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eses, Dissertations and Capstones
1-1-2009
e Eect of Virtual Clinical Gaming Simulations
on Student Learning Outcomes in Medical-
Surgical Nursing Education Courses
Robin A. Lewis
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THE EFFECT OF VIRTUAL CLINICAL GAMING SIMULATIONS ON STUDENT
LEARNING OUTCOMES IN MEDICAL-SURGICAL NURSING EDUCATION
COURSES
Robin A. Lewis, EdD, MSN, FNP-BC, RN
Marshall University
Graduate School of Education and Professional Development
Dissertation submitted to the faculty of the
Marshall University Graduate College
in partial fulfillment of the requirements
for the degree of
Doctor of Education
in
Curriculum and Instruction
Committee Chair, Lisa A. Heaton, PhD
Rudy Pauley, EdD
Samuel Securro, EdD
David L. Rodgers, EdD
Huntington, West Virginia, 2009
Keywords: Gaming, Simulation, Nurses, Nursing Education, Learning Strategies
Copyright 2009 by Robin A. Lewis
ABSTRACT
The Effect of Virtual Clinical Gaming Simulations on Student Learning
Outcomes in Medical-Surgical Nursing Education Courses
The purpose of this study was to determine what the effects of virtual clinical
simulation instruction were on the learning outcomes of students in higher education
medical-surgical nursing education courses. This study fills a gap in the literature by
adding data to the body of knowledge related to the use of this strategy for practical
application in the classroom. This study used a causal comparative design. Data were
acquired from the ATI Content Mastery Series (CMS) 2.1 Medical Surgical Examination
™ information for the fall 2006 through fall 2008 academic semesters. Additionally, data
were collected using a pre- and post-course Medical-Surgical Nursing Self-Assessment
Survey administered to the medical-surgical virtual clinical simulation comparison group
during the fall 2008 semester. Participants were higher education undergraduate medical-
surgical nursing students at one urban private university enrolled during the 2008-2009
academic year. Students were fluent English speakers and had a grade point average
(GPA) of 2.5 or greater in nursing coursework. Participation in the survey was voluntary.
Benefits of the research included positive effects of using virtual clinical simulation to
deliver medical-surgical nursing content. Findings revealed that students who received
virtual clinical simulation instruction significantly demonstrated (p = .000) for medical-
surgical content mastery and 100% of students demonstrated positive growth (p = .000)
in perceived competency. Results empower nursing stakeholders such as administrators,
program chairs, faculty, and students with information for decision-making about
learning outcomes, limitations, and recommendations related to the use of virtual clinical
simulations in medical-surgical nursing education courses.
iii
DEDICATION
This work is dedicated to professional nursing educators who strive to create
enjoyable learning in the classroom using innovative virtual clinical simulation
instruction integrated with multimedia technology preferred by today’s digital native
students. Using virtual clinical simulations for nursing process application with didactic
material provides increased student experiences during training independent of instructor
and clinical site availability. Lastly, I dedicate this study to the University of Charleston
professional nurse graduating class of 2009 for volunteering then demonstrating
achievement and competence in medical-surgical nursing content mastery with virtual
clinical simulation instruction.
ACKNOWLEDGEMENTS
Without the influence, guidance, dedication, scholarship, and service of the doctoral
faculty of the Marshall University Graduate School of Education and Professional
Development at South Charleston, West Virginia, this dissertation research study would not
have been imagined or possible.
To Dr. Lisa Heaton I want to express my gratitude for your guidance, nurturing,
prompting, and superior example as an educator, researcher, advisor, and scholar. Through
your passionate and dedicated professional practice of education, you have excelled as a leader
and innovator of technology-integrated instruction in your field creating, exploring,
investigating, and publishing best-educational practices with students of all ages. Your
influence on the profession lives and grows through the students and peers you have mentored
and guided along the way. I have been influenced by you in both roles and I will be eternally
grateful for the knowledge, skills and behaviors you have instilled in me to practice as a
professional nurse educator using technology to deliver nursing content and to engage in
research to determine the effects of these innovative strategies on student learning.
To Dr. Rudy Pauley I want to convey my appreciation for your influence as an
educational leader and practitioner. Through your innovative words and deeds, you
demonstrate that technology integration in curriculum can promote learning for understanding
from communication, collaboration, and problem solving that is fun and creative.
To Dr. Samuel Securro I offer my gratitude and thanks for your inspiration as an
educator, researcher and statistician. Through your innovative teaching using technology
enhanced simulation instruction in the computer analysis in educational leadership studies
iv
research course, you made learning the connection between research design and appropriate
statistical decision-making interactive and enjoyable. Thank you for demonstrating an effective
teaching model for simulation instruction in the classroom.
To Dr. David L. Rodgers I wish to extend my thankfulness to you for being a role
model for simulation instruction to prepare healthcare providers in realistic settings for future
performance during critical health incidents with patients. Your work reveals that simulation
provides opportunities for students to practice life-saving measures in safe settings to gain
experience that can affect their future performance and ultimately a patients’ health.
To my family I extend my gratitude and appreciation for instilling in me the belief that
education is a life-long process toward enriched existence and professional practice. The
guidance and support I received from the hard work of my parents provided me my first
opportunity for a college degree. Thank you to my mom Joyce Lewis for all the sacrifices you
made to give me the chance to attain my dream of being a nurse. To my dad who passed away
before I reached this milestone I remain thankful for the life lessons that he taught. First, to live
each day as if it were a last telling those you love you love them as often as you can. Second, to
seize every opportunity to experience the things you love doing. Third, to love yourself by
never giving up on your dreams but instead persevering because when all seems lost the time
comes when your preparation and circumstance meet and life becomes your dreams.
To my friends and colleagues I say thanks for listening, sharing and caring during the
experiences of this journey. Your empathy, criticism, laughter, chocolate, and coffee were
appreciated. Special thanks to Annie Dick, Chelsea Rose, Rose Kyle, Cookie and Ronnie Ison,
Mary Wells, Nancy Chandler, Dr. Sandra Bowles, Dr. Laura Meeks Festa, Dr. Paula Reilley,
and Dr. Debra Kay Mullins for your support and encouragement.
v
TABLE OF CONTENTS
ABSTRACT ................................................................................................................................ ii
DEDICATION ........................................................................................................................... iii
ACKNOWLEDGEMENTS ...................................................................................................... iv
LIST OF TABLES ................................................................................................................... viii
LIST OF FIGURES ................................................................................................................... ix
CHAPTER ONE: INTRODUCTION ....................................................................................... 1
BACKGROUND .................................................................................................................. 2
Nursing Education ....................................................................................................... 2
Instructional Methods .................................................................................................. 4
Learning Theory .......................................................................................................... 5
Student Characteristics ................................................................................................ 7
Achievement ................................................................................................................ 9
Competence ............................................................................................................... 11
PROBLEM STATEMENT .................................................................................................... 12
PURPOSE OF THE STUDY ................................................................................................. 13
RESEARCH QUESTIONS ................................................................................................... 13
DEFINITION OF TERMS .................................................................................................... 14
OPERATIONAL DEFINITIONS ........................................................................................... 15
SIGNIFICANCE OF THE STUDY ......................................................................................... 16
ASSUMPTIONS ................................................................................................................ 17
LIMITATIONS OF THE STUDY........................................................................................... 18
CHAPTER TWO: REVIEW OF RELATED LITERATURE ............................................ 19
NURSING EDUCATION ..................................................................................................... 19
INSTRUCTIONAL METHODS ............................................................................................. 22
Gaming Instruction .................................................................................................... 23
Simulation Instruction ............................................................................................... 30
Gaming Simulation Instruction ................................................................................. 40
LEARNING THEORY ........................................................................................................ 42
Adult Learning Theory .............................................................................................. 42
Chaos Theory ............................................................................................................. 44
Cognitive Theory ....................................................................................................... 45
Constructivism ........................................................................................................... 46
STUDENT CHARACTERISTICS .......................................................................................... 48
ACHIEVEMENT ................................................................................................................ 51
COMPETENCE ................................................................................................................. 55
OPINION ......................................................................................................................... 58
SUMMARY ...................................................................................................................... 60
CHAPTER THREE: RESEARCH METHODS .................................................................... 62
RESEARCH QUESTIONS ................................................................................................... 62
RESEARCH DESIGN ......................................................................................................... 62
Research Question One ............................................................................................. 63
Research Question Two ............................................................................................. 63
vi
Research Question Three ........................................................................................... 63
POPULATION AND SAMPLE ............................................................................................. 63
Research Question One ............................................................................................. 64
Research Question Two ............................................................................................. 64
Research Question Three ........................................................................................... 65
INTERVENTION ............................................................................................................... 65
INSTRUMENTATION......................................................................................................... 66
DATA ANALYSIS ............................................................................................................. 67
Research Question One ............................................................................................. 67
Research Question Two ............................................................................................. 68
Research Question Three ........................................................................................... 68
SUMMARY ...................................................................................................................... 68
CHAPTER FOUR: FINDINGS .............................................................................................. 70
POPULATION AND SAMPLE ............................................................................................. 70
MAJOR FINDINGS ............................................................................................................ 71
Research Question One ............................................................................................. 72
Research Question Two ............................................................................................. 76
Research Question Three ........................................................................................... 80
ANCILLARY FINDINGS .................................................................................................... 83
SUMMARY OF FINDINGS ................................................................................................. 84
CHAPTER FIVE: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ......... 86
POPULATION AND SAMPLE ............................................................................................. 87
METHODS ....................................................................................................................... 88
SUMMARY OF FINDINGS ................................................................................................. 88
FINDINGS RELATED TO THE LITERATURE ....................................................................... 89
Major Findings .......................................................................................................... 90
Ancillary Findings ..................................................................................................... 90
CONCLUSIONS ................................................................................................................ 92
IMPLICATIONS ................................................................................................................ 93
RECOMMENDATIONS FOR FUTURE STUDIES ................................................................... 94
REFERENCES .............................................................................................................. 97
APPENDICES ......................................................................................................................... 109
APPENDIX A: PARTICIPANT LETTER .................................................................. 110
APPENDIX B: PARTICIPANT SURVEY ................................................................. 112
APPENDIX C: PANEL OF EXPERTS ....................................................................... 115
APPENDIX D: PARTICIPANT LETTER WITH MARSHALL UNIVERSITY
INSTITUTIONAL REVIEW BOARD APPROVAL .................................................. 117
APPENDIX E: MARSHALL UNIVERSITY INSTITUTIONAL REVIEW BOARD
APPROVAL ................................................................................................................ 119
CURRICULUM VITAE .............................................................................................. 121
vii
LIST OF TABLES
Table 1: Research Question One - Descriptive Statistics. .......................................................... 73
Table 2: Research Question One - ANOVA. ............................................................................. 74
Table 3: Research Question One - Bonferroni Post Hoc Test. ................................................... 74
Table 4: Research Question Two - Descriptive Statistics. ......................................................... 77
Table 5: Research Question Two - ANOVA. ............................................................................. 78
Table 6: Research Question Two - Least Significant Difference (LSD) Post Hoc Test. ........... 79
Table 7: Research Question Three - Descriptive Statistics. ....................................................... 81
Table 8: Research Question Three - Mean Rank. ....................................................................... 82
Table 9: Research Question Three -Two-Related Samples Wilcoxon Matched-Pairs Signed-
Rank Test. ................................................................................................................................... 83
Table 10: Ancillary Findings - Student Opinion Analysis. ........................................................ 83
viii
1
CHAPTER ONE: INTRODUCTION
Over the past decade, higher education institutions have undergone reform to integrate
technology into instruction (Allen & Seaman, 2006; Brill & Galloway, 2007; Hancock, Bray &
Nason, 2002; Vogel & Klassen, 2001). Despite these trends, nursing educators continue to rely
on traditional methods of teaching (Henry, 1997; Royse & Newton, 2007). Pleas for
educational reform in nursing using innovative strategies and technology that make the
teaching/learning process enjoyable while preparing students for a demanding chaotic health
care system are emerging (Jefferies, 2007; National Council of State Boards of Nursing
[NCSBN], 2006; National League for Nursing [NLN], 2008; Royse & Newton, 2007). The
importance of this issue to nursing education exists because today’s students are different; they
are the Net-Generation (N-Geners) (Tapscott, 1998), known as digital natives (Prensky, 2001a,
2001b), and as such, require changed instructional and assessment strategies (Howell, 2004).
