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  Comparing the Effects of Simulation-Basedand Traditional Teaching Methods onthe Critical Thinking Abilities andSelf-Confidence of Nursing Students Mashael-Hasan AlAmrani 1 *  &  Kamila-Ahmad AlAmmar 2 &  Sarah-Saad AlQahtani 3 &  Olfat A. Salem 4 Introduction In the late 20th century, simulation-based clinical skilltraining employed optimized clinical learning activities innursing education and promoted critical thinking to movestudents out of their knowledge comfort zone (Linthacum,2011). Critical thinking and self-confidence are imperativeto success in clinical practice. Simulation is intended to helpnursing students learn and become more self-confident incritical thinking (Kaddoura, 2010). Moreover, simulationhas been considered an important part of nursing programcurricula for decades, allowing students to practice specificprocedures in a controlled environment before perform-ing these procedures on actual patients (Hicks, Coke, & Li,2009). Simulation is used ‘‘to replace or amplify real ex-periences with guided experiences that evoke or replicatesubstantial aspects of the real world in a fully interactivemanner’’ (Gaba, 2007).Nurse educators are required to implement teachingstrategiesthatpromotethecriticalthinkingskillsoflearners,because many important institutions (e.g., the NationalLeague for Nursing and the American Association of Colleges of Nurses) mandate these skills for baccalaureatenursing education and because critical thinking andproblem-solving skills are required in professional nursingpractice (Vacek, 2009). In addition, critical thinking skillshelp students solve problems and make sound clinicaljudgments 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 theprobabilityofadesirableoutcome.’’Studiesassessingcriticalthinking training have yielded inconclusive findings. One  ABSTRACT Background:  Critical thinking and self-confidence are impera-tive to success in clinical practice. Educators should useteachingstrategies that will help students enhance their criticalthinking and self-confidence in complex content such aselectrocardiogram interpretation. Therefore, teaching electro-cardiogram interpretation to students is important for nurseeducators. Purpose:  This study compares the effect of simulation-basedand traditional teaching methods on the critical thinking andself-confidence of students during electrocardiogram interpre-tation sessions. Methods:  Thirty undergraduate nursing students volunteeredto participate in this study. The participants were divided intointervention and control groups, which were taught respectivelyusing the simulation-based and traditional teaching programs.All of the participants were asked to complete the study in-strument pretest and posttest to measure their critical thinkingand self-confidence. Results:  Improvement was observed in the control andexperimental 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   G  .05). However, theindependent  t   test and Mann  Y  Whitney  U   test indicate that thedifference between the two groups was not significant ( p   9  .05). Conclusions/Implications for Practice:  Thisstudyevaluatedan innovative simulation-based teaching method for nurses. Nosignificant differences in outcomes were identified between thesimulator-basedandtraditionalteachingmethods,indicatingthatwell-implementededucationalprogramsthatuseeitherteachingmethod effectively promote critical thinking and self-confidencein nursing students. Nurse educators are encouraged to designeducational plans with clear objectives to improve the criticalthinking and self-confidence of their students. Future researchshould compare the effects of several teaching sessions usingeach method in a larger sample. K  EY   W ORDS : simulation, electrocardiogram, self-confidence, criticalthinking. ORIGINAL ARTICLE The Journal of Nursing Research  h  VOL. 00, NO. 0, MONTH 2017 1 1 MSN, RN, Demonstrator, Faculty of Applied Medical Science,Department of Nursing, University of Tabuk, Saudi Arabia  & 2 MSN, RN, Nurse Educator, Nursing Education Adminstration,King Fahad Medical City, Saudi Arabia  &  3 BSN, RN, Clinical Instructor,Nursing Education Department, AlAmal Complex for Mental Health,and Master’s Student, College of Nursing, King Saud University, SaudiArabia  &  4 PhD, Associated Professor, Nursing Administration and Education Department, College of Nursing, King Saudi University,Saudi Arabia, and Faculty of Nursing, Nursing AdministrationDepartment, Menoufiya University, Egypt. Copyright © 2017 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.  