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Effectiveness of Simulation on Knowledge Acquisition, Knowledge Retention,

and Self-Efficacy of Nursing Students in Jordan

Article  in  Clinical Simulation in Nursing · September 2013

DOI: 10.1016/j.ecns.2012.05.001

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Featured Article

Effectiveness of Simulation on Knowledge

Acquisition, Knowledge Retention, and
Self-Efficacy of Nursing Students in Jordan
Laila M. Akhu-Zaheya, RN, PHDa,*, Muntaha K. Gharaibeh, RN, PhDb,
Ziad M. Alostaz, RN-BC, MSN, ACNSc
a
Faculty of Nursing, Department of Adult Health Nursing, Jordan University of Science and Technology, Irbid 22110, Jordan
b
Faculty of Nursing, Department of Maternal and Child Health Nursing, Jordan University of Science and Technology, Irbid
22110, Jordan
c
Al-Baha University, Faculty of Applied Medical Sciences, Nursing school, Kingdom of Saudi Arabia

KEYWORDS Abstract
high-fidelity simulation; Background: The purpose of this quasi-experimental research study was to examine the effect of high-
Jordan; fidelity basic life support (BLS) simulation on knowledge acquisition, knowledge retention, and self-
knowledge acquisition; efficacy of Jordanian nursing students.
knowledge retention; Method: The experimental group (n ¼ 52) received traditional teaching of BLS (3-hour PowerPoint
self-efficacy presentation and demonstration on static manikin in groups of 6 to 7 students) and high-fidelity
BLS simulation, while the control group (n ¼ 58) received only traditional teaching of BLS (3-hour
PowerPoint presentation and demonstration on static manikin in groups of 6 to 7 students).
Results: Neither knowledge acquisition nor knowledge retention showed any significant differences
between the groups; however, self-efficacy showed significant differences.
Conclusions: Students trained with high-fidelity simulation achieved higher scores in acquired and
retained BLS knowledge and higher self-efficacy perception, indicating the value of simulation in im-
proving knowledge and self-efficacy in nursing students. Nursing students must be educated with the
most realistic technologies available to improve patients’ safety.

Cite this article:

Akhu-Zaheya, L. M., Gharaibeh, M. K., & Alostaz, Z. M. (2012, Month). Effectiveness of simulation on
knowledge acquisition, knowledge retention, and self-efficacy of nursing students in jordan. Clinical
Simulation in Nursing, Vol(X), XXX-XXX. doi:10.1016/j.ecns.2012.05.001.
Ó 2012 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier
Inc. All rights reserved.

Introduction providers at all levels and disciplines. Simulation is

growing in popularity in nursing education (Comer, 2005)
High-fidelity simulation (HFS) represents the state of the for augmenting learning, teaching patient safety, enhancing
art in technology for educating students and health care clinical practice, teaching resuscitation, and teaching clini-
cal judgment skills (Henneman & Cunningham, 2005; Parr
* Corresponding author: lailanurse@just.edu.jo (L. M. Akhu-Zaheya). & Sweeney, 2006). Simulation offers students low-risk

1876-1399/$ - see front matter Ó 2012 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ecns.2012.05.001
Effectiveness of Simulation with Nursing Students in Jordan e2

