Evaluation of the Effect of Standardized Child Patient Use on Preparing the Child for Process Skill; A Mix Method Study
Condition: Anxiety; Pediatric Nursing; Patient Simulation; Self Efficacy; High Fidelity Simulation Training
Study type: Interventional

Summary: 
      Background: Performing simulation applications using standardized patients provides realistic
      educational results that support critical thinking and learning, conducted using complex,
      effective communication scenarios.

      Objective: This study was planned to evaluate the effect of the use of standardized pediatric
      patient practice in pediatric nursing education on the ability of nursing students to prepare
      the child for the procedure.

      Method: The research was conducted using a convergent parallel design, which is a mixed
      method design. Ethics committee approval was obtained with the decision numbered 19/376
      regarding the ethical suitability of the research. The sample of the study consists of 106
      students. The students included in the study were given an introductory information form and
      the state trait anxiety scale and self-efficacy efficacy scale as pre-tests, and then the
      theoretical course "Preparing the child for the process according to age periods and
      communicating with the child patient" was explained. The students were divided into
      intervention and control groups by randomization. The students in the intervention group
      participated in the simulation application using standardized pediatric patients. Qualitative
      data were collected during the debriefing phase of the simulation and student satisfaction
      and self-confidence in learning scale was applied to the students in the intervention group.
      Before clinical practice, state trait anxiety scale, self-efficacy scale and perceived
      learning scale were applied as posttests. During the clinical practice, all students were
      evaluated in terms of their ability to prepare a real school-age child patient for the
      procedure.
    

Detailed description: 
      Background The use of high-fidelity simulation in healthcare education has emerged as a
      solution to address clinical experiences where patient, educational, or clinical setting
      limitations exist. Simulation, used to provide competence and competence in learning, is a
      technique or tool that attempts are made to create features of the real world. In the
      simulation performed using standardized patients; The patient or case study is portrayed by
      playing the role/scenario prepared with structured steps. Use of standardized/simulated
      patient in teaching; It contributes to the development of students' communication skills,
      history taking and physical examination skills. Training using standardized patients cannot
      be substituted for encountering real patients, but it is accepted as a practice that should
      be increased in a standard and integrative way. Simulation-based education is ideal for
      nursing education because it is an interactive method that can be used to help teach
      cognitive, psychomotor, or affective skills to individuals or groups of any skill or
      proficiency level. Simulation is a technique that can be used as a training method and/or
      research method. Simulation gives the opportunity to apply techniques that cannot be applied
      or tested, and provides realism and standardization. It is stated that it is beneficial to
      use in high-risk applications such as pediatric applications and where the probability of
      encountering students is low. For the child, the concept of illness and hospitalization
      include experiences that cause fear and discomfort. The hospital environment, healthcare
      professionals, materials and procedures create a sense of uncertainty for all children in the
      hospital. All procedures applied in the hospital affect the child physically, emotionally,
      behaviorally and cognitively. As a result, many behaviors such as fear, anxiety, anger,
      aggressive behaviors, impaired concentration, and rejection of further medical applications
      develop in the child. If children are not prepared before the procedure, they may become
      withdrawn, never speak or become aggressive due to the fear and anxiety they experience. This
      situation increases the psychological and physical pain and pain sensation of the child and
      complicates the work of the healthcare team. Preparation before the procedure, support during
      the procedure and follow-up after the procedure can help the child cope with invasive
      interventions. Nurses trying to provide sensitive care to the child should assume that every
      procedure applied to the child may be traumatic for the child.