studybySullivan-Mann, Perron, and Fellner (2009) found thatsimulation-based teaching significantly increased criticalthinking abilities, whereas another found that this mode of teaching did not significantly increase critical thinkingabilities in nursing students (Shinnick & Woo, 2013). None-theless, simulations appear to promote self-confidence instudents (Lubbers & Rossman, 2016). Confidence in nursingisacriticalattributeofprofessionalcaring,whichfostersmutualtrust, respect, and truthful communications between nursesand their patients (Roach, 2002). High-fidelity simulationhas been suggested as a new and supplemental teaching  Y  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 simulationsdid not significantly differ from that among students who re-ceived traditional instruction (Brannan, White, & Bezanson,2008). Finally, human patient simulators may increase the cri-tical thinking abilities of students but not their self-confidence(Soucy, 2011).Fewstudieshaveexaminedtheeffectivenessofsimulationwith respect to electrocardiogram (ECG) learning. ECGassists in the diagnosis, treatment, and monitoring of arrhythmias, coronary syndromes, and cardiac revasculari-zation (Lessard et al., 2009) and is considered the goldstandard in the evaluation of rhythm. Nurse educatorscommonly experience difficulty in teaching ECG interpre-tation. Moreover, only a few studies have compared ECGteaching strategies. Direct instruction, lectures, self-directedlearning, and textbooks are considered traditional methodsfor teaching ECG interpretation. Advanced teaching methodsincludePC-basedECGsoftwarepackages,12-leadECGsignalgenerators, and advanced training mannequins (patient simu-lators). The data presented by Mahler, Wolcott, Swoboda,Wang, and Arnold (2011) found that using workshop andlecture-based formats is more effective than self-directed learn-ing. Moreover, using simulation in ECG courses has beenshown to improve self-confidence and critical thinking abilityin students (Brown & Chronister, 2009).Insummary,althoughtheavailableevidencesuggeststhatsimulation-based teaching is important, the effect of simula-tion on the critical thinking skills and self-confidence of studentsremainsunclear.Additionalresearchisnecessarytocomparetheresultsofsimulationtechnologyandtraditionalteaching methods (Medley & Horne, 2005).Many universities in Saudi Arabia, including King SaudUniversity (KSU) and Princess Nourah bint AbdulrahmanUniversity, have expressed interest in simulation and haveintegrated simulation technology in their curriculum toovercome clinical education barriers (e.g., lack of clinical sitesor preceptors). Nonetheless, few studies have evaluated simu-lation, which are required by nurse educators aiming to opti-mallypromote the critical thinking ability and self-confidenceof their students. Accordingly, this study compared the effectof simulation-based and traditional teaching methods on thecritical thinking ability and self-confidence of students. Methods Design A pretest  Y  posttest design was used to compare the effects oncriticalthinkingabilityand self-confidenceinundergraduatenursing students of an ECG interpretation course that wastaught using either simulation-based or traditional teachingmethods. The experimental and control groups receivedsimulation- and lecture-based teaching, respectively. Sample and Setting Participants were a convenience sample of 30 eighth-levelundergraduatenursingstudentswhowererecruitedfromtheCollege of Nursing. Inclusion criteria were as follows:completedthefundamentalsofnursingandmedical  Y  surgicalnursing course, had no previous experience with ECGcourses, and voluntarily provided written consent. Beforeimplementation, the chief educator, who is certified in car-diovascular nursing, debriefed and trained the educatorson the data collection procedure. The chief educator gavelecture-based training, and three educators conducted theECG interpretation training using simulation under thesupervision of the chief educator to prevent a confoundingeducator effect. Lectures were considered to constitute‘‘traditional teaching.’’ All study sessions were conductedat the Laboratory for Nursing Simulation in the College of Nursing, KSU, and simulation used a high-fidelity patientsimulator. Data Collection After ethical approval from the College of Nursing, theresearchers recruited the students on the appointed day inMarch 2016. Participants were assigned randomly to eitherthe experimental or control group. The investigatorexplainedthepurposeofthestudytoeachparticipantbeforecommencingthe study. All participantsvoluntarily providedwritten consent. Participants received assurance that partic-ipation was voluntary, that their results were confidential,andthattheir scoresand participationwould notaffecttheircourse grade. Participants completed an ECG pretest 30minutes before course commencement. Both participantgroups attended a 2-hour PowerPoint presentation (on thecore concepts of ECG) to create a common ECG knowledgebase. Control group participants continued a session of lec-turelasting 60 minutes (on basic arrhythmiainterpretation).Duringthis60-minuteperiod,studentsweregivenanoppor-tunity for questions and discussion with the educator. Experi-mental group participants subsequently completed a session of simulation training (on basic arrhythmia interpretation) last-ing 60 minutes and a debriefing session of 20 minutes. Thestudent  Y  investigatorratiowas5:1.Inthefollowing30minutes,both groups completed a posttest that examined criticalthinking ability and self-confidence in ECG interpretation. The Journal of Nursing Research  Mashael Hasan AlAmrani et al. 2 Copyright © 2017 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.  