Because today’s students are different, nurse educators need awareness of their
distinctiveness. Digital natives have grown up with an Internet and digital technology presence
throughout their entire lives making them the first digitally literate generation (Howell, 2004;
Prensky, 2001a, 2001b; Tapscott, 1998). This unique life experience has yielded developmental
differences in learning, thinking, and working (Howell, 2004; Prensky, 2001a, 2001b; Tapscott,
1998).
For instance, digital media has supplied digital natives a platform to explore, socialize,
communicate, interact, discover, create, and debate in different ways than previous generations
(Tapscott, 1998). Thus, they are characterized as a curious, tolerant, assertive, self-reliant,
assured, highly clever, and quarrelsome group (Tapscott, 1998). In addition, digital natives
communicate differently than their predecessors because they use digital resources, to
frequently and readily, converse with the world (Howell, 2004; Prensky, 2001a, 2001b;
Tapscott, 1998). Increased communication with diverse groups makes them more connected,
experiential, social, and service oriented than prior students (Prensky, 2001a, 2001b; Tapscott,
1998). Because digital natives have always had access to and used digital media for
communication and information, they anticipate similar experiences for learning and evaluation
(Howell, 2004; Prensky, 2001a, 2001b; Tapscott, 1998). Thus, digital natives expect
immediacy, structure, engagement, teamwork, and visual and kinesthetic media (Howell, 2004;
Prensky, 2001a, 2001b; Tapscott, 1998). Since digital natives as learners are different from
previous generations, educational transformation is needed. Therefore, if nursing educators
want to teach digital native students effectively, they need to reform their practice with
innovative instructional strategies that integrate digital media and technology.
Background
Nursing Education
Historically, since the first university nursing education program at Yale University in
1923, nursing educators have predominantly used traditional instructional methods of lecture in
university classrooms, reserving experiential methods for clinical settings (Aranda, 2007;
Henry, 1997; Royse & Newton, 2007; Schmitz, MacLean, & Shidler, 1991). This phenomenon
is related to the profession of nursing evolving from an applied vocation in bedside and hospital
apprenticeships to a professional discipline in higher education institutions (Aranda, 2007). The
approach of separating didactic content and clinical situations in current university settings
results in a delay of practical application of realistic nursing care for students. Furthermore, the
nature of clinical experience in hospital settings is dependent upon the care needs of available
2
patients and the availability of an instructor to provide safe opportunities for the student to
practice nursing care functions (Larew, Lessans, Spunt, Foster & Covington, 2006). Nursing
education reform directed at increasing realistic practical experience in the classroom would
decrease time delays between didactic and practical application as well as eliminate patient and
instructor availability barriers for nursing student experiences.
To increase realistic practical application in objective, safe environments, some higher
education institutions have integrated digital media and technology into instruction (Allen &
Seaman, 2006; Brill & Galloway, 2007; Hancock et al., 2002; Larew et al., 2006; Vogel &
Klassen, 2001). Currently, technology is thought to be “the practical application of
knowledge… [and]…a capability given by the practical application of knowledge”
(Technology, 2008, ¶ 1). Thus, technology is the use of digital media integrated as either an
antecedent or consequence to practical or experiential learning in the classroom. Simply stated,
technology integration in nursing education is an instructional strategy to transform educational
delivery with applied methods.
Though colleges and universities have begun educational reform to integrate technology
into instruction, the discipline of nursing is lagging in the adoption of technology for practical
application in the classroom, creating barriers for adult learners who prefer doing an action
while simultaneously hearing and seeing how it is done (Ward & O’Brien, 2005). However,
pleas for educational reform in nursing to incorporate digital media that provides instruction
that is more realistic are emerging (Barber & Norman, 1989; Barnes & Rudge, 2005; Jefferies,
2007; Mallow & Gilje, 1999; NCSBN, 2006; Nehring, Ellis, & Lashley, 2001; Nehring &
Lashley, 2004; NLN, 2001; Royse & Newton, 2007; Sauvé, Renaud, Kaufmann, & Marquis,
3
2007). The innovative teaching strategy of virtual clinical simulation instruction applied with
educational gaming software is an option to meet this need.
Instructional Methods
A game is defined as an “artificial situation in which players, put in a conflict with one
another or against other forces, are governed by rules that structure their actions in order to
meet learning objectives and a goal determined by the game” (Sauvé et al., 2007, p. 251).
Gaming refers to simulation or reenactment of “real-life” activities containing the element of
realism (Tashiro, 2006). Simulation is an instruction and evaluation method in which students
practice “tasks and processes in …[realistic]… circumstances using models or virtual reality,
with feedback from observers, peers, actor-patients and video cameras to …[develop]… skills”
(Eder-Van Hook, 2004, p. 4). For this study, gaming and simulation are synonymous terms
used to represent an instructional method that incorporates practice, experience, and feedback
for knowledge construction in real-world situations using digital media.
Virtual clinical gaming simulations are a form of digital media instruction designed to
provide realistic interactive patient care scenarios for learning with educational gaming
software (Tashiro, 2006). Practice disciplines like sociology (Petranek, 2000) and medicine
(Agazio, Pavlides, Lasome, Flaherty, & Torrance, 2002; Eder-Van Hook, 2004) use gaming
simulation instruction in classroom and clinical laboratories to integrate content with
application. However, nursing has been slow to adopt gaming simulation instruction though the
method is suitable for adult learners when the goal is to construct knowledge from doing
(Henry, 1997; Morton, 1997; Walljasper, 1982; Ward & O’Brien, 2005).
Reluctance in nursing to implement gaming simulation instruction may be linked to the
limited number of studies reporting on the effectiveness of simulation as a teaching strategy to
4
enhance student learning (Alinier, Hunt, Gordon, & Harwood, 2006; Ballatine, 2003; Bays &
Hermann, 1997). By contrast, adoption of gaming simulation instruction by nurse educators
may also be hampered by empirical findings that demonstrate similar student performance
between traditional and gaming simulation instruction, or that there is no statistical difference
in student achievement for traditional instruction compared to gaming simulation instruction.
For instance, no statistical difference was found between conventionally instructed students and
gaming simulation instructed students on their ability to generate hypotheses and learn issues in
nursing problem-based learning (PBL) courses (Ingram, Ray, Landeen, & Keane, 1998).
Additionally, traditional instruction was found to be more effective than gaming simulation
instruction (p = .000) for student achievement on immediate recall of geriatric concepts
(Montpas, 2004).
Learning Theory
Theoretical discussions about digital media virtual clinical gaming simulations for
learning in nursing are evolving. The perspectives of adult learning theory, chaos theory,
cognitive load theory, and constructivism support the integration of digital media into
instruction (De Miranda, 2004; Hmelo-Silver, 2004; Henry, 1997; Leigh & Spindler, 2004;
Lewis, Saydak, Mierzwa & Robinson, 1989; Paas, Tuovinen, Tabbers, & Van Gerven, 2003;
Peters, 2000; Spigner-Littles & Anderson, 1999; Vogel & Klassen, 2001; Ward & O’Brien,
2005).
Proponents of adult learning theory contend that adult learners are self-motivated, self-
directed individuals who prefer learning that involves active participation, practical experience,
and real-world problem solving (Henry, 1997; Knowles, 1979; Lewis et al., 1989; Ward &
O’Brien, 2005). Thus, digital media instructional strategies that incorporate these components
5
are appropriate for adult learners. The instructional strategy of virtual clinical gaming
simulation uses digital media instruction created to provide realistic interactive patient care
scenarios that prompt users to apply the nursing process of assessment, diagnosis, outcome
identification, planning, implementation, and evaluation to problem-solve clinical situations in
a virtual hospital (Tashiro, 2006). Therefore, the use of virtual clinical gaming simulation is an
appropriate instructional strategy for adult learners who have been introduced to the nursing
process within nursing curriculum (Ward & O’Brien, 2005).
Chaos theory promoters suggest that direction and logic coexist with chaos in dynamic
systems (Leigh & Spindler, 2004). Open simulations are virtual experiences representing
scenarios created and guided by educators to sensitize or prepare learners for action in
patterned chaotic and unpredictable real life settings. Virtual clinical gaming simulations are
open simulations of patient care scenarios created to prepare nurses for action in unpredictable
healthcare settings through learning to use the structured and logical nursing process in
patterned changing patient problems.
The viewpoint from cognitive load theory assumes that humans have a working
memory with a limited capacity to apply or transfer acquired information to new situations and
an unlimited long-term memory that interacts or processes visual/auditory information to hold
schemas that vary in complexity and automation (Paas et al., 2003). Based on this premise,
cognitive theorists argue that instruction should be designed with multimedia to be effective
and mentally efficient in promoting schema construction and automation.
Additionally, advocates of constructivist learning theory assert the viewpoint that
knowledge and learning are constructed through the acts of communication, collaboration, and
problem solving in real-world settings (Hmelo-Silver, 2004; Spigner-Littles & Anderson, 1999;
6
Vogel & Klassen, 2001). Constructivists believe that learning occurs best through practical
application and doing that builds upon prior knowledge (Hmelo-Silver, 2004; Spigner-Littles &
Anderson, 1999; Vogel & Klassen, 2001). Virtual clinical gaming simulations are rich with
digital media such as sounds, video clips, and visual cues to engage learners actively in realistic
patient care scenarios (Tashiro, 2006). Furthermore, virtual clinical gaming simulations require
students to solve patient problems, applying previously learned nursing actions through
collaboration and communication with virtual actors (i.e., patients, other healthcare
professionals, and peers) within the game or simulation (Tashiro, 2006). Thus, virtual clinical
gaming simulations are suitable instructional strategies to use with nursing students in
constructivist classrooms.
