used to educate and

develop competency in other fields including aviation, military training, anesthesiology training,

and for mass casualty and catastrophic training (Aebersold & Tschannen, 2013; Broussard et al.,

2009; Gore & Thomson, 2016; Kilmon et al., 2010; Stokowski, 2013).

Evolution of Simulation

Today, simulation education supports the teaching and learning of nursing competencies

and nursing educational objectives, especially in the areas of highly complex patient care

environments (Abelsson, Lindwall, Suserad & Rystedt, 2017; Broussard et al., 2009). Patient


acuity continues to increase emphasizing the importance of ensuring educational pedagogies that

allow opportunities to practice the application of knowledge and skills for a competent

healthcare workforce (Hayden et al., 2014: Shin, Sok, Hyunk, & Kim, 2015). Most simulation

based learning research has been on high fidelity laboratory studies in which a computerized

human size manikin and technology are used. Outcomes have been evaluated in all three learning

domains: cognitive, psychomotor and affective (Cantrell et al., 2017). However, there is

opportunity for research to be done in simulation with students to evaluate the development of

situation awareness and the ability to recognize elements of clinical encounters after a simulation

experience (Cantrell et al., 2017).

Shalestak and Voshall (2011) suggested that faculty do their best and take necessary steps

to ensure simulation experiences developed provide accurate and consistent measures of student

ability. For example, in a study on trauma care, Abelsson et al. (2017) summarized that repetition

of simulation in trauma care skills may contribute to improved clinical performance. The study

consisted of sixty-three nurses participating in a trauma simulation in prehospital emergency care

using high fidelity simulation. The aim of the study was to examine the effects of a trauma

simulation on the trauma care skills of nurses using the Global Rating Scale. Care actions were

evaluated on whether skills were performed or not performed. Nurses were placed into one of

two groups. Group A had four repeated simulation experiences and group B had 2 experiences.

Mean response time to care actions were recorded by two blinded independent raters. Results

were noted in both groups from the first simulation to the last simulation. There were notable

increases of 18-19% with inspection of the chest for both groups. For the examination of the

pelvis, group A demonstrated an 11% percent increase whereas group B did worse by 22%.

Other identified improvements noted were skills for performing jaw thrust, applying oxygen, and


efforts to stop bleeding. The limitations of this study were the inconclusive results on the specific

effects of the repetition of simulation on trauma skills, the small sample size and the lack of

appreciation for the clinical experience of the nurses (Abelsson et al., 2017)

Cantrell et al. (2017) conducted a literature review using the Joanna Briggs guideline on

simulation. The authors reported that the meta-analysis completed by Harakanen, Voutilainen,

Turuven and Vehvilaine-Julkunen (2016) comparing classroom teaching to simulation learning

for medication administration skills and safety favored simulation for improvement of the skills.

However, after conducting the review, Cantrell et al. (2017) concluded that simulation based

learning research has relied too much on self-reported evaluations noting that more research that

is rigorous is needed to evaluate the teaching instruction. In contrast, Shin et al. (2015) and Kim,

Park, and Shin (2016) conducted analyses that showed simulation experiences had a strong effect

in the psychomotor learning domain in which students improve in safety practice behaviors.

The study conducted by Swenty and Eggleston (2011) demonstrated efforts for designing

a more rigorous research study on simulation. Nursing students participated in four high fidelity

simulations. Students were evaluated at completion of the simulations for active learning,

fidelity, student satisfaction and confidence using the instruments developed by the National

League for Nursing: The Educational Practices in Simulation Scale (EPSS), The Simulation

Design Scale (SDS), The Student Satisfaction with Learning Scale and The Self Confidence in

Learning Using Simulation Scale. The results of the study showed the EPSS scores ranged from

4.32 to 4.57 out of a 5-point Likert scale indicating students perceived active learning occurred

in all the scenarios. The SDS mean scores ranged from 4.36 to 4.58. The mean scores of the

Student Satisfaction with Learning Scale ranged from 4.24 to 4.54 and the Self Confidence in

Learning with Simulation Scale ranged from 4.20 to 4.50. Students indicated a value for high


level of fidelity to be incorporated into a simulation and self-confidence was reported to have

increased with each of the scenarios (Swenty & Eggleston, 2011)

The evolution of simulation has expanded the capacity for education to remodel teaching

strategies for nursing with the integration of virtual simulation technology (Verkuyl, Romanuik,

Atack & Mastrilli, 2017). Virtual simulation is described as a pedagogy that incorporates

technology, as well as, teaching and learning strategies to create experiences that mimic realistic

clinical patient case scenarios (Gore & Thomson, 2016). The scenarios expose students to

clinical situations and include interactive computerized sessions for conducting assessments,

planning, interventions, promoting critical thinking, and decision making. The scenarios can also

be repeated by students at another time, further optimizing student learning and confidence

(Chee, 2013; Scherer, Foltz-Ramos, Fabry, & Chao, 2016).

There is a variety of nomenclature used in the literature to describe virtual simulation and

include terms such as virtual reality or serious games (Aebersold, Tschannen, & Bathish, 2012;

Kilmon et al., 2010). For the purpose of this study the terms virtual simulation will be used to

describe a simulation that is computerized or a virtual simulation learning environment that

enhances medical training by engaging and involving a participant in an immersive virtual space

while simultaneously promoting learning of knowledge and skills on a subject (Riccardi &

DePaolis, 2014).

Virtual simulation can be included in nursing courses in different ways. Examples

include incorporating the simulation in combination with lecture (Foronda & Bauman, 2014;

Heinrich, Pennington, & Kuper, 2012), in web based courses (Gu, Zou, & Chen, 2017; Farra et

al., 2012) or to replace a portion of clinical hours when there is difficulty finding clinical

placements for students (Verkuyl et al., 2017). Reshaping nursing education through the use of


virtual simulation can also help accommodate experiences for students usually deemed unsafe as

an assignment in a clinical setting. The teaching strategy allows students to be exposed to patient

clinical scenarios of higher complexity and have a realistic feel to them (Broussard et al., 2009;

Gore & Thomson, 2016; Jenson & Forsyth, 2012).

Types of Simulation

There are various simulation techniques that can be used to replicate patient clinical

scenarios that students may encounter as future nurses. The types of simulation, the manner in

which they are developed and the equipment used can all be correlated to how realistic a

simulation experience is portrayed. The term fidelity is used to describe the different types of

simulations and refers to the capability of the equipment to reproduce a realistic scenario

(Adamson, 2015; Aebersold & Tschannen, 2013; Broussard et al., 2009; Shelestak & Vishall,

2014). Simulation fidelity is described in the context of low level, moderate level, and high level

and the simulation techniques are categorized into these levels (Adamson, 2015; Broussard et al.,

2009).

Task or skill trainers such as anatomical body parts are usually considered to be low

fidelity simulators and are useful in the development of psychomotor skills. (Aebersold &

Tschannen, 2013; Broussard et al., 2009). The skills are practiced in nursing laboratories and

include examples of anatomical models for wound dressings, urinary catheter insertions, and

intravenous applications (Broussard et al., 2009: Galloway, 2009). An advantage of low fidelity

simulations is the ability to practice skill acquisition in a standardized way. A disadvantage of

this type of simulation is the lack of realism and the single task purpose it serves (Galloway,

2009).


Moderate fidelity simulation is the use of static mannikins with computerized technology.

The goal of this type of simulation is to facilitate a deeper understanding of specific content or

skills (Broussard et al., 2009). Broussard et al. (2009) described a moderate fidelity simulation

using the example of a cardiac simulation modulator with a screen monitor which displays

patient vital signs such as heart rate, respiratory rate, and blood pressure. A facilitator of this type

of simulation can verbalize the scenario using the static mannikin while increasing or decreasing

the vital signs in the modulator to demonstrate a change in a patient’s status (Broussard et al.,

2009). These simulations are useful in improving the confidence level with decisions and critical

thinking, however, a disadvantage is the limitation of the equipment to produce a sense of

realism without the verbal guidance of a facilitator.

High fidelity simulation is described by Cant and Cooper (2014) as a technique that

incorporates a computerized full body mannikin that is programmable to provide realistic

responses using technology. Hicks, Coke, and Suling (2009) defined high fidelity simulations as

structured student learning experiences that use a technologically computerized human patient

simulator. This description is similar to the one defined by Aebersold and Tschannen (2013) and

this type of simulation is widely used in academia and in the practice setting as a method to

enhance clinical and nonclinical knowledge and skills of health professionals (Aebersold &

Tschannen, 2013; Lewis et al., 2012).

Virtual simulation is a form of high fidelity simulation technique that is computer

generated and has three dimensional capabilities to make objects and images appear real (Bai et

al., 2012; Meakim, Boese, Decker, Franklin, Gloe, Lioce, et al., 2013). The technique has also

been found to support the learning style of different types of learners and enables the learner to

manipulate and interact with the environment, as well as, to receive timely written, visual, and


auditory feedback (Bai et al., 2012; Duff, Miller & Bruce, 2016; Jenson & Forsyth, 2012;

Kilmon et al., 2010). Duff et al. (2016) conducted a review of twelve studies on virtual

simulation and reported that studies from medicine, nursing and other different healthcare

professions have found that virtual simulation reinforces critical thinking and clinical reasoning

skills either as a teaching instruction by itself or in combination with other teaching instructions.

Verkuyl et al. (2017) conducted a study comparing a pediatric nursing virtual simulation

experience with a laboratory high fidelity simulation in second year pre-licensure baccalaureate

nursing students on the domains of knowledge, self-efficacy and satisfaction. The authors

hypothesized that students in the virtual simulation group would have higher scores than those in

a traditional laboratory simulation using a pediatric nursing care knowledge test, a pediatric self-

efficacy survey and a simulation satisfaction survey. Results demonstrated comparable

improvements in all three of the domains in both groups. In the pediatric knowledge test, there

was no statistically significant difference in the pretest scores between the two groups (control =

7.3/10, experimental = 7.4/10). Both groups improved in the post test (control = 7.6/10,

experimental = 8.0/10) with a statistically significant difference in the virtual simulation group

(t= -2.12, df = 22, p = .045). There was a statistically significant difference between the groups in

the post pediatric skills survey (t = -2.1, df = 44, p = .041) and there was no statistically

significant difference found in the simulation satisfaction survey (Verkuyl et al., 2017).

Limitations of the study were noted as a small sample size and the self-reported measurement

tools. These results emphasize that similar student outcomes can be achieved with virtual

simulation as in traditional simulation (Verkuyl et al., 2017).

Gu, Zou, and Chen (2017) also noted similar results in their study on virtual simulation.