Educational Activities Lecture content  The lecture introduced the core concepts of ECG, address-ing the interpretation of basic arrhythmias. A purposefullyselected panel of three faculty members, who were expertsin clinical and academic nursing, reviewed the lecture content. Simulation scenario  Six scenarios were simulated. The panel of three expertfaculty members had experience in the content of eachscenario and had reviewed each scenario to ensure contentvalidity and course content fidelity. The simulation sessionincluded an ECG demonstration and illustrations. A high-fidelity simulator was used (a computerized full-bodymanikin that simulates human functions and includes acardiac monitor that displays hemodynamic waveforms,ECG rhythms, and vital signs). Instruments Critical thinking  The authors developed a 15-item multiple-choice question-naire to measure the critical thinking ability of participantsregarding ECG interpretation. A well-constructed multiple-choice questionnaire can test the cognitive skills of students(Khan & Aljarallah, 2011). Moreover, multiple-choice testitems can be highly discriminating and measure the abilityof a respondent to think critically when written properly(Morrison & Walsh Free, 2001). Possible scores rangedfrom 0 to 15, with higher scores indicating greater criticalthinking ability in ECG interpretation. Each item includedone correct response and three distracter responses. Partic-ipants received ECG strips for interpretation. The multiple-choice questions used in this study were drawn from avariety 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 haveclinical and academic experience of more than 15 yearseach, and one cardiologist with experience in the criticalcare units at King Fahad Medical City. The panel approvedthe face validity of items for measuring the critical thinkingability of participants regarding ECG. The panel rated itemrelevance, and the item-level content validity indices rangedfrom 0.75 to 1.00, whereas the scale-level content validityindex, using the averaging approach, was 0.95. Self-confidence  Self-confidence was measured using the five-item C-Scale; theconcurrent validity was supported by the administration of two additional instruments of confidence that had moderateto high correlations with the C-Scale (Grundy, 1993). Re-sponses to items used a 5-point Likert scale. Grundy (1993)found that the Cronbach’s    coefficient of this scale was .85,indicating good reliability. Ethical Considerations EthicalapprovalforthisstudywasreceivedfromtheCollegeof Nursing, KSU.The following ethical considerations were addressed bythe researcher regarding this study: Participants wereprotected from physical and psychological harm; beforecommencing the study, an information sheet explaining thestudy purpose, process, risks, benefits, and alternative pro-cedures, if any, were disclosed; and participants receivedformal assurances of anonymity and confidentiality. Partic-ipants were asked to sign a consent form attached to thequestionnaire.Participantswerealsoinformedthattheyhadtherighttowithdrawfromthestudyatanytimeandforanyreason 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 signifi-cant differences existed between the pretest and posttestscores of critical thinking and confidence for both groups.Independent  t   tests and Mann  Y  Whitney  U   tests were usedto compare score changes between the experimental andcontrol groups from pretest to posttest. Results Byusingpairedsamples t   test and Wilcoxon signed-rank tests,the critical thinking and self-confidence scores of both groupsimproved significantly (  p  G  .05; Table 1). Regarding self-confidence, the mean scores of the control group at pretestand posttest were 1.99 and 3.80, respectively (  p  = .001), andthose of the experimental group were 2.20 and 3.89 (  p  =.001), respectively. Regarding critical thinking, the scores of thecontrolgroupwere5.47and11.00(  p  = .001), and thoseof the experimental group were 5.33 and 9.47 (  p  G  .05).In Table 2, an independent  t   test and Mann  Y  Whitney  U  tests indicated no significant