opportunities to practice rare and critical events in a con- lack of available patients in educational wards. In Novem-
trolled environment. Simulation allows students to practice ber 1999, the Institute of Medicine broke the silence
more than once, with or without errors. The simulation surrounding medical errors in its report To Err Is Human
session can be stopped at any time and ended by debriefing, (Institute of Medicine, 1999). The report highlighted the
which is an important phase for successful learning (Bruce, number of medical errors and their burden on national
Bridges, & Holcomb, 2003; cost and public trust. The Institute’s committee concluded
Decker, Sportsman, Puetz, that ‘‘health care organizations and teaching institutions
Key Points & Billings, 2008). should participate in the development and use of simulation
 Students trained with High-fidelity simulation for training novice practitioners, problem solving, and cri-
HFS showed im- are being introduced into sis management, especially when new and potentially haz-
provements in their nursing programs world- ardous procedures and equipment are introduced’’ (Institute
self efficacy. wide, and Jordan is no ex- of Medicine, 1999).
 Using HFS to train ception. In Jordan, 15 Simulation is a teaching method or technique that, once
students allow them nursing programs offer var- adopted, should be evaluated to determine its usefulness as
to be active learners ious undergraduate and a teaching method. Previous studies have reported positive
rather than being pas- graduate programs. Simula- effects of simulation on knowledge acquisition and/or skills
sive learners. tion labs are part of their training (Hoffmann, O’Donnell, & Kim, 2007; Ravert,
 HFS provides equal- infrastructure, as stated in 2002) and on students’ self-efficacy (Bambini, Washburn,
ity for all student’s the Accreditation and Qual- & Perkins, 2009; Brown & Chronister, 2008; Smith &
training. ity Assurance Standards de- Roehrs, 2009). Nursing students’ knowledge of and confi-
veloped and monitored by dence in performing cardiopulmonary resuscitation (CPR)
the Jordanian High Accreditations Commissions. The is one of the major concerns of nursing educators
standard on simulation emphasizes that the use of simula- (Ackermann, 2009; Hamilton, 2005). Students should
tion for students’ training should not exceed 20% of all have the knowledge and skills of basic life support (BLS)
total training methods, encouraging more training in real to practice as rapidly as possible in an emergency situation,
practice settings. In addition, the use of simulation is since the American Heart Association (AHA) has verified
a major faculty development activity in nursing programs. that rapid recognition and treatment of an event requiring
In Jordan, training hospitals and clinical sites are not resuscitation would increase survival rates after cardiac ar-
considered ideal settings for training students because of rest to double to triple the current levels (American Heart
the lack of procedural policies and protocols. In addition, Association, 2010). Various teaching methods have been
hospitals vary in capacities and capabilities for training; used to promote CPR competency. A method that has
students get different educational experiences and learning gained popularity among educators is simulation and spe-
opportunities that may not always meet their educational cifically HFS.
goals. The lack of consistency can affect competency HFS enables students to train in a safe and realistic
levels. Training hospitals are also crowded with medical environment. Using simulation to practice BLS would
and nursing students from various academic institutions and promote retention and improve students’ comfort with
universities, and this competition for education resources BLS (Oermann et al., 2010). However, the use of HFS in
threatens the education quality of prospective graduate BLS courses has not been well documented in the litera-
nurses, which is of national concern. ture. Studies of nursing students performing BLS also ap-
Our interest in this topic stemmed from the fact that the pear rarely. Determining the effect of HFS on educational
culture of using technology in nursing education in Jordan outcomes is important in helping faculty understand its
is fairly new. Findings of this study can contribute to pros, cons, and limitations and the changes necessary for
a paradigm shift in Jordanian nursing education, toward the integration of HFS into the students’ curriculum
more advanced educational approaches. The health care (Oberleitner, Broussard, & Bourque, 2011). The use of sim-
system in Jordan has relied on traditional medical ap- ulation in nursing education is a new culture in a developing
proaches until recently, when advances in medical technol- country such as Jordan. Therefore, the integration of simu-
ogies started to appear, especially in the critical care areas. lation into nursing education requires the creation of this
The acceleration of technology use in this area created culture by enhancing and strengthening the technical capa-
a gap in graduate competence to meet the demands of the bilities of all nurse educators and helping them implement
critical care areas. Therefore, changing the culture of these strategies safely. The purpose of this research study
nursing education to improve patient safety required the was to examine the effect of high fidelity basic life support
introduction of standardized approaches and advanced (BLS) simulation on knowledge acquisition, knowledge re-
technologies to simulate the realities of health care settings. tention, and self efficacy of Jordanian nursing students.
Many factors contributed to the evolution of simulation The conceptual framework of the current study was
use. These factors included but are not limited to the drawn from Bandura’s (1977, 1986) self-efficacy theory
shortage of clinical faculty, errors and patients’ safety, and and Benner’s (1984) ‘‘novice to expert’’ theory.

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Effectiveness of Simulation with Nursing Students in Jordan e3

