Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

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Use understanding of informatics and telehealth to post a discussion that answers the following questions: How can telehealth tools improve outcomes? What populations of patients can benefits from these tools? What are the consideration for telehealth that need to be address in terms of providers and patients in order for these programs to be successful.

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I attached some articles and also a link to a video that my help

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BRIEF REPORT Nurse Practitioners in Telehealth: Bridging the Gaps in Healthcare Delivery Kristi Henderson, DNP, FNP, Tearsanee Carlisle Davis, DNP, FNP, Mary Smith, DNP, FNP, and Melissa King, MSN, FNP ABSTRACT There is no denying that many changes must be made in the health care delivery system in order to meet the needs of all people and improve the health of our nation. Because of advances in technology over the past 2 decades, telehealth has greatly improved patient access to health care and equipped providers with innovative tools to provide quality health care to a larger population. The health care climate demands an innovative approach to health care delivery with an attention to scalable and sustainable models. Telehealth, and the use of nurse practitioners, will be an integral part of these new models. Keywords: connected care, nurse practitioners, telehealth, telemedicine Ó 2014 Elsevier, Inc. All rights reserved. T here is no denying that many changes must be made in the health care delivery system in order to meet the needs of all people and improve the health of our nation. Because of advances in technology over the past 2 decades, telehealth has greatly improved patient access to health care and has equipped providers with innovative tools to provide quality health care to a larger population.1 No longer does geographic location limit the health care services one can access. The health care climate demands an innovative approach to health care delivery with an attention to scalable and sustainable models. Telehealth, and the use of nurse practitioners (NPs), will be an integral part of these new models, which provide a scalable approach to coordinated and collaborative care. However, the widespread adoption and integration of telehealth can be difficult. Telehealth is a broad term that includes videoconferencing, exchange of medical information via electronic communications, remote patient monitoring, population health management, and mobile health technologies.2 Our academic medical center (AMC) has answered the call to minimize health care disparities related to geographic barriers to gain access to health care by using technology to bring collaboration among multiple disciplines in a virtual environment. Our AMC operates a system-wide center for telehealth that began as a pilot project nearly 11 years ago. The first program that launched www.npjournal.org in 2003 was the telemergency program. This program uses NPs as the distant site providers and allows for direct connection to board-certified emergency physicians at our level I trauma center for a higher level of care using telecommunication equipment.3 In some rural areas, the closest, fully staffed emergency room was 40 miles away, and some rural emergency rooms were staffed with physicians or NPs with little or no formal emergency medicine training. As a result, the AMC frequently received poorly managed critical care patients in transfer to their emergency department, and some patients did not make it that far. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

The tele-emergency program trains NPs through an intense didactic and clinical continuing education program that is in addition to the education received as a part of the NP’s formal degree-granting education and certification required for practice. The content is focused on the clinical knowledge and diagnostic procedure skills necessary to work in an emergency department and incorporates appropriate use of the telemedicine equipment, which allows them to collaborate with board-certified emergency medicine physicians. This curriculum focuses on topics such as the approach to the emergency patient, cardiac emergencies, psychiatric emergencies, toxicologic emergencies, obstetrical emergencies and delivery, and pediatric and orthopedic emergencies. This content is taught through a combination of inperson classes, online modules, simulation laboratory The Journal for Nurse Practitioners – JNP 845 sessions, and clinical rotations. Once the NP completes this 3- to 6-month training, they may go on to staff rural emergency departments that are a part of the AMC’s telehealth network. This program provides a sustainable model for the utilization of NPs to positively impact rural communities through telemedicine. In this program, the NP uses bidirectional audioconferencing and videoconferencing for collaboration with emergency medicine physicians at the academic medical center (Figure 1). The rural hospital emergency departments are outfitted with telemedicine equipment that is either mounted in the emergency department’s examination room or contained on a telemedicine cart that allows for mobility between examination rooms in the emergency department and the inpatient hospital rooms. In either scenario, a video monitor, camera, and microphone allow for videoconferencing between 2 geographically distant sites. The NP can easily consult with the AMC’s department of emergency medicine’s physicians or a stroke neurologist with a push of a button. Any of the AMC’s resources and specialties can be consulted as the emergency physician deems necessary. This virtual care team provides a treatment recommendation to the NP at the rural hospital. Should the patient require a transfer to a facility offering expanded services, the care that was delivered through telemedicine results in an improved transition of care from the rural hospital to the academic medical center. A study by Henderson et al4 compared patient outcomes of cardiac arrest patients in 8 rural hospitals using the telemergency program to that of our AMC. The survival of cardiopulmonary arrest patients in rural emergency departments has historically been significantly lower than that in the Figure 1. AMC telemedicine workstation. 846 The Journal for Nurse Practitioners – JNP urban emergency department setting. In this study, rural emergency departments using resuscitation guided by telemedicine consultation with emergency specialists were found to have survival rates that were not significantly different from those in our AMC. This finding suggests that telemedicine may improve the quality of emergency care delivery in the rural setting. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

4 Although the impact on access to care and quality of care is critical, in order for a telehealth program to be adopted and integrated, there must be a solid business plan that shows a positive return on investment. The economic evaluation of a telehealth program to determine the benefit-cost analysis should consider the broad range of impact a program has on the health of individuals; the workforce and populations, and the impact on new jobs, economic development, and the cost of health care.5 The financial impact of a telehealth program on a hospital or other clinical entity can be assessed in a number of ways such as the ability to retain patients admitted in the community hospital (avoiding unnecessary transfers of patients), a reduction in medical staffing costs (shared resources), an added medical service line, a decrease in the length of hospital admission, and/or the prevention of a financial penalty from hospital readmissions. The literature is growing to show the positive financial impact and the win-win scenario found in a telehealth program.5-10 In some cases, telemedicine has prevented the unnecessary transfer of a patient to the AMC when the condition could have been managed at the local hospital with support via telemedicine. This results in benefits for both the patient and the rural hospital. If the patient is stabilized and can stay at their local hospital, they are closer to home and family and are able to receive the care they need in a familiar environment. If the rural hospital is able to keep the patient, it keeps the revenue in the community and expands that hospital’s ability to support the community. In an analysis of the first 8 tele-emergency hospitals, a comparison was done between the operational cost and the hospital census pre- and postimplementation of the telemergency program. The program analysis revealed a decrease in provider staffing costs of 25% in the tele-emergency model and showed an increase in the distant hospital patient admissions of 20%.11 Although this report has Volume 10, Issue 10, November/December 2014 been submitted for peer review and publication, the findings have already led to telemedicine program expansion and increased adoption. With avoided transfers, the AMC is then able to focus on the more critically ill patients who need the level of care only they can provide. The success of this initial telehealth program and the increase of supporting literature created the impetus for us to replicate this model in other specialties. Over the past 10 years, the institution has expanded this initial program to a statewide telehealth network and achieved the designation as a center for telehealth in July 2013. The center is led by a chief telehealth and innovation officer who is a doctorally prepared nurse. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

The mission of the center for telehealth is to fill the gaps in health care and to improve the quality and accessibility of health services in order to decrease health disparities, manage chronic diseases, and improve the quality of life. Our center for telehealth supports the institution’s commitment to provide health care statewide and matches the state’s need and demand for telemedicine services. To date, over 30 different specialties are being offered via telemedicine to over 100 unique nonaffiliated sites across our state, many of which are manned by NPs. The center is now receiving requests nationally and internationally to extend these telehealth services outside the state. Currently, the AMC’s telehealth program does not extend outside of the state. TELEHEALTH TODAY Telehealth is being delivered in a variety of inpatient and outpatient settings in our state, providing services such as telestroke, teledermatology, telepediatrics, telepsychiatry, teleneonatology, and telecardiology care to underserved areas. A primary focus of telehealth programs is to fill the need for health care providers, thereby improving access to care for anyone, regardless of their location. In October 2013, our AMC hired its first telehealth NP dedicated to the delivery of health care through telehealth technology for corporations and schools (Figure 2). The program uses e-clinics to deliver care to students in their school clinics and to employees in their workplace. Because of this program, employees are able to seek care for minor illnesses without leaving www.npjournal.org Figure 2. Corporate Telehealth workstation. work. Employers benefit from this service because it limits the loss of productivity and reduces health care costs. The program has seen great success in the pilot phase and has hired 2 additional NPs to meet the demands of Mississippi corporations. The school telehealth program is similar in that students are allowed to receive episodic care for minor illnesses via telehealth, which allows parents to stay at work when they choose to do so. In this program, the school nurse serves as the facilitator who connects to the telehealth system for an NP teleconsult at which time the patient is assessed, diagnosed, and treated. If there are needs that require in-person examination or follow-up, the NP coordinates these appointments with a local provider in the patient’s community. The benefit is that students who may not have a primary care provider have access to care when they need it and receive assistance in securing a medical home for ongoing needs. NPs working in these 2 programs have a family medicine and/or urgent care background and are knowledgeable about resources in the community. COORDINATION OF CARE IN THE COMMUNITY Health care reform is placing a strong focus on the coordination and continuity of care among all populations but specifically for those populations with multiple chronic illnesses and risk factors, which leave them the most vulnerable. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