A total of twenty-eight nursing students participated and were evenly distributed between a


control and experimental group. Students in the experimental group received didactics and

virtual simulations. A knowledge test was distributed and the scores on the knowledge test were

significantly higher in the experimental group than the control group (M = 65.36, SD = 8.93, t =

2.27, p = .032). Results from the study conducted by Smith and Hamilton also showed that there

were statistically significant differences between the experimental and control groups. The study

evaluated the effects of virtual simulation on the performance of a urinary catheter insertion skill

compared to classroom instruction. Independent t-tests were conducted and were noted to be

statistically significantly different between the groups in visual analog scores (t (11.719) = 1.194,

p = .05), overall performance scores (t (18) = 0.821, p = .05) and time in minutes spent on

nonhuman (t (18) = 1.862, p = .05). Similarly, Heinrich, Pennington and Kuiper (2012) used a

pre-post design in their study to assess content knowledge on the topics of pulmonary embolus

and diabetic ketoacidosis in students after participating in virtual simulation. Significant

differences were found in the students using tests composed of multi-logical multiple choice

questions. The mean difference in scores between pretest 1 and the posttest demonstrated

improvement on the knowledge of pulmonary embolus and was statistically significant (t = -

23.39, p < .001). The improvement in scores was also noted between the pretest 2 and the

posttest for pulmonary embolus and was statistically significant (t = -28.39, p < .001). The mean

difference in scores between the pretest 1 and the posttest for diabetic ketoacidosis showed

improvement and was statistically significant (t = -24.12, p < .001) and a significant difference

was also found between pretest 2 and the posttest for diabetic ketoacidosis (t = -30.53, p < .001).

An advantage of virtual simulation is learner satisfaction and engagement (Bai et al.,

2012; Duff et al., 2016; Jenson & Forsyth, 2012). Duff et al. (2016), reported that virtual

simulation scenarios were thought to have a more realistic approach than mannikins due to the


ability to create scenarios that demonstrate transient changes in vital signs, signs and symptoms

of disorders or diseases and interactions with the avatars (computerized virtual simulation

people). Jenson and Forsyth (2012) described the technique as being delivered in two ways: 1). a

desk top version that can be manipulated using a keyboard, mouse, stylus or a wand, and 2). a

total immersive virtual simulation environment delivered either by multiple screens or through a

head gear. Factors to consider before using virtual simulation include the financial cost, time

constraints required for implementation, the education of faculty in order to use the program,

how best to deliver the teaching instruction and how to evaluate the students’ performance and

learning outcomes (Bai et al., 2012; Farra et al., 2012).

The growing body of evidence on virtual simulation and the advances in technology

provide opportunity for wider use of the technology in nursing education. For example, in a

longitudinal study conducted by Farra et al. (2012), virtual simulation demonstrated a stronger

effect on retention of disaster planning. A convenience sample of associate degree nursing

students enrolled in a disaster course were randomly assigned to one of two groups. The control

group received web based modules and the experimental group received the web based modules

and virtual simulation experiences. A twenty question multiple choice test was provided as a pre

and a post knowledge test. A secondary post-test was given at two months after the intervention.

The virtual group showed significantly higher scores in the knowledge test at the two-month

evaluation and demonstrated improved retention (p < .0001) (Farra et al., 2012). Chia (2013)

conducted a study noting that the use of virtual games in healthcare professions enhances

knowledge and improves a team’s collaborative decision making process. The aim of this study

was to evaluate students’ perception about participating in a virtual simulation before a

laboratory simulation using a computerized human patient simulator. A survey was distributed to


one hundred and sixty-one students with a response rate of ninety-four percent. Questions asked

on the survey related to participants’ view on the virtual simulation relevance, like or dislike,

interest, duration and perceived knowledge gained. There was no control group and descriptive

results showed that students reported they found the virtual simulation relevant to their learning

(99%). Students also reported they found the virtual simulation interesting (94%) and it prepared

them well for the learning activity (97%) (Chia, 2013).

As an innovative teaching strategy, virtual simulation addresses diverse styles of learning

and gives a learner a meaningful experience on the subject to be learned and which interventions

are applicable to a given situation (Chia, 2013). Kilmon Brown, Ghosh, and Mikitiuk (2010)

explored the literature on virtual simulation as a potential educational strategy and reported that

virtual simulation may help inexperienced nurses become more proficient in their ability to

function as a team member as well as feel confident with care delivery and the communication of

assessments or concerns about a patient’s status. Although the virtual simulation technique has

demonstrated the potential to enhance learning, further research would help to evaluate its effects

on student learning outcomes and provide insight for best ways to integrate the teaching strategy

in nursing education (Aebersol et al., 2012; Duff et al., 2017; Tilton, Tiffany & Holland, 2015;

Weideman & Culletiton, 2014).

Concept Mapping

Concept maps were developed by Novak and Gowin (1984) as a teaching and learning

tool to stimulate critical thinking that facilitates the construct of new knowledge built onto

existing knowledge by linking relationships of concepts. The method is based on Ausubel’s

theory of assimilation and can help students understand how or where to place concepts within a

hierarchy of thought processing, as well as, how to code information in a meaningful manner for


learning, retrieval, and recall (Atay & Karabakh, 2012; Daley & Torre, 2010; Harrison &

Gibbons, 2013; Noonan, 2011). A systematic literature review completed by Daley and Torre

(2010) noted that concept mapping is a teaching and learning strategy that can help students

connect theoretical knowledge to clinical practice. Schuster (2008) noted that clinical care plans

prepared by students using concept mapping were more comprehensible and promoted higher-

level critical thinking and reflection when compared to the standard format care plans completed

in nursing educational courses. Noonan (2011) reported that concept mapping allows the

organization of large bodies of complex knowledge and engages students in an active learning

processes that helps with recalling information.

Daley, Morgan and Black (2016) summarized the process by which concept mapping

facilitates the linking of concepts and relationships in three theoretical premises: deductive

reasoning, progressive differentiation and integrative reconciliation. The authors proposed that

lower order concepts fall within higher order concepts and through deductive reasoning and

differentiation, these concepts can be deciphered into more detail using an analytical process.

Concepts are synthesized together to form a full understanding of a topic (Daley et al., 2016)

Daley et al (2016) also reported that concept mapping can be used to support and build

simulation experiences, however, further research is needed to evaluate the value concept

mapping may have for preparing students for a simulation experience. An example of the effects

of using concept mapping for simulation is the research conducted by Daley, Beman, Morgan,

Kennedy and Sheriff (2017). The study involved 104 senior nursing students who participated in

the research to evaluate the effects on how a video recorded simulated learning experience

differed for students who created a concept map prior to the simulation experience versus those

who did not prepare a concept map. Observed behaviors were classified as noticing, interpreting,


responding and reflecting. The mean number of behaviors observed in students who had

completed concept maps prior to the simulation were higher than students who did not complete

a concept map for each of the identified behaviors: noticing (concept M = 7.1, non-concept M =

4.2), interpreting (concept M = 4.6, non-concept M = 4.2), responding (concept M = 7.4, non-

concept M = 7.2), reflecting (concept M = 1, non-concept M = 0). The limitations of the study

were the small sample size and the inability to determine statistical significance. The authors

identified notable behaviors and reported students felt that the concept maps assisted with

organizing knowledge structures for application (Daley et al., 2017).

There are different types of concept maps ranging from simple to complex and the type is

usually selected based on the purpose (Harrison & Gibbons, 2013; Noonan, 2011). One type of

concept mapping is systems mapping and the design accommodates input, outputs and

relationships of concepts for problem solving (Noonan, 2011). Nursing practice requires early

recognition of a change of status in a patient. Critical thinking and prioritization of nursing

interventions are pivotal in life threatening situations (Gerdeman, Lux, & Jack, 2012; Willis &

McConnell, 2008). Systems mapping is an analytical form of concept mapping that can be used

in nursing for synthesizing information and data which can then lead to effective critical thinking

and clinical decision making (Willis & McConnell, 2008). The map helps to organize the

information, which in turns helps students link theory with practice. This type of mapping is also

useful for developing simulation cases and is often used within the development of virtual

simulation (Bai & Lavin, 2016). In virtual simulation platforms, concept maps are used to create

and plan realistic scenarios by linking necessary concepts such as symbols, networks, chain of

events, and the environment (Bai & Lavin, 2016). The concept mapping process used to create


virtual simulations correlates with the concepts identified in the NLN Jeffries Simulation Model

of context, backgrounds and design.

Content Mastery

Many educators use the terms content mastery and competence synonymously because of

the similarity in the definitions. This may lead to confusion for educational studies and for

student evaluations (Guskey & Anderman, 2014). Rosenberg (2012) argued that there is a

difference between mastery and competence and explained that competence is one step in a four

step process needed in order to reach mastery: novice, competent, experienced, and

master/expert. Rosenberg’s explanation correlates with the notion of an apprentice moving

through steps to reach proficiency and then to mastery (Guskey & Anderman, 2014). Rosenberg

(2012) used the example that a patient with a medical issue would likely prefer a nurse and

physician team that have mastered the field of healthcare rather than a team who is merely

competent. This concept is similar to the models used in nursing education known as the Benner

Model and the Nurse of the Future Core Competencies (NOFCC) (Benner, 2004; Massachusetts

Department of Higher Education, 2016;).

The NOFCC are a set of assumptions that serve as a framework for

designing competency based education and a practice model. The core essence of the

framework is that competence is developed over time and through a series of evaluations using

objectives. The framework is composed of ten topics categorized for knowledge, attitudes and

skills that reflect the cognitive, affective and psychomotor domains of learning (Massachusetts

Department of Higher Education, 2016). These categories facilitate a gradual process of

progression towards mastery in nursing and a transition period into the practice environment of

nursing. Similarly, the Benner Model uses stages to describe clinical competence (Benner, 2004).


The model projects that nurses advance through five levels to acquire and

develop skills: novice, advanced beginner (technical), competent, proficient,

and expert.

Asthma Diagnosis

Approximately 25 million Americans and over 235 million people worldwide have been

diagnosed with the chronic lung disease, asthma. In the United States, asthma had increased from

3.1% in 1980 to 8.4% in 2010 (Center for Disease Control [CDC], 2016). Statistics show that

one in twelve people were diagnosis in 2010 (CDC). The mortality rate of asthma differs

globally due to reporting structures: however, in most countries it remains at less than one

percent (Global Initiative for Asthma, 2014). Although the death rates have improved overall due

to advances in medicine, better patient education on the diagnosis is needed (Global Initiative for

Asthma). Asthma is caused by airway inflammation in response to triggers such as dust mites,

allergens, and environmental factors. The response is characterized by symptoms of wheezing,

chest tightness, and coughing. The attack can become a medical emergency if symptoms persist

and worsen (American Lung Association, 2017; Global Initiative for Asthma, 2017; National

Heart, Lung, and Blood Institute [NHLBI], 2014). These statistics and the potential severity of

illness caused by the disease merit the inclusion of the diagnosis in nursing curricula.

Nurses play an important role in the delivery of health promotion and health prevention

education (Murray & O’Neill, 2016). Providing patient education for self-management of

chronic diseases like asthma is necessary to help patients recognize and manage their symptoms,

as well as develop strategies for controlling symptoms (Newell, 2006). Teaching self -

management of illness assists patients and their families to better manage chronic conditions and

contributes to decreasing health care utilization and cost by reducing hospitalizations,


readmissions, emergency room visits and length of days in a hospital (Dinh, Clark, Bonner, &

Hines, 2013). Mismanagement and noncompliance of medication increases the use of healthcare

and decreases the overall wellbeing and quality of life for those living with asthma (Global

Initiative for Asthma, 2014). As a common chronic illness seen in healthcare today, it is pivotal

to ensure nurses are adequately educated on the disease and treatment (American Lung

Association, 2017). Exploring what is important for each patient and evaluating their level of

health literacy allows nurses to help patients comprehend their healthcare plans and to make

informed choices for improving their health (Murray & O’Neill, 2016; Wood & Bolyard, 2011;

Yang, Chen, Chiang, & Chang, 2005).