Student Characteristics
Modern adult student learners differ from previous generations. Contemporary higher
education students, characterized as digital natives (Howell, 2004; Prensky, 2001a, 2001b;
Tapscott, 1998), are the first generation to develop encircled by and using digital technology
(i.e., Internet, computers, videogames, etc.) their entire lives. Digital natives have grown up in a
digital media environment so their experiences differ from previous generations. Physicians,
neuroscientists, psychologists, and psychiatrists contend that if an individual has exposure to
different types of experiences it will lead to changed brain structures, functioning, and
processing (Farah et al., 2008; Greenough, Black, & Wallace, 1987; Grossman et al., 2003;
Hammock, 2006; Heidelise et al., 2004; Prensky, 2001a, 2001b; Wilkinson, 2004). Because
digital natives have had the distinct experience of digital media exposure throughout life, their
brain makeup is unlike their predecessors; they think and process information differently
(Howell, 2004; Prensky, 2001a, 2001b; Tapscott, 1998). A changed student population in
7
higher education prompts educational reform. College and university educators must empower
themselves with knowledge of digital native characteristics so they can implement educational
strategies appropriate for this new type of student.
Digital natives are the group of students who have always had access to a commercial
Internet, launched in the United States (US) in 1992, and who have always used digital
technology in a digital world (Howell, 2004; Prensky, 2001a, 2001b; Tapscott, 1998). For
everyone else “not born into the digital world but have, at some later point …become
fascinated by and adopted many or most aspects of new technology are, and always will be
…digital immigrants” (Prensky, 2001a, p. 2).
The important difference between these two groups is in the way they obtain
information. For example, digital immigrants always “retain to some degree their ‘accent’, that
is their foot in the past” (Prensky, 2001a, p. 2). “Digital immigrant assertion… [is exemplified
in actions such as]…turning to the Internet second rather than first… [for information]… or in
reading the manual for a program rather than assuming that the program itself will teach us to
use it” (p. 2). Thus, digital immigrants prefer to gain knowledge similar to their life experiences
in a digital free world, seriously, slowly, in sequenced steps from text and lectures (Prensky,
2001a). By contrast, digital natives desire to receive information and be evaluated the way they
have acquired information from their experiences with and using digital media first, and for
nearly everything, including entertainment, communication, collaboration, and learning
(Howell, 2004; Prensky, 2001a, 2001b; Tapscott, 1998). Digital natives prefer learning
playfully, quickly, in multitasking situations from graphics, audio and multimedia games
(Prensky, 2001a; Tapscott, 1998).
8
Learning preferences of digital natives are elucidated further by the account that
“today’s average college grads have spent less than 5,000 hours of their lives reading, but over
10,000 hours playing video games” (Prensky, 2001a, p.1). In other words, digital natives favor
interactive hands on methods like multimedia gaming experiences for acquiring information
over traditional passive methods like reading. Therefore, higher education faculty who use
innovative multimedia and gaming strategies for instruction, compared to traditional teaching
approaches, facilitate the fun and interactive learning environments preferred by digital native
students for knowledge achievement.
Achievement
Achievement of knowledge or content mastery in nursing has traditionally been
measured by objective written examinations (Davenport, 2007; Jacobs & Koehn, 2006; Mosser,
Williams, & Wood, 2006; Newman & Williams, 2003; Rushton & Eggett, 2003; Seldomridge
& DiBartolo, 2004). For instance, all professional nurses in the US must be licensed to practice.
Licensure is obtained after student nurse candidates take and pass the National Council
Licensure Examination for Registered Nurses (NCLEX-RN
®
) that is developed by the National
Council of State Boards of Nursing, Inc. (NCSBN). The NCLEX-RN
®
measures student
competencies essential in meeting health needs of patients (Assessment Technologies Institute
[ATI], 2004; NCSBN, 2004). Schools of nursing are currently measuring student mastery and
competence of NCLEX-RN
®
content by using standardized tests such as those marketed by
Assessment Technologies Institute (ATI), LLC (ATI, 2008). Standardized exams are
independently developed using the NCLEX-RN
®
Test Plan, and provide the student and school
a way to measure student readiness objectively for NCLEX-RN
®
success (ATI, 2008; Jacobs &
9
Koehn, 2006; NCSBN 2004). NCLEX-RN
®
achievement signifies that graduates have the
competence needed for entry-level practice (NCSBN, 2004).
10
Competence
Competence encompasses a combination of the knowledge, skills, and behavior that a
professional needs to have the ability to perform a specific role (Competence, 2008;
Competence, n.d.; U.S. Department of Education, 2002). Accordingly, competence is complex
requiring multiple strategies for assessment and promotion (Piercey, 1995; Redfern, Norman,
Calman, Watson & Murrells, 2002; Sifford & McDaniel, 2007; Slezak & Saria, 2006; Yaeger
et al., 2004). Consumers of an ever-changing US healthcare delivery system have mandated
that schools of nursing provide students with current and practical learning to achieve
competency in the professional nursing role (Pew Health Professions Commission, 1998).
Furthermore, nursing graduates are unable to practice in the role as a professional nurse until
their nursing competence is assessed by the standardized NCLEX-RN
®
and licensure is granted
upon passing (NCSBN, 2004). Thus, while students are enrolled in nursing programs, schools
of nursing use the NCLEX-RN
®
Test Plan, a concise summary of the content and scope of
NCLEX-RN
®
, to determine students’ competency needs for the professional nursing role
(NCSBN, 2004, 2007).
Currently, the NCLEX-RN
®
Test Plan lists four major client need categories tested on
the NCLEX-RN
®
(NCSBN, 2004, 2007). The client need categories are safe and effective care,
health promotion and maintenance, psychosocial integrity, and physiological integrity. Within
the client need categories, the specific competence needs of students are established. For
instance, the medical-surgical competency knowledge and skills that students’ need for caring
for clients with altered health states is located within the physiological integrity category.
Therefore, self-reported data collection measures that include information from the
physiological integrity category of the NCLEX-RN
®
blueprint provides information on
11
students’ perceived competence in the medical-surgical content needed for beginning level
practice in caring for clients with altered health states that is tested on the NCLEX-RN
®
.
However, obtaining self-reported information from students using a numerical scale about their
competence on medical-surgical content from the NCLEX-RN
®
Test Plan only provides a
general evaluation. If depth or insight is sought about a subject or event, then qualitative
techniques like interviewing or opinion questioning that seek non-numerical or verbal data
should be used (AQR: The Association for Qualitative Research, 2008). Although, if a
nationally normed instrument such as the Assessment Technologies Institute Content Mastery
Series 2.1 Medical Surgical Exam™ (ATI CMS 2.1 MS Exam™), ( ATI, 2008) is used, that is
developed from the NCLEX-RN
®
Test Plan (NCSBN, 2004), then it can provide a standardized
objective measure of student readiness in specific content areas measured on the NCLEX-RN
®
(Jacobs & Koehn, 2006).
Problem Statement
Today’s nursing students are different then previous generations. They are adult learner
digital natives who prefer learning similar to the way they have obtained information
throughout their entire lives, interactively, using digital technology that is enriched with audio,
visual and kinesthetic media. The instructional strategy of virtual clinical gaming simulation is
an innovative computer-assisted teaching method that integrates media and technology into
instruction with software to create content specific realistic patient care scenarios for practical
experience application use in medical-surgical course classrooms and laboratories. Research on
the use of gaming simulation instruction to educate nurses is limited and a gap in evidence
exists on the use of virtual clinical gaming simulation instruction to deliver content in medical-
surgical courses where no studies could be located. Medical-surgical content mastery is
12
essential for nursing graduate readiness for entry-level professional practice determined by
successful performance on the high stakes exam known as NCLEX-RN
®
. Because nursing
program accreditation and graduate licensure is connected to student success on NCLEX-RN
®
,
schools of nursing are using nationally normed instruments like the ATI CMS 2.1 MS Exam™
developed from the NCLEX-RN
®
Test blueprint to provide standardized objective measures to
determine student readiness in the specific content areas measured on the NCLEX-RN
®
.
Therefore, research investigating the use of gaming simulation instruction to deliver essential
medical-surgical content for entry level nursing practice assessed on the high stakes NCLEX-
RN
®
in courses provides new information to nursing education stakeholders charged with
decision-making on adoption of its use.
Purpose of the Study
Research studies have reason. The purpose of this study is to determine if the use of the
instructional strategy of virtual clinical gaming simulation to deliver medical-surgical content
has an effect on the learning outcomes of students in higher education medical-surgical nursing
education courses.
Research Questions
The research questions addressed in this quantitative study are as follows:
1. What are the differences in post-instruction exam achievement scores on the
Assessment Technologies Institute Content Mastery Series 2.1 Medical-Surgical
Exam™ among higher education medical-surgical nursing students taught with and
without virtual clinical simulation instruction during the fall of 2006 through the fall of
2008 semesters?
13
2. What are the differences in pre/post-instruction exam achievement scores on the
Assessment Technologies Institute Content Mastery Series 2.1 Medical-Surgical
Exam™ among higher education medical-surgical nursing students taught with and
without virtual clinical simulation instruction during the fall 2008 semester?
3. What are the differences in pre/post-instruction perceived competence summative
scores on the Medical-Surgical Nursing Self-Assessment Survey among higher
education medical-surgical students who received virtual clinical simulation instruction
during the fall 2008 semester?
Definition of Terms
To clarify the meaning of terms and concepts used in this study, the following
definitions are provided:
1. Virtual clinical simulation - A form of digital media instruction using software designed
to provide realistic interactive patient care scenarios for learning that prompts users to
problem-solve clinical situations in a virtual hospital setting. For this study, the specific
educational software used to implement this application was Virtual Clinical Excursions
(VCE) 3.0, by Elsevier, Inc. (Evolve
®
, 2008). VCE is computer-based interactive partial
virtual reality clinical simulations delivered in 2D using a computer screen, speakers,
mouse and printer stimulating participant hearing and vision.
2. Assessment Technologies Institute Content Mastery Series 2.1 Medical-Surgical
Exam™ (ATI CMS 2.1 MS Exam™) - A standardized nationally normed medical-
surgical content instrument developed by Assessment Technologies Institute, LLC
(ATI), using the NCLEX-RN
®
Test Plan to assess nursing student mastery of medical-
surgical content assessed on NCLEX-RN
®
to provide nursing education stakeholders an
14
objective measure for determining student readiness for entry level professional nursing
practice with medical-surgical patients.
3. Medical-Surgical Nursing Self-Assessment Survey (Appendix B) - A researcher
developed demographic and competence level tool created from relevant literature and
the NCLEX-RN
®
Test Plan and validated by a panel of content experts (Appendix C) to
assess higher education medical-surgical students’ self-reported characteristics and
current level of skill in medical-surgical nursing practice.
Operational Definitions
For the purpose of this study, the following operational definitions are used:
1. Achievement - Student composite scores on the Assessment Technologies Institute
Content Mastery Series 2.1 Medical-Surgical Exam™.
2. Students - Higher education students enrolled in medical-surgical nursing courses from
the associate and baccalaureate degree nursing programs at one private university who
participated in this study by completing the Assessment Technologies Institute Content
Mastery Series 2.1 Medical-Surgical Exam™ and/or the Medical-Surgical Nursing Self-
Assessment Survey.