12 Risk factors such as polypharmacy, poor health literacy, and lack of supportive resources place a greater need for interprofessional collaboration and can all be The Journal for Nurse Practitioners – JNP 847 positively affected with the appropriate use of telehealth. Telehealth will play an instrumental role in the utilization of a collaborative approach that delivers quality care, enhances patient safety, and generates cost savings.13 Telemedicine is instrumental in preventing excessive health care costs through remote patient monitoring. Research studies are beginning to reveal the impact of remote patient monitoring on hospital readmissions, disease management, avoidance of emergency room visits, and patient satisfaction.10,14,15 A study by Pekmezaris et al10 studied the impact of remote patient monitoring on heart failure patients. The study indicates that remote patient monitoring has the potential to provide a cost-effective and convenient method to manage heart failure.10 Remote patient monitoring aids in containing healthcare costs by enabling nurses and other health care providers to intervene when there is a change in health status and eliminates the need for costly home care visits for monitoring only.16 Cost savings are seen with an efficient and coordinated delivery system that minimizes exacerbations of chronic illnesses, curtails adverse events, reduces hospitalizations, and reserves the use of emergency rooms for truly emergency care. The National Rural Health Association reports that rural areas have greater shortages of primary and specialty health care providers, a larger population of individuals who rely on Medicare and Medicaid, an increased prevalence of chronic disease, and geographic barriers that force travel over long distances in order to gain access to specialty health care services.17 Telehealth technology will allow for vulnerable populations in underserved areas to overcome some of these challenges by reducing geographic disparities and health care workforce shortages and increasing access to preventive services. An example of how telemedicine is bringing needed services to the rural community is telepsychiatry. There is a vast shortage of mental health providers in rural communities. Often, primary care providers are forced to treat patients suffering from mental illness without the expertise of mental health professionals. Telepsychiatry allows patients in rural communities to have access to the same level of care as those in 848 The Journal for Nurse Practitioners – JNP larger cities by using videoconferencing to conduct mental health evaluations and regular follow-up.18 The provision of subspecialty care to children with special health care needs who live in rural communities is also a benefit of using telehealth. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

Traditionally, parents would be taxed with the burden of traveling far distances to receive the care that their children needed. Marcin et al19 reported that pediatric subspecialty consultations can be provided to these children with high satisfaction for families and rural providers. The utilization of telehealth has the potential to meet the Institute for Healthcare Improvements’ triple aim for better health, better health care, and lower costs.5-10,13,15 Population health management and chronic disease management programs are also capitalizing on the use of technology.14 A program recently implemented by our AMC, the Mississippi Diabetes Telehealth Network, aims to bring a diabetes care team to an existing rural health clinic that currently does not offer any specialty care. Diabetics whose disease is currently uncontrolled are eligible for this program. Patients enrolled in the program are provided with a computer tablet that allows for realtime health sessions and coaching as well as remote monitoring of vital signs and glucose levels.20 The community physician or NP in the rural health clinic will have access to endocrinologists, ophthalmologists, specialty NPs, nurses, diabetes educators, pharmacists, and nutritionists to bring a team approach to their health care. Until now, this type of approach was only accessible to those in urban areas. Because so much of diabetes management is related to behavior and life style changes, this program will also provide daily health sessions delivered through a computer tablet to include symptom and compliance assessment, education, and remote monitoring of the patient’s glucose level and vital signs. NPs who staff the rural health clinic will be able to refer patients to specialists located at the AMC for care that would otherwise not be accessible. It is expected that patient compliance to treatment will improve because their primary care provider, the NP, will be able to facilitate additional services via telemedicine. This is another example of how NPs are pivotal in the improving access to care in rural communities. Volume 10, Issue 10, November/December 2014 CRITICAL CARE SERVICES The use of technology can provide a cost-effective and efficient way to deliver health care, provide education, and manage chronic disease. The health care system is demanding more with fewer resources. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

Workforce shortages, the geographically disproportionate spread of health care providers, and the lack of access to care, whether caused by a lack of transportation or a lack of health care services in an area, create barriers that the current model of health care have been unable to overcome. In the current telee intensive care unit (ICU) program, critical care patients are monitored remotely 24 hours a day by experienced critical care nurses. This is in addition to the bedside critical care nurse. The preliminary data from our model suggest it to have a positive impact on safety and quality and allows for earlier intervention for changes in patient status. Initially, there was uncertainty as to whether it was cost-effective at our AMC, which resulted in the program being “turned off.” The result was an increase in safety and quality concerns that led to reinvigoration of the program. The program remains active and is expanding in our AMC. The literature reveals a similar picture of inconsistent outcomes of an ICU telemedicine program. The data are conflicting on the cost-benefit analysis, but numerous studies suggest that when telehealth services are implemented with well-defined patient inclusion criteria and protocols that it can be cost-effective.21-24 This has been true for our AMC. Plans are currently being drafted that will include adding acute care NPs to the ICU telemedicine model currently used in the AMC. The NP would be a part of the intensivist team and will ensure continuity of care in this population. The NP in the tele-ICU will be able to intervene much sooner and place orders that will prevent a delay in care and improve patient outcomes. Future studies are needed to determine the impact of the NP on this model. MOVING FORWARD Rural and community hospitals have threatened viability and survivability. The tele-ICU program and other telehealth services allow the smaller hospitals to keep their own patients in their facility safely and www.npjournal.org prove to be a quality and financial benefit to the community.15 Financial challenges have often been the reason that rural agencies have shied away from nontraditional models of care delivery. The center for telehealth not only creates and implements the programs, but doctorally prepared NPs work with community agencies to identify needs and create programs that produce a revenue stream that will ensure sustainability. Each site has different resources, and with that in mind, no 2 programs are identical. Based on the needs of the agency and the resources available, the center for telehealth devises a realistic plan, and NPs are a key component to this transformed health care delivery model. Technology will continue to change the way nurses practice. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