Current practice for educating patients and families on maintaining compliance with

asthma medications is the use of a written asthma action plan (Newell, 2006; NHLBI, 2014). The

plan focuses on medication management, inhaler use, early recognition of symptoms, monitoring

of symptoms, and remediation steps for exacerbations. However, the action plan does not

individualize patient preferences nor does it take into consideration health literacy. The plan is

developed on a standardized form and color coding is used to determine severity of symptoms.

The green zone identifies criteria that lets the patient know the asthma is well controlled. The

yellow zone indicates the asthma is worsening and the red zone criteria indicates the symptoms

are significant and require emergent medical management. Medication dosages and

interventions are provided on the plan for the patient to follow daily (NHLBI, 2014). However,

the literature notes that although plans are provided to patients and families, there continues to be

compliance issues for following the plans. Findings in the literature reflect that asthma plans are

frequently developed by providers separate from the patients and families, and without fully

investigating challenges or barriers they may have for following the plan (Newell, 2006).


Patient education is a primary responsibility of nurses and being instrumental in

messaging effective asthma education to patients for self-management is known to improve

asthma knowledge, self-efficacy, compliance, and quality of life of patients (Rance, 2011; Yang

et al., 2005). In a systematic review of studies on interventions to improve adherence to

medication compliance for chronic illness, Viswanathan, Golin, Jones, Ashok, Blalock and

Wines et al. (2012) evaluated seventy-three articles and found that case management, patient

education with behavioral support and reduction of out of pocket expenses improved medication

adherence in eight of the studies reviewed on asthma. Building the nurse’s knowledge,

confidence and skill in asthma education through simulations may improve the communication

skills of the nurse, lead to better patient-provider partnerships and improved adherence with

therapeutic plans of care (Hoskin, William, Abhyankar, Donnan, Duncan, Pinnock et al., 2016;

Rance, 2011; Taylor- Fishwick, Okafor & Fletcher, 2012).

Teach-Back Method

Individualized goal setting is recognized as an effective method for helping patients learn

key steps in self-management of their illnesses (Murray & O’Neill, 2016). Setting goals is ideal

for assessing patients’ capabilities, health literacy and possible language barriers. An example of

a goal setting patient education method is the teach-back method (Dinh et al., 2013; Peter,

Robinson, Jordan, Lawrence, & Casey, Salas-Lopez 2015). Teach-back is defined as an effective

communication technique that engages patients and families in realistic goal setting strategies

and management skills about their health and healthcare educational needs (AHRQ, 2014; Dinh

et al., 2013). The technique provides an opportunity for providers to clarify the patient’s

understanding of their diagnosis, the education provided and the medication instructions

(Kornburger, Gibson, Sadowski, Maletta & Klingbeil, 2013). Kornburger et al. (2013) conducted


an evidence based educational study evaluating the effects of the teach-back process on nurses’

teaching practices and their perceptions of patient and family understanding of discharge

instructions. A total of seventy-four nurses were provided education on the process. Pre-surveys

were sent to all before the intervention and after the four-week trial. Fifty-eight nurses (78%)

responded to the pre-survey and fifty-three nurses (72%) responded to the post survey.

Responses were grouped into three conceptual themes: knowing, doing and valuing. An increase

in knowledge of health literacy and the teach-back process was reported by the nurses with a

92.5% confirming they knew what health literacy meant in the post survey and 87% were able to

explain their understanding of the teach-back process when provided an open ended question.

Under the themes of doing and valuing, nurses also reported improvement in their ability to ask

questions to assess understanding of information and 98% agreed that teach-back helps patients

and families to better understand discharge instructions (Kornburger et al). The teach-back

technique can also uncover any learning gaps that need to be addressed and readdressed until

learning is achieved (Schillinger et al., 2003).

A common mistake by health providers when conducting patient education is the failure

to ask clarifying questions related to the learner’s ability to understand and act on the healthcare

information (Peter et al., 2015). As a teaching tool, the teach-back method works by creating an

environment that invites open communication between the patient and the provider. The

technique places accountability of poorly understood information on the provider rather than on

the patient, and validates that improvement on patient education is possible through inclusion of

the patient in the process (Peter et al.,2015). In a study conducted by White, Garbez, Carroll,

Brinker and Howie-Esquivel (2013) two hundred and seventy-six patients were included in a

heart failure teach-back study during hospitalization and within several days after discharge.


Two registered nurses educated in the teach-back method provided the education to patients

using four questions that related to diuretics, weight gain, awareness of sodium in foods and

recall of warning signs. Results demonstrated that patients answered three of the four teach-back

questions 84.4% of the time correctly while hospitalized and 77.1% of the time during the

follow-up. In addition, the amount of time spent teaching was significant (p <.001) and

associated with the patient’s ability to answer the teach-back information correctly. There was no

association found with the teach-back method and reduced readmission rates (p = .775).

Limitations of the study included the lack of a control group for a comparison and the difficulty

to control the fidelity of the procedure due to the interactive and openness of the method (White

et al., 2013). Similarly, in a study conducted by Peter et al. (2015) four hundred and sixty-nine

patients received heart failure education and of the total, one hundred and eighty patients

received the education using the teach-back process. Patients in the teach-back group

demonstrated reduced rates of readmission from twelve to fifty percent in one of the pilot units

(Peter et al.,2015).

The teach back method is also known as the “show me” or “closing the loop” method and

involves a process of questioning and repeat demonstration instruction to determine what the

patient has learned from the health education session (Dinh et al., 2013). The individualized

patient centered approach does not test the patient nor does it require that the patient have a

certain level of health literacy. Griffey, Shin, Jones, Agnam, Gross, & Kinsella et al. (2015)

conducted a randomized study in patients with limited health literacy who were being discharged

from an emergency room. The experimental group received the discharge instruction using the

teach-back method and the control group received the standard discharge instructions. Subjects

completed an audio-recorded structured interview evaluating comprehension of the diagnosis,


the emergency room experience, the post emergency care, reasons for returning, and satisfaction

with care using the Consumer Assessment of Healthcare Providers and Systems Questionnaire.

Subjects who received the teach-back method had higher comprehension of post emergency care

for medications (p <.02), self-care (p <.03), and follow up instructions (p <.0001). There were no

statistically significant differences in patient satisfaction and perceived comprehension.

Limitations of the study included that it was a single center study, a convenience sample of

subjects, and the inability to conceal the interventions from other nurses and patients not

participating in the study (Griffey et al., 2015). The teach-back approach uses active

participation by both patient and provider offering an integrative and collaborative approach that

is helpful for meaningful goal setting and better identification of learning needs (Dinh et al.,

2013; Peter et al., 2015; Xu, 2012).

Quality patient education is an important component of healthcare and one highly

regarded in the practice setting for improving healthcare (American Health Consultant, 2011).

Nursing students must be prepared to effectively provide patient education. Providing students

different opportunities to practice patient education sessions is essential for building knowledge

and skills in delivering patient education. Avallone and Cantwell (2016) reported on the use of

peer teaching with the teach-back technique in pre-licensure nursing students and noted an

improvement in students’ cognitive knowledge and confidence in the ability to perform a patient

education session. The study used a pre-post design to evaluate an educational program in sixty-

six nursing students. The intervention consisted of heart failure information, a case study, role

playing and simulation activities. The ability to conduct the teach-back technique increased from

17% to 94% (p <.001). The limitation of the study was that it was a single site study (Avallone &

Cantwell, 2016). Mangold (2016) noted that the teach-back method for patient education can be


effectively used and practiced in a simulation experience. Ninety-six nurses in an acute care

transplant unit engaged in a standardized patient simulation using the teach-back technique on

self-care after a kidney transplant. Subjects demonstrated the technique using actual teaching

tools in practice. The Kirkpatrick Model’s Four Levels of Evaluation for reaction, learning,

behavior and results was used as the data collection tool. Ninety-nine percent of the subjects

reported an increase in confidence with the method and an increase in knowledge and retention

of the topics discussed with the method.

The teach-back framework is an effective strategy to support patient education

(Kornburger et al., 2013) and offers an ability to assess learning in patients (Dinh et al., 2013).

Chronic diseases and adherence to healthcare plans and medication instruction is pivotal to

reduce exacerbations of illnesses, misuse of medication and adverse events (Dinh et al.).

Incorporating the technique into nursing education has shown usefulness for increasing

confidence in nursing students when providing patient education (Avallone & Cantwell, 2016).

Summary of the Literature

The rapid changes evolving in health care and the demand for safe quality care has

elevated the need in academia to find innovative teaching strategies to prepare healthcare

professionals. Students value an active learning environment and report a perceived gain in

knowledge and confidence when provided simulation experiences (Bai et al., 2012; Broussard et

al., 2009; Linnard-Palmer, 2012). In addition, simulation experiences offer the opportunity to

improve and promote teamwork (Cantrell et al., 2017). Advancements in technology have

provided options for interactive learning through virtual simulation, however, further research is

needed to explore whether virtual simulation promotes retention of knowledge and skills and

whether students are able to transfer the learning into a practice setting (Hayden et al., 2014).


Nurses play an important role in providing patient-centered education (Murray & O’Neill, 2016).

Using different pedagogies for nursing students to effectively learn and develop communication

skills, critical thinking and clinical judgment optimizes their abilities in delivery of care and in

providing health promotion and health prevention. The virtual simulation instruction offers

nursing students the opportunity to learn clinical skills and decision making using different

patient case scenarios without imposing risk of harm on real patients, as well as, learn and

understand their professional identity as nurses to best gain confidence (Berragan, 2011).

As a student centered learning approach, virtual simulation offers a setting that provides

an integration into the profession, active learning and facilitates closing the gap between the

classroom theory and the practice setting (Bai et al., 2012). Virtual simulation may also be used

in a course curriculum to enhance learning (Bai et al., 2012; Duff et al., 2016). The strategy can

be used as a formative assessment to provide feedback on clinical performance or it can be used

as a summative assessment to evaluate clinical judgment. There are many advantages noted in

the literature on simulation, however further research is needed on virtual simulation as a

teaching strategy due to the evolution of its technological capabilities (Bai et al., 20120; Forunda

& Bauman, 2014). Evidence from stronger studies with rigorous methods and reliable and valid

measurement tools is needed to fully appreciate the value and utility of the instruction and its

ability to promote knowledge and skills in the practice setting (Hayden et al., 2014). Valid

measures and results are needed in order to fully appreciation the value virtual simulation could

provide in nursing education.


Chapter 3

Methods

Design

A quantitative experimental design was used in this study to gather data to compare the

teaching instructions virtual simulation and the concept mapping instruction. The design allowed

for an exploration of the effects of virtual simulation compared to concept mapping on the

content mastery of asthma in undergraduate pre-licensure nursing students who have completed

the medical-surgical nursing courses.

