Woo Sook Lee; Miok Kim

doi:10.4040/jkan.2011.41.4.433

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Original Article
Effects and Adequacy of High-Fidelity Simulation-Based Training for Obstetrical Nursing: Woo Sook Lee¹, Miok Kim²; Journal of Korean Academy of Nursing 2011;41(4):433-443.
DOI: https://doi.org/10.4040/jkan.2011.41.4.433
Published online: August 12, 2011

¹Associate Professor, Red Cross College of Nursing, Seoul, Korea

²Full-time Lecturer, Department of Nursing, Namseoul University, Cheonan, Korea

¹Associate Professor, Red Cross College of Nursing, Seoul, Korea

²Full-time Lecturer, Department of Nursing, Namseoul University, Cheonan, Korea

Address reprint requests to : Kim, Miok Department of Nursing, Namseoul University, 21 Maeju-ri, Seonghwan-eup, Seobuk-gu, Cheonan 331-707, Korea Tel: +82-41-580-2716 Fax. +82-41-580-2931 E-mail: aprilsea@hanmail.net

• Received: November 2, 2010 • Revised: November 4, 2010 • Accepted: August 4, 2011

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
REFERENCES

Abstract

Purpose
Clinical training for nursing students is limited to rudimentary skills to avoid potential risks. Simulation-Based Training (SBT) can overcome the shortcomings of clinical training. We evaluated the educational effect of SBT for obstetrical nursing students using high-fidelity simulation courses.
Methods
We developed a simulation program for obstetrical nursing students to practice nursing skills that are necessary to provide quality care. The program consisted of four sessions. 1st: An orientation and a preliminary test. 2nd: Learning core skills required in obstetrical nursing. 3rd: Testing each student with scenario. 4th: Providing a debriefing session. At the beginning of the program, students were surveyed about their self-confidence in obstetrical nursing care, and at the end of the program, they were surveyed about the adequacy of SBT as well as self-confidence.
Results
Students’ self-confidence showed a significant difference before and after simulation. Mean adequacy of SBT was 7.15±1.35 (out of 10). Most students became more interested in Women’s Health Nursing after SBT.
Conclusion
The results from evaluating the effects of simulation-based obstetrical nursing training show that SBT provides invaluable clinical experience for obstetrical nursing students by overcoming the lack of actual clinical involvement in clinical training programs.
Keywords: Obstetrical nursing; Simulation-based training

Figure 1.

Running process of the simulation-based training.

Table 1.

General Characteristics of Participants (N=138)

Variables	Mean±SD	n (%)
Age (yr)	21.3±2.7
Gender
Female		125 (90.6)
Male		13 (9.4)
Simulation experience
Yes		106 (76.8)
No		31 (22.4)
Satisfaction with the obstetric clinical experience
Very high		22 (15.9)
High		41 (29.7)
Middle		34 (24.6)
Low		31 (22.5)
Very Low		10 (7.2)

Table 2.

Self-confidence about Clinical Practices for Obstetric Nursing (N=138

Sub-domain	Items	Before simulation	After simulation	p
Sub-domain	Items	Mean±SD	Mean±SD	p
Knowledge about clinical situation	Preparation of clients for Leopold’s maneuver	3.17±0.90	3.80±0.75	<.001
	Correct understanding of the relationship between uterine contraction and fetal heart rates	2.87±0.85	3.46±0.92	<.001
	Correct interpretation of fetal monitoring results	2.46±0.83	3.09±0.94	<.001
	Thorough understanding of process of labor	3.01±0.83	3.25±0.82	.003
	Understanding of the clients reaction during labor	2.98±0.81	3.30±0.90	<.001
	Thorough understanding of postpartum changes (Height of fundus, etc.)	3.41±0.86	3.70±0.77	.001
	Sub-total	2.98±0.63	3.43±0.64	<.001
Precise assessment	Appropriate assessment of clients (physical examination, pain assessment, etc.)	2.92±0.76	3.32±0.85	<.001
Appropriate intervention	Proper performance for each step of Leopold’s maneuver	3.06±0.94	3.70±0.83	<.001
	Check fetal heart rate at correct location and correct interpretation	3.01±0.86	3.67±0.84	<.001
	Clear explanation to client about clients’ medical status	2.67±0.82	3.30±0.78	<.001
	Right position change for the condition of the client	3.02±0.88	3.68±0.86	<.001
	Appropriate breathing technique according to the clients’ status	2.78±0.87	3.58±0.84	<.001
	Nursing interventions for anxiety	3.15±0.91	3.60±0.85	<.001
	Client education for postpartum management	3.28±0.86	3.64±0.78	<.001
	Proper comfort care for clients	3.25±0.78	3.60±0.89	<.001
	Privacy protection for the client in all the possible situations	3.88±0.82	3.76±0.97	.208
	Correct judgement and report on clients’ condition	2.27±0.79	3.21±0.81	<.001
	Providing nursing care calmly	3.07±0.78	3.33±0.92	.003
	Sub-total	3.08±0.60	3.55±0.60	<.001
Prioritization	Priority nursing care plan according to clients’ condition	2.68±1.06	3.16±0.90	<.001
Appropriate communication	Appropriate communication with clients and colleagues	3.28±0.71	3.53±0.83	.001
Total		3.03±0.58	3.48±0.60	<.001