The standard of care now includes telehealth to improve access, quality, and patient outcomes. For more information, contact the center for telehealth at (601) 815-2020 or www.umc.edu/telehealth and follow us on Facebook and Twitter. References 1. Keely E, Liddy C, Afkham A. Utilization, benefits, and impact of an e-consultation service across diverse specialties and primary care providers. Telemed J E Health. 2013;19(10):733-738. 2. What is telemedicine? American Telemedicine Association. http://www .americantelemed.org. Accessed August 15, 2014. 3. Galli R, Keith JC, McKenzie K, Hall G, Henderson K. TelEmergency: a novel system for delivering emergency care to rural hospitals. Ann Emerg Med. 2008;51(3):275-284. 4. Henderson K, Woodward L, Summers R. Relative survivability of cardiopulmonary arrest in rural emergency departments utilizing telemedicine. J Rural Emerg Med. 2014;1(1):9-12. 5. Davalos M, French M, Burdick A, Simmons S. Economic evaluation of telemedicine: review of the literature and research guidelines for benefit-cost analysis. Telemed J E Health. 2009;15(10):933-948. 6. Bynum A, Irwin C, Cranford C, Denny G. The impact of telemedicine on patients’ cost savings: some preliminary findings. Telemed J E Health. 2003;9(4):361-367. 7. Vergara R, Gagnon M. A systematic review of the key indicators for assessing telehomecare cost-effectiveness. Telemed J E Health. 2008;14(9):896-904. 8. Yuji A, Masatsugu T. Measuring the effect of telecare on medical expenditures without bias using the propensity score matching method. Telemed J E Health. 2012;18(10):743-747. 9. Baker L, Johnson S, Macaulay D, Birnbaum H. Integrated telehealth and care management program for Medicare beneficiaries with chronic disease linked to savings. Health Aff (Millwood). 2011;30(9):1689-1697. 10. Pekmezaris R, Pecinka K, Lesser M, Swiderski J, Younker R. The impact of remote patient monitoring upon Medicare beneficiaries with heart failure. Telemed J E Health. 2012;18(2):101-108. 11. Henderson K. Telemergency: distance emergency care using nurse practitioners. Poster session presented at: American Academy of Nursing 36th Annual Conference; November 5-7, 2009; Atlanta, GA. 12. Robinson KM. Care coordination: a priority for health reform. Policy Polit Nurs Pract. 2010;11(4):266-274. 13. Kvedar J, Coye M, Everett W. Connected health: a review of technologies and strategies to improve patient care with telemedicine and telehealth. Health Aff (Millwood). 2014;33(2):194-199. 14. Cusack CM, Knudsen AD, Kronstadt JL, Singer RF, Brown AL. Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care. Rockville, MD: Agency for Healthcare Research and Quality; 2010. The Journal for Nurse Practitioners – JNP 849 15. Lowery C, Bronstein J, Benton T, Fletcher D. Distribution medical expertise: the evolution and impact of telemedicine in Arkansas. Health Aff (Millwood). 2014;33(2):235-243. 16. Field M, Grigsby J. Telemedicine and remote patient monitoring. JAMA. 2002;288(4):423-425. 17. National Rural Health Association. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

Health care workforce distribution and shortage issues in rural America. National Rural Health Association Policy Brief. 2012. http://www.ruralhealthweb.org/go/left/policy-and-advocacy/ policy-documents-andstatements/official-nrha-policy-positions. Accessed August 2, 2014. 18. Swinton J, Robinson W, Bischoff R. Telehealth and rural depression: physician and patient perspectives. Fam Syst Health. 2009;27(2):172-182. 19. Marcin J, Ellis J, Mawis R, Nagrampa E, Nesbitt, Dimand R. Using telemedicine to provide pediatric subspecialty care to children with special health care needs in a underserved rural community. Pediatrics. 2004;113(1):1-6. 20. USA Today. With $245B spent on diabetes, telemedicine looks to cut the cost. 2014. http://www.usatoday.com/story/news/nation/2014/04/18/statelinediabetes/ 7864369/. Accessed August 8, 2014. 21. Franzini L, Sail KR, Wueste L. Costs and cost-effectiveness of a telemedicine intensive care unit program in 6 intensive care units in a large health care system. J Crit Care. 2011;26(3):329.e1-329.e6. 22. Lilly CM, Zubrow M, Kempner K, et al. Critical care telemedicine: evolution and state of the art. Crit Care Med. 2014;42(9). 23. Breslow MJ, Rosenfeld B, Doerfler M, et al. Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing. Crit Care Med. 2004;32:31-38. 850 The Journal for Nurse Practitioners – JNP 24. Young L, Chan P, Lu X, et al. Impact of telemedicine intensive care unit coverage on patient outcomes: a systematic review and meta-analysis. Arch Intern Med. 2011;171:498-506. All authors are affiliated with the University of Mississippi Medical Center. Kristi Henderson, DNP, FNP, ACNP, FAEN, is chief telehealth and innovation officer and an RWJF executive nurse fellow and can be reached at khenderson@umc .edu. Tearsanee Carlisle Davis, DNP, FNP, and Mary Smith, DNP, FNP, are telehealth nurse practitioners and Melissa King, MSN, FNP, is the TelEmergency NP director. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/14/$ see front matter © 2014 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2014.09.003 Volume 10, Issue 10, November/December 2014 Nurse Education Today 34 (2014) 252–258 Contents lists available at ScienceDirect Nurse Education Today journal homepage: www.elsevier.com/nedt Simulation in nursing education: An evaluation of students’ outcomes at their first clinical practice combined with simulations Rabia Khalaila ⁎ Nursing Department, Zefat Academic College, 11 Jerusalem St., P.O.B. 169, Zefat 13206, Israel a r t i c l e i n f o Article history: Received 10 October 2012 Received in revised form 9 August 2013 Accepted 25 August 2013 Keywords: Simulation Anxiety Nursing students Caring ability Caring efficacy Self-confidence s u m m a r y Background: Nursing students frequently report feeling anxiety prior to entering their first clinical setting. Education through simulations reduces the anxiety level of nursing students and contributes to various outcomes for students’ learning processes. Objectives: The purpose of this study was twofold: to evaluate the effectiveness of simulations in reducing anxiety and promoting self-confidence, caring ability, and satisfaction with simulation; and to investigate the predictors and mediators for caring efficacy among nursing students. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

The authors examined concepts that have been studied only minimally in the literature. Design: A descriptive quantitative study. Setting: Zefat Academic College, Nursing Department, Zefat, Israel. Participants: 61 second-year nursing students at their first clinical practice. Method: Data was collected before the first clinical and simulations practice (T1), and four months later (T2) after they had finished their first clinical practice in a hospital setting. Hierarchical linear regression was applied to examine the research hypotheses. Results: The results revealed that anxiety scores decreased, while self-confidence and caring ability scores increased after using simulations. Caring efficacy was negatively predicted by anxiety, and positively with selfconfidence, caring ability and satisfaction with simulation. Conclusions: The use of simulations before and during nursing students’ first clinical practice is a useful and effective learning strategy. Nursing educators should be aware of the high level of anxiety among nursing students during their first clinical practice, and design a program to reduce the anxiety through simulations. © 2014 Published by Elsevier Ltd. Introduction Quality and Safety Education for Nurses (QSEN) addresses the nursing competencies needed to ensure the quality and safety of patient care. Adapted from the Institute of Medicine (IOM) competencies for nursing (2003), QSEN outlines the essential features of competent nursing practice (nursing competencies) to improve patient safety and quality in healthcare settings. The six QSEN competencies are: patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (Cronenwett et al., 2007). Subsets of each QSEN competency include knowledge, skills, and attitudes (KSAs) achievable during the educational process. Therefore, adding QSEN to every simulation experience is one potential avenue to ensure exposure to the wide array of experiences needed to confer competency. Unlike the hospital setting, these created scenarios in simulations can virtually guarantee exposure to multiple KSAs and QSEN competencies not available otherwise to students (Durham and Alden, 2012). ⁎ Tel.: +972 4 692 7778; fax: +972 4 692 7776. E-mail address: rabeikh@zefat.ac.il. 0260-6917/$ – see front matter © 2014 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.nedt.2013.08.015 Evidence based practice related to the Human Patient Simulator (HPS) becomes an essential component of the contemporary nursing education (Bremner et al., 2006, 2008). This approach led the healthcare service to use HPS as a teaching strategy for healthcare professionals (Hofmann, 2009), and for nursing students (Alfes, 2011; Bearnson and Wiker, 2005; Shepherd et al., 2010; Ward-Smith, 2008). Further contemporary motivation to include simulation in nursing education is that opportunities for learning in clinical settings are increasingly limited, so alternatives to traditional approaches for clinical learning must be found (Edwards et al., 2004). This contemporary approach in nursing education raises the question: to what extent does using the HPS in nursing education impact nursing students’ perceived anxiety levels, self-confidence, caring ability and caring efficacy in their first clinical experience? Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