      The school-age child knows about infections and how they spread. The child in this period has
      a realistic perception about the disease, the cause of the diseases and their effects on the
      organs. The concept of the child's body parts and functions begins to develop. It is
      important to learn the child's knowledge about hospitalization and medical procedures and
      correct misunderstandings through play. Before the procedure, it is necessary to introduce
      himself to the child and allow the child to introduce himself. Parents should be encouraged
      to be with the child. All procedures and their reasons should be explained to the child
      without using medical terminology. The materials to be used during the procedure should be
      introduced to the child, and if possible, the process should be shown to the child on a toy
      or anatomical drawing. Giving the child the opportunity to ask questions about the procedure
      and answering their questions will reduce their anxiety. He should be allowed to choose as
      much as possible and his participation in the process should be encouraged. Before starting
      the procedure, the child's consent should be obtained and the child's privacy should be
      considered during the procedures. It is important to be rewarded or appreciated for the
      compliant behaviors displayed during the procedure.

      Child health and diseases nursing is one of the fields where the use of simulation is most
      necessary, since pediatric patients are more likely to be harmed by medical errors. The use
      of children as standardized patients in medical education; It is not very common because the
      physical and mental development of children is incomplete and it is difficult to train
      children as standardized patients. However, despite the difficulties, it is very necessary to
      use children as standardized patients, to protect real patients from inappropriate
      experiences and to ensure patient safety. Clinical practice of child health and diseases
      nursing often causes feelings of fear and anxiety, and this reduces the performance of
      students. Alleviating these concerns can contribute to improving student performance and
      quality of care in the pediatric clinical setting.

      Studies using children as standard patients are very limited. This study was planned to
      evaluate the effect of using children as standard patients on the child's ability to prepare
      for procedures in pediatric nursing education.

      Method

      Design This research was planned to evaluate the effect of the use of standardized pediatric
      patient practice in child health and diseases nursing education on the ability of nursing
      students to prepare the child for the procedure. The convergent parallel design, which is one
      of the mixed method designs in which quantitative and qualitative research methods are used
      together, was used in the research. The purpose of the convergent parallel design is to
      collect different but complementary data on the same topic in order to best understand the
      research problem.

      Sample and arrangements The sample of the study consists of 106 students studying in the
      third year of a nursing faculty and taking the child health and diseases nursing course. The
      inclusion criteria of the study are as follows; Being a third year student at the faculty of
      nursing, taking the child health and diseases nursing course for the first time, being able
      to speak and understand Turkish, and giving consent to participate in the research. The
      exclusion criteria of the study are as follows; Being a foreign student, having taken the
      Child Health and Diseases Nursing course before, not accepting to participate in the
      research.

      Ethical considerations Ethics committee approval was obtained with the decision numbered
      19/376 regarding the ethical suitability of the study. The purpose of the study and the
      process were explained to the participants, confidentiality was assured, and they were given
      the freedom to withdraw from the study at any time. After the researchers explained the
      informed consent form, written consent was obtained from the participants. Numbers were used
      instead of real names to identify the participants, and the letter M was added to these
      numbers in the intervention group and the letter K in the control group.

      Measuring tools

        -  Introductory features form The introductory characteristics form contains the
           sociodemographic data of the students and was prepared by the responsible researchers.

        -  Perceived learning scale The perceived learning scale was developed by Rovai et al.
           (2009). The Turkish validity and reliability of the scale was performed by Albayrak et
           al. in 2014. The scale consists of 9 items and has three factors. The level of
           participation of each item in the scale; Definitely false (1) and absolutely true (7). A
           score between 9 and 63 is obtained from the entire scale. The Cronbach's alpha value of
           the scale was found to be 0.83.

        -  Self-efficacy efficacy scale It was developed by Sherer et al. in 1982 to measure the
           individual's general self-efficacy-efficacy perception. The Turkish validity and
           reliability of the self-efficacy efficacy scale was performed by Gözüm et al. in 1999.
           The Cronbach's alpha value of the scale was calculated as 0.81. The scale is a 5-point
           Likert type scale consisting of 23 items. For each item, one of the options 1-"Does not
           describe me at all", 2-"Describes me a little", 3-"I am undecided", 4-"Describes me
           well", 5-"Describes me very well' is expected to be ticked. Thus, each individual can
           get a total score between the lowest 23 and the highest 115. A high total score from the
           scale indicates a high perception of general self-efficacy, and a low total score
           indicates a low perception of self-efficacy.