Self-efficacy is becoming an important concept for nurse child CPR and management of stroke were excluded from
educators. The theory of self-efficacy posits that an individ- the BLS test. Knowledge retention, which measures a stu-
ual’s behavior is determined through continuous interaction dent’s ability to retain knowledge for 1 month, was measured
among cognitive, behavioral, and environmental factors by the 12 items of the of BLS knowledge acquisition test de-
(Bandura, 1977). Goldenberg, Andrusyszyn, and Iwasiw veloped by the AHA (2010). Self-efficacy was measured by
(2005) studied the effect of classroom simulation on the self-efficacy questionnaire developed by Arnold et al.
nursing students’ self-efficacy and found that self-efficacy (2009) and modified by us to include 12 items on students’
increased following role-playing case studies, indicating self-efficacy in performing BLS skills.
more perceived confidence in performing health teaching.
Furthermore, self-efficacy increased following training of
Participants
nurses and midwives with the use of low-tech high-fidelity
obstetric simulation (Cohen, Cragin, Wong, & Walker,
All 2nd-year students (140) enrolled in a baccalaureate
2012). Bambini et al. (2009) evaluated simulated clinical
nursing program in adult health clinical course during the
experiences of nursing students in their initial clinical
summer of 2010 were asked to participate. The baccalau-
course and found that their self-efficacy and confidence
reate nursing program at the Jordan University of Science
were greater after these experiences.
and Technology (JUST) is a 4-year program requiring 134
Benner (1984) introduced the theory of ‘‘novice to
credit hours. English is the language of teaching, and text
expert’’ and emphasized that development of knowledge in
books are the same as those used in the United States. The
applied disciplines such as nursing is composed of the
program is accredited both nationally and internationally. It
extension of practical knowledge and that experience is
also meets the global standards of the American Nurses
a prerequisite for becoming an expert. Experience is devel-
Association and the International Council of Nurses.
oped by passing through five levels: novice, advanced
Graduates of our program are eligible for US State Board
beginner, competent, proficient, and expert. In this study,
Exams and Commission on Graduates of Foreign Nursing
we hypothesized that 2nd-year nursing students who receive
Schools (CGNFS). Nursing students in the adult health
HFS training in BLS would exhibit differences in knowledge
nursing clinical course were purposely selected because of
acquisition, knowledge retention, and self-efficacy, com-
the naivete of the students at this level to both the
pared with students who receive traditional training methods
technology and the content of BLS. Students were excluded
(classroom lecture and demonstration on a static manikin).
from the study if they had a current BLS certificate from
any institution or had previous hospital experience.
All those who agreed to participate (N ¼ 121) were ran-
Method domly assigned to experimental and control groups to en-
sure that both groups were equivalent. The components of
Design the BLS instruction provided for both groups were identical
except for the method of conveying the information.
A quasi-experimental, preepost test design was used to After the students were randomly assigned to a group, the
examine the effectiveness of an HFS BLS scenario on control group participated in 3-hour sessions of traditional
knowledge acquisition, knowledge retention, and self- training, which consisted of a PowerPoint presentation of
efficacy in 2nd-year students in a Jordanian nursing AHA adult BLS, automated external defibrillator (AED)
program. sequences, and a demonstration on a half-torso static
manikin. Infant BLS, airway management, and head trauma
were excluded. The experimental group participated in the
Study Variables
same traditional training provided to the control group and
also received high-fidelity simulator training using the
The independent variable was the teaching method: HFS
METIÔ Version 6, with simulator features including
versus the traditional training method. HFS teaching was
palpable pulse, chest expansion, electrocardiogram moni-
implemented with a human patient simulator, the Medical
toring, and simulator voice. Students in the experimental
Education Technologies, Inc. (METI)Ô Version 6. The
group were provided with all information needed to
traditional method of training involved a lecture on BLS
complete the session (e.g., how to begin, when to end and
skills designed by the AHA for CPR certification. The
the training scenario) and then participated in the cardiac
lecture consists of a 3-hour PowerPoint presentation of BLS
arrest scenario. The CPR crash cart and AED were provided.
and a demonstration on static half-torso manikins.
The dependent variables were knowledge acquisition,
knowledge retention, and self-efficacy. Knowledge acquisi- Setting
tion was measured with a 12-item BLS multiple-choice
knowledge test extrapolated from the AHA (2010) BLS The study was conducted in the nursing lab at JUST, which
exam and the Flinders University BLS exam. Infant and is considered to be the largest governmental university in

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Effectiveness of Simulation with Nursing Students in Jordan e4