Sample

The population studied in this research was nursing students from two liberal arts

colleges. The traditional programs are composed of students with a high school diploma and the

non-traditional program are composed of second degree students and adults returning back to

school who have a baccalaureate degree in another field. A sample size was estimated using the

information from the pilot study of the CQ and HQ questionnaires conducted by Kritikos et al.

(2005). A difference in the mean asthma knowledge scores of 1.5 and a standard deviation of 3.5

was used from the results of the authors’ pilot study. Using an online sample calculator, a mean

of 4.59, a mean of 6.9, and a standard deviation of 3.5 were entered. The results showed that a

minimum of 37 subjects was needed for each group.

Setting

The study was conducted in two undergraduate liberal arts colleges in Boston,

Massachusetts with schools of nursing. Both schools of nursing were comparable in size and in

number of students. Approval to conduct the study was obtained from the Institutional Review

Board (IRB) of both the colleges.


Procedures

In this study the independent variable is type of group: the concept map group was the

professionals. Key characteristics of the tool are its ability to assess the knowledge of health care

professionals about asthma and the ability to identify probable gaps in knowledge that may be

addressed through educational initiatives. In the original psychometric testing of the tool, validity

and reliability was evaluated in physicians and respiratory therapists and demonstrated a

Cronbach’s alpha of 0.95 (Kritikos et al., 2005). Basheti, Hamadi, and Reddel (2016) conducted

an interprofessional study that evaluated the tool using pulmonary specialists, general physicians,

pharmacist, pharmacist assistants, nurses and respiratory therapist. The tool demonstrated higher

scores with the pulmonary specialists and lower scores with nurses. The study was the first to

report the use of the tool across different healthcare disciplines who care for patient with asthma.

The results showed the tool identified higher asthma knowledge scores in the specialist group

(M=12.2, SD = 2.70) and lower scores in nurses (M= 7.95, SD = 2.29). Interestingly, the scores

across all the groups did not demonstrate a high score as defined by the authors of HQ tool.

Results identified potential knowledge gaps healthcare professionals have on asthma and these

can be used to develop educational workshops on asthma management (Basheti et al., 2016).

There are 18 items on the HQ tool with response categories of true and

false. This study focused on adult asthma and questions that addressed

pediatric asthma care were omitted. Only one item (#17) was noted to have

a distinct specificity to pediatrics and, therefore, was omitted in control and the

virtual simulation, the experimental. The dependent variables of the study were: 1). a change in

the mean asthma knowledge scores between the virtual simulation group and concept map group

for the pre and post quiz developed by the NLN for the vSim Medical Surgical Nursing


scenario on asthma (Appendix A), 2). a change in the mean asthma knowledge scores between

the virtual simulation group and the concept map group using the Healthcare Professional

Asthma Knowledge Questionnaire (HQ) (Appendix B), 3). a change in the mean teach back

scores between the virtual simulation group and the concept map group using the Teach-Back

Observation tool (Appendix C), 4). A change in the mean Consumer Asthma Knowledge

Questionnaire (CQ) correct scores between the virtual simulation group and the concept map

group using the CQ tool (Appendix D). Permission to use the NLN pre-post quiz was obtained

through the NLN (Appendix E) and permission to use the HQ tool and the CQ tool was obtained

from the authors of the tools (Appendix F.).

Subjects were recruited through direct request in the classroom, by email with permission

from the faculty and approved flyers throughout the colleges. Classes that were visited for

recruitment included the clinical decision making course, the pediatrics course, the maternal-

child nursing course, a nursing leadership course and an evidence based practice course.

Inclusion criteria for the study were nursing students in the pre-licensure undergraduate nursing

program who had completed the medical surgical nursing courses. The courses consist of

medical surgical lectures and include the topic of asthma. Exclusion criteria were nursing

students who were licensed as registered nurses or enrolled in the master’s degree program.

A numeric identification was used to randomize subjects who agreed to participate in the

study. All consent forms had a numeric identification number listed on them. An online program

called Research Randomizer was used to conduct the randomization. The randomizer required

that a set of numbers be entered into the program and upon submission, the randomizer provided

a subset of numbers from the group of numbers entered. The subset of numbers produced by the

program were used to identify subjects for the experiment group. Subjects whose consent form


had one of the identified numbers provided from the randomizer program were placed into the

experimental group (virtual simulation).

Data Collection Tools

The data collection tools used in the study were the pre and post quiz on the subject of

asthma from the vSim program, the HQ tool, the CQ tool, and the Teach Back Observational

Tool. The demographic variables were collected using a short survey and included age, gender,

program of study (traditional or nontraditional) and whether the subjects had experience with

virtual simulation or concept mapping.

The pre and the post quiz used in the study were developed by the

NLN in collaboration with Laerdal Medical for the virtual simulation series

called vSim Medical Surgical Nursing (NLN, 2015). The items were

developed by the NLN by faculty content knowledge experts. No

psychometric testing had been completed on the questions at the time of

this study. The pre and the post quiz used in the study contained 16 identical

items and a paper version was provided before and after the interventions to

both the virtual simulation group and the control group. The pre-quiz served

as a method to prompt the subjects’ knowledge prior to the intervention and

for the facilitating critical thinking. The post quiz served to evaluate

knowledge gained after completing the intervention. For the purpose of this

study, subjects in both groups were allowed only one opportunity to complete

the pre and the post quiz.

Healthcare Professional Knowledge Questionnaire. Following the quizzes, subjects

were asked to complete the Healthcare Professional Asthma Knowledge Questionnaire (HQ).


The tool was developed by Kritikos et al. (2005) using the international guidelines for the

diagnosis and management of asthma and was designed to be used with different healthcare

professionals. Key characteristics of the tool are its ability to assess the knowledge of health care

professionals about asthma and the ability to identify gaps in knowledge that may be addressed

through educational initiatives. In the original psychometric testing of the tool, validity and

reliability was evaluated with physicians and respiratory therapists and demonstrated a

Cronbach’s alpha of 0.95 (Kritikos et al., 2005). Basheti, Hamadi, and Reddel (2016) conducted

an interprofessional study that evaluated the tool using pulmonary specialists, general physicians,

pharmacists, pharmacist assistants, nurses and respiratory therapists. The tool demonstrated

higher scores with the pulmonary specialists and lower scores with nurses. The study was the

first to report the use of the tool across different healthcare disciplines who care for patients with

asthma. The results showed that the tool identified higher asthma knowledge scores in the

specialist group (M=12.2, SD = 2.70) and lower scores in nurses (M= 7.95, SD = 2.29).

Interestingly, the scores across all the groups did not demonstrate a high score as defined by the

authors of HQ tool. Results identified potential knowledge gaps of healthcare professionals about

asthma; this lack of knowledge can be used to develop educational workshops on asthma

management (Basheti et al., 2016).

There are 18 items on the HQ tool with response categories of true and

false. This study focused on adult asthma and questions that addressed

pediatric asthma care were omitted. Only one item (#17) was noted to have

a distinct specificity to pediatrics and, therefore, was omitted in the final

analyses of the data in this study. Scores in the study were analyzed using

the discriminate proposed by the authors of the tool and the median was


used to determine the high scores versus low scores (Kritikos et al., 2005). A

high HQ asthma knowledge score was determined as greater than or equal

to thirteen and a low HQ asthma knowledge score was less than or equal to

twelve.

Consumer Asthma Knowledge Tool. A third tool used was the Consumer Asthma

Knowledge Questionnaire (CQ). This tool was also validated by Kritikos et al. (2005). Testing

for reliability and validity was conducted and demonstrated a reliability with a Cronbach’s alpha

0.78 (Kritikos et al., 2005). The statements from the tool were used to develop questions and a

script for the standardized patient in the patient education session. The questionnaire was used in

the study as an observational tool by an expert nurse to evaluate how subjects addressed the

questions asked by the standardized patient. The questionnaire has twelve items with response

categories of true and false. The authors of the tool determined a high CQ asthma knowledge

score as greater than or equal to ten and a low CQ asthma knowledge score as less than or equal

to nine using the median. Students were not required to complete the questionnaire. Therefore,

the nurse expert evaluated only the questions asked by the standardized patient and whether

subjects responded correctly.

Teach-Back. A fourth tool used in the study was the Teach Back Observation Tool. The

tool was created by a group of health professionals through a grant from the Picker Institute and

Des Moines University and endorsed by the Agency for Healthcare Research and Quality

(AHRQ) (2014). Use of the tool is permitted on the AHRQ website and may be downloaded by

researchers. The observation tool is composed of 14 behavioral characteristics and

communication techniques that a care team member should demonstrate during a teach back


patient education session. To date, there has been no psychometric testing that can be found in

the literature on the Teach Back Observational Tool. A nurse expert recruited for this research

study evaluated the behaviors and characteristics of the teach back technique portrayed by the

subjects in the videos.

The tools used to collect data in this study evaluated the students’ ability to recall

knowledge, skills, and attributes on the diagnosis and management of asthma. The tools also

evaluated whether students could transfer the asthma knowledge into a simulated patient

education scenario. Each of the tools provided a total score that could be used to measure

possible differences between the experimental and control groups.

Intervention

Content Mastery. The researcher conducted this study using a two-step process. Figure

2 displays the flowchart of the procedures that took place in the study. The product vSim for

Nursing by Laerdal Medical was used for the experimental group. The product was designed in

collaboration between the NLN, Laerdal and Wolters Kluwer Health (NLN, 2015). The virtual

simulation scenario on asthma created in the medical surgical nursing product was used for this

study in the experimental group. The scenario was created using a clinical story of a patient

encounter and is designed to facilitate critical thinking and decision making (NLN, 2015). The

scenario experience was designed to offer an opportunity to conduct a formative assessment

prior to the scenario and after the completion of the scenario. The assessment provides the

student and the instructor feedback on how well the information is received by the student

(NLN). Formative assessments are explained by Bradshaw and Lowenstein (2011) as a method

for examining whether a learner is proceeding as planned and to evaluate an opportunity to

adjust the educational experience for successful completion.


Figure 2. Flowchart of Research Procedure

A blank concept map template (Appendix G) was developed by the researcher and used

in the study for the concept map group. The purpose of the template was to prompt thinking on

the topic and to provide a structure for subjects who were not familiar with this method of

teaching. The first part of the template had questions that promoted thinking on how to define the

disease, to describe how it affects the body, to list signs and symptoms that may be seen and to

describe how the disease is treated using the headers of medications, diagnostics, laboratory

values and potential invasive or surgical procedures associated with the disease. The second part

of the template focused on the identification of nursing diagnoses and potential interventions to

address the diagnoses. Nursing diagnoses are defined by North American Nursing Diagnosis

Association [NANDA] International (2018) as clinical judgments about a patient, family or

community responses or experiences to actual or potential health issues. The diagnoses provide a

foundation for selecting interventions that best meet patient needs and for optimizing patient


outcomes (NANDA, 2018). Creating a template for subjects to use during the intervention

assisted in maintaining consistency of the study design and consistency for analyzing results.