An evaluation of students’ outcomes might provide us with an answer. Background The literature defines simulation as a near representation of an actual life event, which can be presented through different methods such as computer software, case studies, written clinical scenarios, R. Khalaila / Nurse Education Today 34 (2014) 252–258 live actors, role playing, games or mannikins (Bearnson and Wiker, 2005; Beaubien and Baker, 2004; Goldenberg et al., 2005; Mould et al., 2011). High-fidelity simulation is a relatively new method in nursing education, utilizing high technology simulation monitors and computers (Sanford, 2010). Simulations have long been used to promote learning in the healthcare professions and provide a safe, acceptable environment for practicing skills (Ward-Smith, 2008). The literature points out several advantages and many positive outcomes in using simulations for nursing education. For example, simulation may improve students’ critical thinking skills and retention of content, and provides students with the opportunity to practice simple and complex skills in a non-threatening environment. Such skills include cardiopulmonary resuscitation, maternal and newborn care using a birthing simulator, urinary catheter insertion, nasogastric tube insertion and the like (Sanford, 2010). Findings reported by the literature also stated that simulation could be a helpful intervention to strengthen the connection between theory and practice (Morgan, 2006), and is a productive learning strategy which broadens theoretical learning and supports the practice element of nursing education (Prescott and Garside, 2009). For example, Morgan (2006) found that students reported that simulations which they identified as basic nursing skills, which were taught in the clinical skills laboratory before the first practice placement, as useful. Practice through simulations of nursing skills such as taking and recording patients’ vital signs and hygiene needs enabled them to integrate theory with practice during their first practice placement. Learning through simulation also provides immediate feedback, facilitates repeated experiences activated on various levels of difficulty, activates different varied learning strategies, enables drills and individual learning, defines clear and achievable goals, and imitates real life to a certain extent (Issenberg et al., 2005). The literature also shows that simulation-based learning consistently decreases anxiety among novice nursing students at their first clinical experience (Bremner et al., 2006, 2008; Szpak and Kameg, 2011), and promotes their level of self-confidence and clinical competence (Brannan et al., 2008). For example, Bremner et al. (2008) found that a majority (71%) of the nursing students agreed or strongly agreed that using the Human Patient Simulator (HPS) gave them confidence with physical assessment skills, and 65% agreed or strongly agreed that the HPS relieved their stress on their first day of clinical placement. Szpak and Kameg (2011) also found that students’ anxiety level significantly decreased by 0.3 points after the simulation experience. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

Learning through simulation also raises the students’ satisfaction with learning (Alfes, 2011; Blum et al., 2010; Mould et al., 2011; Prescott and Garside, 2009), and improves their level of knowledge, and clinical performance (Bearnson and Wiker, 2005; Liaw et al., 2011) as well as their self-efficacy (Goldenberg et al., 2005). Moreover, simulation experience reinforces the development of skills in assessment, psychomotor activity, problem solving, decision making, and critical thinking by encouraging the students to think deeply and ask appropriate questions, and by providing feedback (Cant and Cooper, 2010; Mikkelsen et al., 2008). It also can affect patient care, health and safety (Rothgeb, 2008). The presence of anxiety in beginning students in the clinical setting is well-documented in the literature (Sharif and Masoumi, 2005; Shipton, 2002). Anxiety may negatively affect students’ caring efficacy (King, 2010), and actual patient care in the clinical learning setting (Beddoe and Murphy, 2004), for example, by reducing their performance level during clinical practice (Cheung and Au, 2011). Moreover, Szpak and Kameg (2011) claimed that if students feel less anxious, they may be more effective in establishing a therapeutic relationship with the patients, and ultimately enhance patient outcomes. The literature also cites three factors that may mediate the correlation between the student’s anxiety level and caring efficacy: self- 253 confidence, caring ability, and satisfaction with simulation (see Fig. 1). The literature showed that the use of simulation scenarios throughout the undergraduate curriculum can be beneficial in reducing anxiety and enhancing student’s confidence and ability regarding patient care decisions since no harm to the patient occurs (Rhodes and Curran, 2005). Other investigators have noted that high levels of anxiety can lead to the student’s decreased confidence levels (Horsley, 2012); and inhibit the student’s ability to care for others (King, 2010). King (2010) also noted a negative correlation between students’ anxiety and satisfaction from clinical practice. White (2003) and King (2010) reported that when students lack confidence in their ability to complete a nursing skill, they focus on their concern that they might make a mistake, which leads to disruptions in their decision making and critical thinking, and lowers their caring efficacy. Therefore, it is interesting to examine these mediating effects in the context of simulations combined with the first clinical experience among nursing students. The use of simulation has resulted in increasing interest in engaging in evaluating the outcomes of simulation. Although many student outcomes have been examined in the literature within the context of nursing simulation, caring ability and caring efficacy are two outcomes that have never been examined in the context of simulation, until now. The present analysis is one of the few efforts to examine the effectiveness and outcomes of using simulation in nursing education in Israel. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

Hypotheses Three major hypotheses were considered. First, that anxiety will decrease, while self-confidence and caring ability will increase between T1 (before the first clinical experience and simulations sessions), and T2 (after they finished their first clinical experience with the simulation Caring ability Anxiety – – Caring efficacy Self confidence Satisfaction with simulation Fig. 1. The study model: predicting and mediating paths. 254 R. Khalaila / Nurse Education Today 34 (2014) 252–258 Method in meaning. The complete questionnaire underwent a pilot test on five different students from the third year baccalaureate nursing program. The questionnaire took approximately 20 min to complete, the written and verbal instructions were comprehensible, and there was no need for further changes prior to administering the questionnaire. The pre-test of State-Trait Anxiety Inventory (STAI), Caring Ability Inventory (CAI), and Caring Efficacy Scale (CES) yielded an alpha of 0.70, 0.68, 0.73 respectively. Study Design and Participants Measures A descriptive quantitative study was conducted with a single group of all second year students using a pretest–post-test design. After approval by the Institutional Review Board, a convenience sample of 61 of the second-year baccalaureate nursing students (100% enrollment rate) from the Zefat Academic College, Israel, was enrolled in the study. Demographic Characteristics Self-reported age, gender, own religion, and employment status were assessed at T1. Own religion included (1) Muslim, (2) Christian, (3) Jewish, and (4) Druze. sessions); second, that anxiety at T2 is negatively related to caring efficacy after controlling the anxiety at T1; while the third hypothesis posits that three particular measures mediate the presumed association between anxiety and caring efficacy in this study population: selfconfidence, satisfaction with simulation, and caring ability that were measured at T2. Procedure The study was approved by the institutional ethics committees and the Research Ethics Committee of the college at which the research took place. Participants gave written consent and received an explanation of their right to withdraw at any time without academic penalty. Strict confidentiality was maintained. After giving written consent, each student was asked to complete a pre-test questionnaire (T1) which comprised background variables and a scale of anxiety, self-confidence, and caring ability during the first semester of the second year of studies. Two months later each of them begins their first clinical experience at the hospital in the adult internal or surgical departments. Each student was scheduled to participate in two simulation days in separate weeks during the three months of the first clinical experience group. Each simulation day consisted of two to three clinical scenarios (of one and half hours each), such as chest pain, asthma, pneumonia, or post-surgical assessment. Each day was facilitated by different clinical instructors with different scenarios (see Appendix A: Examples of scenarios). All instructors were baccalaureate nurses with educator certification who have worked in a hospital sitting for at least two years in the same simulation field. Each instructor had to prepare three to six different clinical scenarios from their clinical field of expertise at least one month before the simulation day. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

Each simulation scenario was then validated by relevant clinical textbooks by the relevant nurse expert in the nursing department. All instructors were instructed to build scenarios, and received orientation and training on how to use the simulators and the equipment in the simulation center. Before beginning the simulation sessions, all students attended an orientation session on the simulators and the equipment in each of the four simulation rooms at the college. Next, each student was given a small cart with the “patient” history, such as medication and comorbidity, and clinical details such as pulse, blood pressure and saturation. They were also instructed to act as a staff nurse to perform the appropriate nursing assessment and interventions for the simulated patient. After each scenario, the instructors conducted a 15-minute structured debriefing to answer questions, clarify concerns, and offer feedback on students’ performance and knowledge. Following the first clinical experience on two simulation days, each student was asked to complete post-test questionnaires (T2) which comprised a scale ranking anxiety, self-confidence, caring ability, and satisfaction with simulation; and caring efficacy. The self-administered structured questionnaires took about 15 min to complete. All instruments were translated into Hebrew by two bilingual translators via the translation\ back-translation process. This procedure continued until the two bilingual translators agreed that the two versions of the instruments were identical, with no discrepancies Anxiety The students’ anxiety was measured at T1 and T2 by adapting the 20-item State-Trait Anxiety Inventory (STAI) developed by Spielberger (1983). This instrument provides measures of the individual’s emotional state in response to a particular situation or moment, which includes symptoms of apprehension, tension, and activation of the autonomic nervous system. Students were asked to rate the degree to which each statement describes their present feeling best, from “not at all” (1) to “very much so” (4). Various reliability and validity tests have been conducted on the STAI and have provide sufficient evidence that the STAI is an appropriate and adequate measure for studying anxiety in research and the clinical setting (Sesti, 2000). In the current sample, the scale achieved a standardized alpha coefficient of .82, .81 at T1, T2 respectively. Higher scale scores indicate higher levels of anxiety. Self-confidence Level Students were asked to rate their level of confidence in caring for a real patient at T1 and T2, on a 5-point single scale ranging from “not confident” (1) to “very confident” (5). Satisfaction with Simulation A six-item satisfaction with simulation scale was developed by the researcher. Students were asked to express their degree of agreement at T2 with each statement on a 5-step Likert scale from “strongly disagree” (1) to “strongly agree”(5). Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