3. Instructional method - Two instructional methods were used in this study: multimedia
enriched virtual clinical simulation instruction (VCSI) using virtual clinical gaming
simulation software to create practical application patient experiences in the classroom
to deliver medical-surgical content in conjunction with facilitated discussion and lecture
versus traditional instruction (TI) for medical-surgical content delivered with facilitated
discussion and lecture with no use of virtual clinical gaming simulation software.
15
4. Pre/post self-report survey - The researcher developed Medical-Surgical Nursing Self-
Assessment Survey used to assess higher education medical-surgical students’ self-
reported characteristics and current level of skill in medical-surgical nursing practice
before and after medical-surgical content instruction.
5. Perceived competence - Students self-reported medical-surgical nursing practice level
summated scores, on 20 items on the Medical-Surgical Nursing Self-Assessment
Survey, based on a rating scale of 1 = none, 2 = low competence, 3 = moderately low
competence, 4 = moderately high competence, and 5 = high competence.
Significance of the Study
This study fills a gap in nursing education literature. No studies were located reporting
on the effects of virtual clinical gaming simulation instruction on the learning outcomes of
students in medical-surgical nursing education courses. Thus, a consequence of this inquiry is
quantitative data is added to the body of knowledge related to the effects on achievement and
competence of students when medical-surgical content specific computer-assisted multimedia
enriched partial reality virtual clinical gaming simulation software is used as an instructional
strategy for practical applications in medical-surgical nursing classrooms.
Results from this study provide new evidence for nursing education stakeholders
consisting of accreditors, administrators, program chairs, faculty, students, educational software
designers, standardized nursing content examination developers, textbook publishers, patients,
and researchers to use for decision-making with gaming simulation instruction. For instance,
accreditors can use the data when creating standards and recommendations for instructional
delivery practices for nursing education. Administrators and program chairs can employ the
evidence when supporting, verifying or denying departmental budget needs for equipment
16
purchases and faculty/staff development related to multimedia gaming simulation instruction.
Accreditors, administrators, faculty, students, and patients can use the information when
determining evaluation methods to assess nursing graduate readiness for entry-level medical-
surgical patient practice. Faculty and students can use the data when choosing interactive
digital media instruction methods that are congruent with learning preferences of today’s digital
native higher education medical-surgical nursing students. Educational software designers,
standardized nursing content examination developers, and textbook publishers can use this
evidence when establishing needs for continued and future development of specific nursing
content gaming simulation software products. Lastly, researchers can use the information from
this study to determine results, limitations, and recommendations related to the use of virtual
clinical simulation instruction for nursing education for future investigations.
Assumptions
An assumption is defined as a fact or proposition that is taken for granted as if it were
known to be true (Assumption, 2008). This study assumes that the National League for Nursing
Accrediting Commission, Inc., (NLNAC) Standards and Criteria for Associate and
Baccalaureate Nursing Programs is representative of the current curriculum goals and student
learning outcomes of higher education nursing education providers in the US (National League
for Nursing Accrediting Commission [NLNAC], 2008). In addition, this study assumes that the
ATI CMS 2.1 MS Exam™ assesses medical-surgical nursing content similar to the NCLEX-
RN
®
. Furthermore, this study assumes that participants honestly and completely answered all of
the questions on the Medical-Surgical Nursing Self-Assessment Survey.
17
Limitations of the Study
Limitations refer to known areas of a study that the researcher lacks control over that
may negatively affect the results or the ability to generalize findings (Roberts, 2004). Areas of
concern in this study that cannot be controlled for by the researcher are related to the lack of
standardization in nursing education in the US.
This study was conducted at one higher education undergraduate accredited nursing
school. There are over 1,559 undergraduate associate (ADN) and baccalaureate in nursing
(BSN) higher education accredited nursing school programs in the United States (Bureau of
Labor Statistics, 2008). Though nursing programs use the NCLEX-RN
®
Test Plan to regulate
the appropriate medical-surgical content that students need to master to be prepared for the
NCLEX-RN
®
, there is a limitation to generalizing this study to the greater population of higher
education medical-surgical nursing education courses nationwide because of the differences in
school and program philosophies, objectives, and curricula.
Additionally, the sample size for this study was small and limited to undergraduate
higher education medical-surgical nursing students at one institution. Therefore, a limitation of
this study is the inability to generalize findings to other groups of nursing students with varying
levels of entry-level preparation.
18
CHAPTER TWO: REVIEW OF RELATED LITERATURE
Examination of the related literature on gaming simulation instruction is the point of
this chapter. The purpose of a literature review is to find, analyze, integrate, and interpret
previous documents and research to determine what is known and not known about a topic
(Roberts, 2004). The information provided expands the discussion of gaming simulation as it
relates to nursing education, instructional methods, learning theory, student characteristics,
achievement, competence, and opinion.
Nursing Education
Since the beginning of formal nursing education programs in the US, traditional
instructional methods of lecture and discussion have been used for didactic nursing material
with experiential methods reserved for clinical settings (Henry, 1997; Larew et al., 2006;
Nehring et al., 2001; Schmitz et al., 1991; Ward & O’Brien, 2005). This trend of traditional
instruction in nursing classrooms relates to the profession’s origin of evolving from an applied
vocation of bedside and hospital apprenticeship to a formal professional discipline in higher
education institutions (Aranda, 2007).
University affiliated nursing education originated at Yale in 1923 with a curriculum that
combined on campus coursework with hospital apprenticeships requiring students to meet
educational standards to graduate (Aranda, 2007). A separation of classroom and clinical
practice prevails in nursing today with one main difference, some of the coursework is now
offered via online classrooms (Aranda, 2007). The approach in nursing to separate didactic and
patient management experiences contradicts recommendations to provide participation and
practical experience opportunities concurrently for adults to foster an environment that matches
19
their preference for learning (Ballatine, 2003; Ward & O’Brien, 2005). Thus, educational
reform that changes nursing curriculum delivery from separated to combined practice and
didactic experiences could benefit adult learners.
Pleas for reform in higher education to use innovative instruction integrated with
technology and digital media to increase practical applications (Brill & Galloway, 2007) and
real world problem-solving into classroom teaching are emerging (Jefferies, 2007; NCSBN,
2006; NLN, 2001). Gaming simulation instruction is a teaching method that incorporates
practice, experience, and feedback into realistic situations. Gaming simulation instruction can
be applied using virtual reality software (Tashiro, 2006) or realistic models (Eder-Van Hook,
2004). Moreover, when gaming simulation instruction is applied as a virtual clinical simulation
it is teaching that uses digital media to provide realistic interactive patient care situations in a
virtual clinical or hospital setting for learning (Tashiro, 2006). Thus, virtual clinical gaming
simulation instruction integrated with technology is an appropriate way that nurse educators
can deliver nursing curriculum combining virtual practice and content. Therefore, knowing
how virtual clinical gaming simulation instruction has been explored, described, and researched
in nursing education is essential to implementing its use.
Examination of the literature on virtual clinical gaming simulation instruction and
nursing education exposed limited information on the method. Findings included two
theoretical writings. A theory is “an abstract generalization that presents a systematic
explanation about the relationships among phenomena” (Polit & Beck, 2004, p. 734). Analysis
of the literature on virtual clinical gaming simulation instruction and nursing education
revealed varied theories to explain the associations of connection as it relates to nurse educator
preparedness to use and evaluate the method, and to the transformative nature of virtual
20
environments to nursing practice, located literature is presented (Barber & Norman, 1989;
Barnes & Rudge, 2005).
In 1989, Barber and Norman reviewed the literature to determine nurse educators’
preparedness to use and evaluate gaming simulation instruction in experiential learning
climates and found that more research was needed to explore the effects of gaming simulation
on student nurse learning. In addition, Barber and Norman discussed problems of evaluation
and determined that nurse educators need to reject classical evaluation founded on learning
objectives expressed in behavioral terms in favor “of ‘illuminative’ evaluation and the approach
of ‘new paradigm research’ ” (p. 146). Ultimately, Barber and Norman concluded that teacher
preparation for gaming simulation and illuminative evaluation requires therapeutic growth
gained from experiencing a similar condition themselves as learners, in a facilitated democratic
learning environment with other participants, inquiring and interacting during the event.
Barnes and Rudge (2005) used spatial theories to analyze the literature on the use of
virtual environments to coordinate and operate managed care and how nurses interact with
these networks. The authors explored the development of virtual reality technologies in nursing
and identified a collection consisting of computer networks, databases, information systems,
and software programs. Conclusions by the writers implied that virtual technology has
prompted a paradigm shift in the discipline from the holistic care of human beings to a reduced
focus on fragmented problems because the flow of information and time has moved toward
network systems and managed care based on aggregates and averages, and away from
individuals. Thus, Barnes and Rudge contend that virtual environments are transformative to
nurses influencing practice from the holistic care of humans to the focused care of managed
problems prompting scholarly inquiry and research to explore this phenomenon.
21
Overall investigation of the located literature on virtual clinical gaming simulation
instruction and nursing education revealed that published information is limited to two
theoretical articles. Therefore, it can be concluded that more work is needed in the discipline,
especially theoretical and conceptual frameworks explaining the relationships between virtual
clinical gaming simulation teaching and learning, because no articles were found exploring this
connection. Additionally, a gap was found in published evidence from research on virtual
clinical gaming simulation instruction in nursing education since no studies could be located.
Therefore, the discipline could benefit from studies using experimental, quasi-experimental and
descriptive designs to build the body of knowledge.
Instructional Methods
Instruction refers to the act, practice, or vocation of teaching (Instruction, 2009). A
method is the organized plan followed in delivering information for instruction (Method, 2009).
Therefore, an instructional method can be inferred to be a systematic way to deliver content for
teaching.
Gaming simulation instruction refers to the organized way instructors transmit material
using practical experience with realistic or virtual scenarios (Eder-Van Hook, 2004; Tashiro,
2006). Traditionally, nursing has relied on the time-honored methods of lecture to convey
content in the classroom reserving practical applications for clinical laboratories (Henry, 1997;
Morton, 1997; Walljasper, 1982; Ward & O’Brien, 2005). However, gaming simulation
instruction has been suggested as a way to facilitate practical experiences in conjunction with
didactic material delivery in classrooms and clinical laboratories (Agazio, et al., 2002; Eder-
Van Hook, 2004; Petranek, 2000; Tashiro, 2006). Therefore, an exploration of the literature on
the instructional method of gaming simulation and nursing content was undertaken. No studies
22
were found reporting on gaming simulation and nursing content using virtual clinical
simulation educational gaming software to deliver nursing content. However, overall analysis
of the literature on gaming simulation and nursing content revealed that gaming, simulation,
and gaming simulation instruction to deliver nursing content using other non-digital and digital
media have been studied. Gaming simulation literature is reported.