In the asthma scenario of the vSim program, there are a set of seven questions used as a

pre quiz and a set of nine questions used as a post quiz following the virtual simulation

experience. For the purpose of this study, all 16 items were combined together as one set of

questions and were provided to the subjects in both the experimental and control groups as a pre

and a post quiz using a paper version. Providing the quizzes in a paper version maintained the

design, and consistency of the study between the two groups. Following the post quiz, subjects in

both the experimental and control groups were asked to complete the HQ tool as a post

evaluation. The questionnaire is the only designed survey that has been psychometrically tested

to quantify the general level of asthma knowledge of healthcare professionals in clinical practice

or in a research setting (Kritikos et al., 2005).

Transferability of Knowledge. The second step of the research study consisted of a

simulated patient education session using a standardized patient and the teach-back technique.

Both the virtual simulation and the concept map groups participated in the session. The

researcher was blinded from this portion of the study and therefore, a facilitator, serving as

videographer, and a nurse, with expert knowledge on the teach-back process, were recruited. The

facilitator served as the videographer during the patient education session and the expert nurse

was not present during the session and served as the evaluator of the videos. Blinding the expert

nurse from the video session and from knowing which of the interventions the subjects had

received eliminated the risk of bias in the study. The nurse had extensive experience in

professional staff development and had completed a formal training on the teach-back method.


Subjects received a briefing on teach back from the researcher prior to participating in

the patient education session using the power point provided by the Agency for Healthcare and

Research Quality on Teach Back (Appendix H). Subjects were then escorted to a separate room

where the facilitator waited. A trained standardized patient role played a person newly diagnosed

with asthma. The standardized patient was escorted into the room and the subjects were asked to

suspend disbelief and to enact a simulated patient education session on asthma as if they were

currently nurses using the teach-back technique. A video was made of the patient education

session by the videographer using an Apple iPod video application. All videos were later

uploaded to a computer USB flash drive by the videographer and provided to the expert nurse for

evaluation of the teach-back technique and responses students gave the standardized patient on

asthma.

The total time to complete the study for each subjects was approximately one hour and

thirty minutes to two hours. Subjects were provided the opportunity to complete the patient

education sessions either as one individual or in pairs. The opportunity to conduct the session as

a pair was dependent on the number of subjects who participated at a given time when the study

interventions were held. The rationales for allowing the subjects to do the education session as a

pair was primarily to reduce the length of time subjects would need to be present for the study, to

decrease the anxiety of being videoed, and to create a supportive environment during the study

interventions. Subjects who conducted the session as one individual addressed the diagnosis,

causes, triggers, and best health practices on asthma, as well as, the treatment options, use of

inhalers, and the asthma action plan that informs patients when to call the physician and when to

seek help. Subjects who conducted the patient education session as a pair shared the

responsibility. One subject completed the first half of the patient teaching session and addressed


the diagnosis, causes, triggers, and best health practices on asthma. The second subject addressed

the treatment options, use of inhalers, and the asthma action plan that informs patients when to

call the physician and when to seek help. Subjects were allowed to use their laptops if they

wished to reference or integrate educational tools from the internet into the patient educational

teaching session.

The patient education session was video recorded by the facilitator and each recording

served as one observation of each of the subjects. If there were a pair of subjects conducting the

session together, each subject was evaluated individually. The videos were evaluated by the

expert nurse using the elements of the Teach Back Observation Tool on behaviors and

communication techniques needed for conducting a patient education session using the method.

The CQ tool was also used to evaluate the videos. The tool assesses the knowledge a patient has

on asthma after being educated on the diagnosis. The statements of the tool were used to develop

questions for the standardized patient to use with the subjects during the patient education

session.

Data Analysis

Analyses of the data were performed using the program Statistical Package for the Social

Sciences (SPSS) version 23. Data on the demographic variables were collected from a short

survey provided to subjects after obtaining consent for participation. The data was analyzed

using descriptive statistics and included an evaluation of assumptions of normality and

homogeneity of variance, the means and standard deviations for continuous variables, and the

relative frequencies for categorical variables. Inferential analyses were also performed to

examine the research question and aims of the study. For content mastery and transferability of

knowledge, data was evaluated using the independent variables of virtual simulation and concept


mapping in the pre -post quiz scores, HQ scores, teach back score and the CQ correct scores.

Data tables of mean scores, median scores, data frequency and measures of central tendency

were also completed.

Content Mastery. The change in the means of the pre quiz asthma knowledge scores,

the post quiz asthma knowledge scores and the difference in pre-post quiz scores were examined

between the virtual simulation (experimental) and the concept map (concept map) interventions.

Assumptions of normality testing were conducted on the pre quiz scores and the post quiz scores

prior to the statistical analyses. An independent sample t-test or the Mann-Whitney U test was

used to evaluate the scores based on the results of the assumptions of normality tests. The Mann

Whitney U test was done between the pre quiz scores and the virtual simulation and concept map

group. An independent sample t-test was completed between the post quiz scores and the virtual

simulation and concept map groups. To evaluate the change in the pre-post difference scores, an

independent sample was performed between the pre-post difference in scores and the virtual and

concept map intervention groups. For each of the tests, a level of significance was set at .05 with

a corresponding confidence level of 95%.

The HQ tool was provided as a post intervention evaluation. Assumptions of normality

tests were computed. An independent t-test was performed between the HQ asthma knowledge

scores and the virtual simulation and concept map interventions. A level of significance was set

at .05 with a corresponding confidence level of 95%.

Transferability of Knowledge. Data analysis was also conducted on the video

recordings of the patient education session using the Teach-Back Observation tool and the CQ

tool. The CQ tool was used to assess whether students addressed the questions asked by the

standardized patient. Twelve statement compose the tool and were coded as being addressed


correctly, incorrectly addressed or not addressed. Items of the tool intended for pediatrics were

omitted from the analysis because the simulated patient education session was designed for an

adult patient with asthma. Statement #11 addressed when a parent should provide asthma

medication and, therefore, was omitted. Assumptions of normality test was completed on the CQ

correct scores. A Mann Whitney U test was performed between the CQ correct scores and the

virtual simulation and concept mapping intervention groups. A level of significance was set

at .05 with a corresponding confidence level of 95%.

The Teach-Back Observation Tool was used to evaluate the behavior and communication

objectives of the teach back technique and were coded as met, not met and not addressed. A

scale measuring 0 to 55mm was used and the expert nurse was asked to score the extent to which

a subject portrayed a teach-back behavior or communication technique. The expert nurse used a

data collection tool with the teach back objectives and each objective had a scale with no

numbers annotated on it. The expert nurse was explained that the left end of the scale was the

lowest score and that the right end of the scale was the highest score. A numeric measure using a

millimeter ruler was later obtained by measuring the mark placed on the scale by the nurse expert

to obtain a score between 0 and 55. A high numeric score was preferred in all but one of the

objectives. A reverse score was used in the objective that noted whether or not the subjects

avoided asking questions that could be answered with a yes or no. Ten of the fourteen objectives

from the Teach Back tool were used to evaluate the subjects. Four objectives were omitted

because the patient education session was not designed for subjects to be able to demonstrate

them. The omitted objectives were: 1). establish a follow up appointment, 2). take responsibility

for making sure they were clear with instructions, 3). document use of teach back and patient’s

response, and 4). include family members or caregivers if present.


Assumptions of normality tests were run between the teach back scores and the virtual

simulation and concept map groups. Based on the normality test, a Mann Whitney U test was

performed between the teach back scores and the virtual simulation and concept map

interventions. A level of significance was set at .05 with a corresponding confidence interval of

95%.

Human Protection

Approval to conduct the study was obtained from the IRBs of the two colleges. An

explanation of the study was provided to the subjects and those who agreed to take part in the

study were asked to sign an informed consent (Appendix I). Subject were informed that there

were no foreseeable risks associated with participating in the study and that all data collected

was confidential and de-identified. Subjects were also informed that those who wish to withdraw

from the study could do so at any time without penalty or risks to grades and academic standing.


Chapter 4

Results

The chapter describes the results obtained from the statistical analyses conducted in this

study. The purpose of the study was to evaluate the effects of virtual simulation compared to

concept mapping instruction for content mastery using the subject asthma and to explore the

transferability of content mastery on asthma using a simulated patient education session. Results

presented are the demographics of the sample for the experimental and the control groups and

are reported in descriptive frequencies. Inferential statistical analyses depict results presented in

the context of content mastery and transferability of knowledge.

Summary of the Demographics of the Sample. A total of 28 undergraduate nursing

students from the prelicensure nursing baccalaureate programs of two urban colleges in Boston,

Massachusetts participated in the study. Subjects were randomly assigned and equally distributed

between groups. The experimental group included 14 students assigned to the virtual simulation

intervention and 14 subjects assigned to the control group concept mapping intervention. Table

4.1 on the following page shows the demographics, frequencies and percentages of the subjects.

All students had completed the medical surgical nursing courses of the program

curriculum. Twenty-three subjects (82%) were from one college and an additional five subjects

(18%) were from the other college. The demographic results noted the mean age of the subjects

was M = 24.54, SD = 5.634 and the median was Mdn = 21.50. The majority of the subjects were

females (96%) compared to males (4%) and one subject did not report on gender identity. The

sample was composed of equal numbers of subjects of the traditional and nontraditional

program. Sixty-one percent (n = 17) subjects were assigned to the virtual group and 39% (n =11)

of the subjects were assigned to the concept map group. Twenty-five subjects (89%) reported on


whether they had experience with virtual simulation and concept mapping. A total of 20 subjects

(80%) reported not having experience with virtual simulation and a total of 17 (68%) of the

subjects noted having had experience with doing concept maps.

Table 4.1 Demographics of the Sample

Variables Virtual Grp.Concept Map

Grp. PercentGender Male FemaleTotal

113

14(51.9%)

013

13(48.1%)

496100

Age 20-21 22-23 24-30 31-36 37-38Total

43132

13(54.2)

81110

11(45.8)

50178178

100ProgramTraditionalNontraditionalTotal

710

17(61%)

74

11(39%)

5050100

Virtual Exp. No YesTotal

112

13(52%)

93

12(48%)

8020100

Concept Exp. No YesTotal

49

13(52%)

48

12(48%)

3268100

Fisher’s Exact tests (Table 4.2) were conducted between group assignments and for the

variables gender, program of study (traditional and nontraditional), previous experience with

virtual simulation and previous experience with concept mapping. No variables came close to

statistical significance in the p-values.


Table 4.2 Fisher's Exact Tests of Variables ∙ Groups

Variables p-value

Gender 1.000

Program of Study 0.440

Virtual Simulation 0.645

Concept Map 1.000

Content Mastery. The NLN pre quiz and post quiz were provided to measure asthma

knowledge in the students prior to and after the interventions. The NLN reported that

psychometric testing had not validated the questions. A Cronbach’s alpha was performed on the

pre quiz to evaluate overall reliability of the tool on nursing students. The tool demonstrated a

strong level of reliability for internal consistency as determined by the Cronbach’s alpha of 0.883

(Table 4.3).