Table 3.

Adequacy of Simulation-based Training (N=138

Sub-domain	Items	Mean±SD
Relevance of the simulation learning process
	Simulation-based training increased confidence in nursing	7.31±1.74
	Simulations were realistic	7.38±1.84
	Simulation helped to establish nursing goals for clients	7.27±1.74
	Simulation-based training increased students’ interest in women’s health nursing	8.33±1.26
	Simulation-based training may help nursing practice in the future	8.01±1.90
	Total	7.17±1.38
Adequacy of simulation-based training in each session
Orientation & Preliminary test	Orientation helped in understanding the simulation program	7.09±1.91
	The goal of the simulation program was made clear	7.44±1.84
	The simulation scenarios were easily understood	6.79±1.72
		7.10±1.52
Learning core skills	Open Lab was properly used for simulation preparation	6.30±2.39
Simulation test	Students could confirm abnormal status of clients through simulation	7.01±1.68
	Students could prioritize nursing interventions during the simulation	6.49±1.73
	Students knew what should be done to resolve clients’ problems	6.32±1.79
	Students could perform correct procedure for nursing skills	6.30±1.76
		6.52±1.48
Debriefing	Constructive feedback was given after simulation	7.75±1.78
	Debriefing helped the student identify his or her strength	7.29±1.85
	Debriefing helped to identify the weakness of the student	8.12±1.71
		7.72±1.55
	Total	6.99±1.36
Relevance of the simulation learning environment
	The installation and equipment of the simulation program were appropriate	7.95±1.83
	The duration of the simulation tests were appropriate	7.61±1.81
	The simulation tests were interesting enough to hold students’ attentio	7.53±1.95
	Appropriate nursing information was provided during the simulation program	7.33±1.67
	Total	7.60±1.60
Total		7.15±1.35