differences between the controland experimental groups with regard to gains in either self-confidence or critical thinking (  p  9  .05). There were nosignificant differences in gains in self-confidence betweenthe control and experimental groups ( t   = 0.393,  p  = .698;Mann  Y  Whitney  U   test:  p  = .870,  ns ). Likewise, nosignificant difference in gain was found with respect tocritical thinking ( t   = 1.250,  p  = .222; Mann  Y  Whitney  U  test:  p  = .512,  ns ). Discussion This study compared the effects of simulation-based andtraditional teaching methods on the critical thinking ability VOL. 00, NO. 0, MONTH 2017 Simulation and Traditional Teaching Methods 3 Copyright © 2017 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.  and self-confidence of nursing students with regard to ECGinterpretation. The results indicate that both teaching meth-ods had beneficial effects on the examined parameters. Thelack of a significant difference between the examined teach-ing methods may partly reflect the limited statistical power(due to the small sample) and the limited exposure. How-ever, the present findings (drawn from a single exposure)resemble those of Ravert (2008) and Blum, Borglund, andParcells (2010), who compared the effects of simulationand traditional education over time using a longitudinaldesign. This suggests that a single exposure to simulation-based education affects the critical thinking and self-confidenceabilitiesofstudentssimilarlytomultipleexposures.These findings collectively suggest that simulation-basedand traditional teaching methods provide significant butapproximately equal benefit to the critical thinking abilityand self-confidenceof undergraduatenursing studentsinthecontext of ECG interpretation.Alternatively, the results further confirmed that well-implemented educational programs may effectively promotepositive student outcomes independent of method. Studentoutcomessuchascriticalthinkingabilityandself-confidenceare not easily influenced by teaching methods as the onlyvaluable factor. Some studies such as that of Heston (2010),which compared the effects of simulation and traditionalteaching methods on self-confidence, suggest that students’behavior and performance may be improved by applyinggreat effort to increase their confidence, regardless of whichteaching method is used by the educator. In addition,previous studies have shown that critical thinking differssignificantly between learning styles and by student char-acteristics such as year of study, nationality, and previousexperience (Andreou, Papastavrou, & Merkouris, 2014;Hunter, Pitt, Croce, & Roche, 2014). However, in thepresent attempt, learning style was not assessed, asparticipants were all in the same year of school, lackedexperience, and were of the same nationality. Consequently,future empirical studies may help better define the relation-ship between learner characteristics and learning style andits effect on the critical thinking ability and self-confidenceof students using different teaching methods. Limitations and Future Research This study is affected by the following limitations. The sam-ple was small, resulting in limited statistical power. Samplesize is often a concern in nursing education research becauseof small class size (Ravert, 2008). In our attempt, the smallsample size was due to the small number of enrolled stu-dents at the targeted nursing college. In addition, the samplemaynothavebeenrepresentative,asallparticipantsoriginatedfrom a single college and were women and of the same na-tionality. Accordingly, the present results should be tested inalargersamplebyincludingstudentsfromnumerousnursingcolleges. Finally, future research should examine learningoutcomes in a broad range of complex educational content. TABLE 2. Independent t Test and Mann   Y  Whitney U Test Comparing Gains in CT and SC Between Study Groups (N = 30)  VariableExperimentalGroup ( n   = 15)Control Group( n   = 15) t p   Mann  Y  Whitney  p M SD M SD  CT 9.47 2.669 11.00 2.591 1.250 .222 .512SC 3.89 0.636 3.80 0.737 0.393 .698 .870 Note.  CT = critical thinking; SC = self-confidence. TABLE 1. Paired Samples t Test and Wilcoxon Signed-Rank Test Comparing Gains in CT and SC (N = 30)  VariableExperimental Group ( n   = 15) Control Group ( n   = 15)Pretest Posttest t p  WilcoxonTest,  p  ValuePretest Posttest t p  WilcoxonTest,  p  Value M SD M SD M SD M SD  CT 5.33 1.839 9.47 2.669  j 4.769 .001 .002 5.47 1.506 11.00 2.591  j 7.798 .001 .001SC 2.20 0.997 3.89 0.636  j 9.052 .001 .001 1.99 0.880 3.80 0.737  j 7.500 .001 .001 Note.  CT = critical thinking; SC = self-confidence. The Journal of Nursing Research  Mashael Hasan AlAmrani et al. 4 Copyright © 2017 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.

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