key: cord-1006359-8twf5gts authors: Yang, Sun‐Yi title: Effectiveness of neonatal emergency nursing education through simulation training: Flipped learning based on Tanner’s Clinical Judgement Model date: 2021-01-11 journal: Nurs Open DOI: 10.1002/nop2.748 sha: 9c3ad3161d6a1749512bc2e10ce09f3da32c12d5 doc_id: 1006359 cord_uid: 8twf5gts AIM: To examine the effects of neonatal simulation‐based practice by applying flipped learning based on Tanner's clinical judgement model to pre‐simulation briefing for nursing students. DESIGN: A quasi‐experimental non‐equivalent control group pre‐ and postintervention design. METHODS: Using Tanner's clinical judgment model, flipped learning was developed and applied to the pre‐simulation briefing curriculum prior to the neonatal nursing simulation exercise. Flipped learning was compared with a general pre‐simulation briefing with 65 South Korean students. From September 7, 2019, to October 25, 2019. RESULTS: The experimental group's critical thinking, self‐confidence and clinical judgement ability increased, but knowledge, satisfaction and anxiety did not differ from that of the control group. Pre‐simulation briefing design focuses on improving students’ environmental comfort and reducing anxiety rather than developing complex reasoning skills and clinical judgement abilities. Applying flipped learning based on Tanner's clinical judgement model to pre‐simulation briefing increased critical thinking, self‐confidence and clinical judgement ability. Clinical judgement is an essential component of nursing practice in medical institutions (McCartney, 2017) . Nurses' clinical judgement can have profound effects on patient outcomes, so careful thinking and decision-making are needed (Manetti, 2018) . However, studies mention that nursing students are not developing the complex reasoning skills and clinical judgement abilities to function effectively on graduation because of knowledge deficiency and lack of opportunity to practice in the ever-changing healthcare environment (Graan et al., 2016) . Knowledge improvement and repetitive practice can assist to transform from a novice to an expert with more analytic, inductive and critical thinking contextual patterns (Pouralizadeh et al., 2017) . In clinical practice, due to high-risk newborns' safety and infection control, many hospitals do not allow nursing students to practice | 1315 YANG in neonatal intensive care units. Therefore, even if clinical practice is allowed, the practice is observation only . Nursing students with experience in the neonatal intensive care unit (Choi, Kim, et al., 2015) reported that they were surprised and felt fear as they saw the treatment of high-risk newborns and various therapeutic devices (Choi, Kim, et al., 2015) . The greater the exposure to emergencies, the better the proficiency to resolve the situation . Therefore, nursing students need training programmes to cope effectively and promptly in emergency situations frequently encountered in the neonatal intensive care unit, which may help nursing students transition to working there after graduation (Foster et al., 2016) . To overcome these limitations in the clinical practicum, flipped learning and nursing simulation training methods were used (Peisachovich, 2016) . The flipped learning with simulation training methods approach offers students opportunities for application of clinical judgement, attaining engagement knowledge and professional experience (Park & Ha, 2016; Shin et al., 2015) . Flipped learning methodology provides increased class time for meaningful experiential education and active learning exercises with students' ownership of their learning processes and enables students to share their own views and perspectives and link the content to their personal and professional experiences. The methodology provides opportunities to apply clinical thinking and judgement and develop the ability to "think like a nurse" (Peisachovich, 2016) . According to systematic review, the pre-simulation briefing may include additional simulation preparatory activities such as independent reading assignments, video-and web-based modules, assessment rubrics or laboratory practices (Tyerman et al., 2019) . The pre-simulation briefing process is critical to ensure successful simulation experiences for students, because students are prepared and motivated by pre-scenario information through pre-simulation briefing (Tyerman et al., 2019) . However, there were few studies that used a pre-simulation briefing method, which included a theorybased direct way to enhance clinical judgement ability. A possible solution to this problem was a flipped learning approach to the presimulation briefing process. Flipped learning is a pedagogical approach whereby students study the learning material or video clips prepared by the professors before class time, allowing students to discuss, role-play and problem-solve with classmates in class (Simko et al., 2019) . Previous studies have demonstrated that flipped learning was significantly effective for academic achievement, teamwork, therapeutic communication, problem-solving and information management skills when applied to clinical practice and nursing courses (Lee et al., 2017; Peisachovich et al., 2016) . To formulate education strategies that develop integrated clinical reasoning skills in nursing