REFERENCES

Alinier G, Hunt W &, Gordon R. 2004;Determining the value of simulation in nurse education: Study design and initial results. Nurse Education in Practice. 4:200–207. doi:10.1016/S1471(03)00066-0.Article PubMed
Baillie L &, Curzio J. 2009;Students’ and facilitators’ perceptions of simulation in practice learning. Nurse Education in Practice. 9:297–306. doi: 10.1016/j.nepr.2008.08.007.Article PubMed
Beaubien J M &, Baker D P. 2004;The use of simulation for training teamwork skills in health care: How low can you go? Quality & Safety in Health Care. 13:i51–i56.Article
Choi J Y, Jang K S, Choi S H &, Hong M S. 2008;Validity and reliability of a clinical performance examination using standardized patients. Journal of Korean Academy of Nursing. 38:83–91. doi:10.4040/jkan.2008.38.1.83.Article PubMed
Cohen J. 1988.Statistical power analysis for the behavioral sciences. 2nd ed.Hillsdale, NJ: Erlbaum.Article
Deering S, Brown J, Hodor J &, Satin A J. 2006;Simulation training and resident performance of singleton vaginal breech delivery. Obstetrics & Gynecology. 107:86–89.Article
Ellis D, Crafts J F, Hunt L P, Read M, Fox R &, James M. 2008;Hospital, simulation center, and teamwork training for eclampsia management: A randomized controlled trial. American Journal of Obstetrics and Gynecology. 111:723–731.
Eom M R, Kim H S, Kim E K &, Seong K. 2010;Effects of teaching method using standardized patients on nursing competence in subcutaneous injection, self-directed learning readiness, and problem solving ability. Journal of Korean Academy of Nursing. 40:151–160. doi:10.4040/ jkan.2010.40.2.151.Article PubMed
Fanning R M &, Gaba D M. 2007;The role of debriefing in simulation-based training. Society for Simulation in Healthcare. 2:115–125.
Feltz D L. 1988;Self-confidence and sports performance. Exercise and Sport Sciences Reviews. 16:151–166. doi:10.1249/00003677-198800160-00016.Article
Gardner R &, Raemer D B. 2008;Simulation in obstetrics and gynecology. Obstetrics and Gynecology Clinics of North America. 35:97–127. doi: 10.1016/j.ogc.2007.12.008.Article PubMed
Goffman D, Heo H, Chazotte C, Merkatz I &, Bernstein P S. 2008;Using simulation training to improve shoulder dystocia documentation. Obstetrics & Gynecology. 112:1284–1287.Article
Hertel J P &, Millis B J. 2002.Using simulations to promote learning in higher education: An introduction. Sterling VA: Stylus.
Jude D C, Gilbert C G &, Magrane D. 2006;Simulation training in the obstetrics and gynecology clerkship. American Journal of Obstetrics and Gynecology. 195:1489–1492. doi:10.1016/j.ajog.2006.05.003.Article PubMed
Lasater K. 2007;High-fidelity simulation and the development of clinical judgement: Students’ experiences. Journal of Nursing Education. 46.
Maslovitz S, Barkai G, Lessing J, Ziv A &, Many A. 2007;Recurrent obstetric management mistakes identified by simulation. Obstetrics & Gynecology. 109:1295–1300.Article
McCaughey C S &, Traynor M K. 2010;The role of simulation in nurse education. Nurse Education Today. 30:827–832. doi:10.1016/j.nedt.2010.03.005.Article PubMed
McIntosh J B, Alexander M, Veitch L &, May N. 1997;Evaluation of Nursing Times. 93:46–48.
Mikkelsen J, Reime M H &, Harris A K. 2008;Nursing students’ learning of managing cross-infection scenario-based simulation training versus study groups. Nurse Education Today. 28:664–671. doi:10.1016/ j.nedt.2007.11.003.Article PubMed
Mole L J &, McLafferty I H. 2004;Evaluating a simulated ward exercise for third year student nurses. Nurse Education in Practice. 4:91–99. doi: 10.1016/S1471(03)00031-3.Article PubMed
Moule P, Wilford A, Sales R &, Locker L. 2008;Student experiences and mentor views of the use of simulation for learning. Nurse Education Today. 28:790–797. doi:10.1016/j.nedt.2008.03.007.Article PubMed
Park H, Lee J, Hwang H, Lee J, Choi Y, Kim H. . 2003;The agreement of checklist recordings between faculties and standardized patients in an objective structured clinical examination (OSCE). Korean Journal of Medical Education. 15:141–150.Article
Park J H, Jung E, Ko J K &, Yoo H B. 2008;Delivery training for undergraduate medical students using birth simulator. Korean Journal of Obstetrics and Gynecology. 51:950–956.
Park S I. 1998.Teory and practice of the teaching-learning method (II). Paju: Kyoyookbook.
Pittini R, Oepkes D, Macrury K, Reznick R, Beyene J &, Windrim R. 2002;Teaching invasive perinatal procedures: Assessment of a high fidelity simulator-based curriculum. Ultrasound in Obstetrics and Gynecology. 19:478–483. doi:10.1046/j.1469-0705.2002.00701.x.Article PubMed PDF
Siassakos D, Draycott T, Brien K, Kenyon C, Bartlett C &, Fox R. 2010;Exploratory randomized controlled trial of hybrid obstetric simulation training for undergraduate students. Te Journal of the Society for Simulation in Healthcare. 5:193–198. doi:10.1097/SIH.0b013e3181d3ee0b.Article
Vu N V, Barrows H S, March M L, Verhulst S J, Colliver J A &, Travis T. 1992;Six years of comprehensive, clinical, performance-based assessment using standardized patients at the Southern Illinois University School of Medicine. Academic Medicine. 67:42–50. doi:10.1097/00001888-199201000-00009.Article PubMed
Wilford A &, Doyle T J. 2006;Integrating simulation training into the nursing curriculum. British Journal of Nursing. 15:604–607.Article PubMed
Yoo M S, Yoo L Y, Park Y O &, Son Y J. 2002;Comparison of students’ clinical competency in different instructional methods for fundamentals of nursing practicum. Journal of Korean Academy of Nursing. 32:327–335.Article PDF
Ziv A, Small S D &, Wolpe P R. 2000;Patient safety and simulation-based medical education. Medical Teacher. 22:489–495. doi:10.1080/01421590050110777.Article PubMed