Jordan. The nursing lab at JUST serves both undergraduate international guidelines. Permission to use the questions
and graduate students, who use various teaching methods was obtained from AHA and Flinders University School
and techniques to meet individualized student learning of Nursing.
needs. The lab provides the opportunity to practice many The original self-confidence emergency response tool
procedures related to basic nursing skills (e.g., bed making, was developed by Arnold et al. (2009) to assess individual
hygiene, and positioning), maternalechild health nursing, participants’ confidence in responding to an emergency sit-
and advanced nursing skills (e.g., advanced cardiac life uation. It consists of 17 items on BLS and ACLS related to
support [ACLS], BLS, and AED). The lab contains the task’s emergency resuscitative event. Each item has
teaching materials (models, videotapes, and advanced a percentage score that can range from 0 (not confident)
technology materials such as simulators). To provide to 100% (confident; Arnold et al., 2009). Cronbach’s alpha
students with real situations for practice, it also includes of the original tool was .92, indicating high internal consis-
new simulation rooms that each contain a computerized tencies for the entire set of the items. In the current study,
manikin. we modified the tool to include 12 items that sought to de-
Many faculties at JUST (medical, dental, and nursing) termine only the students’ degree of self-efficacy in per-
have purchased different types of simulators within the past forming BLS tasks in a resuscitative event. Students were
2 years; however, simulation use in some faculties, such as asked to recall their performance and rate their perception
nursing, is limited. The nursing labs are well equipped with of their self-efficacy in performing BLS, using a percentage
advanced equipment such as the METIÔ Version 6 human scale that ranged from 0 (not confident) to 100% (more con-
patient simulator. Students’ training in both the control and fident). A student’s total score was obtained by summing
experimental groups was conducted in a physically com- the items’ percentages. Then the mean score for each group
fortable environment that allowed students to work in small was calculated. The internal consistency of the modified
groups, with no obstacles. tool revealed a Cronbach’s alpha of .83 for all 12 items.

Ethical Considerations Procedure

The study was approved by the Faculty of Nursing The procedure for conducting the study took place in three
Research Committee for Protection of Human Subjects phases: the initial phase, the acquisition phase, and the
and by the institutional review board at JUST. Students, retention phase. Figure 1 shows the sequence of events.
who were willing to participate, received a cover letter
explaining the purpose and outcomes of the study and Initial Phase
assuring them that their participation was voluntary and Students who agreed to participate in the study were invited
that they had the right to withdraw at any time without any to attend the 1st day of the study, which was considered its
penalty. Furthermore, students were assured that all in- initial phase. In this phase, the demographic data sheet,
formation they provided and scores obtained would be kept knowledge pretest, and self-efficacy pretest were distrib-
confidential. Students who agreed to participate signed uted. Afterward, all students received the traditional
a written consent form. training method of BLS. The reason for providing both
groups with the traditional training method was to stan-
Measurements dardize the students’ knowledge of BLS. Then students
were randomly assigned into either the experimental or the
A demographic information sheet and knowledge and control group.
modified emergency self-efficacy tools were used in this
study. The demographic information sheet (requesting age, Acquisition and Retention Phases
gender, and grade point average) enabled us to determine The acquisition phase started 1 week after the initial
any potential group variances. phase. In this phase, students in the experimental groups
The knowledge assessment tool consisted of 12 started the BLS training with HFS training, using a car-
multiple-choice questions extrapolated from the BLS diopulmonary arrest scenario that lasted for 15 minutes,
exam provided by the AHA (AHA, 2010) and from the followed by 10 minutes of debriefing. The scenario was
standard BLS algorithm of the Australian Resuscitation adapted from a study by Ackerman (2009) after permis-
Council, published by Flinders University School of sion was obtained from the original author. The scenario
Nursing (Flinders University, 2010). The questions covered involved a patient who complained of chest pain and
content of adult BLS. In this study, the questionnaire was developed a sudden cardiac arrest, requiring students to
administered in English since it is the teaching language respond immediately. The students in the experimental
at JUST. The total score was obtained by calculating the group were assigned randomly into groups of three, in
correct answers for each student; then the mean was calcu- which each student was assigned, also randomly, a specific
lated for each group. Content validity of the instrument was role, either team leader, nurse, or nurse assistant. Students
already established as the questions were extrapolated from were required to start by performing an assessment for the

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Effectiveness of Simulation with Nursing Students in Jordan e5

Pretest for BLS knowledge and self-efficacy,

followed by traditional training method (3-
Initial Phase hour adult BLS presentation and demonstration on
static manikin in groups of 6 to 7 students)

Random assignment

Control Experimental

Acquisition Cardiopulmonary arrest scenario

Phase (After 1 METIMAN Version 6 for 15 minutes
in groups of 3 to 4 students
week)

First posttest for knowledge First posttest for knowledge

and self-efficacy and self-efficacy

Retention
Phase (1 month All participants were invited to complete second posttest
Later) For BLS knowledge retention

Figure 1 Sequence of events of the study phases. BLS ¼ basic life support.