students, proposals have been made to nursing educators and researchers to arrange flipped learning classes that apply clinical judgement skills . There are some rare studies on the development and assessment of pre-simulation briefing methods globally (Tyerman et al., 2016) , and there are limited studies on pre-simulation briefing methods that apply flipped learning and are grounded in a theoretical framework. Tanner's (2006) clinical judgement model consists of four stages: a noticing stage when a given clinical situation is perceived; an interpreting stage to develop an adequate understanding of the situation; a responding stage to determine the appropriate actions and responses to the situation and to provide appropriate intervention; and a reflecting stage to focus on the patient's condition and response, to analyse the response and to consider the appropriate measures for improved clinical judgement in the future. Several previous studies have used Tanner's clinical judgement model as a conceptual framework for a simulation programme (Ashcraft et al., 2013; Dillard et al., 2009; Jeong & Yun, 2017 The application of Tanner's (2006) clinical judgement model to the pre-simulation briefing as a theoretical basis is expected to provide an opportunity to learn and to improve the systematic thinking process step by step, thereby improving clinical judgement ability. In this study, a preliminary simulation briefing using flipped learning methodology based on Tanner's clinical judgement model is applied and its effects are investigated. This study aimed to examine the effects of neonatal simulationbased practice by applying flipped learning based on Tanner's clinical judgment model to the pre-simulation briefing for nursing students. To this end, six hypotheses were established. Hypothesis 3 The experimental group will have greater confidence in nursing performance than the control group. Hypothesis 4 The experimental group will have greater simulation practice satisfaction than the control group. Hypothesis 5 The experimental group will have greater clinical judgement than the control group. Hypothesis 6 The experimental group will have lower anxiety than the control group. A quasi-experiment using non-equivalent control group pre-and postintervention design was employed to identify the efficacy of neonatal nursing simulation training in pre-simulation briefings applied Tanner's clinical judgement model to flipped learning ( Figure 1 ). This study was conducted at the Cheju Halla University after obtaining approval from the department head, to whom the study's purpose was explained. Senior nursing students were sampled; the recommended sample size was 21 students per group, according to a significance level of.05, a test power of.80 and a large effect size of.80, with 1 degree of freedom, using the one-tailed independent t test. The sample size was calculated using G*power 3.1.9 (Faul et al., 2007) . The final analysis included 35 (100.0%) participants in the experimental group and 30 (85.7%) in the control group. Five participants were excluded from the control group because three failed to participate in the simulation practice and two did not complete the questionnaire. The simulation programme for improving neonatal nursing simulation training using flipped learning for clinical judgement was developed using the six-step approach to curriculum development (Thomas et al., 2015) . In the first step (problem identification and general needs assessment), problems in neonatal nursing practice were analysed via a needs assessment, which was conducted by senior nursing students, Registered Nurses from the nursery and neonatal intensive care unit and paediatric nursing faculty members. In addition, the Korean Society of Nursing Science (2017) learning objectives for the Bachelor of Science in Nursing were analysed. The results indicated limitations in acquiring paediatric nursing skills through clinical practice due to difficulties in securing practice opportunities in neonatal intensive care units. The sub-learning objectives of the paediatric nursing curriculum included performing resuscitation care for high-risk neonates (Korean Society of Nursing Science, 2017). In the second step, a needs assessment was conducted with senior nursing students who completed their clinical practicum, which confirmed that the students desired the opportunity to experience high-risk neonatal care in simulation classes. In the third step (goals and objectives), course outcomes were determined based on the nursing departments' learning outcomes and core competencies. Learning outcomes for each week were determined based on the learning outcomes of nursing job analysis, national nursing board examinations and paediatric nursing courses. Assessment details, methods and proportions were organized based on the learning outcomes of courses. The topic selected for the simulation scenario in the fourth step (educational strategies) involved the most frequent situations requiring precise initial newborn assessment and care or quick judgement and emergency treatment in the neonatal intensive care units. Authentic clinical data were collected from nurses and physicians from the neonatal intensive care units of clinical institutions, and YANG descriptions of clinical situations were considered when writing the scenario modules