Figure & Data

Figure 1.

Running process of the simulation-based training.

Table 1.

General Characteristics of Participants (N=138)

Variables	Mean±SD	n (%)
Age (yr)	21.3±2.7
Gender
Female		125 (90.6)
Male		13 (9.4)
Simulation experience
Yes		106 (76.8)
No		31 (22.4)
Satisfaction with the obstetric clinical experience
Very high		22 (15.9)
High		41 (29.7)
Middle		34 (24.6)
Low		31 (22.5)
Very Low		10 (7.2)

Table 2.

Self-confidence about Clinical Practices for Obstetric Nursing (N=138

Sub-domain	Items	Before simulation	After simulation	p
Sub-domain	Items	Mean±SD	Mean±SD	p
Knowledge about clinical situation	Preparation of clients for Leopold’s maneuver	3.17±0.90	3.80±0.75	<.001
	Correct understanding of the relationship between uterine contraction and fetal heart rates	2.87±0.85	3.46±0.92	<.001
	Correct interpretation of fetal monitoring results	2.46±0.83	3.09±0.94	<.001
	Thorough understanding of process of labor	3.01±0.83	3.25±0.82	.003
	Understanding of the clients reaction during labor	2.98±0.81	3.30±0.90	<.001
	Thorough understanding of postpartum changes (Height of fundus, etc.)	3.41±0.86	3.70±0.77	.001
	Sub-total	2.98±0.63	3.43±0.64	<.001
Precise assessment	Appropriate assessment of clients (physical examination, pain assessment, etc.)	2.92±0.76	3.32±0.85	<.001
Appropriate intervention	Proper performance for each step of Leopold’s maneuver	3.06±0.94	3.70±0.83	<.001
	Check fetal heart rate at correct location and correct interpretation	3.01±0.86	3.67±0.84	<.001
	Clear explanation to client about clients’ medical status	2.67±0.82	3.30±0.78	<.001
	Right position change for the condition of the client	3.02±0.88	3.68±0.86	<.001
	Appropriate breathing technique according to the clients’ status	2.78±0.87	3.58±0.84	<.001
	Nursing interventions for anxiety	3.15±0.91	3.60±0.85	<.001
	Client education for postpartum management	3.28±0.86	3.64±0.78	<.001
	Proper comfort care for clients	3.25±0.78	3.60±0.89	<.001
	Privacy protection for the client in all the possible situations	3.88±0.82	3.76±0.97	.208
	Correct judgement and report on clients’ condition	2.27±0.79	3.21±0.81	<.001
	Providing nursing care calmly	3.07±0.78	3.33±0.92	.003
	Sub-total	3.08±0.60	3.55±0.60	<.001
Prioritization	Priority nursing care plan according to clients’ condition	2.68±1.06	3.16±0.90	<.001
Appropriate communication	Appropriate communication with clients and colleagues	3.28±0.71	3.53±0.83	.001
Total		3.03±0.58	3.48±0.60	<.001

Table 3.