Table 4.3 Reliability Tests on Asthma Knowledge Tools

Data Tools M SD

Cronbach's

Alpha

N of

Items

Pre Quiz Asthma Knowledge Test 11.39 11.341 0.883 15

Healthcare Asthma Knowledge Questionnaire 14.44 11.342 0.730 17

A summary of the pre-quiz scores for the two groups are shown in Table 4.4. The mean

and median of the pre quiz scores for the virtual simulation group were 9.07 and 8.50

respectively. The corresponding scores for the concept map group were 10.5 and 11.0. The


skewness in the concept map group suggested a Mann Whitney test rather than a t-test in this

context. The p-value for the Mann Whitney (p = .210) indicated no significant difference

between the experimental and control median scores.

Table 4.4 Summary of Pre-quiz Scores n M Mdn SD

VS 14 9.07 8.5 2.731CM 14 10.5 11 2.139

M-WU = 70.50, p = 0.210

A summary of the post quiz scores was conducted and assumptions of normality tests

demonstrated the interval data were consistent with normality. Parametric tests were conducted

for the post quiz scores. The mean post quiz scores were higher in the concept map group (M =

10.86, SD = 2.033) compared to the virtual simulation group (M = 10, SD = 2.075). There was no

statistically significant difference between the mean post quiz scores and the virtual simulation

group and the concept map group, M = .857, 95% CI [-2.453, .739], t (25.989) = 1.104, p = .280.

A summary of the pre-post quiz differences in scores was conducted and assumptions of

normality test demonstrated the data were consistent with normality. The mean pre-post

difference in scores were higher in the virtual simulation group (M = .93, SD = 2.645) compared

to the concept map group (M = .36, SD = 1.550). There was no statistically significant difference

between the mean pre-post difference in scores and the virtual simulation group and the concept

map group, M = .571, 95% CI [-1.132, 2.275], t (20.948) = .698, p = .493.

The Healthcare Asthma Knowledge Questionnaire provided a post evaluation measure

for asthma knowledge in the both the virtual simulation and the concept map groups. The tool

had not been validated in nursing students by the authors during the psychometric testing. A

Cronbach’s alpha was performed on the tool to evaluate overall reliability in the nursing students

and demonstrated a moderately strong level of reliability for internal consistency as determined


by the Cronbach’s alpha of 0.777. Question #17 of the HQ tool related to pediatric medications

and was omitted from the final analysis of the tool in this study. The Cronbach alpha remained at

a moderately strong level of reliability for internal consistency at 0.730 (Table 4.3).

A summary of the HQ scores was conducted and interval data were consistent with

normality. The mean HQ score was higher in the virtual simulation group (M = 11.64, SD =

2.098) compared to the concept group (M = 11.43, SD = 1.785). There was no statistically

significant difference between the mean HQ scores and the virtual simulation and concept map

groups, M = .214, 95% CI [-1.301, 1.729], t (25.351) = .291, p =.773. Table 4.5 displays the

results of the independent sample t-tests conducted on the NLN post quiz scores, the NLN pre-

post quiz differences in scores and the HQ scores

Transferability of Knowledge. The CQ tool was used in this study for two purposes: a).

for development of a script for the standardized patient to use in the patient education session

and b). as an observational tool assessing student ability to answer the questions posed by the

standardized patient in the education session. A summary of the CQ correct scores for the two

groups are shown in Table 4.6. The skewness of the scores in the two groups suggested a Mann

Table 4.5 Results for Independent Sample t-Tests

Virtual Concept

Scores M SD N M SD N 95% CI T df P

Post Quiz 10 2.075 14 10.86 2.033 14 -2.453, .739 1.104 25.989 0.28

Pre-Post 0.93 2.645 14 0.36 1.55 14 -1.132, 2.275 0.698 20.958 0.493

HQ 11.64 2.098 14 11.43 1.785 14 -1.302, 1.729 0.291 25.351 0.773


Whitney U test rather than a t-test. The mean and median CQ correct scores for the virtual

simulation group were 3.71 and 4.0 respectively. The corresponding scores for the concept map

group were 4.79 and 5.0. The p-value for the Mann Whitney (p = .05) indicated statistically

significant difference between the CQ correct median scores.

Table 4.6 Summary of CQ Correct Scores N M Mdn SD

VS 14 3.71 4 1.437CM 14 4.79 5 1.718

M-W U = 55.00, p = .05

A summary of the teach back scores for the two groups are noted in Table 4.7. The mean and

median scores for the virtual simulation were 266.64 and 228.0 respectively. The corresponding

scores for the concept map group were 266.93 and 230.0. The skewness of the scores in both

groups suggested a Mann Whitney test instead of a t-test in this context. The p- value for the

Mann Whitney (p = .982) indicated no statistically significant difference between the teach back

median scores.

Table 4.7 Summary of Teach Back Scores n M Mdn SD

VS 14 266.64 228.0 69.178CM 14 266.93 230.0 69.822

M- W U= 97.0, p = .982

Summary

The data in this study were analyzed using descriptive statistics and inferential analyses.

There was a statistically significant difference between the CQ correct scores and the concept

map group. There was no statistically significant difference between the pre-post knowledge quiz

and the HQ scores. There was no attrition of subjects in this study. The study interventions were

implemented and completed with all subjects in one hour and thirty minutes to two hours. After

completing the formal study protocols, the subjects offered commentary and anecdotally reported


finding the experience positive. Subjects related the teaching techniques provided them with

different ways to approach simulation learning. Subjects who completed the virtual simulation

reported the teach back method as helpful in promoting critical thinking and application of

knowledge about asthma.


Chapter 5

Discussion

For learning to be most effective in the current nursing student population, different

teaching strategies should be offered to allow for both interpretation and application of

information. The teaching strategies must also take into account different learning styles and

encompass opportunities to practice and apply knowledge and skills in a way that facilitates

critical thinking and clinical reasoning. The primary aims of this study were 1). to evaluate the

effects of virtual simulation compared to concept mapping for developing content mastery and

2). to evaluate whether content mastery was transferable using virtual simulation compared to

concept mapping in a simulated patient education session that encompassed the teach-back

method as a framework. The overall findings in this study did not demonstrate major differences

between virtual simulation and concept mapping. However, the results do provide a basis for

using virtual simulation in a complementary manner to support nursing curriculum.

An unexpected finding in the data was noted in this study. A statistically significant

difference in the change in mean CQ correct scores was found to be higher in the concept map

group, demonstrating a p = .05. The finding suggests subjects in the concept map group

demonstrated a positive trend for correctly answering the standardized patient’s questions on

asthma. The results are consistent with previous findings reported in the literature noting that

concept map facilitates the linking of concepts, incorporating new knowledge into existing

knowledge (Atay & Karabakh, 2012; Daley & Torre, 2010; Harrison & Gibbons, 2013; Noonan,

2011). The concept map used in this research study was structured to walk the subjects through a

holistic patient care approach along the illness to wellness continuum. The structural design of a

concept map, as identified by Schuster (2008), facilitates students in the critical analysis of the


educational and discharge needs of the patients through active learning. The ability for subjects

to link concepts possibly accounted for the statistically significant differences found with the CQ

correct scores. Sixty-eight percent of the subjects reported having previous experience with

concept mapping. Previous knowledge about how to construct a concept map could possibly also

explain the higher CQ scores in the concept map group, although no direct association was noted

by the Fisher Exacts test.

Despite rigorous methods and recruitment efforts, the sample size was not achieved. The

study demonstrated no statistically significant differences between the experimental and control

groups. Both treatment groups did demonstrate improvement. The possible rationales for the null

findings may be due to not achieving power as originally designed for the study or that in fact

there are no differences between the two groups in light of the almost identical means. The

current literature on virtual simulation is showing that it is a comparable teaching strategy to

other instructions such as concept mapping, simulations that uses high fidelity mannikins in a

laboratory, and case studies (Gu et al., 2017; Tschannen et al; 2012; Verkuyl et al., 2017).

While this study had a small sample size, there were notable findings. The Cronbach’s

alpha conducted on the NLN pre quiz is the first one reported on the items. Prior to this research

study, the HQ tool had been tested in health professionals but not in nursing students. The

Cronbach’s alpha conducted on the tool also demonstrated reliability. Both the tools can be used

in future virtual simulation studies with nursing students.

In the psychometric testing of the HQ tool, Kritikos et al. (2005) used median scores to

determine high and low scores. A high score was determined at a median greater than thirteen.

Both groups in this study demonstrated medians less than thirteen. The virtual simulation group

had a median of Mdn. = 11.50 and the concept map had a median of Mdn. = 12. These findings


support the idea for the need to further explore different active teaching strategies such as virtual

simulation for the topic of asthma. In one study by Basheti et al. (2016), nurses demonstrated a

mean score of 7.95 in the HQ tool. In contrast, in the current study, the mean HQ scores were

higher for the nursing students in both the virtual simulation and concept map groups. Given the

results of this study and those identified in the study by Basheti et al. (2016), there is support for

exploring different teaching strategies to address knowledge gaps about asthma in nursing

education. Applying multiple pedagogies for teaching the topic asthma could help to support and

enhance different learning styles of nursing students to increase in asthma knowledge.

Recent studies in the literature note similar results as those found in this study. Gu et al.

(2017) evaluated the effects of vSim® as a teaching instruction for nursing using the

fundamentals of nursing scenarios and compared it to laboratory high fidelity simulations. The

difference between the study designs by Gu et al. (2017) and this current research was that the

authors used multiple virtual simulation scenarios and this study used one virtual simulation

scenario. In addition, the HQ tool used to measure asthma knowledge in the current study was

previously psychometrically tested for reliability and the knowledge test used in the study by Gu

et al. (2017) was not psychometrically tested prior to use.

Gu et al. (2017) reported that virtual simulation may help to develop nursing knowledge

and proposed that virtual simulation may promote knowledge through the interactivity of

measuring physiological parameters, communication with the virtual patient, and the real time

feedback provided at the completion of the virtual simulation. The entire activity was also

thought to promote a connection between and among the concepts introduced in the simulation

(Gu et al., 2016). The described process assimilates the method for developing concept maps

and may be one reason for why using concept mapping may be beneficial for developing a


simulation experience. Further research is needed to support and explore the effects of concept

mapping on simulation development.

Verkuyl et al. (2017) also discovered that knowledge gained from virtual simulation was

similar to a laboratory simulation with a high fidelity human patient simulator. Scores for the

laboratory simulation increased between 0.3 and 0.6 points for the virtual simulation group.

Other findings included an increase in students’ confidence with knowledge and an increase in

satisfaction with the ability to directly participate in the virtual simulation. Usually only a few

students can be directly involved in a laboratory simulation, whereas virtual simulation can be

experienced and completed individually by each student. These findings support the notion of

individual student engagement for active learning offered by virtual simulation (Verkuyl et al.,

2017). Virtual simulation also offers the opportunity for problem solving and critical thinking,

as well as, motivation and excitement for learning (Foronda & Bauman, 2014).