and flow scenario. For scenario re-enactment, a simulation scenario based on a high-technology manikin-based simulator and standardized participants as the high-risk baby's mother and paediatrician were used. As a pre-simulation briefing strategy, the flipped learning method was used. The protocols for APGAR scoring, gavage-tube feeding, Neonatal Escalation Situation-Background-Assessment-Recommendation (Raymond & Harrison, 2014) and neonatal resuscitation algorism (Wyckoff et al., 2015) were uploaded to an online education platform before the course, so students could learn them in advance. Moreover, a simulation briefing form based on Tanner's clinical judgement model was evaluated by six experts: a Registered Nurse at the neonatal intensive care unit, three nursing professors, one paediatrician and one professor of education. Only those with I-CVI (item-content validity index) scores higher than .80 were used for the experimental group. In the fifth step (simulation class implementation), each group, comprising of four or five people, performed neonatal resuscitation. During the course orientation, explanations were provided through the course outline and learning outcomes, assessment criteria and methods, distribution of flipped learning materials, course schedules and assignments. Experimental participants had to write a pre-simulation briefing form based on Tanner's clinical judgement model (Appendix S1). In the sixth stage (evaluation and feedback), the Korean version of Lasater's Clinical Judgment in Simulation Rubric was modified for resuscitation care for high-risk neonates by the principle investigator. It was evaluated by a Registered Nurse at the neonatal intensive care unit, three nursing professors, one paediatrician and one professor of education. Discrepancies between two evaluators were identified, evaluators were retrained through pilot education and thereafter the rubric was reconsidered. The final intraclass correlation coefficient was high (r = .83). A content validity test (Item-Content Validity Index) for the course content and method was conducted by a Registered Nurse at the neonatal intensive care unit, three nursing professors, one paediatrician and one professor of education. Only content with an I-CVI of 0.8 or higher was included in the final programme. The scenario was about a premature baby born at 34 weeks due to pre-eclampsia. The baby had apnea and muscle weakness, so students had to recognize the need for neonatal resuscitation. The scenario was performed by using a high-fidelity simulator (Simbaby) to show breathing, cyanosis, oxygen saturation, heart rate and respiratory rate on the patient monitor. Equipment was prepared to create an environment as similar as possible to the hospital NICU. The scenario was implemented by one researcher and one operator driving the simulator and patient monitor from the operator room in the NICU simulation laboratory. The programme ran for four weeks. A week before the first class started, the intervention group received the online flipped learning materials and short lecture videos (50 min The pre-survey of the control and experimental groups was conducted to measure their general characteristics, knowledge of neonatal emergency care, critical thinking and confidence in performing nursing, satisfaction with simulation practice, clinical judgement and degree of anxiety before the commencement of the intervention. The postsurvey measured the dependent variables after the programme. Neonatal emergency care knowledge Following core knowledge areas of the American Heart Association's Neonatal Resuscitation Program (Hazinski et al., 2015) , this study used Yoo's (2013) measure of knowledge tools for neonatal emergency situations. The tools to assess knowledge related to neonatal emergency care comprised 30 items. For each item, a score of 0 was assigned if the answer was incorrect or unknown and a score of 1 when correct. A higher score indicated a higher level of knowledge. A preceding study (Jeong & Choi, 2017) used the Kuder-Richardson formula 20 to assess this measure's reliability, which was 0.65; however, in this study, it was 0.71, indicating high reliability. Example items from the Neonatal Emergency Care Knowledge Tool: 1. When aspirating a newborn, first aspirate the nose and then the mouth. 2. When aspirating a newborn, the pressure of the aspirator is 120-140 mmHg. 3. If the baby's heart rate is lower than 60 bpm, even after 30 s of positive pressure ventilation, chest compressions are performed. This study used Yoon's (2004) Critical Thinking Disposition Measurement, with standardization based on the verification of its reliability and validity. It comprises 27 items concerning seven areas: intellectual enthusiasm/curiosity, prudence, confidence, systematicity, intellectual fairness, healthy skepticism and objectivity. The responses are provided on a five-point Likert scale ranging from "not at all" (1 point) to "very much so" (5 points). Higher scores indicate a higher critical thinking capacity. Cronbach's α was 0.84 in a preceding study (Yoon, 2004) and 0.93 in the present study. Example items from the Yoon's (2004) Critical Thinking Disposition Measurement: 1. Judgement is withheld and contemplated until valid, and sufficient evidence is obtained. 