Adequacy of Simulation-based Training (N=138

Sub-domain	Items	Mean±SD
Relevance of the simulation learning process
	Simulation-based training increased confidence in nursing	7.31±1.74
	Simulations were realistic	7.38±1.84
	Simulation helped to establish nursing goals for clients	7.27±1.74
	Simulation-based training increased students’ interest in women’s health nursing	8.33±1.26
	Simulation-based training may help nursing practice in the future	8.01±1.90
	Total	7.17±1.38
Adequacy of simulation-based training in each session
Orientation & Preliminary test	Orientation helped in understanding the simulation program	7.09±1.91
	The goal of the simulation program was made clear	7.44±1.84
	The simulation scenarios were easily understood	6.79±1.72
		7.10±1.52
Learning core skills	Open Lab was properly used for simulation preparation	6.30±2.39
Simulation test	Students could confirm abnormal status of clients through simulation	7.01±1.68
	Students could prioritize nursing interventions during the simulation	6.49±1.73
	Students knew what should be done to resolve clients’ problems	6.32±1.79
	Students could perform correct procedure for nursing skills	6.30±1.76
		6.52±1.48
Debriefing	Constructive feedback was given after simulation	7.75±1.78
	Debriefing helped the student identify his or her strength	7.29±1.85
	Debriefing helped to identify the weakness of the student	8.12±1.71
		7.72±1.55
	Total	6.99±1.36
Relevance of the simulation learning environment
	The installation and equipment of the simulation program were appropriate	7.95±1.83
	The duration of the simulation tests were appropriate	7.61±1.81
	The simulation tests were interesting enough to hold students’ attentio	7.53±1.95
	Appropriate nursing information was provided during the simulation program	7.33±1.67
	Total	7.60±1.60
Total		7.15±1.35