Examples from this scale are, “The teaching methods used in this simulation were helpful and effective,” and “The simulation tested my clinical ability.” Content validity for the satisfaction scale was established by two nurses expert in quality assurance and clinical simulation followed by a pilot study. A higher average score on the scale reflects a higher satisfaction with learning by simulation (α = 0.83 at T2). Caring Ability The Caring Ability Inventory (CAI: Nkongho, 2003) was used to measure the extent of the student’s ability to care for others. This measure was conducted at T1 and T2. The CAI consists of 37 items with 13 reverse-scored items. The response format was a 7-point Likert scale (1 = “strongly disagree,” to 7 = “strongly agree”). An example of a reverse item is, “There is very little I can do for a person who is helpless,” While a high-score item is, “I understand people easily.” Nkongho (2003) reported an internal consistency of 0.79 to 0.84, a test retest coefficient of 0.75, and a content validity index of 0.80. Validity of the CAI was further supported by its ability to discriminate between students and nurses and between females and males, by factor analysis, and by results supporting hypotheses consistent with theory. Higher mean scores represent greater caring ability. The average score had good internal consistency (α = 0.70, 0.75 at T1, T2 respectively). R. Khalaila / Nurse Education Today 34 (2014) 252–258 Caring Efficacy The Caring Efficacy Scale (CES) measures the belief or selfconfidence in students’ ability to express caring behaviors and establish caring relations with patients (Coates, 1997). Permission to use the scale was obtained from Dr. Coates. The CES consists of 30 items, of which15 were positively worded and 15 negatively worded. Students were asked to express their degree of agreement with each statement on a 6-step Likert scale, from “strongly disagree” (− 3) to “strongly agree” (3). Sample items include, “I do not feel confident in my ability to express a sense of caring to my patients,” and “I can usually establish a close relationship with my patients.” The negatively worded items were recoded so that “strongly disagree” = 6 (− 3 on the original Likert scale) would reflect “strongly agree” = 1 (+ 3 on the re-coded Likert scale). The positively worded items were recoded to reflect “strongly disagree” = 1 (−3 on the original Likert scale) and strongly agree = 6 (+3 on the re-coded Likert scale). The overall mean is based on all 30 statements. Coates (1997) reported an internal consistency of 0.84 to 0.88. Concurrent validity of the CES was supported by assessment of the degree of relationship between the CES as a measure of caring and clinical evaluation tool as a measure of clinical competence. The higher the mean, the more students perceive that they have the ability to establish and express caring behaviors (α = 0.84). This measure was assessed at T2 after the simulation sessions. Data Analyses Differences at the two points of time were assessed by repeated ANOVA measures followed by post hoc analysis. Variables were analyzed on three levels: a univariate examination of means, standard deviations and ranges; on the bivariate level, Pearson product moment correlations, and independent t-tests were computed to clarify the associations between the independent variables and the outcome. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

The first hypothesis was analyzed by repeated measure analysis. Next, the second hypothesis was analyzed by means of hierarchical multiple linear regression to determine the extent to which anxiety level at T1 predicts caring efficacy after controlling for the effects of the control variable – the anxiety level at T1. The predictors of caring efficacy were entered in the following three steps: (a) control variable – anxiety level at T1, (b) anxiety level at T2, and (c) mediating variables. In the third phase, the mediating hypothesis was addressed. In order to demonstrate that caring ability, self confidence and satisfaction with simulation have a mediating effect between the anxiety level at T2 and caring efficacy, after controlling for the effects of the anxiety level at T1, it was necessary to carry out an additional regression beyond those 255 Table 2 Means (SDs) and differences at the time points in anxiety, self-confidence and caring ability measures. Variables Possible range Anxiety Self-confidence Caring ability 1–4 1–5 1–7 Time 1 Time 2 Mean SD Mean SD 1.80 3.6 5.19 0.35 0.9 0.45 1.71 4.2 5.38 0.35 0.6 0.45 F P value 6.17 24.69 24.43 P = 0.02 P = 0.001 P = 0.001 employed in the previous analyses. The mediating variables were entered in this subsequent model. To support a hypothesis of full mediation it is necessary to show that the beta weights for predicting the variable (anxiety at T2) were reduced from their beta weights in the equations that contained only the control variable and the predicting variable, and were not statistically significant. Partial mediation is demonstrated when the beta weights for the predicting variable are reduced, (but not to insignificance), from their beta weights in the equations that contained only the control variable and the predicting variable (Baron and Kenny, 1986). In all the regressions executed in the current inquiry, we included only those independent variables that were identified earlier in the bivariate analyses as significant. All tests of significance were two-tailed, with P values b 0.05 considered statistically significant. Data analysis used the Statistical Package for Social Sciences (SPSS) version 17.0. Results The majority of the students in the present sample were women (59%). About 88% of the students were unemployed, in a broad range of ages from 19 to 34, with an average age of about 22. Slightly more than half were Muslims (54.1%), followed by Christians (19.7%), Jews (16.4%), and Druze (9.8%). Table 1 shows the Pearson product moment correlations between the independent variables measured at T1 and T2, and the caring efficacy outcome at T2. The data show clearly that caring efficacy was negatively correlated to anxiety level at T1 (r = − 0.30, P = 0.02) and at T2 (r = − 0.46, P = 0.001). However, caring efficacy was positively associated with caring ability at T1 (r = 0.31, P = 0.02) and at T2 (r = 0.41, P = 0.02). Self-confidence at T2 was also positively correlated with caring efficacy (r = 0.54, P = 0.001); however self-confidence at T1 was not correlated (r = 0.16, P = 0.21). Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