2. When dealing with complex problems, I judge and deal with the problems according to the criteria I set. 3. When you disagree with someone else's opinion, explain why. Following the core knowledge areas of the American Heart Association's NRPTM (Hazinski et al., 2015) , this study used Yoo's (2013) measure of confidence based on the verification of its reliability/validity to standardize the nursing tools for neonatal emergency situations. The measure of Confidence in Performing Nursing Tool related to neonatal emergency care and included 15 questions. Each question was answered on a five-point Likert scale ranging from "not at all" (1 point) to "very much so" (5 points). Higher scores indicated higher confidence in performing nursing. Cronbach's α was 0.96 in a previous study (Yoo, 2013) and for this study, it was 0.83. Example items from the Confidence in Performing Nursing: 1. The newborn's APGAR score can be calculated. 2. The newborn can be suitably oxygenated with a self-inflating bag and mask. 3. After intubation, the ET tube can be fixed in the correct position. (1 point) to "very much so" (5 points). Higher scores indicate higher satisfaction with the simulation exercise. Cronbach's α was 0.78 in a preceding study (Yoou & Kwon, 2015) and 0.82 in this study. 3. Reflecting on and discussing the simulation enhanced my learning. Lasater's (2007) Cronbach's α was 0.88 in both the original (Lasater, 2007) and translation studies . The clinical judgement rubric tool can be used to observe video footage of nursing students' simulations and debriefings. In this study, Cronbach's α was 0.86 and the intraclass correlation was 0.83. This study used the State-Trait Anxiety Inventory developed by Spielberger (1972) and translated into Korean by Kim and Shin (1978) . This tool is designed to measure the degree of anxiety, with responses rated on a four-point Likert scale ranging from "not at all" (1) to "very much so" (4). A score below 30 indicates low or no anxiety and 31 or above indicates medium to high levels of anxiety. In a preceding study (Kim & Shin, 1978) , Cronbach's α was 0.93 and in this study, it was 0.94. The collected data were analysed using SPSS 19.0, and parametric methods were used as the data were normally distributed. Homogeneity tests on the general characteristics and dependent variables of groups were conducted using the chi-square test, Fisher's exact test and independent t test. Independent t tests for the pre-post-dependent variables of the two groups were also performed. Critical thinking, which showed a significant difference between the two groups in the homogeneity test, was analysed using Kolmogorov-Smirnov test, Fisher's exact test, chi-square test and independent two-sample t test. The average differences between the pre-and postintervention scores of the two groups were analysed using repeated-measures analyses of covariance. This study was reviewed and approved by the institutional review board of Chungwoon University (IRB # 201906-001) before the start of the research. The participants were informed that their privacy and confidentiality were absolutely guaranteed and that they could leave the study at any time to no disadvantage. Further, the participants were informed that the survey data were used for research purposes only. No significant differences were found between groups related to sex (χ 2 = 0.13, p = .205) or academic performance (χ 2 = 4.79, p = .188), verifying the homogeneity of variance between the groups (Table 1 ). The homogeneity of the pre-intervention dependent variables between the two groups was tested. Results showed that there were no significant differences between the groups in knowledge related to neonatal emergency care (t = 0.61, p = .539), confidence in nursing practice (t = 0.69, p = .460), satisfaction with simulation practice (t = 0.58, p = .563), clinical judgment (t = 0.63, p = .169) and anxiety level (t = −0.82, p = .410). Thus, the results indicated that the two groups were largely homogeneous. However, a significant difference was found in critical thinking (t = −2.20, p = .031) between the groups, indicating insufficient evidence of homogeneity of variance (Table 1) . ANCOVA using the prior critical thinking score as a covariate revealed statistically significant mean differences (F = 2.28, p = .026) between the two groups, respectively. Thus, hypothesis 2 was supported. ANCOVA using the prior score of learners' satisfactions as a covariate revealed no significant mean differences (F = 0.94, p = .352) between the two groups. Thus, hypothesis 4 was rejected. Hypothesis 5. The clinical judgement ability score of the experimental group increased from pre-intervention (20.12 SD 5.52) to postintervention (27.51 SD 3.98), while that of the control group decreased from pre-intervention (19.86 SD 3.65) to postintervention (23.81 SD 3.12). ANCOVA using the prior clinical judgement ability score as a covariate revealed statistically significant mean differences (F = 6.76, p < .001) between the two groups. Thus, hypothesis 5 was supported. Hypothesis 6. The anxiety of the experimental group decreased from pre-intervention (45.42 SD 7.45) to postintervention (43.97 SD 8.65) and that of the control group decreased from pre-intervention (43.97 SD 8.65) to postintervention (42.19 SD 7.93). ANCOVA using the prior anxiety score as a covariate revealed no significant mean differences (F = 