patient using the ‘‘PQRST’’ method of pain assessment (frequencies, percentages, means, and standard deviations)
(provoking and precipitating pain factors, quality, radia- based on the level of measurement were used to describe
tion, severity, and timing of pain). During the assessment, the sample and the study variables. An independent t test
the patient went into cardiac arrest; the students then was used to compare the mean difference in the study out-
could interact with the simulator and demonstrate BLS. comes (BLS knowledge acquisition, knowledge retention,
The students were informed that the session would end and self-efficacy) between the experimental and the control
when the students felt that they could end the task (treat- group.
ing the patient), were unable to continue, or reached the
time limit of 15 minutes. At the end of the scenario,
a 10-minute debriefing was held to discuss notes taken Results
during the scenario. The simulation session was super-
vised by the same ACLS-certified expert who supervised Participants’ Characteristics
the traditional training. The role of this expert was only
to observe students, take notes, and give hints to the stu- Of the 121 students at the initial phase, only 110 (91%)
dents during debriefing. Furthermore, the engineer respon- completed the study. Of those, 52 (47%) were in the
sible for the maintenance of the METIÔ equipment and experimental group, and 58 (53%) were in the control
for uploading the scenarios attended to overcome any group. An independent t test showed no significant differ-
problems encountered during the procedure. ences between the groups regarding age, grade point aver-
The control group, however, did not receive any in- age, pretest BLS knowledge, or perception of self-efficacy
tervention during this phase. At the end of the acquisition in performing BLS, indicating that the groups were homo-
phase, the first posttests were provided to both groups in geneous. The mean age for participants was 20 years (SD ¼
order to assess students’ knowledge of BLS and to rate their 0.60; range, 19-23), and the majority of participants (74, or
perception of their self-efficacy. 67%) were women. See Table 1.
One month later, the students in both groups were
invited to attend the retention phase of the study in order to Hypotheses Testing
retake the test for BLS knowledge retention (Figure 1).
Our results revealed an increase in knowledge acquisition
Data Analysis and retention for both the experimental and the control group.
However, the results of the independent t test for BLS knowl-
Data were analyzed with the Statistical Package for Social edge acquisition mean differences between the experimental
Sciences (SPSS) Version 16 for Windows. Data were (M ¼ 9.1) and the control group (M ¼ 8.6) showed that there
cleaned and coded before analysis. Descriptive values was no significant difference (t ¼ 1.6, df ¼ 108, p ¼ .1). Thus,

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Effectiveness of Simulation with Nursing Students in Jordan e6

Table 1 Demographic Characteristic and Pretest Results of the Experimental and Control Groups
Experimental Group Control Group
Variable n ¼ 52 (47%) n ¼ 58 (53%) p Value
Age, years, M (SD) 20 (.70) 20 (.50) .50
Age range, years 19e23 19e21
Grade point average, M (SD) 70.2 (6.78) 71.7 (8.16) .30
Grade point average, range 59e86 56e91
Pretest knowledge, M (SD) 4.6 (1.2) 4.5 (1.9) .65
Pretest self-efficacy perception, M (SD) 56.1 (21.7) 55.3 (21.9) .85
Note: Independent t test at a ¼ .05 (two-tailed).

the null hypothesis was accepted. However, the independent t be explained by the notion that life support skills require
test showed significant difference in self-efficacy in BLS be- mastery-level competency and are a professional responsi-
tween the experimental (M ¼ 84.4) and the control group bility regardless of the method used to teach them. This
(M ¼ 75.1; t ¼ 3.91, df ¼ 108, p ¼ .001) The null hypothesis explanation is based on Bloom’s three domains for learning:
was rejected. See Table 2. the cognitive, the psychomotor, and the affective (Bloom,
The results of the independent t test showed that there 1956). Translation of Bloom’s taxonomy into HFS reveals
was no significant difference on BLS knowledge retention that gains in cognitive knowledge could be readily achieved
(after 1 month) between the experimental (M ¼ 8.29) and if the outcome measure primarily required students to re-
the control group (M ¼ 8.28; t ¼ 0.03, df ¼ 108, p ¼ member, understand, or apply the principle taught during
.97). The null hypothesis was accepted. See Table 3. the simulation session. The use of BLS scenarios with novice
students requires them to function on a higher level of
Bloom’s cognitive taxonomy. Thus, in order to demonstrate
Discussion a gain in cognitive knowledge, the students must analyze,
evaluate, or create in a situation of uncertainty. The lack of
The findings revealed a lack of support for differences significant differences suggests that BLS training with HFS
between knowledge acquisition of BLS and knowledge is at least as effective as the traditional training method. In
retention. However, the study lends support to the statistically the current decade, technology advancements create
significant difference in students’ self-efficacy in the two opportunities for students as active learners to make clinical
training methods: HFS versus the traditional training method. judgments in a real patient’s situation without harming the
In our study, there is lack of support for the hypothesis that patient’s safety. Students’ engagement in the process of
nursing students engaged in BLS training using HFS would teaching and learning is very important.
exhibit significant differences in knowledge acquisition and The lack of differences in knowledge acquisition from
knowledge retention compared with those who engaged in simulation vs traditional methods might also be explained
the traditional training method. These findings are consistent by the limited amount of time allocated for the simulation
with the findings of previous studies (Burns, O’Donnell, & session. One benefit of simulation is that it allows students
Artman, 2010; Dobbs, Sweitzer, & Jeffries, 2006; Jeffries the opportunity for deliberate, repetitive practice with
& Rizzolo, 2006; Jeffries, Woolf, & Linde, 2003; Kardong- expert feedback (Kneebone, 2005). It is obvious that stu-
Edgren, Anderson, & Michaels, 2007; Sittner, Schmaderer, dents’ competence is acquired as a result of time, practice,
Zimmerman, Hertzog, & George, 2009). The findings could and exposure to contextual variations (Ericsson, 2004).
Thus, improvement in knowledge (acquired and retained)
might be noted with repetitive BLS training with HPS dur-
Table 2 Difference in Basic Life Support Knowledge Acquisi- ing the semester and until graduation.
tion and Self-Efficacy during the Acquisition Phase of the The differences in results between the current and
Study, N ¼ 110 previous studies might also be explained by Jordanian
Basic Life Support
Knowledge
Acquisition Self-Efficacy Table 3 Difference in Knowledge Retention of Basic Life Sup-
Groups M t Value p M t Value p port during the Retention Phase, N ¼ 110