Gaming Instruction
Review of the literature on gaming instruction and nursing content resulted in a finding
of 15 articles. Overall analysis of gaming instruction literature and nursing content revealed no
published studies reporting on digitally enhanced virtual clinical simulation educational gaming
software to deliver nursing content. Located articles on non-digital gaming techniques were
found and are reported (Bartfay & Bartfay, 1994; Bays & Hermann, 1997; Berbiglia, Goddard,
& Littlefield, 1997; Cessario, 1987; Cowen & Tesh, 2002; Gruending, Fenty, & Hogan, 1991;
Henry, 1997; Ingram et al., 1998; Kuhn, 1995; Montpas, 2004; Royse & Newton, 2007;
Schmitz et al., 1991; Sisson and Becker, 1988; Walljasper, 1982; Ward & O’Brien, 2005).
In 1994, nursing faculty Bartfay and Bartfay conducted a quasi-experimental study to
evaluate the effectiveness of using gaming as a strategy for teaching health promotion
information related to heart disease and cancer prevention to children. Researchers used a
convenience sample of 23 grade-school students from one class in Winnipeg, Manitoba that
were randomly selected to a treatment or control group using 12 red tokens and 12 blue tokens.
Data collection occurred pre- and post-training by administering a 30-item written examination.
Results of the study indicated the differences between pre-test and post-test scores were found
to be significant for the treatment group (p < .05) of students receiving gaming instruction but
not for the control group receiving traditional instruction.
23
A quasi-experimental study directed by Bays and Hermann (1997) examined the effects
of using the teaching technique of gaming on content retention of the endocrine system on a
convenience sample of 69 baccalaureate-nursing students enrolled in a medical-surgical nursing
course at one urban university. A multiple-choice, single-response, 16-question examination
using the same test blueprint, administration and scoring was used for post-test only data
collection. The investigators found that groups had similar results or no significant difference
on posttest exams (p >.05), demonstrating that gaming was as effective as lecture for student
learning. However, researchers reported that the groups did differ in comments on interest in
the subject content, with the gaming group reporting higher interest than the non-gaming group.
Berbiglia et al. (1997) used the instructional strategy of gaming in a game-show format
with 31 baccalaureate-nursing students to deliver course content. Evaluators reported that
gaming stimulated group involvement, cooperation, competition, thinking, creativity, content
reinforcement, relaxed environment, and variety in learning. The faculty evaluators indicated
that the strategy promoted excitement, prior learning validation, group interaction, competition,
and attention-seeking behavior.
Cessario (1987) carried out a quasi-experimental investigation on a convenience sample
of 23 undergraduate and graduate students enrolled in courses dealing with conceptual models
of nursing to investigate the effect of board gaming to motivate students to learn the content.
The researcher-developed board game was field tested on 12 graduate students who had taken a
course dealing with conceptual models of nursing to determine if there were any
inconsistencies, unknowns and/or rule gaps when played. Ambiguous or inappropriate
statements were reworded or deleted before the board game was used in the study. Instruments
for data collection include a researcher-developed questionnaire and examination. The Likert-
24
type questionnaire was used to determine the experimental groups’ post-intervention opinions
on the experience. The 29-question multiple-choice examination, administered at both pre-test
and post-test intervals, was used to evaluate conceptual models of nursing knowledge. An
expert panel of four nursing theory instructors determined the construct validity of the
examination. Results established that post-test scores of students in the experimental group
were significantly higher than the control group (p < .05). Additionally, percentages of
responses on the questionnaire from the experimental group indicated all of these participants
found the game to be motivating, fun, and a support to learning.
A quasi-experimental study conducted by Cowen and Tesh (2002) on a convenience
sample of 85 pediatric nursing student undergraduates in one university, investigated the effects
of gaming on student knowledge retention of pediatric cardiovascular dysfunction. Data
collection was completed using two 15-question pre/post-examinations. Content validity was
conducted using other pediatric nursing faculty and the instruments were pilot tested the
academic year before the study. Test-retest reliability data on the final pre-test and post-test
yielded r = .84 and r = .80 respectively. Internal consistency reliabilities were determined by
Kuder Richardson scores (i.e., .73 for the post-test and .69 for the pre-test). Researchers
determined that students who received gaming instruction answered 94% of post-test content
questions compared to 85% in the comparison group receiving traditional instruction.
Furthermore, after controlling for initial differences in pre-test scores, the post-test scores in the
treatment group were significantly higher than in the comparison group (p = .0002).
The staff development coordinators, Gruending et al. (1991), of one acute care hospital,
appraised the use of gaming to educate staff nurses about the agencies policies and procedures.
Data were collected from participant comments during a debriefing session and a questionnaire
25
administered after the intervention. The assessors reported that the majority of students agreed
or strongly agreed that the experience of the gaming method for learning was fun, informative,
and non-threatening.
Henry (1997) conducted a review of the literature to explore the use of gaming as a
teaching strategy in nursing education. The appraiser found that more research is needed on its
effectiveness for student learning but, what studies had been done illuminate that gaming adds
innovation, diversity, immediate feedback, safety, and fun to instruction.
A stratified experimental crossover design was used by Ingram et al. (1998) to
investigate a convenience sample of 131 four-year generic (Gn) and post-diploma (PD) two-
year nursing students enrolled in Year III problem-based learning (PBL) courses at one school.
The study explored the effects of gaming on students’ abilities to generate hypotheses and learn
issues. The sample was stratified by student type, Gn or PD, and then randomized to one of 14
PBL groups. An equal number of PBL groups from each student type were randomized to use
either a game (GM) or conventional method (CM) during the first term (Term 1) for three PBL
cases. The groups switched or crossed over to the opposite method in the second term (Term 2).
Investigators collected data from student scores on posttests measuring: total responses, correct
responses, accuracy, expertise, and breadth at the end of Terms I and II. Researchers found that
during Term I GM users outperformed CM users on accuracy (p = .001) and breadth (p =
.023); however, the findings in Term II demonstrated similar performance on all measures for
both groups. Conclusions were that students’ overall abilities to generate hypotheses or learn
issues are similar whether they are instructed conventionally or with gaming.
A systematic review of the literature was undertaken by Kuhn (1995) to determine the
current advantages and disadvantages of using the teaching technique of gaming. The
26
advantages of gaming were attentiveness from novelty, content mastery from review, improved
critical thinking, reduced anxiety, increased involvement, decreased boredom, facilitated fun,
and enhanced relaxation. Disadvantages of gaming were intensity of time use, a stress creator,
an inconsistent evaluation tool, competitive, costly to develop, and reliant upon orientation and
debriefing periods.
Montpas (2004) conducted a quasi-experimental pre/post-test longitudinal study on a
convenience sample of 68 nursing students at one local community college to determine if
student achievement and retention of geriatric nursing concepts differed for students who
received gaming instruction versus traditional lecture. Data collection occurred using a
researcher-developed examination for geriatric-nursing concepts, administered three times,
once as a pre-test, and twice as a post-test (i.e., immediately after post-intervention and two
weeks after post-intervention). Results showed that lecture was statistically more effective than
gaming in the achievement scores between pre-test and post-test one (p = .000) of geriatric
concepts. However, retention of geriatric concepts was greater in the gaming group between
pre-test and post-test two (p = .007) than the lecture group. Conclusions from the research on
the use of gaming as an instructional strategy for nursing are that it is an appropriate
methodology as long as it is not used for immediate recall of information.
In 2007, Royse and Newton engaged in an exploratory review to determine if published
evidence-based literature supported the use of gaming in nursing education as an innovative
teaching strategy. The reviewers found that research on gaming instruction was scarce.
However, located studies did report that gaming instruction was effective for improving
learning outcomes specifically, knowledge retention, critical thinking, real-world problem
solving, and motivation.
27
Schmitz et al. (1991) used gaming as an instructional strategy to teach two teams of four
nurses on one general acute nursing unit of a large tertiary hospital a program on emergency
decision-making skills. Evaluators found that gaming facilitated a safe environment for
learning in collaborative groups, and accommodated learners with diverse preferences and
needs.
In a study by Sisson and Becker (1988), nurse education coordinators at one urban acute
care hospital used the instructional strategy of gaming in varied formats of board games to
provide nursing education. Student and faculty evaluators of gaming indicated that the method
was enjoyable, interesting, and a way to learn and review information.
Walljasper (1982) performed an exploratory search of the literature on the theoretical
and practical aspects of gaming as an educational strategy. Conclusions were that games are
like simulation exercises and involve competition. Additional conclusions included advantages
and disadvantages of gaming to learning over traditional ways. Gaming advantages included
actively involving learners in real-world problems or issues, requiring interaction, and
motivating users. Disadvantages of games transpired if students are unable to abstract the ideas
presented or follow directions, competition evoked negative emotions, and time investment
exceeded the benefits of the gaming process.
To provide nursing education to newly hired nurses, Ward and O’Brien (2005)
implemented gaming as an instructional strategy. The focus of the training was to facilitate
staff development in the management of difficult clinical situations in a risk-free environment.
Review of participant evaluations revealed that gaming promoted learning through action,
experience, safety, fun, and interaction.
28
Overall analysis of gaming instruction and nursing content literature revealed student
post-test scores were significantly improved or similar when gaming was used to deliver
content when compared to students receiving traditional instruction. Moreover, student
evaluators reported that gaming instruction stimulated group involvement, cooperation,
competition, thinking, creativity, content reinforcement, a relaxing environment, variety in
learning, motivation, and fun. Faculty evaluators indicated that gaming promoted excitement,
prior learning validation, group interaction, competition, and attention-seeking behavior.
Further analysis revealed that more research is needed on gaming instruction and
nursing content delivery exploring effectiveness to student learning especially when virtual
clinical simulation software is used. In addition, more research with varied designs is needed,
especially those with a quasi-experimental or experimental design. Of the studies located,
researchers reported gaming instruction has the advantages of adding innovation, diversity,
immediate feedback, safety, fun, attentiveness from novelty, content mastery from review,
improved critical thinking, reduced anxiety, increased involvement, decreased boredom, learner
involvement, real-world problem solving, interaction, motivation, and enhanced relaxation.
Additionally, researchers reported the disadvantages of gaming as time intensive, stressful, an
inconsistent evaluation tool, competitive, costly to develop, reliant upon orientation and
debriefing periods, and less effective than traditional instruction when used as a methodology
for immediate recall of information. Based on identified attributes of games from this analysis,
games are distinguished as innovative structured simulated situations involving interaction of a
player or players presented with conflict or problems to solve using rules, and when used as an
instructional method enhances learning through content review, critical thinking, experience,
enjoyment, and diversity.
29
Simulation Instruction
Simulation instruction refers to an instruction and evaluation method in which students
practice “tasks and processes in …[realistic]… circumstances using models or virtual reality,
with feedback from observers, peers, actor-patients and video cameras to …[develop]… skills”
(Eder-Van Hook, 2004, p. 4). Assessment of the literature on simulation instruction and nursing
content resulted in a finding of 16 studies. Overall, analysis of simulation instruction and
nursing content literature revealed that the method promoted experience, technical skills and
application of the nursing process. No published research was found reporting on virtual
clinical simulation to deliver nursing content. Located studies are reported (Agazio et al., 2002;
Alinier et al., 2006; Aronson, Rosa, Anfinson, & Light, 1997; Bearnson & Wiker, 2005;
Bremner, Aduddell, Bennett, & VanGeest, 2006; Butler, Frotjold, & Hardy, 2007;
Farnsworth, Egan, Johnson, & Westenskow, 2000; Feingold, Calaluce, & Kallen, 2004;
Haskvitz & Koop, 2004; Kidd & Kendall, 2006; Larew et al., 2006; Morton, 1997; Nehring et
al., 2001; Nehring & Lashley, 2004; Rodgers, 2007; Rowell & Spielvogle, 1996).