0.04, p = .572) between the two groups. Thus, hypothesis 6 was rejected (Table 2) . Additionally, editing the video not exceeding 10-15 min is recommended, for optimum concentration (Choi, Kim, et al., 2015) . A study by Danker (2015) also mentioned that online video lecture should be relatively short, no longer than 20 min, to maintain students' attention; the online training video in this study lasted 90 min. Students had too much content to focus on and learn, which was probably a primary determinant in the apparent failure in increasing knowledge levels. Therefore, future research needs to reduce the learning time in online training materials. Teachers should strengthen their role as supporters and facilitators in encouraging learners to learn in online and offline environments. In addition, quizzes and oral tests were provided to both groups as pre-simulation briefing activities in this study may have indicated no knowledge gap between the two groups. This study showed that critical thinking skills increased in the experimental group as compared with the control group. A previous study (Sharoff, 2015) also enhanced critical thinking skills after providing pre-simulation briefing materials. In research on the development of simulation scenarios and effectiveness verification of emergency care cases (Cerra et al., 2019) , education and experience were highlighted as playing a major role in enhancing critical thinking. In this study, nursing students experienced neonatal emergency care through simulation, which was an unusual opportunity. Additionally, nursing students received neonatal care and resuscitation education using online video footage TA B L E 2 Comparison of Dependent Variables between Groups at Postintervention (N = 65) through the flipped learning method in the pre-simulation briefing, which appeared to improve critical thinking. Evidence indicated that nurses' high critical thinking skills translate to better decision-making in emergencies and lower patient mortality rates (Chau et al., 2015; Tumapang, 2018) . The experimental intervention was effective in increasing nursing confidence in the experiment group relative to the control group. In a previous study, when pre-simulation briefing based on Tanner's clinical judgement model was provided instead of the general pre-simulation briefing, confidence in nursing performance increased (Tyerman et al., 2016) . In another previous study, where structured pre-simulation briefing was provided, nursing students' self-confidence increased more after general pre-simulation briefing (Kim et al., 2017 (Kim et al., , 2019 . to do. Thus, providing more specific and detailed orientation and information will make students feel adequately prepared and more confident for problem-solving and clinical decision-making (Kim et al., 2019) . Moreover, flipped learning using online materials in a clinical practice showed greater improvement of nursing confidence than traditional learning (Lee & Park, 2018) . This suggests that providing structured and written pre-simulation briefing materials prior to the simulation enabled learners to improve their ability to interpret and analyse scenarios independently and increased their confidence in nursing. Nevertheless, there is a lack of evidence on which the pre-simulation briefing method is more effective and preferred. Therefore, further research will be needed to compare the effectiveness of the validated pre-simulation briefing methods. The experimental group did not have significantly higher levels of satisfaction with simulation practice than the control group. On the other hand, in a previous study, when pre-simulation briefing based on Tanner's clinical judgement model was provided instead of the general pre-simulation briefing, satisfaction with practice did increase relative to the provision of normal pre-simulation briefing (Tyerman et al., 2016) . In addition, another previous study (Kim et al., 2017) showed that students who received multiple stepbased pre-simulation briefings were more satisfied than those who received single or double pre-simulation briefing activities. In this study, there was no difference in satisfaction with simulation practice between the experimental and control groups, probably because the professor provided multiple pre-simulation activities and acted as a collaborator and facilitator, thus encouraging learning activities in both groups. The experimental group had significantly higher levels of clinical judgement skills than the control group. In previous studies, when a theory-based structured pre-simulation briefing was provided instead of the normal pre-simulation briefing, clinical judgement increased, supporting this study's findings (Page-Cutrara & Turk, 2017; Sharoff, 2015) . In this study, an opportunity was given to apply the components of Tanner's clinical judgement model on the cognitive thought process of the pre-simulation briefing, which played a key role in enhancing clinical judgement. In particular, the results of clinical judgment in this study were derived through observation by two experts, which is particularly significant as it provided more validity than measurement based solely on self-report. The experimental group did not have significantly lower anxiety levels than the control group. In this study, the anxiety levels of both groups fell