        -  Student satisfaction and self-confidence in learning scale The scale, which is widely
           used to measure students' attitudes and beliefs about simulation, was published by the
           National League for Nurses=NLN. The Turkish validity and reliability of the scale were
           performed by Karaçay et al. in 2017. It consists of two sub-dimensions, "satisfaction in
           learning" and "self-confidence", and a total of 13 items. The student satisfaction
           sub-dimension score is obtained from the sum of the scores of the 1st, 2nd, 3rd, 4th and
           5th items. The self-confidence in learning sub-dimension score is obtained from the sum
           of the scores of the 6th, 7th, 8th, 9th, 10th, 11th, 12th and 13th items. The highest
           total score that can be obtained from the scale is 65, and the lowest is 13. The high
           score that can be obtained from the total of the scale indicates high satisfaction and
           self-confidence. The Cronbach's alpha value of the scale was found to be 0.88.

        -  State trait anxiety scale The state trait anxiety scale was developed by Spielberger et
           al. It was translated into Turkish by Öner and Le Compte (1985) and its validity and
           reliability studies were carried out. The Cronbach Alpha internal consistency
           coefficient for the Trait Anxiety scale ranged from 0.83 to 0.87; It was found to be
           between 0.94 and 0.96 for the State Anxiety Inventory. There are 40 expressions in the
           scale that individuals can use to express their feelings. The first twenty of them
           measure the level of anxiety related to the situation and are scored by putting four
           options for each statement. These are: "Not at all" (1), "Somewhat" (2), "Many" (3),
           "Totally" (4).

        -  Skill checklist for preparing the school-age child for processing The skill checklist
           for preparing the school-age child for processing was created by the responsible
           researchers by reviewing the literature. For the content validity of the skill
           checklist, expert opinion was obtained from the faculty members of Health Sciences
           University, Gülhane Nursing Faculty, Department of Child Health and Diseases Nursing.

      The skill checklist for preparing the school-age child for processing consists of 9 items.
      While evaluating the students, each applied item was marked and it was accepted that the
      student got a "1" point from that item. Accordingly, a student can get a minimum of "0" and a
      maximum of "9" points from the skill checklist. The Cronbach alpha value of the skill
      checklist for preparing the school-age child for processing was calculated as 0.83.

      Developing Scenarios Two scenarios were used in the simulation application. The scenarios
      were prepared by the responsible researchers who were trained in simulation training. While
      preparing the content of the scenarios, it was necessary to choose a skill for preparing the
      pediatric patient for the procedure. Taking the opinions of the faculty members of the
      Department of Child Health and Diseases Nursing at the University of Health Sciences, Gülhane
      Nursing Faculty, it was decided to choose the skill of preparing the child for bloodletting,
      which is one of the skills that students have the most difficulty during clinical practice.

      While developing the scenarios, simulation practice standards of the International
      Association for Clinical Simulation and Learning Nursing (INACSL) were taken into account.

      Standardized Patient Education Two school-age children aged 7-12 years were used as
      standardized pediatric patients. Due to the absence of children enrolled in standardized
      patient programs in our country, standardized pediatric patients were selected voluntarily
      among the school-age children of the faculty members of the Faculty of Health Sciences
      Gülhane Nursing Faculty. Standardized pediatric patients and their parents were informed
      about the study before participating in the study and their written consent was obtained.
      Their parents were present during the education of the children and the execution of the
      simulation.

      When a literature review was made, it was determined that in standardized patient practice, a
      person should undergo 4-8 hours of training after accepting to be a "standardized patient". A
      total of 8 hours of standardized patient education was conducted with standard pediatric
      patients, lasting 2 hours in 4 separate sessions.