In 2002, Agazio et al. compared the effectiveness and user satisfaction of the virtual
reality high fidelity Cath-Sim Intravenous Training system (Cath-Sim) to the traditional low
fidelity IV arm while in Mission Oriented Protective Posture (MOPP) level 4 biochemical gear
for Army healthcare personnel. Participants consisted of 50 Army medical personnel (i.e.,
RN’s, physicians, medics, etc.) from Walter Reed Army Medical Hospital on active duty with
previous IV insertion experience who were randomly assigned to the Cath-Sim IV group (n =
25), or IV arm (n = 25). No significant differences were found in the success rates, or time to
success among groups. User evaluations identified IV simulation training as an effective to
highly effective method due to multimedia cues, feedback, and scenario variety.
30
Alinier et al. (2006) conducted a pre/post-test quasi-experimental designed study to
determine the effects of scenario-based training in a clinical intensive care laboratory using
intermediate-fidelity human simulations on nursing students’ clinical skills and competence. A
convenience sample of 99 United Kingdom diploma adult nursing students was used. Data
collection was performed using a mixed-mode Objective Structured Clinical Examination
(OSCE). The OSCE assessment was composed of 15 short five-minute exercises or stations
that students rotated through with each situation covering a particular clinical aspect using a
practical skill or a theoretical pen and paper exercise. The experimental group was exposed to
scenario-based simulation training within the stations and the control group was not.
Researchers found no significant difference in student perceptions of confidence or stress
between the control and experimental groups on a questionnaire about the use of technology in
nursing practice. However, researchers did discover a significant difference demonstrated in the
mean post-test scores (p < .001) for competence of students who received simulation
instruction.
To develop a Clinical Problem Solving Learning Laboratory (CPSL) with low-fidelity
mannequins for 90 associate degree senior nursing students at one community technical
college, Aronson et al., (1997), used the instructional strategy of simulation. Instructors
developed nine faculty facilitated simulated patient care scenarios in lab rooms using medical
devices along with fake documents displaying patient verbal and physiological cues. Student
participant groups had to observe and react to the simulated patient scenarios using the nursing
process to provide care. Faculty reported that the instructional strategy of simulation facilitated
collaborative inquiry, critical thinking, decision-making, and problem solving for nursing
31
students in real world, but safe situations. Additionally, student evaluators of the strategy
reported the learning experience as fun and non-threatening.
In 2005, Bearnson and Wiker explored the benefits and limitations of using a high
fidelity Human Patient Simulator Version 6 (HS6) on perceived student learning and self-
efficacy in the management of post-operative pain in an exploratory, descriptive, mixed method
survey and case study investigation. The sample consisted of two first year baccalaureate
nursing student clinical groups who had completed five weeks of a six-week clinical rotation
caring for post-operative patients at one university. Quantitative data collection was performed
with a created questionnaire, using a Likert-type scale ranging from one (strongly disagree) to
four (strongly agree). Qualitative data collection was conducted using three open-ended
questions soliciting student opinions about what they had learned, what would improve their
simulation sessions, and whether they would recommend engaging in the method again.
Investigators found that students perceived their confidence and learning were increased from
the experience, concluding simulation as a valuable asset to nurse training.
A mixed method study by Bremner et al. (2006) examined the value of high-fidelity
human patient simulation (HS) from a convenience sample of 56 first year baccalaureate-
nursing students. Comments and perceptions on learning were measured as overall experience,
confidence, stress, anxiety, and curriculum value related to patient assessment. Data collection
was performed using a two-part questionnaire. The first section of the instrument used
questions with a Likert rating scale to solicit student perceptions about the overall experience of
HS, the use of HS in the curriculum, and the influence of HS on confidence, stress, or anxiety
in performing physical assessment skills. Information in the second section of the tool consisted
of written student comments about the experience. Results of the quantitative data
32
demonstrated that overall, 95% of students rated the simulation experience from good to
excellent. Additionally, 68% of students' valued simulation as an effective way to deliver
nursing curriculum, with 61% reporting greater confidence and 42% less stress. Analysis of
qualitative data revealed four emerging general themes. Results of the frequency distribution of
the responses within each theme revealed that 26% reported on the realism of simulation, 76%
on the use of simulation teaching/learning, 22% on the limitations of simulation, and 4% on the
influence of simulation on their comfort/confidence.
In 2007, Butler et al. evaluated the use of simulation as a teaching strategy to instruct
undergraduate nursing students on perioperative nursing using a Virtual Health Environment
model created from an academic institution and clinical industry facilities collaborative
venture. Students began the course experience in a nonthreatening environment in a state of the
art simulation laboratory, progressed to a real operational suite for observation, and concluded
with a three-week operational department clinical placement. The evaluators found that the
realistic approach of the method resulted in an increased student interest to practice in the
specialty and provided an increased pool of perioperative nursing applicants for hospital
operating room vacancies.
In 2000, Farnsworth et al. examined student content retention of conscious sedation
patient interventions using high-fidelity human patient simulation (HS) instruction in a quasi-
experimental study. A convenience sample was used for the study, consisting of 20 nurses from
one hospital working in areas where conscious sedation was administered. Data collection
occurred at pre/post-intervention intervals using a 30-question multiple-choice examination,
and at the post-intervention interval using an anonymous student satisfaction survey to rate the
overall educational experience ranging from one (equal to poor) to four (equal to excellent).
33
Investigators evaluated that post-test scores improved significantly (p = .001) concluding that
simulations positively affect teaching/learning processes involving nursing interventions.
Furthermore, the overall mean for student satisfaction with the educational experience was 3.75
indicating that participants rated the simulation education method as good to excellent.
Feingold et al. (2004) conducted a quantitative descriptive study to evaluate the use of
high-fidelity human patient simulation from a convenience sample of 47 senior nursing
students and four faculty members in one Advanced Acute Care of the Adult undergraduate
baccalaureate-nursing course. Data were collected using student and faculty surveys. The
student survey had characteristic and perception questions. Four characteristic questions were
used to solicit information on gender, age, grade point average, and ethnicity. Student
perception data was obtained by a 20-item self-rated questionnaire using a 4-point Likert
format about the value of the overall learning experience, the ability to transfer skills from
simulation to real clinical situations, and the realism of the experience when simulation was
used. The faculty survey had perception questions related to the value, realism, and
transferability of skills from HS, and consisted of 17 items using the same Likert format.
Researchers established that there were high scores for student agreement that simulation was
realistic (86.1%), a valuable learning experience (69.3%), and a good test of decision-making
(87.7%) and clinical skills (83%). In addition, investigators found that there were high scores
for faculty agreement that simulation was realistic (100%) and a good method to prepare
students to function in real clinical situations (100%).
In a descriptive qualitative exploration, Haskvitz and Koop (2004) proposed a model of
remediation using high-fidelity human simulation instruction for clinical skill remediation for
students having learning difficulties. The authors recommended a four-step process model
34
consisting of assessment, planning, implementation, and evaluation that nurse educators could
use to guide teaching with patient simulators.
In 2006, Kidd and Kendall performed an assessment of the literature to examine the
current issues regarding the use of simulation for advanced cardiac life support (ACLS)
training of nurses and other healthcare professionals. Reviewers concluded that ACLS training
using collaborative teams in practical real-world experiences using simulation scenarios should
improve ACLS outcomes because it enhanced learning by stimulating critical thinking,
technical skill competence, communication, assessment, and reflection.
An instructional protocol developed and implemented by Larew et al. (2006) was used
to educate 190 junior and senior baccalaureate adult health students in a clinical laboratory
using high-fidelity human patient simulation with escalating vague to specific verbal and
physiological cue progression. The goal of the initiative was to facilitate practice performance
of novices while challenging higher functioning students on patient management and
collaborative practice skills. Evaluations revealed that simulations provided a vast amount of
information on student weaknesses and strengths and required multiple assessment techniques
such as written examinations, digital recording, and performance tools. Additional evaluation
findings revealed that simulation in clinical laboratories was expensive to start up and labor
intensive to use, requiring time for instructional protocol development, constructed
environment orientation, patient information collection, student-directed scenario pacing,
debriefing sessions, and technical staff support. Designers concluded that simulation instruction
in clinical laboratories offered a way to provide safe, structured, and consistent learning
experiences for all students.
35
In 1997, Morton reviewed the literature on simulation as a teaching method to
determine the advantages and disadvantages of using this approach to teach critical care
nursing. Simulation offered the opportunities for learning through safe low anxiety controlled
environments, student engagement, immediate feedback, and reinforcement. Depicted
disadvantages included costs for obtaining and maintaining equipment, and a limited ability to
mimic the reality of a high-stressed, fast-paced, emotionally charged environment in a critical
care unit. Moreover, the reviewer identified that the learning prospects of a critical care
simulation laboratory were many. For instance, the lab offered faculty ways for teaching that
promoted development of learning in the cognitive domain that encompassed “knowledge,
comprehension, application, analysis, synthesis, and evaluation of information” (p. 67). In
addition, instructors can facilitate the affective domain of learning, depicted as an emotional
element, consisting of feelings, values, and ideas, with simulation through nursing role
exercises in real-world experiences. Lastly, educators can promote development of the
psychomotor domain of learning that involves technical skills, tasks, and procedures because
simulation provides a safe environment allowing the opportunity for experience and knowing
that comes from doing or practice.
Nehring et al. (2001) introduced the instructional framework of critical incident nursing
management (CINM) for teaching that used high-fidelity computerized mannequin human
patient simulation (HS) in clinical laboratories. CINM allowed students to assess the patient
incident through interaction by observing physiological and verbal cues, planning care based on
current and changing information, intervening to correct the situation and evaluating to take
additional or altered steps. Thus, the authors contended that the outcome of simulation CINM
instruction was appropriate for nursing students because it facilitated “satisfactory performance
36
of nursing care using appropriate knowledge, technical skills and critical thinking within the
nursing process model” (p. 195).
Nehring and Lashley (2004) conducted a descriptive study of an international sample of
34 schools of nursing (33 in the US, one in Japan) and six simulation centers (one each in
Australia, England, New Zealand and US, two in Germany) to explore the use of high-fidelity
human patient simulators (HS) in nursing education. Data were collected using a researcher-
designed 37-item closed and open-ended survey. Content validity was conducted through a
literature comparison and expert panel review. Investigators found that HS was used more in
advanced medical-surgical courses in community college programs (M = 11.18 hours, SD =
10.21) compared to the basic skills courses in university programs (M = 3.77 hours, SD =
10.96). Furthermore, 93.8% of all schools indicated that 25% or less of faculty used HS.
