Comparing the Effects of Simulation-Based and Traditional Teaching Methods on the Critical Thinking Abilities and Self-Confidence of Nursing Students

Abstract

Background: 

Critical thinking and self-confidence are imperative to success in clinical practice. Educators should use teaching strategies that will help students enhance their critical thinking and self-confidence in complex content such as electrocardiogram interpretation. Therefore, teaching electrocardiogram interpretation to students is important for nurse educators.

Purpose: 

This study compares the effect of simulation-based and traditional teaching methods on the critical thinking and self-confidence of students during electrocardiogram interpretation sessions.

Methods: 

Thirty undergraduate nursing students volunteered to participate in this study. The participants were divided into intervention and control groups, which were taught respectively using the simulation-based and traditional teaching programs. All of the participants were asked to complete the study instrumentpretest and posttest to measure their critical thinking and self-confidence.

Results: 

Improvement was observed in the control and experimental groups with respect to critical thinking and self-confidence, as evidenced by the results of the paired samples t test and the Wilcoxon signed-rank test (p < .05). However, the independent t test and Mann–Whitney U test indicate that the difference between the two groups was not significant (p > .05).

Conclusions/Implications for Practice: 

This study evaluated an innovative simulation-based teaching method for nurses. No significant differences in outcomes were identified between the simulator-based and traditional teaching methods, indicating that well-implemented educational programs that use either teaching method effectively promote critical thinking and self-confidence in nursing students. Nurse educators are encouraged to design educational plans with clear objectives to improve the critical thinking and self-confidence of their students. Future research should compare the effects of several teaching sessions using each method in a larger sample.

Introduction

In the late 20th century, simulation-based clinical skill training employed optimized clinical learning activities in nursing education and promoted critical thinking to move students out of their knowledge comfort zone (^{Linthacum, 2011}). Critical thinking and self-confidence are imperative to success in clinical practice. Simulation is intended to help nursing students learn and become more self-confident in critical thinking (^{Kaddoura, 2010}). Moreover, simulation has been considered an important part of nursing program curricula for decades, allowing students to practice specific procedures in a controlled environment before performing these procedures on actual patients (^{Hicks, Coke, & Li, 2009}). Simulation is used “to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner” (^{Gaba, 2007}).

Nurse educators are required to implement teaching strategies that promote the critical thinking skills of learners, because many important institutions (e.g., the National League for Nursing and the American Association of Colleges of Nurses) mandate these skills for baccalaureate nursing education and because critical thinking and problem-solving skills are required in professional nursing practice (^{Vacek, 2009}). In addition, critical thinking skills help students solve problems and make sound clinical judgments in the healthcare environment (^{Smith-Blair & Neighbors, 2000}). Critical thinking has many definitions. ^{Halpern (1999)} proposed that critical thinking refers to “the use of cognitive skills or strategies that increase the probability of a desirable outcome.” Studies assessing critical thinking training have yielded inconclusive findings. One study by ^{Sullivan-Mann, Perron, and Fellner (2009)} found that simulation-based teaching significantly increased critical thinking abilities, whereas another found that this mode of teaching did not significantly increase critical thinking abilities in nursing students (^{Shinnick & Woo, 2013}). Nonetheless, simulations appear to promote self-confidence in students (^{Lubbers & Rossman, 2016}). Confidence in nursing is a critical attribute of professional caring, which fosters mutual trust, respect, and truthful communications between nurses and their patients (^{Roach, 2002}). High-fidelity simulation has been suggested as a new and supplemental teaching–learning strategy that improves the transfer of students’ self-confidence and competence into the clinical environment (^{Bambini, Washburn, & Perkins, 2009}); however, in one study, confidence among students who participated in simulations did not significantly differ from that among students who received traditional instruction (^{Brannan, White, & Bezanson, 2008}). Finally, human patient simulators may increase the critical thinking abilities of students but not their self-confidence (^{Soucy, 2011}).

Few studies have examined the effectiveness of simulation with respect to electrocardiogram (ECG) learning. ECG assists in the diagnosis, treatment, and monitoring of arrhythmias, coronary syndromes, and cardiac revascularization (^{Lessard et al., 2009}) and is considered the gold standard in the evaluation of rhythm. Nurse educators commonly experience difficulty in teaching ECG interpretation. Moreover, only a few studies have compared ECG teaching strategies. Direct instruction, lectures, self-directed learning, and textbooks are considered traditional methods for teaching ECG interpretation. Advanced teaching methods include PC-based ECG software packages, 12-lead ECG signal generators, and advanced training mannequins (patient simulators). The data presented by ^{Mahler, Wolcott, Swoboda, Wang, and Arnold (2011)} found that using workshop and lecture-based formats is more effective than self-directed learning. Moreover, using simulation in ECG courses has been shown to improve self-confidence and critical thinking ability in students (^{Brown & Chronister, 2009}).