Experimental 9.1 1.6 .1 84.4 3.91 .001* Group Mean t Value p

(n ¼ 52) Experimental (n ¼ 52) 8.29 0.035 .97*
Control (n ¼ 58) 8.6 75.1 Control (n ¼ 58) 8.28
* Significant at a ¼ .05 (two-tailed). * Significant at a ¼ .05 (two-tailed).

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Effectiveness of Simulation with Nursing Students in Jordan e7

students’ and faculty members’ resistance to change and for evaluation of students’ knowledge and self-efficacy and
acceptance of new learning methodologies. Changing the the use of self-report, known for response bias, to assess
culture of teaching and learning is an effective way to students’ self-efficacy. Furthermore, debriefing was oral,
reduce environmental uncertainty. Creating a culture of students work was not recorded to allow students to view
acceptance of technology and familiarity with new ad- their mistakes, and the simulation labs were still under
vances is the responsibility of nurse educators when construction at the time of this study, which made it difficult
preparing future nurses. Furthermore, the use of a single to recreate the reality of the health care setting.
scenario may also have affected the result of knowledge
acquisition and knowledge retention. The result might have Implications
been different if we had used various scenarios, with each
scenario building on the previous one, so that the novice The study findings have implications for nursing education
students could gather new information, analyze it, and add and the use of nontraditional methods to prepare competent
to their previous knowledge base with each simulation future nurses in light of the challenges of the faculty shortage
experience. This is consistent with Benner’s continuum and the increasing number of nursing students. Findings of
from novice to expert (Benner, 1984). this study add to the existing evidence on the effectiveness of
Self-efficacy is an individual’s belief in his or her different BLS training methods on students’ knowledge
capabilities in performing certain tasks or activities acquisition, knowledge retention, and self-efficacy. Human
(Larew, Lessans, Spunt, Foster, & Covington, 2006). There patient simulators need to be considered by nursing educators
was a significant difference in self-efficacy between the two as one of the teaching strategies that would promote active
groups (HFS vs. traditional training method). This result is learning in a risk-free environment. These simulators allow
consistent with other studies (Bambini et al., 2009; Brown students to be active learners rather than simply to receive
& Chronister, 2008; Goldenberg et al., 2005; Smith & information passively, and the simulators also provide
Roehrs, 2009). Bandura (1977) stated that the self- equality for all student’s training. Educators should de-
efficacy of students could be determined by continuous in- termine the best educational practices when HFS is in-
teraction among cognitive, behavioral, and environmental tegrated into a nursing curriculum. The educators should
factors. The use of HFS allows for continuous integration choose simulation scenarios suitable to the students’ level
of cognitive knowledge, skills, and interaction with the sur- and determine both the students’ and the teacher’s role when
rounding environment. Thus, HFS could explain why stu- developing simulation as a teaching strategy. The benefits of
dents in the experimental group reported a significantly the use of simulation in nursing education and training of
higher self-efficacy perception score than did the control practice nurses should be highlighted to policy makers in
group. However, the finding regarding self-efficacy should order to build collaboration on this issue between educational
be taken cautiously for two reasons. First, the study partic- institution. Further research on the effectiveness of HFS in
ipants were junior nursing students who had had no previ- nursing education, using different samples and settings, is
ous contact with HFS or BLS. It was noted that challenging needed. Further research is also required to determine
novice students with complex patient care simulation re- whether a simulator’s benefits outweigh its costs and to
sulted in their feeling of being overwhelmed and anxious, assess different simulation-related outcomes.
which would affect their self-efficacy perception (Larew
et al., 2006). Second, students’ awareness of their previous Conclusion
assignment to groups could influence their decision when
rating their efficacy in performing BLS. Students in the ex- Our study adds to the evidence of the value of integrating
perimental group could have given answers that are consis- simulation into the traditional method in nursing education.
tent with their prevailing social views that they should be Our results demonstrate that the use of traditional training,
the best, and thus they would rate their confidence higher when teaching BLS to undergraduate nursing students, is as
than the control group members rated theirs. effective as HFS. The current nature of nurses’ work requires
graduates who are well trained to respond to service needs
Limitations and who are competent to work in complex care environ-
ments. Shifting toward the integration of technology into
In spite of the strength of the study design, a few limitations nursing education will minimize the serviceeeducation gap,
need to be acknowledged. The study was conducted with enhance quality of education, and protect patients’ safety.
baccalaureate students in their 2nd year, which limits the
generalizability of the findings. The power analysis indicated
a sample of at least 128 participants was necessary; however, References
the final number of participants was 110. This was because
Ackermann, A. D. (2009). Investigation of learning outcomes for the
the study was conducted during the summer semester, which acquisition and retention of CPR knowledge and skills learned with
usually has fewer enrolled students. Another limitation the use of high-fidelity simulation. Clinical Simulation in Nursing,
includes threats to internal validity, such as the short time 5(6), e213-e222. doi:10.1016/j.ecns.2009.05.002.