Additionally, researchers found that undergraduate university programs used HS most often for
competency evaluation and in the areas of knowledge synthesis (76.9%), technical skills
(61.5%), and critical event management (53.8%).
Rodgers (2007) conducted a quasi-experimental study investigating the effect of
simulation instruction on educational outcomes in advanced cardiovascular life support (ACLS)
training using a convenience sample of 34 senior nursing students, 16 in the treatment group
(high-fidelity manikin instruction) and 18 in the comparison group (low-fidelity manikin
instruction), from three Central and Southern West Virginia higher education institutions.
Instruments used for single measure data collection included: the demographic survey,
modified ACLS Mega Code Performance Score Sheet, Affective Learning Scale, and Student
Motivation Scale. Instruments used for pre/post-test data collection included ACLS written
examinations and a Participant Self-Assessment. Findings indicated that neither the high-
37
fidelity manikin nor low-fidelity manikin simulation group significantly outperformed the other
on the post-tests. However, the high-fidelity manikin-based instruction group did significantly
improve their cognitive knowledge between pre/post-test scores compared to the low-fidelity
manikin instruction group (p = .002).
Rowell and Spielvogle (1996) instructed healthcare personnel in one acute care hospital
using simulation techniques. The purpose of the training was to increase awareness of staff
about infection control practices. The simulation consisted of a created isolation room
developed with 37 infractions or violations of good infection control practices in an actual
patient room. Participants received a mock patient scenario and instructions directing them to
search and identify as many infractions as they could find before entering the simulation.
Evaluations revealed that students found the method to be fun and informative.
Overall analysis of the literature on simulation instruction and nursing content revealed
current published information related to use of the strategy in lab settings predominantly using
low or high fidelity manikins or props. No published literature was found investigating student
learning of nursing content with virtual clinical simulation instruction using software. Most of
the research on simulation instruction used a descriptive and quasi-experimental design.
Student evaluators of simulation instruction reported that it promoted multimedia cue use,
feedback, scenario variety, fun, safety, confidence, increased learning, experience, less stress,
nursing curriculum delivery, and nurse training.
Faculty evaluators of simulation instruction to deliver nursing content reported
advantages including facilitating collaborative inquiry, critical thinking, decision-making,
safety, problem solving, structured environments, consistent learning, student-directed scenario
pacing, real world situations, student interest to practice in the specialty presented in a
38
simulation, required multiple assessment techniques, and provided student performance data.
Faculty identified advantages of simulation instruction for critical-care nurse training included
student engagement, immediate feedback, reinforcement, safety, practice, knowledge
comprehension, application, analysis, synthesis, evaluation, feeling and value use, ideas, role
playing, and real-world experience. Instructor reported disadvantages for simulation instruction
for critical care training of nurses included cost for obtaining and maintaining equipment and
limited ability to mimic the reality of a high-stressed fast-paced emotionally charged critical
care environment.
For students who received simulation instruction, researchers found that students had
improved competence, student satisfaction, practical experience, learning experience, decision-
making skills, clinical skills, and realism. Additionally, researchers found simulation
instruction was used differently in community colleges typically for advanced medical-surgical
courses compared to basic skills courses in university programs. Few faculty used simulation in
colleges or universities, and undergraduate university programs used simulation most often for
competency evaluation to assess knowledge synthesis, technical skills, and critical event
management. In addition, one researcher reported students trained with high fidelity manikins
significantly improved their cognitive knowledge between pre/post-test scores compared to
those instructed with low-fidelity manikins.
Further analysis of research literature revealed a four-step process model consisting of
assessment, planning, implementation, and evaluation was recommended to guide simulation
instruction. Moreover, researchers found that simulation instruction using collaborative
practical real-world experience in teams enhanced learning by stimulating critical thinking,
technical skill competence, communication, assessment, and reflection. In addition, simulation
39
instruction was effective for critical incident training because it promoted realism,
teaching/learning, learner comfort and confidence from experience, interaction, observation,
and application of knowledge, technical skills and critical thinking using the nursing process
model of assessment, diagnosis, planning, intervention, and evaluation.
Based on the identified elements of simulation to deliver nursing content from this
review, simulation is identified as a means and method. Simulation instruction is a way to
deliver nursing curriculum in an enjoyable safe student-directed structured realistic healthcare
environment using interactive multimedia scenarios to promote learning from experience in
nursing practice and process application while problem solving independently and
collaboratively using feedback to gain competence in knowledge, skills, and behaviors needed
in the nursing role.
Gaming Simulation Instruction
Review of the literature on gaming simulation instruction and nursing content resulted
in a finding of one descriptive study. Overall analysis of gaming simulation instruction
literature is that more research is needed using experimental, quasi-experimental and
descriptive designs to build the body of evidence. Findings from the study are reported (Sauvé
et al., 2007).
A systematic review of the literature by Sauvé et al. (2007) on 98 articles and research
reports that provided a definition of or discussed critical attributes of games and simulations
was conducted to identify and describe the essential attributes of educational games and
simulations. The authors determined that games have the attributes of a player or players,
conflict, rules, predetermined goals, artificial environment (reality or fiction referenced), and if
40
educational, a socioconstructivist pedagogy. Moreover, Sauvé et al. (2007) used the gaming
literature to define a game as:
A fictional, fantasy or artificial situation in which players, put in conflict with one
another or against other forces, are governed by rules that structure their actions in order
to meet learning objectives and a goal predetermined by the game (for example,
winning, being victorious or overcoming an obstacle). (p. 251)
In addition, Sauvé et al. (2007) identified that simulation elements include a reality system,
dynamics, simplicity, precision and learning. Using the identified attributes, Sauvé et al. (2007)
defined a simulation as “a simplified, dynamic, and accurate model of reality that is a system
used in a learning context” (p. 253).
Analysis of the literature on gaming simulation instruction and nursing content resulted
in the finding that gaming simulation instruction has the component of realism or real-world
experience. Furthermore, the terms game and simulation have been defined and used differently
with games distinguished as simulated situations where a player or players are put in a position
of conflict, governed by rules, structured, and when used for teaching are integrated into
educational content to enhance learning in the cognitive, affective, and/or psychomotor
domains. Contrarily, simulations are pronounced as a basic, dynamic, accurate, portrayal of a
reality system, unless, the method is merged into a simulation game. When gaming simulation
combines like in a virtual clinical simulation using educational gaming software, then, the
demonstrated attributes of each merge into a definition. Based on the attributes identified in this
review, gaming simulation is a two or three dimensional dynamic virtual reality system
requiring a player or players to interact with visual, auditory, kinesthetic or psychomotor digital
41
media to discover conflict or problems and seek resolution using rules and processes toward
specific or directed learning objectives.
Analysis of the gaming simulation instruction and nursing content literature revealed
that more theory generating and testing research is needed in this area since only one
descriptive study was found. No published studies were located reporting on the use of virtual
clinical simulation instruction applied with digital media educational gaming software. This
reveals a gap in the literature especially on its effects to teaching/learning, prompting a need for
research to add to the body of knowledge.
Learning Theory
Learning is “the process through which experience causes permanent change in
knowledge or behaviors” (Woolfolk, 2004, p. 603). Moreover, a theory refers to an event
clarification made-up of integrated principle statements that attempt to make a prediction about
something (Woolfolk). Thus, reasoned definitions of learning theory are presented as a
forecasted explanation about learning based on a set of integrated principles and categorized by
the variance in the main belief sets to predict learning. Analysis of the literature on gaming
simulation instruction and learning theory revealed various theories to predict learning with this
strategy (De Miranda, 2004; Henry, 1997; Hmelo-Silver, 2004; Leigh & Spindler, 2004; Lewis
et al., 1989; Paas et al., 2003; Peters, 2000; Spigner-Littles & Anderson, 1999; Vogel &
Klassen, 2001; Ward & O’Brien, 2005).
Adult Learning Theory
In 1997, Henry reviewed the literature to examine the relationship between adult
learning theory and gaming. Adult learning theorists contend that adults are self-motivated,
self-directed individuals who prefer learning that involves active participation, practical
42
experience, variety, feedback, and real-world problem solving. Gaming/simulation is an
educational strategy that promotes interaction, decision-making, practice, feedback, and
diversity. Conclusions are that gaming is an appropriate method of instruction to use for adult
learners.
In 1989, Lewis et al. explored the theoretical aspects of gaming as an instructional
strategy for adult learners. Gaming instruction was found to incorporate interaction, stimulate
cognitive process, and facilitate a non-threatening learning environment. Adult learning theory
suggests adults prefer learning in enjoyable, stimulating, and interactive environments. The
authors concluded that gaming is an appropriate method of instruction for adults.
An appraisal of the literature by Spigner-Littles and Anderson (1999) determined
effective learning theories, methodologies, and techniques with adult learners. Appraisers
found two well-established theories for adult learners, Cognitive Learning Theory that
characterizes experience as a contributing aspect in learning described as permanent behavior
transformation, and Constructivism, which assumes that understanding acquisition, constructs
from experience. Identified instructional/teaching methods and techniques consistent with
Cognitive and Constructivist Learning Theories were simulated real life scenarios or problems,
probing, questioning, goal setting, self-evaluation, project supervision, critical thinking,
collaboration, group participation, facilitated discussion, cooperative learning, active
participation, student-centered instruction, and social interaction.
In 2005, Ward and O’Brien analyzed the literature to determine if the instructional
method of gaming is suitable for adult learners. Adult learners were established as independent
and active students who seek learning for a skill or knowledge need, retain knowledge by
integrating new information with current understanding, and favor learning environments that
43
provide practice and involvement. Gaming was considered an instructional method that
supports learning because it promotes student enjoyment, critical thinking, confidence, creative
behavior, divergent thinking, knowledge retention, collaboration, calmness, interaction,
communication, experience, practice, security, ideas, and opinion. Conclusions were that
gaming instruction is suitable for adult students because it is an informative interactive strategy
suitable for the needs of adult learners for new information or skills, and it combines new and
current knowledge in realistic practical settings.
Chaos Theory
Leigh and Spindler (2004) searched the literature to establish if a chaos theoretical
framework could be of benefit in understanding and managing the structure and management of
open simulations. Chaos theory refers to dynamic systems that contain order and logic that
change continuously never repeating themselves. Moreover, chaos theory assumes that active
arrangements and methods combine order and reason in chaos to culminate in a chaordic event.
Open simulations were found to refer to activities designed to guide students to acquired
“insight into the complex relationships and interconnected structures within a particular
context” (p. 54). Reviewers established that open simulations mean virtual experiences
representing wholes created by improviser educators to sensitize or prepare learners for action
in patterned chaotic and unpredictable real life settings. The role of educators in open
simulations is one of an improviser using readiness, vigilance and reassurance in the
unpredictable chaordic environment rather than commands, controls, and directions to promote
student participants to engage, interact and reflect on the whole scenario to learn and
understand from the event. Conclusions were that open simulations were chaotic events within
44
an ordered scenario making them chaordic, a view that emerges from the assumptions of chaos
theory.