Smith and Hamilton (2015) noted there was also statistically significant differences for

students who participated in a virtual simulation on urinary catheter insertion compared to

students who received a regular class instruction on the skill. All students in the virtual

simulation group completed the catheter insertion skill on the first attempt compared to 90% of

students in the control group. Despite the small sample size in the study by Smith and Hamilton

(2015), the difference in the mean scores displayed a positive trend. The current research

supports this finding with the mean of the HQ scores and the teach back method showing a

positive trend in the virtual simulation group. Smith & Hamilton (2015) recommended that

virtual simulation be used as a supplemental teaching strategy in nursing education and in other

healthcare professions.


Heinrich, Pennington & Kuiper (2012) reported significant difference in content

knowledge after virtual simulation was provided in a classroom setting. The authors reported

that using the virtual simulation scenarios concurrently with case studies enhanced class

discussions and facilitated application of knowledge, critical thinking and problem solving

techniques (Heinrich, Pennington & Kuiper, 2012). Anecdotal reports from students after

completing this study indicated that perhaps integrating virtual simulation into class lectures as

an activity could be helpful for learning. According to Foronda and Bauman (2014), faculty

should consider using different methods of instruction in their teaching. Having students engage

in virtual simulation after a classroom lecture on a topic facilitates active learning, engaging

students in deliberate practice and application of new knowledge. The nearly equal means in

both the HQ scores and teach back scores from the education session suggest that virtual

simulation promotes interactivity and facilitates the ability for students to recall and use

knowledge in decision making and clinical reasoning skills.

The purpose of the patient education session in this current study was to evaluate the

effects of virtual simulation compared to concept mapping for transferring content mastery of

asthma. There were no statistically significant differences found between teach back scores for

the experimental and control groups. The mean differences were equitable between both groups.

The virtual simulation group had a mean of M=266.64 and the concept map group had a mean of

M=266.93. These findings are supported by Tschannen et al. (2012) who explored the use of

virtual simulation to improve knowledge transfer in nursing students. Students in the control

group received traditional didactic content and participated in three laboratory simulations and

students in the experimental group received didactic content and participated in three virtual

simulations. The Capacity Rescue Instrument (CRI) was used to evaluate knowledge transfer


through performances in both the control and experimental group. The CRI scores were higher in

the intervention group (M=21.98, SD = 4.29) compared to the control group (M = 20.09, SD =

4.05) at the end of the semester simulation using a high fidelity patient simulator. Students who

completed the virtual simulations were able to transfer knowledge from the classroom better than

those who had not participated in the virtual simulations. The authors proposed that deliberate

practice facilitated the ability of the intervention group to communicate better, practice skills

more effectively and to make better decision during the end of the semester simulation

(Tschannen et al., 2012). Simulation instruction allows for deliberate practice in a safe learning

environment and the use of virtual simulation provides opportunity to participate in deliberate

practice and application of knowledge learned in a class (Tschannen et al., 2012).

In the study by Gu et al. (2017), students were asked to participate in virtual simulation

scenarios prior to class. Upon finishing the virtual simulation assignment, students completed a

knowledge test, two nursing skill performances on medication administration and an aseptic

technique on a non-human model. The performance scores were statistically significantly

different between the groups. The results of the study suggest that to measure knowledge, skills,

and attributes using virtual simulation, systematic instruction of skills need to be incorporated

into the virtual case scenarios (Gu et al., 2017). In contrast, the virtual simulation on asthma

used in this research did not include discharge teaching. Although qualitative responses were not

measured in the study, nursing students verbally reported that the virtual simulation intervention

prompted them to think critically about ways to improve the virtual patient’s acute health

problem, including how to communicate instructional patient education on medications provided

for asthma and additional discharge teaching needs. Both groups demonstrated nearly identical

means for teach back scores in the patient education session. This finding suggests that students


in the virtual simulation group anticipated the virtual patient’s educational needs and transferred

the knowledge learned to the patient teaching simulation session.

Limitations

Strengths of the study included its design methodology and the reliability of the tools

used to measure asthma knowledge. The randomization process also assisted in controlling for

potential confounding variables influencing results. However, a few limitations were noted in the

research study. The small sample limits generalizability and may have contributed to the failure

of the study demonstrating an actual difference. Recruitment efforts extended over three

semesters and the length of time could have provided opportunity for subjects to share aspects of

the study, accounting for pre-exposure to information about the study protocol. A third possible

limitation was the inexperience the subjects had in using the virtual program. In addition, the

teach back observation tool used in this study had not been psychometrically tested for reliability

and validity. Understanding how to navigate and answer key steps in the virtual simulation

becomes easier with practice. Many of the subjects had reported not having experience with

virtual simulation.

Conclusion

Although more research on virtual simulation is needed to generalize the effects it has on

content mastery and transferability of knowledge, the teaching strategy demonstrated in this

study that it is similar to the teaching strategy concept mapping. The deliberate practice of

applying knowledge and the availability for students to be exposed to a range of repeatable

different patient clinical scenarios enables learning in a safe environment. For example,

facilitating the learning and clinical decision making for students on high risk patient situations is

especially important for nursing students to learn how to detect possible altered patterns in a


patient’s status, especially in medically complex patients. Incorporating high risk, low incident

simulation opportunities through virtual simulation prepares students for the possible nursing

challenges and stressors they may experience in a practice setting.

Several factors should be considered prior to implementing virtual simulation. Cost to

students is an important consideration, especially when there are teaching strategies such as

concept mapping that are free. Single user fees, such as the vSim product for the medical

surgical nursing course, range from $80 to $100. If the vSim products were to be used

throughout all nursing courses in a nursing curriculum, the cost per student could be as high as

$800 to $1000 for an entire nursing program. A second fact to consider before implementing

virtual simulation in a nursing curriculum is the provision of faculty training. Providing faculty

training and support for the use of the program is important to ensure achievements of student

outcomes. The training prevents failures with the implementation of the technology, the ability to

use virtual simulation in a curriculum and the ability to measure student learning outcomes. For

example, prior to conducting this study, the researcher completed a training session on the

program and conducted several practice sessions to build proficiency before implementing the

study. The practice exercise with the program assisted the researcher in the development of the

study methodology and in training the students on how to use the program prior to the research

study beginning.

Patient safety and quality of care, as well as, the evolution of technology, has set the

stage for academia to engage in new teaching strategies that can may be introduced in nursing

education. Virtual simulation offers a contemporary way to innovate teaching. This web-based

platform is noted in research to be an effective teaching strategy for use in nursing education.

The teaching strategy offers faculty a method for introducing experiences to nursing students that


they may never see or experience in a clinical setting. This exposure will help nursing students to

apply and recall knowledge preparing them for critical thinking and enhancing development of

clinical reasoning skills in a safe environment. A benefit of virtual simulation is the ability for

students to be able to repeat the simulation. The repeated exposure and immediate feedback

provides the students a way to practice knowledge and skills through experiential learning that is

meaningful. The NLN Jeffries Simulation Model, used as a framework for this study, facilitates

the development of simulation experiences that are synergistic and that promote experiential,

interactive, active and collaborative learning. Virtual simulation encompasses these

characteristics and this type of setting promotes a student centered learning environment in

which the goal is for successful learning.

Future Educational Recommendations and Research

There are many different ways in which virtual simulation can be used in nursing

education to promote meaningful learning. Many colleges offer online distance nursing

programs and the student population is global. An online platform offers asynchronous or

synchronous technology and virtual simulation can be used as an online clinical experience

where students can demonstrate clinical skills and knowledge for evaluation (Farra et al., 2012;

Foronda & Bauman, 2014; Gu et al, 2014). Virtual simulation can also be used to augment

lectures and engage students in active learning by having them use their laptops in class to

participate in an assigned virtual patient case scenario (Foronda & Bauman, 2014; Heinrich,

Pennington, & Kuper, 2012). When virtual simulation is used as a homework assignment, a

rubric with objectives can be used to determine and help explain expectations to students for

completing the assignment (Heinrich, Pennington, & Kuper, 2012). Virtual simulations may also

be used as a venue of additional clinical assignments that provide students with experiences on


high risk care simulations as well as opportunity to practice documentation of patient

information in an electronic health record (Foronda & Bauman, 2014; Gore & Thomson, 2016;

Jenson & Forsyth, 2012). As a complementary teaching instruction, virtual simulation offers

nursing faculty an alternative teaching strategy to enhance learning and to address barriers that

may arise with the implementation of new models of contemporary nursing education such as

online learning (Foronda & Bauman, 2014).

Findings from this research study add to the body of knowledge on virtual simulation but

are limited in generalizability. Virtual simulation is demonstrating usefulness in nursing

education and further research is needed as the technology is advanced. The research methods

used in the study are strong and provide opportunity for future research on virtual simulation.

Recommendations for future studies include:

Conducting studies with a larger sample size using the same methods and

randomization measures as in this study to increase generalizability.

Integrating virtual simulation into lecture based classes and measuring course specific

learning outcomes by comparing it with lecture only classes using reliable tools.

Conducting a comparison of learner achievement of competencies in clinical skill

performance between a virtual simulation group and a laboratory high fidelity

simulation group using valid and reliable tools.

Exploring a longitudinal academic – practice study using virtual simulation with pre-

licensure undergraduate students and measuring transferability of knowledge, skills,

and interprofessional teamwork and collaboration six months after transitioning into

practice.


Replicating the current study using the same methods with similar students across

different colleges and embedding the study within a nursing course.

The landmark study by Hayden et al. (2014) endorsed simulation as an effective teaching

strategy for nursing education. As a teaching strategy, virtual simulation offers faculty an

innovative way to integrate active rich learning experiences into nursing classes. Further research

on the effects of virtual simulation on student outcomes will assist in developing guidelines,

standards and practices for use in nursing education.


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Tables and Graphs

Table 4.1 Demographics of the Sample

Variables Virtual Grp.