within the mid-range on average in preand postintervention, indicating that systematizing the cognitive thinking process did not lower anxiety levels. On the other hand, according to the previous study (Sharoff, 2015) , receiving the pre-briefing preparatory material had significantly decreased anxiety levels. The study mentioned that cognitive demands and overload increased anxiety (Hepsomali et al., 2019) . In this study, the intervention group received too much content by the online training video that lasted 90 min, which may be a major factor in the failure to decrease anxiety levels. In addition, offline group discussion, which is a learner-centred method, was not comfortable for the eastern nursing students, who were culturally more conservative in sharing personal opinions than western students (Iyer, 2015) . Felicity (2018) mentioned that the professor had to encourage students to rely on themselves during the learning process. However, the study showed that faculties did not provide enough encouragement and feedback to students. Future research should explore methods to lower anxiety during nursing students' simulation practice by addressing the above problems and applying the proposed approach, such as by providing a virtual reality game instead of lecture-based materials. The limitations of this study are as follows. First, the data were collected from students of a single college; therefore, the results of this study should be generalized with caution. In future studies, it is necessary to select students from various schools and countries and conduct repeated studies. Second, this programme was developed and operated in a mixed form involving face-to-face and non-faceto-face classes. It seems necessary to develop education through non-face-to-face instructions due to the coronavirus pandemic. It is necessary to develop a nursing programme that incorporates non-face-to-face learning and to verify its effectiveness. Third, in this study, video lectures were provided to the intervention group during the week before simulation, while only lecture notes were provided to the control group. In this process, although the intervention group was not contacted directly, voice contact was provided one week earlier than for the control group. This could be interpreted as an additional contact opportunity and longer contact duration; hence, careful attention was necessary in the study design and application. In future studies, to determine whether the results are due to a difference in contact period or a difference in method, it is necessary to provide a lecture video and discussion to the intervention group and to provide face-to-face lectures to the control group during the same period. In addition, it should be determined whether there are differences in results between the online video materials provided one week prior and during the first week of the simulation class. When designing a study, it is necessary to block factors other than the educational method from affecting exogenous variables through strict control. The development and application of scenarios based on the application of simple clinical skills are insufficient in preparing students for various clinical situations requiring clinical judgment and inference. Using Tanner's clinical judgement model, flipped learning was developed and applied to the pre-simulation briefing curriculum prior to the neonatal nursing simulation exercise and critical thinking, self-confidence and clinical judgement ability were significantly increased in implementation. The experience gained through the simulation training for neonatal emergency nursing-which is difficult to experience through clinical practice-has helped to promote critical thinking and build confidence. In addition, it has been reported that clinical judgement increased when a theory-based structured pre-simulation briefing was provided, instead of the normal pre-simulation briefing (Page-Cutrara & Turk, 2017; Sharoff, 2015) . In this study, the components of Tanner's clinical judgement model were applied to pre-simulation briefing, which played an important role in enhancing clinical judgement ability. Due to the coronavirus disease (COVID-19) pandemic, reinforcement of non-face-to-face online education is being discussed as an educational alternative; thus, future studies should verify that online pre-simulation briefings and online simulation scenario discussions are part of clinical practice and are alternatives to a face-to-face simulation class. I would like to extend my thanks to Prof. Yun-Hee Oh and the students who enthusiastically participated in the classes. The author reports no conflict of interest. This study was conducted at Chungwoon University after obtaining approval (IRB # 201906-001). The data that support the findings of this study are available from the corresponding author upon reasonable request. 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Catholic University, Seoul. In nursing Study about the satisfaction with simulation practice course experience on ACLS of paramedic students Additional supporting information may be found online in the Supporting Information section. How to cite this article: Yang S-Y. Effectiveness of neonatal emergency nursing education through simulation training: Flipped learning based on Tanner's Clinical Judgement Model