Table 1 Pearson correlations among study variables (N = 61). Variables 1 1. Anxiety — T1 2. Anxiety — T2 1.00 0.70 P = 0.001 −0.46 P = 0.001 −0.39 P = 0.002 −0.30 P = 0.05 −0.28 P = 0.03 −0.08 P = 0.54 −0.31 P = 0.02 3. Caring ability — T1 4. Caring ability — T2 5. Self-confidence — T1 6. Self-confidence — T2 7. Satisfaction with simulation 8. Caring efficacy 2 3 4 5 6 7 1.00 −0.40 P = 0.001 −0.34 P = 0.008 −0.33 P = 0.01 −0.41 P = 0.001 −0.08 P = 0.55 −0.46 P = 0.001 1.00 0.77 P = 0.001 0.14 P = 0.28 0.32 P = 0.01 0.14 P = 0.27 0.31 P = 0.02 1.00 0.01 P = 0.98 0.22 P = 0.09 0.25 P = 0.05 0.41 P = 0.02 1.00 0.42 P = 0.001 0.02 P = 0.88 0.16 P = 0.21 1.00 0.15 P = 0.24 0.54 P = 0.001 1.00 0.36 P = 0.005 256 R. Khalaila / Nurse Education Today 34 (2014) 252–258 Finally, satisfaction with learning by simulation at T2 was also positively correlated with caring efficacy (r = 0.36, P = 0.005). Table 2 presents the descriptive statistics and the repeated measures ANOVA with post hoc analysis for anxiety, self-confidence and caring ability. The average score for anxiety level at T1 was moderate (M = 1.80, SD = 0.35), and it significantly decreased to (M = 1.71, SD = 0.35) at T2 (F[1, 60] = 6.17, P = 0.02). The average score for self-confidence was slightly high, increasing significantly between T1 (M = 3.6, SD = 0.9) and T2 (M = 4.2, SD = 0.9) (F[1, 60] = 24.69, P = 0.001). The mean score for caring ability was also slightly high, with a small SD, and increased significantly between T1 (M = 5.19, SD = 0.45) and T2 (M = 5.38, SD = 0.45) (F[1, 60] = 24.43, P = 0.001). To sum up, Hypothesis No. 1, which examined the changes in anxiety level, self-confidence and caring ability over time, was confirmed. Table 3 displays the hierarchical regression. We entered five independent variables in this analysis. The final model identified four significant predictors (F[5, 60] = 9.79, P = 0.001) of caring efficacy with an adjusted R2 of .42 (P = 0.001). The control variable (anxiety at T1) was entered first and, although it made a significant contribution in the first model (8%), it did not contribute to the dependent variable in the subsequent models. Looking at the second model, we can see a negative correlation between anxiety level at T2, and the outcome — caring efficacy, after controlling the effect of anxiety at T1. To sum up, Hypothesis No. 2, which examined the contribution of the anxiety level at T2 to caring efficacy, was also confirmed. The third model explored the extent to which the mediating variable (caring ability, self-confidence and satisfaction with simulation) mediates the effect of anxiety level at T2 on caring efficacy (Hypothesis No. 3). To test this, we entered the relevant variable in step 3, following prior entry of the anxiety level at T2. The results revealed that the mediating variable was found to be significant, and its inclusion added much explained variance to the model (ΔR2 = .23, P = 0.001). The results show that the standardized regression coefficients for anxiety at T2 declined from step 2 (Beta = − .48) to step 3 (Beta = − .29). The mediating variables have partially mediated between anxiety and caring efficacy at T2. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

The mediating variables also emerged as independent predictors: students who had higher scores of caring ability, selfconfidence and satisfaction with simulation were more likely to have higher scores on the caring efficacy. Discussion There are very few published empirical studies using caring ability and caring efficacy scales, which is why the comparative data are limited. The first research hypothesis, which investigated the change in the student’s self-reported anxiety, self-confidence and caring ability, was fully confirmed. We found that the level of anxiety decreased significantly after learning by simulations during the students’ first clinical experience. This finding support previous results which found that the use of high-fidelity simulation decreased nursing students’ level of anxiety at their first clinical experience (Rhodes and Curran, 2005; Szpak and Kameg, 2011). The latter findings contradict findings by other scholars, who found no significant difference in anxiety scores of students who participated in a critical care simulation training before an actual clinical critical care experience, as compared to those students who did not (Erler and Rudman, 1993). One possible explanation for this result is related to the students’ expectations of the unknown, of what can potentially occur, which may increase their worry, fear and anxiety before their first clinical practice. This anxiety can even increase during the first clinical practice in a hospital setting (without simulation) as a result of fear of doing harm to patients, or feeling incompetent and lack of professional nursing skills (Sharif and Masoumi, 2005). However, now that they have had their first clinical experience combined with simulations, it is likely that their reduced anxiety may be due to their having increased their knowledge, skills and clinical judgment, and their feeling of becoming more competent and confident in the clinical setting. Moreover, the findings showed a rise in self-confidence after the students’ first clinical practice with simulations. On one hand this finding supports prior studies which showed increased self-confidence levels after learning by simulations (Blum et al., 2010; Mould et al., 2011). On the other hand, it could be that the increase in students’ confidence results from actually caring for patients in the clinical setting (Brannan et al., 2008). However, other scholars revealed that students participating in the simulation experience were more confident than students participating in the traditional experience without simulation (Alfes, 2011). The results also showed that the students’ caring ability rose as well between the two measuring points. This finding supports the findings of previous studies which showed improved clinical performance by students after they used simulations (Bearnson and Wiker, 2005; Liaw et al., 2011). This finding may also have been related to course content or experiences within the clinical setting. However, other investigators noted that students who practiced with the Human Patient Simulators (HPS) in addition to their usual clinical training had significantly higher scores than the control group (usual clinical training alone) on clinical performance and ability such as patient identification, safety and assessing vital signs (Radhakrishnan et al., 2007). Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

The second hypothesis, which examined the association between students’ anxiety and caring efficacy after controlling their anxiety before their first clinical experience was also fully confirmed. It was found that the higher the anxiety, the lower the student’s caring efficacy. This finding means that students with high anxiety have low self-efficacy for providing care to patients, supporting the conclusions of previous studies which found that high anxiety among Table 3 Linear regressions of caring efficacy on independent variables (N = 61). Variables Anxiety — T1 Anxiety — T2 Caring ability — T2 Self-confidence — T2 Satisfaction with simulation — T2 Adjusted R2 F for change in R2 Model 1 Model 2 Model 3 B β P value B Β P value B β P value −0.41 −.31 0.02 −0.03 −0.63 −.02 −.48 0.88 0.005 −0.13 −0.39 0.22 0.28 0.27 0.42 8.91 P = 0.001 −.09 −.29 .22 .36 .23 0.49 0.04 0.05 0.03 0.001 0.08 6.29 P = 0.02 0.19 8.67 P = 0.005 R. Khalaila / Nurse Education Today 34 (2014) 252–258 students is likely to impact their caring ability and caring efficacy (King, 2010) and the quality of patient care in various clinical settings (Beddoe and Murphy, 2004; Cheung and Au, 2011). This result teaches us that by lowering anxiety scores, the nursing students’ caring efficacy scores increase. The third research hypothesis was also confirmed. The results showed that the variables of self-confidence level, satisfaction at learning through simulation and caring ability partially mediated the relationship between anxiety and caring efficacy. These findings demonstrate that self-confidence level, caring ability and satisfaction with simulation have a protective impact on students against the negative impact of anxiety. We also found that these variables contribute to the prediction of the student’s caring efficacy. Self-confidence level was the major factor contributing to predicting caring efficacy. We found that a student’s higher selfconfidence predicts higher caring efficacy for the student, a finding supported by previous studies (Blum et al., 2010). A higher level of satisfaction with simulation is another factor revealed as having a positive contribution in predicting the student’s caring efficacy. This result proposes that students who experience higher satisfaction with simulation will have more confidence and self-efficacy in patient care. Finally, it was found that students’ caring ability is positively associated with the student’s caring efficacy. This result suggests that students who feel a higher ability to care for others will have more confidence and belief in their ability to express caring behaviors and establish caring relations with patients. However to date there is no empirical evidence to support this in practice. Despite the study’s strengths, a few limitations should be noted. The first is that there is a single group of subjects, and although the study has a pre-test and post-test design, there is no control group. It is possible that students may have been reducing anxiety and improving outcomes as a result of multiple factors, including lectures and clinical practice, rather than as a result of the simulations. The second limitation is the small size and non-random selection of the convenience sample; it may be difficult to generalize the results beyond this population, and it may not be representative of other nursing students. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

Despite these limitations, however, the present study provides initial insights into the correlation between anxiety, self-confidence, caring ability, satisfaction with simulation 257 and caring efficacy among nursing students who are beginning their first clinical experience in a hospital setting, which has not been widely studied in this context thus far. Conclusions and Implications The findings of this study demonstrate that reduced anxiety levels and improved self-confidence, caring ability and caring efficacy among nursing students can be seen over time as students practice and learn with simulations. However, this improvement could be related also to being in a clinical setting during the study. Therefore, future experimental study with a control group is needed to evaluate the effectiveness of learning with simulations as compared to learning without simulations. The results also showed that anxious students were less confident and perceived their ability and efficacy to care patients as lower. Accordingly, nursing educators can identify what causes most anxiety during clinical practice and tailor simulations accordingly. Further, nursing educators should identify the anxious students during their first clinical experience, and suggest an appropriate intervention plan to reduce their anxiety levels. Using simulation methods seems to be a potential method for enhancing limited clinical practical placements. However, it will neither take the place of traditional methods of teaching nor replace good practice experience for nursing students, but can support both elements of nurse education. Nursing educators recommend replication of the simulations at various levels within the curriculum combined with clinical experiences and nursing courses. Simulations learning can provide a less expensive training environment that can be used to practice many KSAs and QSEN competencies, particularly non-technical skills such as clinical judgment, teamwork, leadership, and communication. Future research should examine the anxiety level, caring ability, self-confidence, and caring efficacy over time during all the years of clinical practice among student nurses. It will also be useful to examine the impact of different types of simulation experiences on the QSEN competency, such as knowledge, skills, attitudes, care quality improvement, interdisciplinary teams, and communications. Appendix A. Examples of Scenarios Scenario Situation Objectives Expected actions Asthma attack A 19-year-old soldier, accompanied by his commander, complained of shortness of breath, and a cough not responding to his regular medication. At admission — coughing, difficulty breathing and talking. The goal of this simulated experience is to develop and apply problem solving, critical thinking, knowledge, attitudes and interpersonal communication skills Stroke or Cerebral Vascular Accident (CVA) A 72-year old patient admitted to your internal department with sudden weakness of the face, arm and leg on left side of the body, difficulty talking, unexplained dizziness, headache and confusion. The patient was accompanied by his wife and son. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