pp e1-e8  Clinical Simulation in Nursing  Volume Vol  Issue X

 Effectiveness of Simulation with Nursing Students in Jordan e8

American Heart Association. (2010). The 2010 American Heart Associa- Hamilton, R. (2005). Nurses’ knowledge and skill retention following
tion Guidelines for CPR and ECC. Retrieved December 1, 2010, from cardiopulmonary resuscitation training: A review of the literature. Journal
http://guidelines.ecc.org/2010-guidelines-for-cpr.html of Advanced Nursing, 51(3), 288-297. doi:10.1111/j.1365- 2648.2005.
Arnold, J. J., Johnson, L. M., Tucker, S. J., Malec, J. F., Henrickson, S. E., 03491.x.
& Dunn, W. F. (2009). Evaluation tools in simulation learning: Perfor- Henneman, E., & Cunningham, H. (2005). Using clinical simulation to
mance and self-efficacy in emergency response. Clinical Simulation in teach patient safety in an acute/critical care nursing course. Nurse
Nursing, 5(1), e35-e43. doi:10.1016/j.ecns.2008.10.003. Educator, 30, 172-177.
Bambini, D., Washburn, J., & Perkins, R. (2009). Outcomes of clinical Hoffmann, R., O’Donnell, J., & Kim, Y. (2007). The effects of human
simulation for novice nursing students: Communication, confidence, patient simulators on basic knowledge in critical care nursing with
clinical judgment. Nursing Education Perspectives, 30(2), 79-82. doi: undergraduate senior baccalaureate nursing students. Simulation in
10.1043/1536–5026-030.002.0079. Healthcare, 2(2), 110-114. doi:10.1097/SIH.0b013e318033abb5.
Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Institute of Medicine. (1999). To err is human: Building a safer health
Hall. system. Retrieved May 14, 2012, from http://www.iom.edu/Reports/
Bandura, A. (1986). Social foundation of thought and action: A social cog- 1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx
nitive theory. Englewood Cliffs, NJ: Prentice Hall. Jeffries, P., & Rizzolo, M. (2006). Designing and implementing models for
Benner, P. (1984). From novice to expert: Excellence and power in clinical the innovative use of simulation to teach nursing care of ill adults and
nursing practice. Menlo Park, CA: Addison-Wesley. children: A national, multi-site, multi-method study [summary report].
Bloom, B. (1956). Taxonomy of educational objectives, handbook I: The National League for Nursing. Retrieved May 15, 2012, from http://
cognitive domain. New York: David McKay. www.nln.org/research/LaerdalReport.pdf
Brown, D., & Chronister, C. (2008). The effect of simulation learning on Jeffries, P., Woolf, S., & Linde, B. (2003). Technology-based vs. tradi-
critical thinking and self-confidence when incorporated into an electro- tional instruction: A comparison of two methods for teaching the skill
cardiogram nursing course. Clinical Simulation in Nursing, 5(1), of performing a 12-lead ECG. Nursing Education Perspectives, 24(2),
e45-e52. doi:10.1016/j.ecns.2008.11.001. 70-74.
Bruce, S., Bridges, E., & Holcomb, J. (2003). Preparing to respond: Joint Kardong-Edgren, S., Anderson, M., & Michaels, J. (2007). Does simula-
Trauma Training Center and USAF Nursing Warskills Simulation tion fidelity improve student test scores? Clinical Simulation in Nursing,
Laboratory. Critical Care Nursing Clinics of North America, 15(2), 3(1), e21-e24. doi:10.1016/j.ecns.2009.05.035.