REFERENCES

Alinier G, Hunt W &, Gordon R. 2004;Determining the value of simulation in nurse education: Study design and initial results. Nurse Education in Practice. 4:200–207. doi:10.1016/S1471(03)00066-0.Article PubMed
Baillie L &, Curzio J. 2009;Students’ and facilitators’ perceptions of simulation in practice learning. Nurse Education in Practice. 9:297–306. doi: 10.1016/j.nepr.2008.08.007.Article PubMed
Beaubien J M &, Baker D P. 2004;The use of simulation for training teamwork skills in health care: How low can you go? Quality & Safety in Health Care. 13:i51–i56.Article
Choi J Y, Jang K S, Choi S H &, Hong M S. 2008;Validity and reliability of a clinical performance examination using standardized patients. Journal of Korean Academy of Nursing. 38:83–91. doi:10.4040/jkan.2008.38.1.83.Article PubMed
Cohen J. 1988.Statistical power analysis for the behavioral sciences. 2nd ed.Hillsdale, NJ: Erlbaum.Article
Deering S, Brown J, Hodor J &, Satin A J. 2006;Simulation training and resident performance of singleton vaginal breech delivery. Obstetrics & Gynecology. 107:86–89.Article
Ellis D, Crafts J F, Hunt L P, Read M, Fox R &, James M. 2008;Hospital, simulation center, and teamwork training for eclampsia management: A randomized controlled trial. American Journal of Obstetrics and Gynecology. 111:723–731.
Eom M R, Kim H S, Kim E K &, Seong K. 2010;Effects of teaching method using standardized patients on nursing competence in subcutaneous injection, self-directed learning readiness, and problem solving ability. Journal of Korean Academy of Nursing. 40:151–160. doi:10.4040/ jkan.2010.40.2.151.Article PubMed
Fanning R M &, Gaba D M. 2007;The role of debriefing in simulation-based training. Society for Simulation in Healthcare. 2:115–125.
Feltz D L. 1988;Self-confidence and sports performance. Exercise and Sport Sciences Reviews. 16:151–166. doi:10.1249/00003677-198800160-00016.Article
Gardner R &, Raemer D B. 2008;Simulation in obstetrics and gynecology. Obstetrics and Gynecology Clinics of North America. 35:97–127. doi: 10.1016/j.ogc.2007.12.008.Article PubMed
Goffman D, Heo H, Chazotte C, Merkatz I &, Bernstein P S. 2008;Using simulation training to improve shoulder dystocia documentation. Obstetrics & Gynecology. 112:1284–1287.Article
Hertel J P &, Millis B J. 2002.Using simulations to promote learning in higher education: An introduction. Sterling VA: Stylus.
Jude D C, Gilbert C G &, Magrane D. 2006;Simulation training in the obstetrics and gynecology clerkship. American Journal of Obstetrics and Gynecology. 195:1489–1492. doi:10.1016/j.ajog.2006.05.003.Article PubMed
Lasater K. 2007;High-fidelity simulation and the development of clinical judgement: Students’ experiences. Journal of Nursing Education. 46.
Maslovitz S, Barkai G, Lessing J, Ziv A &, Many A. 2007;Recurrent obstetric management mistakes identified by simulation. Obstetrics & Gynecology. 109:1295–1300.Article
McCaughey C S &, Traynor M K. 2010;The role of simulation in nurse education. Nurse Education Today. 30:827–832. doi:10.1016/j.nedt.2010.03.005.Article PubMed
McIntosh J B, Alexander M, Veitch L &, May N. 1997;Evaluation of Nursing Times. 93:46–48.
Mikkelsen J, Reime M H &, Harris A K. 2008;Nursing students’ learning of managing cross-infection scenario-based simulation training versus study groups. Nurse Education Today. 28:664–671. doi:10.1016/ j.nedt.2007.11.003.Article PubMed
Mole L J &, McLafferty I H. 2004;Evaluating a simulated ward exercise for third year student nurses. Nurse Education in Practice. 4:91–99. doi: 10.1016/S1471(03)00031-3.Article PubMed
Moule P, Wilford A, Sales R &, Locker L. 2008;Student experiences and mentor views of the use of simulation for learning. Nurse Education Today. 28:790–797. doi:10.1016/j.nedt.2008.03.007.Article PubMed
Park H, Lee J, Hwang H, Lee J, Choi Y, Kim H. . 2003;The agreement of checklist recordings between faculties and standardized patients in an objective structured clinical examination (OSCE). Korean Journal of Medical Education. 15:141–150.Article
Park J H, Jung E, Ko J K &, Yoo H B. 2008;Delivery training for undergraduate medical students using birth simulator. Korean Journal of Obstetrics and Gynecology. 51:950–956.
Park S I. 1998.Teory and practice of the teaching-learning method (II). Paju: Kyoyookbook.
Pittini R, Oepkes D, Macrury K, Reznick R, Beyene J &, Windrim R. 2002;Teaching invasive perinatal procedures: Assessment of a high fidelity simulator-based curriculum. Ultrasound in Obstetrics and Gynecology. 19:478–483. doi:10.1046/j.1469-0705.2002.00701.x.Article PubMed PDF
Siassakos D, Draycott T, Brien K, Kenyon C, Bartlett C &, Fox R. 2010;Exploratory randomized controlled trial of hybrid obstetric simulation training for undergraduate students. Te Journal of the Society for Simulation in Healthcare. 5:193–198. doi:10.1097/SIH.0b013e3181d3ee0b.Article
Vu N V, Barrows H S, March M L, Verhulst S J, Colliver J A &, Travis T. 1992;Six years of comprehensive, clinical, performance-based assessment using standardized patients at the Southern Illinois University School of Medicine. Academic Medicine. 67:42–50. doi:10.1097/00001888-199201000-00009.Article PubMed
Wilford A &, Doyle T J. 2006;Integrating simulation training into the nursing curriculum. British Journal of Nursing. 15:604–607.Article PubMed
Yoo M S, Yoo L Y, Park Y O &, Son Y J. 2002;Comparison of students’ clinical competency in different instructional methods for fundamentals of nursing practicum. Journal of Korean Academy of Nursing. 32:327–335.Article PDF
Ziv A, Small S D &, Wolpe P R. 2000;Patient safety and simulation-based medical education. Medical Teacher. 22:489–495. doi:10.1080/01421590050110777.Article PubMed

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Effects and Adequacy of High-Fidelity Simulation-Based Training for Obstetrical Nursing

J Korean Acad Nurs. 2011;41(4):433-443. Published online August 12, 2011

DOI: https://doi.org/10.4040/jkan.2011.41.4.433

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Effects and Adequacy of High-Fidelity Simulation-Based Training for Obstetrical Nursing

Figure 1. Running process of the simulation-based training.

Figure 1.