The goal of this simulated experience is to develop and apply problem solving, critical thinking, knowledge, attitudes and interpersonal communication skills. 1. Administer oxygen therapy as prescribed, 2. Place client in high fowler’s position to facilitate air exchange, 3. Performs patient physical exam. 4. Monitor vital signs and rhythm for changes during an acute attack, 5. Initiate and maintain IV access 6. Give medications as prescribed (bronchodialators, anti-inflammatories), 7. Educate client (recognize triggers: smoke, dust, mold, weather changes). 1. Administer oxygen therapy as prescribed. 2. Perform patient physical exam. 3. Preventing and minimizing complications such as falls and aspiration. 4. Helping patients to fulfill their daily needs. 5. Provide support to the process of coping mechanisms 6. Provide information about disease process, prognosis, treatment and rehabilitation needs to the patient and his family. 258 R. Khalaila / Nurse Education Today 34 (2014) 252–258 References Alfes, C.M., 2011. Evaluating the use of simulation with beginning nursing students. J. Nurs. Educ. 50 (2), 89–93. Baron, R.M., Kenny, D.A., 1986. The moderator–mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J. Personal. Soc. Psychol. 51, 1173–1182. Bearnson, C.S., Wiker, K.M., 2005. Human patient simulators: a new face in baccalaureate nursing education at Brigham Young University. J. Nurs. Educ. 44 (9), 421–425. Beaubien, J.M., Baker, D.P., 2004. The use of simulation for training teamwork skills in health care: how low can you go? Qual. Saf. Health Care 13 (Suppl. 1), i51–i56. Beddoe, A.E., Murphy, S.O., 2004. Does mindfulness decrease stress and foster empathy among nursing students? J. Nurs. Educ. 43 (7), 305–311. Blum, C.A., Borglund, S., Parcells, D., 2010. High-fidelity nursing simulation: impact on student self-confidence and clinical competence. Int. J. Nurs. Educ. Scholarsh. 7. http:// dx.doi.org/10.2202/1548-923X.2035. Brannan, J.D., White, A., Bezanson, J.L., 2008. Simulator effects on cognitive skills and confidence levels. J. Nurs. Educ. 47 (11), 495–500. Bremner, M., Aduddell, K., Bennett, D., VanGeest, J., 2006. The use of human patient simulators: best practices with novice nursing students. Nurse Educ. 31 (4), 170–174. Bremner, M., Aduddell, K., Amason, J., 2008. Evidenced-based practices related to the human patient simulator and first-year-baccalaureate nursing students’ anxiety. Online J. Nurs. Inform. 12 (1) (http:/ojin.org/12_Bremner.html). Cant, R.P., Cooper, S.J., 2010. Simulation-based learning in nurse education: a systematic review. J. Adv. Nurs. 66 (1), 3–15. Cheung, R.Y., Au, T.K., 2011. Nursing students’ anxiety and clinical performance. J. Nurs. Educ. 50 (5), 286–289. Coates, C.J., 1997. The caring efficacy scale: nurses’ self-reports of caring in practice settings. Adv. Pract. Nurs. Q. 3 (1), 53–59. Cronenwett, L., Sherwood, G., Barnsteiner, J., Johnson, J., Mitchell, R., Warren, J., 2007. Quality and safety education for nurses. Nurs. Outlook 55, 122–131. Durham, C., Alden, K., 2012. Integrating quality and safety competencies in simulation. In: Sherwood, G., Barnsteiner, J. (Eds.), Quality and Safety in Nursing. Wiley-Blackwell, West Sussex, UK, pp. 227–249. Edwards, H., Smith, S., Courtney, M., Finlayson, K., Chapman, H., 2004. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

The impact of clinical placement location on nursing student’s competence and preparedness for practice. Nurse Educ. Today 24 (4), 248–255. Erler, C.J., Rudman, S.D., 1993. Effect of intensive care simulation on anxiety of nursing students in the clinical ICU. Heart Lung 22 (3), 259–265. Goldenberg, D., Andrusyszyn, M.A., Iwasiw, C., 2005. The effect of classroom simulation on nursing students’ self efficacy related to health teaching. J. Nurs. Educ. 44 (7), 310–314. Hofmann, B., 2009. Why simulation can be efficient: on the preconditions of efficient learning in complex technology based practices. BMC Med. Educ. 9, 48. http:// dx.doi.org/10.1186/1472-6920-9-48. Horsley, T.L., 2012. The effect of nursing faculty presence on students’ level of anxiety, selfconfidence, and clinical performance during a clinical simulation experience. ((Doctoral dissertation, University of Kansas). Retrieved from http://kuscholarworks.ku. edu/dspace/bitstream/1808/9991/1/Horsley_ku_0099D_12108_DATA_1.pdf). Institute of Medicine (IOM), 2003. Health Professions Education: A Bridge to Quality. National Academies Press, Washington, DC. Issenberg, S.B., McGsghie, W.C., Petrusa, E.R., Lee Gordon, D., Scalese, R.J., 2005. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med. Teach. 27 (1), 10–28. King, L.S., 2010. The Relationship of Anxiety and Caring in a Socially Constructed Learning Environment in Beginning Nursing Students. ((Doctoral dissertation, University of Kansas). Retrieved from: http://kuscholarworks.ku.edu/dspace/bitstream/1808/ 7082/1/King_ku_0099D_11205_DATA_1.pdf). Liaw, S.Y., Scherpbier, A., Rethans, J.J., Klainin-Yobas, P., 2011. Assessment for simulation learning outcomes: a comparison of knowledge and self reported confidence with observed clinical performance. Nurse Educ. Today. http:// dx.doi.org/10.1016/j.nedt.2011.10.006. Mikkelsen, J., Reime, M.H., Harris, A.K., 2008. Nursing students’ learning of managing cross-infections — scenario-based simulation training versus study groups. Nurse Educ. Today 28 (6), 664–671. Morgan, R., 2006. Using clinical skills laboratories to promote theory–practice integration during first practice placement: an Irish perspective. J. Clin. Nurs. 15 (2), 155–161. Mould, J., White, H., Gallagher, R., 2011. Evaluation of a critical care simulation series for undergraduate nursing students. Contemp. Nurse 38 (1–2), 180–190. Nkongho, N., 2003. The caring ability inventory, In: Strickland, O.L., Dilorio, C. (Eds.), Measurement of Nursing Outcomes: Self-care and Coping, 2nd ed. Springer Publishing Co., New York, pp. 184–198. Prescott, S., Garside, J., 2009. An evaluation of simulated clinical practice for adult branch students. Nurs. Stand. 23 (22), 35–40. Radhakrishnan, K., Roche, J., Cunningham, H., 2007. Measuring clinical practice parameters with human patient simulation: a pilot study. Int. J. Nurs. Educ. Scholarsh. 4 (1), 1–11. Rhodes, M., Curran, C., 2005. Use of the human patient simulator to teach clinical judgment skills in a baccalaureate nursing program. Comput. Inform. Nurs. 23 (5), 256–262. Rothgeb, M.K., 2008. Creating a nursing simulation laboratory: a literature review. J. Nurs. Educ. 47 (11), 489–495. Sanford, P.G., 2010. Simulation in nursing education: a review of the research. Qual. Rep. 15 (4), 1006–1011. Sesti, A., 2000. State trait anxiety inventory in medication clinical trials. Qual. Life Newsl. 25, 15–16. Sharif, F., Masoumi, S., 2005. A qualitative study of nursing student experiences of clinical practice. BMC Nurs. 4 (6). http://dx.doi.org/10.1186/1472-6955-4-6. Shepherd, C.K., McCunnis, M., Brown, L., Hair, M., 2010. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