Concept Map Grp. Percent

Gender Male Female Total

11314

01313

496100

Age 20-21 22-23 24-30 31-36 37-38 Total

4313213

8111011

50178178

100Program Tradition Nontraditional Total

71017

7411

6139100

Virtual Exp No Yes Total

11213

9312

8020100

Concept Exp No Yes Total

4913

4812

3268100

Table 4.2 Fisher's Exact Tests of Variables ∙ Groups

Variables p-value

Gender 1.000

Program of Study 0.440

Virtual Simulation 0.645


Concept Map 1.000

Table 4.3 Reliability Tests on Asthma Knowledge Tools

Data Tools M SD

Cronbach's

Alpha

N of

Items

Pre Quiz Asthma Knowledge Test 11.39 11.341 0.883 15

Healthcare Asthma Knowledge Questionnaire 14.44 11.342 0.730 17

Table 4.4 Summary of Pre-quiz Scores n M Mdn SD

VS 14 9.07 8.5 2.731CM 14 10.5 11 2.139

Table 4.6 Summary of CQ Correct Scores N M Mdn SD

Table 4.5 Results for Independent Sample t-Tests

Virtual Concept

Scores M SD N M SD N 95% CI T Df P

Post Quiz 10 2.075 14 10.86 2.033 14 -2.453, .739 1.104 25.989 0.28

Pre-Post 0.93 2.645 14 0.36 1.55 14 -1.132, 2.275 0.698 20.958 0.493

HQ 11.64 2.098 14 11.43 1.785 14 -1.302, 1.729 0.291 25.351 0.773


VS 14 3.71 4 1.437CM 14 4.79 5 1.718

Table 4.7 Summary of Teach Back Scores n M Mdn SD

VS 14 266.64 228.0 69.178CM 14 266.93 230.0 69.822


Appendix A

Pre and Post NLN Quiz

Pre Quiz & Post QuizPre- Quiz Post Quiz Asthma Questions

1. The nurse is aware that which of the following represents the strongest predisposing

factor for asthma?

a. Stress

b. Exercise

c. Allergy

d. Airway irritant

2. In the patient experiencing an asthma exacerbation which of the following changes occur

(select all that apply)

a. Bronchoconstriction

b. Hypotension

c. Airway edema

d. Bronchodilation

e. Airway narrowing

3. The nurse understands that a patient with asthma is likely to exihibit which 3 common

symptoms (select 3)

a. Stridor

b. Cough

c. Dyspnea

d. Wheezing

e. Tachypnea


4. In the patient with asthma, the nurse hears wheezing initially during which part of the

respiratory cycle?

a. expiration

b. none of these

c. inspiration

d. both inspiration and expiration

5. In the patient experiencing asthma, the nurse can expect to find which of the following

sounds on percussion of the chest?

a. Resonant

b. Flat

c. Resonate to hyperresonant

d. Dull

6. The nurse assesses the severity of asthma by monitoring which of the following

measures? (select all that apply)

a. Peak flow

b. Auscultation of lungs

c. Spacer use

d. State of dehydration

e. Severity of symptoms


7. The patient was prescribed methylprednisolone (Solu-medrol) IV for her asthma. For

which adverse effects would the nurse monitor for this medication? (select all that apply)

a. Hypotension

b. Cardiac arrhythmias

c. Pancreatitis

d. Seizures

e. Decrease appetite

f. Hyperglycemia

8. Before administering albuterol sulfate, what should the nurse do with the metered dose

inhaler?

a. Shake the metered dose inhaler

b. None of the above

c. Refrigerate the metered dose inhaler

d. Roll the metered dose inhaler

9. When the patient inhales albuterol sulfate, a spacer device should be used for maximal

drug delivery. _____ false __X___true

10. If more than one inhalation of albuterol sulfate is ordered, how long should the nurse

instruct the patient to wait between inhalations

a. 30 secs

b. 3 minutes

c. no waiting time is required

d. 2 minutes


11. Is the following statement true or false? Prior to administering ipratropium bromide

(atrovent) by the inhaler, the nurse should include the following key point in patient

teaching: ipratropium bromide (Atrovent) via metered dose inhaler is not the medication

of choice as rapid treatment of bronchospasm. ____ false __X__true

12. Is the following statement true or false? Prior to administering ipratropium bromide

(atrovent) by the inhaler, the nurse should instruct the patient to breathe in inhaling as

much air as possible. __X__ false ____ true

13. Albuterol sulfate and ipratropium bromide (Atrovent) via nebulizer are ordered for a

patient with asthma experiencing severe wheezing. Which of the following statements is

correct?

a. Ipratropium bromide should be administered first followed by albuterol via

nebulizer.

b. Albuterol sulfate and ipratropium can be delivered together in a nebulizer

treatment.

c. Albuterol sulfate should be administered first, followed by ipratropium via a

nebulizer

d. Ipratropium is contraindicated as treatment for wheezing.

14. Is the following statement true or false? If a patient’s condition continued to deteriorate,

she could develop status asthmaticus, which is a complication of asthma. If this were to

occur, her wheezing would disappear. ____ false __X__true


15. Arterial blood gases were ordered for the patient to monitor her condition. If her initial

blood gases and second results one hour later were as shown in the table, this would

indicate she initially had ________ and this changed to _________ (name the acid base

disturbance)

pH 7.35 7.32

CO2 45 53

HCO3 22 26

O2 80 72

a. Normal ABG: respiratory acidosis

b. Respiratory alkalosis: respiratory acidosis

c. Respiratory acidosis: respiratory acidosis

d. Normal ABG: metabolic alkalosis

16. The nurse compares the patient’s most recent ABG to her initial ABG and notes an

increased PaCO2 to 55 and a decreased PaO2 to 72. Which of the following is true of the

patient’s condition form the nurse’s evaluation of the ABG changes?

a. Her condition is worsening

b. Her condition is improving

c. Her condition is the same


Appendix B

Healthcare Professional Knowledge Asthma Questionnaire

HEALTH CARE PROFESSIONAL ASTHMA KNOWLEDGE QUESTIONNAIRE (HQ) WITH A TRUE/FALSE RESPONSE

1. Asthma results from complex interactions among inflammatory cells, mediators, and other tissues in the airway. (T)

2. Asthma can be triggered by aspirin or other nonsteroidal anti-inflammatory drugs such as NSAIDS. (T)

3. After the patient has recovered from a severe asthma attack, he/she should be maintained on the same dose of oral corticosteroid permanently to control his/her condition. (F)

4. The aim of asthma management is to empower health care professionals to take control of patients’ disease. (F)

5. Asthma episodes are associated with variable airflow obstruction that is often reversible with treatment. (T)

6. All people with asthma should have a long-acting beta2 agonist for symptom relief. (F) 7. The inflammatory process in asthma does not cause permanent changes in the airways. (F) 8. Multiple actuations of aerosol devices before inhaling from a spacer will result in more

effective medication delivery. (F) 9. The most common problem with Dry Powder Inhaler (DPI) use is incorrectly coordinating

drug release and inhalation. (F) 10. It is a good idea to give cough syrups during an asthma attack to treat asthma-related cough.

(F) 11. The genetic predisposition for the development of an IgE-mediated response to common

aeroallergens is not a predisposing factor for developing asthma. (F) 12. An asthma 3 + visit plan is a plan in which GPs treat an acute asthma exacerbation over 3

visits. (F) 13. Inhaled nonsteroidal anti-inflammatories are recommended as initial preventative therapy for

children with frequent episodic to mild persistent asthma. (T) 14. In some people with asthma, exercise-induced symptoms may be the only manifestation of

asthma. (T) 15. When oral corticosteroids are initiated in an acute asthma attack, inhaled corticosteroids

should be ceased to avoid any complications. (F) 16. Dry Powder Inhalers (DPI) require higher inspiratory flow rates than metered dose inhalers

(MDI). (T) 17. Only nebulizers can be used in children < 2 years who have asthma. (F) 18. Unlike short-acting bronchodilators, Long acting bronchodilators effects usually last for 2

days. (F)


Appendix C

Teach-back Observation Tool


Appendix D

Consumer Asthma Knowledge Questionnaire

Used as an Observational Tool

CONSUMER ASTHMA KNOWLEDGE QUESTIONNAIRE (CQ) WITH A TRUE/FALSE RESPONSE

1. You can become addicted to asthma medications if you use them all the time. (F)

2. An asthma action plan can prevent hospitalizations due to asthma. (T)

3. When you know that you are going to be exposed to something that triggers your asthma, you should take the recommended medication just before exposure. (T)

4. When you know that you are going to be exposed to something that triggers your asthma, you should wait until you develop symptoms before taking medication. (F)

5. Side effects are less likely with inhaled medications than with tablets. (T)

6. With preventer medications, it does not matter if some doses are missed or if you go on and off them. (F)

7. If you get a cold or flu, you should increase your asthma medications. (T)

8. Some medications can trigger asthma attacks. (T)

9. You should use ‘‘preventer medication’’ when you have an asthma attack. (F)

10. Going from a cold to hot environment can trigger asthma, but going from a hot to cold environment does not trigger asthma. (F)

11. Parents should give ‘‘reliever medication’’ to a child as soon as they recognize the first sign of asthma. (T)

12. Medication that come in either a blue puffer, brown buffer, and green puffer are called ‘‘preventer medications,’’ so they should be used every day although you are well. (F)


Appendix E

Response on NLN Pre/Post Questions

doctorate student from Simmons College with questionInbox x

Susan Forneris <[email protected]>

to judith.cullina., Elaine, Lorraine, pjeffries, Beverly

Dear Judith,Thank you so much for your email and your interest in the NLN vSim simulation scenarios.Congratulations to you on your work and we are thrilled that you are moving forward with research of vSim in nursing education. Your questions are excellent. To date, content validity via the expert clause on the site is the only validity that hasbeen done on the vSim scenarios. These scenarios also exist in a full-scale design with manikins. Piloting of the full scale simulations also occurs with content validated through that process as well. The vSim scenarios have also been piloted but their use in nursing curricula has just begun and we do not have any further information on their use over time. The pre-post assessments were developed by the content experts.These assessments were part of an overall curricular approach for use as a formative assessment only with students and not as summative reviews. I am not aware that these pre/post assessments were validated or underwent any reliability testing for use in any research. I wish you the best in moving forward with your research. If you have further questions, please do not hesitate to reach out to us.Kind regards,


Appendix F

Permission for Healthcare Asthma Knowledge Questionnaire and Consumer Asthma


Appendix G

Concept Map Template


Appendix H

AHRQ Teach Back Power Point


Appendix I


Appendix J

Research Infogram


Appendix K

Teach Back Data Tool

TEACH BACK OBSERVATION TOOLVideo#:______________

Did the nurse Yes No N/A Scale Use a caring tone of voice and attitude? (**)

Display comfortable body language, make eye contact, and sit down? (***)

Use plain language? (****)

Ask the patient to explain in their own words what they were told to do about:

Signs and symtoms to call the doctor for?

Key medicines?

Critical self-care activities?

Follow-up appointments?

Use non-shaming, open ended questions?

Use questions that can be answered with a yes or no?

Explain and check again if the patient is unable to use teach back?

Use reader -friendly print materials to support learning?

Document use of and patient;s response to teach-back?

(**): caring tone: warm, comforting, clear, accurate, honest empathatic, sharing the feelings of another as a mean of coming to appreciation of the other. (Weiner & Auster, 2008)(***): smile in proper context, avoid facial grimacing(****): plain language: at level of grade 8 student, no med jargon

lowest highest


Appendix L

Institutional Review Board Approvals


Researcher’s Name: Supervising Faculty Sponsor: Desiree Hensel, Ph.D., RN, PCNS-BC, CNEPh.D. Student: Judith Cullinane, HPED Program PH.D. student, Simmons College

Project Title: Content Mastery and Virtual Simulation

Date of Submission: October 7, 2017

FOR USE BY THE IRB:Exempt Research: Expedited Research: XSignature of IRB member: J. Balboni, Ph.D., Interim Chair, IRB

Date of IRB Review: 10/13/2017 Category of IRB Review: Initial _______ Continuing _______ Expedited review _X___ Full review ______

The Curry College IRB recommends: Approval: X

This study, as described in the proposal materials, has been approved through an Expedited Review process, in accordance with OHRP guidelines, 45 CFR 46.111. Please remember to keep copies of your Informed Consent forms, and to adhere to the protocols you have documented.

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