149-162. doi:10.1016/S0899-5885(02)00080-1. Kneebone, R. (2005). Evaluating clinical simulations for learning proce-
Burns, H. K., O’Donnell, J., & Artman, J. (2010). High-fidelity simulation dural skills: A theory-based approach. Academic Medicine, 80(6),
in teaching problem solving to 1st-year nursing students: A novel use of 549-553.
the nursing process. Clinical Simulation in Nursing, 6(3), e87-e95. doi: Larew, C., Lessans, S., Spunt, D., Foster, D., & Covington, B. (2006). Innova-
10.1016/j.ecns.2009.07.005. tions in clinical simulation: Application of Benner’s theory in an interactive
Cohen, S. R., Cragin, L., Wong, B., & Walker, D. M. (2012). Self-efficacy patient care simulation. Nursing Education Perspectives, 27(1), 16-21.
change with low-tech, high-fidelity obstetric simulation training for mid- Oberleitner, M. G., Broussard, A. B., & Bourque, J. (2011). An unintended
wives and nurses in Mexico. Clinical Simulation in Nursing, 8(1), consequence of simulation: A case report. Clinical Simulation in Nurs-
e15-e24. doi:10.1016/j.ecns.2010.05.004. ing, 7(2), e35-e40. doi:10.1016/j.ecns.2010.03.074.
Comer, S. K. (2005). Patient care simulations: Role playing to enhance Oermann, M. H., Kardong-Edgren, S., Odom-Maryon, T., Ha, Y.,
clinical understanding. Nursing Education Perspectives, 26(6), 357- McColgan, J. K., Hurd, D., et al. (2010). HeartCodeÔ BLS with voice
361. doi:10.1043/1536-5026(2005)026, [0357:PCSRPT]2.0.CO;2. assisted manikin for teaching nursing students: Preliminary results.
Decker, S., Sportsman, S., Puetz, L., & Billings, L. (2008). The evolution of Nursing Education Perspectives, 31(5), 303-308.
simulation and its contribution to competency. Journal of Continuing Ed- Parr, M., & Sweeney, N. (2006). Use of human patient simulation in an un-
ucation in Nursing, 39(2), 74-80. doi:10.3928/00220124-20080201-06. dergraduate critical care course. Critical Care Nursing Quarterly, 29(3),
Dobbs, C., Sweitzer, V., & Jeffries, P. (2006). Testing simulation design 188-198.
features using an insulin management simulation in nursing education. Ravert, P. (2002). An integrative review of computer-based simulation in
Clinical Simulation in Nursing, 2(1), e17-e22. doi:10.1016/j.ecns. the education process. Computers, Informatics, Nursing: CIN, 20(5),
2009.05.012. 203-208.
Ericsson, K. A. (2004). Deliberate practice and the acquisition and Sittner, B. J., Schmaderer, M., Zimmerman, L., Hertzog, M., & George, B.
maintenance of expert performance in medicine and related domains. (2009). Rapid response team simulated training for enhancing patient
Academic Medicine, 79(10), S70-S81. safety (STEPS). Clinical Simulation in Nursing, 5(3), e119-e127. doi:
Flinders University (2010). School of nursing and midwifery, BLS test. 10.1016/j.ecns.2009.02.007.
Retrieved May 22, 2010, from http://flinders.edu.au/nursing/home.cfm Smith, S. J., & Roehrs, C. J. (2009). High-fidelity simulation: Factors cor-
Goldenberg, D., Andrusyszyn, M., & Iwasiw, C. (2005). The effect of related with nursing student satisfaction and self-confidence. Nursing
classroom simulation on nursing students’ self-efficacy related to health Education Perspectives, 30(2), 74-78. doi:10.1043/1536-5026-
teaching. Journal of Nursing Education, 44(7), 310-314. 030.002.0074.

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