Investigating the use of simulation as a teaching strategy. Nurs. Stand. 24 (35), 24–48. Shipton, S.P., 2002. The process of seeking stress-care; coping as experienced by senior baccalaureate nursing students in response to appraised clinical stress. J. Nurs. Educ. 41 (6), 243–255. Spielberger, C.D., 1983. Manual for the State-Trait Anxiety Inventory (Form Y). Mind Garden, Palo Alto, CA. Szpak, J.L., Kameg, K.M., 2011. Simulation decreases nursing student anxiety prior to communication with mentally ill patients. Clin. Simul. Nurs. http://dx.doi.org/10.1016/ j.ecns.2011.07.003. Ward-Smith, P., 2008. The effect of simulation learning as a quality initiative. Urol Nurs. 28 (6), 471–473. White, A.H., 2003. Clinical decision making among fourth year nursing students: an interpretive study. J. Nurs. Educ. 42 (3), 113–120. AJN REPORTS The Value of Simulation in Nursing Education This clinical activity is transforming nursing training and practice. C linical simulation—defined by the National Council of State Boards of Nursing (NCSBN) as “an activity or event replicating clinical practice using scenarios, high-fidelity manikins, medium-fidelity manikins, standardized patients, role playing, skills stations, and computer-based crit­ical thinking simulations”—has become an in­ tegral part of nursing education. In 2010, a national survey of prelicensure nursing programs conducted by the NCSBN revealed that 87% of ­respondents were using medium- or high-fidelity patient manikins in their curricula. And in 2014 a landmark national study, also conducted by the NCSBN, found no statistically significant differences in clinical competency or comprehensive nursing knowledge between students who had undergone traditional clinical experiences and those who had either 25% or 50% of their traditional clinical hours replaced by simulation. The NCSBN determined that nursing programs could substitute up to 50% of traditional clinical practice with simulation, provided they include “faculty members who are formally trained in simulation pedagogy, an adequate number of faculty members to support the student learners, subject matter experts who conduct theory-based debriefing, and equipment and supplies to create a realistic environment.” The NCSBN’s 2014 study led to the development, a year later, of the NCSBN Simulation Guidelines for Prelicensure Nursing Education Programs, which are among the three best practice guidelines currently used by simulation programs. The other two are the International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice: Simulation—which provide “an evidence-based framework to guide simulation design, implementation, debriefing, evaluation, and research”—and the Society for Simulation in Healthcare (SSH) standards, through which simulation programs may receive accreditation and simulation educators may obtain professional certification. ajn@wolterskluwer.com FROM PROTOTYPE TO EVERYDAY USE In 1958, Norwegian doll manufacturer Asmund S. Laerdal, who had years earlier saved his son from drowning by pulling him out of the water and clearing his airways, was asked to develop a manikin for mouth-to-mouth resuscitation, with airways that could be obstructed and cleared, a head that could be turned, and a chest that would respond to inflation. By 1960, Laerdal had developed “Resusci Anne,” the now-ubiquitous CPR manikin. Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

(Today, his company, Laerdal, is among the leading producers of medical simulation and clinical training equipment.) Nearly a decade later, Sim One, the first computer-controlled patient simulator, created by Judson Denson and Stephen Abrahamson at the University of Southern California, allowed anesthesia residents to train in endotracheal intubation. In the decades since those early prototypes, simulation has become integral to nursing education and practice, supplementing learning outside of the classroom or used as an instructional method to further explore such difficult subjects as end-of-life issues, critical illness, and cultural sensitivity. The skills that may be enhanced with the use of simulation include technical and functional expertise, problem-solving and decision-making competence, and interpersonal and communication skills. SIMULATION IN NURSING EDUCATION “Simulation is a sophisticated teaching strategy, and has been around a long time,” says Susan Gross Forneris, PhD, RN, CNE, CHSE-A, excelsior deputy director of the Center for Innovation in Simulation and Technology at the National League for Nursing (NLN). “But with the advent of high-fidelity manikins, the realness factor has changed and simulation has gained more ground. The question is, what are you trying to achieve? The desired outcome drives how much realism you need.” Together with Laerdal, the NLN has launched Simulation Education Solutions for Nursing (SESN), which helps schools and programs—both undergraduate and graduate—to AJN ▼ April 2018 ▼ Vol. 118, No. 4 17 AJN REPORTS Nursing students interact with a manikin that talks and simulates symptoms in a mock ED simulation lab at Northeastern University School of Nursing in Boston. Photo © Melanie Stetson Freeman / Christian Science Monitor / The Image Works. implement simulation training for nursing students. In addition, SESN ensures that programs are compliant with the three best practice guidelines (those of the NCSBN, INACSL, and SSH) and that they adhere to the specific requirements of their individual state boards of nursing, which determine, for ex­ ample, how many hours of clinical practice may be substituted by simulation. “Some states are more prescriptive in their requirements, while others are looser,” says Forneris. “It’s a constantly evolving process.” Simulation training is not limited to students, and many programs exist to help practicing clinicians further their training or to assist hospitals to achieve such benchmarks as low infection rates and early identification and management of sepsis. For example, the Center for Medical Simulation (CMS), affiliated with Harvard University in Boston, provides courses for clinicians, health care educators, administrators, and managers, and consults with organizations on developing simulation programs. The training for clinicians focuses on teamwork, crisis resource management, and error prevention, in such specialties as anesthesiology, labor and delivery, emergency medicine, intensive care, and pediatrics. Nurses who participate receive a certificate of attendance, with credit hours that may be converted to CEs or CEUs. Kate Morse, PhD, MSN, RN, associate director for educational leadership and international programs at the CMS, explains that in any simulation 18 AJN ▼ April 2018 ▼ Vol. 118, No. 4 program course designs are influenced by multiple factors, including the INACSL standards and information from the Best Evidence Medical Education Collaboration, an international organization committed to the development of “evidence-informed education in the medical and health professions.” Discussion: Informatics And Telehealth In Rural Medicines TedEx Video Analysis

Furthermore, she says, “when designing a simulation course or experience, expectations must be made clear: Is the purpose of the assessment summative or formative? What are participants being evaluated on, and what potential consequences are there?” Morse stresses that a psychologically safe learning environment is critical. At the CMS, consistent with best practices, simulation experiences are followed by a structured debriefing that may include video playback. Also gaining ground are virtual simulation courses—which replicate real-life scenarios in virtual clinical environments—although, Forneris says, virtual “isn’t a replacement for live clinical simulation. At least not yet.” That may change in time. One recent literature review of 12 studies published between 2008 and 2015 found that online virtual simulation is at least comparable or even superior to traditional simulation methods and therefore has promise as a teaching and learning tool. However, it is not yet clear whether it’s effective for diagnostic reasoning, and if it’s best used as a teaching tool or an assessment strategy, or both. Several factors have been driving the proliferation of simulation training, including an increase in the number of undergraduate nursing programs, which has led to more competition for clinical placement sites. Furthermore, to ensure patient safety, some acute care facilities have reduced the number of nursing students allowed on a patient unit at one time or restricted the activities students may perform. But another factor, Forneris explains, is that by transforming nursing education from content delivery to contextual learning, simulation offers students the kinds of experiences they need to safely transition into practice, and is encouraging faculty to change their pedagogic approach. “After experiencing a simulation session with students and doing the debriefing,” she says, “many faculty have expressed feeling like they’ve really evolved. Rather than saying to students, ‘I’ll show you how to do this,’ they give them a chance to perform. It’s less show-and-tell.” Debriefing sessions conducted after training, Forneris adds, are often transformational for students and faculty alike. “As nurses, we have long known how to have therapeutic conversations with patients. Then we realized, why not with students? Simulation has changed the conversation.”—Dalia Sofer ▼ ajnonline.com