In summary, although the available evidence suggests that simulation-based teaching is important, the effect of simulation on the critical thinking skills and self-confidence of students remains unclear. Additional research is necessary to compare the results of simulation technology and traditional teaching methods (^{Medley & Horne, 2005}).

Many universities in Saudi Arabia, including King Saud University (KSU) and Princess Nourah bint Abdulrahman University, have expressed interest in simulation and have integrated simulation technology in their curriculum to overcome clinical education barriers (e.g., lack of clinical sites or preceptors). Nonetheless, few studies have evaluated simulation, which are required by nurse educators aiming to optimally promote the critical thinking ability and self-confidence of their students. Accordingly, this study compared the effect of simulation-based and traditional teaching methods on the critical thinking ability and self-confidence of students.

Methods

Design

A pretest–posttest design was used to compare the effects on critical thinking ability and self-confidence in undergraduate nursing students of an ECG interpretation course that was taught using either simulation-based or traditional teaching methods. The experimental and control groups received simulation- and lecture-based teaching, respectively.

Sample and Setting

Participants were a convenience sample of 30 eighth-level undergraduate nursing students who were recruited from the College of Nursing. Inclusion criteria were as follows: completed the fundamentals of nursing and medical–surgical nursing course, had no previous experience with ECG courses, and voluntarily provided written consent. Before implementation, the chief educator, who is certified in cardiovascular nursing, debriefed and trained the educators on the data collection procedure. The chief educator gave lecture-based training, and three educators conducted the ECG interpretation training using simulation under the supervision of the chief educator to prevent a confounding educator effect. Lectures were considered to constitute “traditional teaching.” All study sessions were conducted at the Laboratory for Nursing Simulation in the College of Nursing, KSU, and simulation used a high-fidelity patient simulator.

Data Collection

After ethical approval from the College of Nursing, the researchers recruited the students on the appointed day in March 2016. Participants were assigned randomly to either the experimental or control group. The investigator explained the purpose of the study to each participant before commencing the study. All participants voluntarily provided written consent. Participants received assurance that participation was voluntary, that their results were confidential, and that their scores and participation would not affect their course grade. Participants completed an ECG pretest 30 minutes before course commencement. Both participant groups attended a 2-hour PowerPoint presentation (on the core concepts of ECG) to create a common ECG knowledge base. Control group participants continued a session of lecture lasting 60 minutes (on basic arrhythmia interpretation). During this 60-minute period, students were given an opportunity for questions and discussion with the educator. Experimental group participants subsequently completed a session of simulation training (on basic arrhythmia interpretation) lasting 60 minutes and a debriefing session of 20 minutes. The student–investigator ratio was 5:1. In the following 30 minutes, both groups completed a posttest that examined critical thinking ability and self-confidence in ECG interpretation.

Educational Activities

Lecture content

The lecture introduced the core concepts of ECG, addressing the interpretation of basic arrhythmias. A purposefully selected panel of three faculty members, who were experts in clinical and academic nursing, reviewed the lecture content.

Simulation scenario

Six scenarios were simulated. The panel of three expert faculty members had experience in the content of each scenario and had reviewed each scenario to ensure content validity and course content fidelity. The simulation session included an ECG demonstration and illustrations. A high-fidelity simulator was used (a computerized full-body manikin that simulates human functions and includes a cardiac monitor that displays hemodynamic waveforms, ECG rhythms, and vital signs).

Instruments

Critical thinking

The authors developed a 15-item multiple-choice questionnaire to measure the critical thinking ability of participants regarding ECG interpretation. A well-constructed multiple-choice questionnaire can test the cognitive skills of students (^{Khan & Aljarallah, 2011}). Moreover, multiple-choice test items can be highly discriminating and measure the ability of a respondent to think critically when written properly (^{Morrison & Walsh Free, 2001}). Possible scores ranged from 0 to 15, with higher scores indicating greater critical thinking ability in ECG interpretation. Each item included one correct response and three distracter responses. Participants received ECG strips for interpretation. The multiple-choice questions used in this study were drawn from a variety of sources (e.g., relevant literature, textbooks, the Internet). The test items were reviewed by a panel of experts, which included three nursing faculty members, who currently teach critical care nursing at KSU and have clinical and academic experience of more than 15 years each, and one cardiologist with experience in the critical care units at King Fahad Medical City. The panel approved the face validity of items for measuring the critical thinking ability of participants regarding ECG. The panel rated item relevance, and the item-level content validity indices ranged from 0.75 to 1.00, whereas the scale-level content validity index, using the averaging approach, was 0.95.

Self-confidence

Self-confidence was measured using the five-item C-Scale; the concurrent validity was supported by the administration of two additional instruments of confidence that had moderate to high correlations with the C-Scale (^{Grundy, 1993}). Responses to items used a 5-point Likert scale. ^{Grundy (1993)} found that the Cronbach’s α coefficient of this scale was .85, indicating good reliability.

Ethical Considerations

Ethical approval for this study was received from the College of Nursing, KSU.