Effects and Adequacy of High-Fidelity Simulation-Based Training for Obstetrical Nursing

Variables	Mean±SD	n (%)
Age (yr)	21.3±2.7
Gender
Female		125 (90.6)
Male		13 (9.4)
Simulation experience
Yes		106 (76.8)
No		31 (22.4)
Satisfaction with the obstetric clinical experience
Very high		22 (15.9)
High		41 (29.7)
Middle		34 (24.6)
Low		31 (22.5)
Very Low		10 (7.2)

Sub-domain	Items	Before simulation	After simulation	p
Sub-domain	Items	Mean±SD	Mean±SD	p
Knowledge about clinical situation	Preparation of clients for Leopold’s maneuver	3.17±0.90	3.80±0.75	<.001
	Correct understanding of the relationship between uterine contraction and fetal heart rates	2.87±0.85	3.46±0.92	<.001
	Correct interpretation of fetal monitoring results	2.46±0.83	3.09±0.94	<.001
	Thorough understanding of process of labor	3.01±0.83	3.25±0.82	.003
	Understanding of the clients reaction during labor	2.98±0.81	3.30±0.90	<.001
	Thorough understanding of postpartum changes (Height of fundus, etc.)	3.41±0.86	3.70±0.77	.001
	Sub-total	2.98±0.63	3.43±0.64	<.001
Precise assessment	Appropriate assessment of clients (physical examination, pain assessment, etc.)	2.92±0.76	3.32±0.85	<.001
Appropriate intervention	Proper performance for each step of Leopold’s maneuver	3.06±0.94	3.70±0.83	<.001
	Check fetal heart rate at correct location and correct interpretation	3.01±0.86	3.67±0.84	<.001
	Clear explanation to client about clients’ medical status	2.67±0.82	3.30±0.78	<.001
	Right position change for the condition of the client	3.02±0.88	3.68±0.86	<.001
	Appropriate breathing technique according to the clients’ status	2.78±0.87	3.58±0.84	<.001
	Nursing interventions for anxiety	3.15±0.91	3.60±0.85	<.001
	Client education for postpartum management	3.28±0.86	3.64±0.78	<.001
	Proper comfort care for clients	3.25±0.78	3.60±0.89	<.001
	Privacy protection for the client in all the possible situations	3.88±0.82	3.76±0.97	.208
	Correct judgement and report on clients’ condition	2.27±0.79	3.21±0.81	<.001
	Providing nursing care calmly	3.07±0.78	3.33±0.92	.003
	Sub-total	3.08±0.60	3.55±0.60	<.001
Prioritization	Priority nursing care plan according to clients’ condition	2.68±1.06	3.16±0.90	<.001
Appropriate communication	Appropriate communication with clients and colleagues	3.28±0.71	3.53±0.83	.001
Total		3.03±0.58	3.48±0.60	<.001

Sub-domain	Items	Mean±SD
Relevance of the simulation learning process
	Simulation-based training increased confidence in nursing	7.31±1.74
	Simulations were realistic	7.38±1.84
	Simulation helped to establish nursing goals for clients	7.27±1.74
	Simulation-based training increased students’ interest in women’s health nursing	8.33±1.26
	Simulation-based training may help nursing practice in the future	8.01±1.90
	Total	7.17±1.38
Adequacy of simulation-based training in each session
Orientation & Preliminary test	Orientation helped in understanding the simulation program	7.09±1.91
	The goal of the simulation program was made clear	7.44±1.84
	The simulation scenarios were easily understood	6.79±1.72
		7.10±1.52
Learning core skills	Open Lab was properly used for simulation preparation	6.30±2.39
Simulation test	Students could confirm abnormal status of clients through simulation	7.01±1.68
	Students could prioritize nursing interventions during the simulation	6.49±1.73
	Students knew what should be done to resolve clients’ problems	6.32±1.79
	Students could perform correct procedure for nursing skills	6.30±1.76
		6.52±1.48
Debriefing	Constructive feedback was given after simulation	7.75±1.78
	Debriefing helped the student identify his or her strength	7.29±1.85
	Debriefing helped to identify the weakness of the student	8.12±1.71
		7.72±1.55
	Total	6.99±1.36
Relevance of the simulation learning environment
	The installation and equipment of the simulation program were appropriate	7.95±1.83
	The duration of the simulation tests were appropriate	7.61±1.81
	The simulation tests were interesting enough to hold students’ attentio	7.53±1.95
	Appropriate nursing information was provided during the simulation program	7.33±1.67
	Total	7.60±1.60
Total		7.15±1.35

Table 1. General Characteristics of Participants (N=138)

Table 2. Self-confidence about Clinical Practices for Obstetric Nursing (N=138

Table 3. Adequacy of Simulation-based Training (N=138