      Intervention The quantitative part of the study was conducted in a randomized controlled
      manner. Students were randomly divided into two groups. Students in the intervention group
      were included in a simulation using standardized pediatric patients. In the simulation
      application, 6 groups, 5 of which were 8 students and 1 of which were 9 students,
      participated in the application. Two standardized pediatric patients played the prepared
      scenarios by repeating them 3 times. A time of 10 minutes is planned for each simulation
      application. One student in the group communicated with the standardized pediatric patient,
      and the other students took part as observers. The simulation application was recorded with
      the video recording method and the students were allowed to watch themselves in the analysis
      session held after the simulation. In the last step of the study, all students went into
      clinical practice and during the clinical practice, each student was evaluated in terms of
      their ability to prepare the child for the procedure.

      Data collection The two-hour course "Preparing the child for the procedure according to age
      periods and communication with the child patient" was given to the students who formed the
      universe of the research. State trait anxiety scale and self-efficacy efficacy scale were
      applied as pre-tests to all students who accepted to participate in the study. In the
      debriefing session, each of these questions was discussed with the students one by one. After
      the debriefing session was completed, a form containing the questions asked to them in the
      decoding session was given to the students and they were asked to write their answers. The
      written answers of the students constitute the data of the qualitative part of this research.

      After the analysis session of the simulation, the students in the intervention group were
      applied the student satisfaction and self-confidence scale used in education with simulation.

      After the completion of the simulation application, state trait anxiety scale, self-efficacy
      efficacy scale, and perceived learning scale were administered to all students in the
      intervention and control groups as post-tests.

      Analysis of data In the qualitative part of this mixed method research, the written answers
      given by the students to the questions asked to them during the analysis phase were analyzed
      with the content analysis method, one of the qualitative data analysis methods. In this
      study, deductive content analysis method was used. Qualitative data were read repeatedly by
      the responsible researchers and the data in the text were coded under the categories of
      "doing, watching, feeling, thinking". The editing phase was completed by analyzing the data
      and placing them in the relevant categories. The reporting stage, which is the last step of
      the content analysis method, was completed with the presentation of the content analysis
      steps and findings.

      IBM SPSS Statistics 23 package program was used for statistical calculations and analysis of
      the quantitative data of the research. Normality assumptions of numerical variables were
      examined with Kolmogorov Smirnov normality test. Relationships between two independent
      categorical variables were interpreted with Chi-square analysis. Differences between two
      independent groups (eg, control and intervention groups) were analyzed using the Independent
      Sample T Test for normally distributed variables and the Mann Whitney U test for non-normally
      distributed variables. The differences between two dependent numerical variables (pretest and
      posttest) were examined with the Dependent Sample T test. Statistical significance in the
      analyzes was interpreted at the p<0.05 level.

      Theoretical framework The theoretical framework of this research is David A. Kolb's
      experiential learning theory. Kolb; He designed learning in the form of a circle in his
      experiential learning theory. There are four basic learning stages in this learning circle.
      These stages are; These are the "concrete experience" and "abstract conceptualization"
      stages, which show the conceptualization of experiences, and the "reflective observation" and
      "active experience" stages, which show the transformation of experiences. Written answers to
      the questions asked to the students during the analysis phase of the simulation were coded
      for the concepts of "feeling", "watching", "thinking" and "doing". These concepts form the
      categories of this qualitative research. Qualitative data were read repeatedly by the
      responsible researchers and the data in the text were coded under the categories of "doing,
      watching, feeling, thinking".
    

Intervention name(s): simulation with standardized child patient
Intervention type(s): Other
Intervention description(s): 49 students in the experimental group experienced the ability to prepare a school-age child for the procedure with a simulation using standardized pediatric patients. In the simulation, a school-aged child was used as the standard patient.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: The research was carried out using a convergent parallel design, which is a mixed method, which includes a randomized controlled study with a pretest-posttest control group, which is one of the quantitative research methods, and a phenomenological approach, one of the qualitative research designs.
Masking: Single (Participant)
Primary purpose: Other
Keywords: experiental learning; anxiety; pediatric nursing; patient simulation; self efficiacy; high fidelity simulation training