The following ethical considerations were addressed by the researcher regarding this study: Participants were protected from physical and psychological harm; before commencing the study, an information sheet explaining the study purpose, process, risks, benefits, and alternative procedures, if any, were disclosed; and participants received formal assurances of anonymity and confidentiality. Participants were asked to sign a consent form attached to the questionnaire. Participants were also informed that they had the right to withdraw from the study at any time and for any reason without penalty.

Data Analysis

Data were analyzed using SPSS Version 22.0. The paired t test and its nonparametric equivalent, the Wilcoxon signed-rank test, were used to assess whether statistically significant differences existed between the pretest and posttest scores of critical thinking and confidence for both groups. Independent t tests and Mann–Whitney U tests were used to compare score changes between the experimental and control groups from pretest to posttest.

Results

By using paired samples t test and Wilcoxon signed-rank tests, the critical thinking and self-confidence scores of both groups improved significantly (p < .05; Table 1). Regarding self-confidence, the mean scores of the control group at pretest and posttest were 1.99 and 3.80, respectively (p = .001), and those of the experimental group were 2.20 and 3.89 (p = .001), respectively. Regarding critical thinking, the scores of the control group were 5.47 and 11.00 (p = .001), and those of the experimental group were 5.33 and 9.47 (p < .05).

TABLE 1.: Paired Samples t Test and Wilcoxon Signed-Rank Test Comparing Gains in CT and SC (N = 30)

In Table 2, an independent t test and Mann–Whitney U tests indicated no significant differences between the control and experimental groups with regard to gains in either self-confidence or critical thinking (p > .05). There were no significant differences in gains in self-confidence between the control and experimental groups (t = 0.393, p = .698; Mann–Whitney U test: p = .870, ns). Likewise, no significant difference in gain was found with respect to critical thinking (t = 1.250, p = .222; Mann–Whitney U test: p = .512, ns).

TABLE 2.: Independent t Test and Mann–Whitney U Test Comparing Gains in CT and SC Between Study Groups (N = 30)

Discussion

This study compared the effects of simulation-based and traditional teaching methods on the critical thinking ability and self-confidence of nursing students with regard to ECG interpretation. The results indicate that both teaching methods had beneficial effects on the examined parameters. The lack of a significant difference between the examined teaching methods may partly reflect the limited statistical power (due to the small sample) and the limited exposure. However, the present findings (drawn from a single exposure) resemble those of ^{Ravert (2008)} and ^{Blum, Borglund, and Parcells (2010)}, who compared the effects of simulation and traditional education over time using a longitudinal design. This suggests that a single exposure to simulation-based education affects the critical thinking and self-confidence abilities of students similarly to multiple exposures. These findings collectively suggest that simulation-based and traditional teaching methods provide significant but approximately equal benefit to the critical thinking ability and self-confidence of undergraduate nursing students in the context of ECG interpretation.

Alternatively, the results further confirmed that well-implemented educational programs may effectively promote positive student outcomes independent of method. Student outcomes such as critical thinking ability and self-confidence are not easily influenced by teaching methods as the only valuable factor. Some studies such as that of ^{Heston (2010)}, which compared the effects of simulation and traditional teaching methods on self-confidence, suggest that students’ behavior and performance may be improved by applying great effort to increase their confidence, regardless of which teaching method is used by the educator. In addition, previous studies have shown that critical thinking differs significantly between learning styles and by student characteristics such as year of study, nationality, and previous experience (^{Andreou, Papastavrou, & Merkouris, 2014}; ^{Hunter, Pitt, Croce, & Roche, 2014}). However, in the present attempt, learning style was not assessed, as participants were all in the same year of school, lacked experience, and were of the same nationality. Consequently, future empirical studies may help better define the relationship between learner characteristics and learning style and its effect on the critical thinking ability and self-confidence of students using different teaching methods.

Limitations and Future Research

This study is affected by the following limitations. The sample was small, resulting in limited statistical power. Sample size is often a concern in nursing education research because of small class size (^{Ravert, 2008}). In our attempt, the small sample size was due to the small number of enrolled students at the targeted nursing college. In addition, the sample may not have been representative, as all participants originated from a single college and were women and of the same nationality. Accordingly, the present results should be tested in a larger sample by including students from numerous nursing colleges. Finally, future research should examine learning outcomes in a broad range of complex educational content.

Conclusions

The present findings contribute to the growing body of evidence comparing critical thinking and self-confidence gains between simulation-based and traditional teaching methods, regarding complex content. Simulator-based and traditional teaching methods did not deliver significantly different outcomes after a single simulation session among undergraduate nursing students. The authors suggest that well-implemented educational programs using either teaching method will effectively promote nursing students’ critical thinking ability and self-confidence. Nurse educators, based on the findings of this study, were encouraged to design educational plans with clear objectives for improving critical thinking ability and self-confidence. Ideally, future research should examine these variables in larger samples, include diverse content, address demographic variables (e.g., grade point average), and examine the influence of learning styles.