Cognitive Theory
To review the relationship between cognitive science theoretical viewpoints and
technology education, De Miranda (2004) examined the literature. Technology education is
identified as an emerging discipline that evolved from practical collaborative projects and
problem-based teaching/learning. Discussion determined that cognitive science proposes that
students not teachers are responsible for the cognitive tools for learning. In other words,
students must process information to learn through the self-regulation and monitoring of the
cognitive functions of memory, thinking, reflection, and application. Additionally, cognitive
science recommends that teachers create instructional strategies to promote student action and
collaborative participation that integrates the cognitive and metacognitive strategies for
employing, managing, evaluating, restructuring, and discovering knowledge. Identified shared
learning and instruction elements between technology education and cognitive science included
engagement, reflection, and interaction. Both cognitive based science and technology education
promote learning-in-doing that comes from the authentic practical experience of solving
problems with virtual or simulated scenarios, situations, or projects. Conclusions drawn were
that technology based instructional practices align with the theoretical perspectives of cognitive
science theory.
Analysis of the literature was undertaken by Paas et al. (2003) to ascertain cognitive
load measurement techniques used within a cognitive load theory framework. Cognitive load
theory (CLT) assumes that individuals have limited cognitive processing capacity or short-term
working memory to apply or transfer acquired information to new situations compared to an
45
unlimited long-term memory that interacts or processes visual/auditory information. Based on
this premise, cognitive theorists argue that instruction should be designed to be effective and
efficient to promote schema construction and automation. Discussion acknowledged that the
cognitive load rating scale, in a non-modified format, reliably measures mental effort.
However, variances on instructional efficiency calculations exist. One study pooled mental
effort invested with test performance to attain mental efficiency of test performance that related
to the transfer of acquired knowledge. Subsequent studies joined mental effort spent during
training with test performance to reflect mental efficiency of training or learning efficiency.
Another study combined learning effort, test effort, and test performance to depict a more
sensitive instructional efficiency. Further analysis revealed that a gap in research exists on the
influence of time on task in mental efficiency, as well as the effect of combining mental effort
with performance measures in intelligent interactive learning systems like virtual reality
simulations.
Constructivism
Hmelo-Silver (2004) evaluated the literature to determine if the constructivism premise
that learners build knowledge from reflecting on their experience was congruent with the use of
problem-based learning (PBL) simulation in education. Virtual reality based PBL refers to an
instructional approach that promotes student knowledge construction through reflection on
experience or practice within a complex scenario or real-life problem simulation. The evaluator
determined that the evidence-based research on the use of this strategy is scarce and restricted
to healthcare educators. Conclusions established that PBL simulations are practical learning
experiences that prompt knowledge construction or understanding through reflection, problem-
46
solving abilities, and self-directed learning skills in adult learner healthcare providers and are
congruent with constructivism.
In 2000, Peters reviewed the literature to determine if constructivist epistemology had a
place in undergraduate nursing education. Discussion characterized nursing students as adults
with life experiences who enter nursing programs with a vast amount of formal and informal
knowledge. The reviewer identified that traditional pedagogy in nursing education included
lecturing by teacher experts without regard to acquired knowledge in students, promoting
regurgitation of new information in tests and assignments and de-emphasis in understanding.
Furthermore, the investigator offered constructivist epistemology as an option to adult learner
nursing students over traditional pedagogy because it promoted the focus of knowledge from
the teacher to the learner, understanding comes from experience of the world, self-directed
learning is enhanced, sociocultural interaction influences learning, and previous learning is a
foundation on which new knowledge can be constructed. Reported conclusions were that a
constructivist framework is appropriate for educating undergraduates because real world
simulations or experiences that involve nursing practice enhance transferable understanding in
nursing students because the model promotes reflective practice, evaluation, critique, self-
learning, and metacognitive awareness.
Vogel and Klassen (2000) examined the literature to determine the theoretical aspects of
technology-supported learning. The assessors established that multimedia instruction refers to
integrative computer-based interactive multimedia instruction that may include CD-ROMs and
the World Wide Web as a part of the delivery of content that promotes student-directed or self-
accessed learning constructed through interaction. The role of teachers in technology-supported
learning is as instructional developers and collaborators who promote competency development
47
and talents in student participators through multimedia enabled individualized events,
cooperative activities, and real time assessment. Furthermore, learning with multimedia
technology was characterized as flexible, accommodating a plurality of learning styles and
learners who can experience multi-sensory realistic simulations to develop skills and abilities in
decision-making, critical thinking, communication, team-building, self-assessment, knowledge
comprehension and retention. Conclusions drawn were that multimedia instruction in education
provides the opportunity to promote learning that is student-centered, flexible, diverse,
collaborative, social, interactive, and realistic, compatible with the notions of constructivism.
Overall analysis of the literature on learning theory and gaming simulation instruction
revealed that adult learning theory, chaos theory, cognitive theory, and constructivism all
predict learning from the method because it is found to be an interactive, student centered,
multimedia enhanced, problem based, realistic experience that facilitates knowing from doing.
Thus, published theoretical works on learning theory provide sufficient information for theory
testing research exploring gaming simulation instruction.
Student Characteristics
Student characteristics refer to the distinct qualities that today’s students have from their
development throughout life exposed to digital technology that differs from previous
generations (Howell, 2004; Prensky, 2001a, 2001b; Tapscott, 1998). Analysis of the literature
on student characteristics and digital technology revealed three studies reporting on today’s
students as digital natives developed with digital technology experience making them learners
with unique characteristics. Studies found from this review reporting on digital technology and
student characteristics are reported (Howell, 2004; Prensky, 2001b; Tapscott, 1998).
48
Howell (2004) explored the literature to determine issues surrounding the teaching and
testing practices used with technologically well-informed students who “communicate, learn,
and almost live on keyboards… [and]…the computer” (p. 75). The evaluator identified that the
characteristics of knowledgeable digital technology students included computer access,
impatience with old-fashioned teaching or testing practices, a preference for keyboarding to
handwriting for communication, and attainment of refined motor skills from interaction with
digital devices and gaming experience. In addition, the assessor established that evidence exists
that instructional practices are changed or changing to incorporate rich multimedia and
multidimensional context into the learning environment but testing practices have essentially
stayed in a paper-pencil format, threatening the reliability and validity of these tests when used
to evaluate technologically proficient learners. Conclusions are that educational reform to
create and use multimedia tests for assessment of student learning in digital native students is
necessary to match the multimedia instruction they are receiving.
To determine the evidence on experience and cognitive skill development in digital
natives, Prensky (2001b) analyzed the literature. Neurobiology research established that various
stimulations changed brain configurations and cognitive processing throughout life resulting in
continuous brain restructuring known as neuroplasticity. Neuroplasticity results when a
recipient attends to an input or task sharply focused in frequent sessions over time. Social
psychology research validated that people who are cared for in dissimilar cultures or
circumstances have different thinking demonstrating that cognitive processes have malleability
to experience. Conclusions were that no explicit evidence exists on digital native experience
and cognitive skill development. However, evidence that different experiences resulted in
changed brain arrangements could be reasoned to digital natives because they have received
49
focused frequent interactive sensory information from digital multimedia over time through
video gaming and computer Web-surfing. Thus, because of their life experience the author
concluded that digital native students think differently.
Tapscott (1998) conducted a qualitative study to explore the Net-Generation (N-
Geners), described as “the generation of children who, in 1999, will be between the ages of two
and twenty-two, not just those who are active on the Internet… [but those that]…have some
degree of fluency with the digital media” (p. 3). Data was collected from online discussions,
forums, and surveys, investigating the opinions of 300 Internet users aged from four to 20 over
a one year period and from interviews conducted over an eight month period with dozens of
adult experts from the disciplines of childhood developmental psychology, economics,
marketing, sociology, psychology, pedagogy, technology, parenting, and business strategy.
Analysis revealed N-Geners as a unique group because of their life experience using digital
media, including the Internet, to explore, discover, read, speak, write, create, and communicate
more than previous generations. N-Gener attributes were described as inquisitive, tolerant, self-
confident, independent, argumentative, highly intelligent, connected, experiential, social, and
service oriented. In addition, because of their interactions with digital media to acquire
information, N-Gen learners expect immediacy, structure, engagement, teamwork, and visual
and kinesthetic media with instruction. Conclusions were that these unique learners require
educational change and reform from traditional methods of lecture to digital media enriched
approaches.
Overall analysis of the literature on digital technology and student characteristics
revealed digital native students think and learn differently than previous generations because of
their unique life experience of developing with digital media. Because digital native students
50
learn differently due to development from digital media exposure, educational reform away
from traditional methods of lecture to multimedia methods is needed. Virtual clinical
simulation instruction is a multimedia enriched method of teaching that employs the application
of educational gaming software to deliver nursing content and is appropriate for today’s digital
native nursing students.
Achievement
Achievement in nursing refers to student performance on standardized objective nursing
knowledge/content assessments (ATI, 2008; NCSBN, 2004; Newton, Smith, Moore &
Magnam, 2007; Rushton & Eggett, 2003; Seldomridge & DiBartolo, 2004). Student
achievement on standardized examinations and evaluations has high-stakes. For instance, in the
US all nurse graduates must achieve success on the National Council Licensure Examination
for Registered Nurses (NCLEX-RN
®
) to gain licensure for practice (NCSBN, 2004).
Furthermore, the National League for Nursing Accrediting Commission, Inc., (NLNAC) and
State Boards of Nurse Examiners use the NCLEX-RN
®
passage rates as criteria for nursing
program accreditation (NCSBN, 2004; NLNAC, 2008). Because students and programs are
penalized for poor NCLEX-RN
®
performance, schools of nursing are using standardized
examinations developed by independent companies such as Assessment Technologies Institute
(ATI), LLC that use the NCLEX-RN
®
Test Plan to create objective measures to determine
readiness of graduates for achievement on NCLEX-RN
®
material (ATI, 2008; Jacobs & Koehn,
2006). Analysis of the literature for methods used to determine student readiness for NCLEX-
RN
®
achievement are presented (Davenport, 2007; Jacobs & Koehn, 2006; Mosser et al., 2006;
Newman & Williams, 2003; Seldomridge & DiBartolo, 2004).
51
Davenport (2007) reviewed the literature to identify evidence to support specific
interventions that are most successful in preparing nursing students for achievement on the
NCLEX-RN
®
. The reviewer found that limited evidence exists on the effectiveness of
strategies with the only significant correlation reported to be two content exams. The
recommendation to programs was to use content-area exams to assess student readiness for
NCLEX-RN
®
achievement. In addition, the investigator administered an Internet survey to 26
Indiana associate of science nursing programs to determine successful curriculum planning and
delivery strategies used to promote student achievement on NCLEX-RN
®
. Nine schools
responded. The ATI comprehensive remediation and testing package was reported as the most
commonly used approach to improve test results. Conclusions were that initiation of a
comprehensive assessment and remediation package is appropriate because it helps students
refine test-taking skills, remediate and increase content knowledge, understand the testing
process, advance critical thinking skills, and increase confidence.
An analysis of the literature by Jacobs and Koehn (2006) was undertaken to determine
if student achievement on NCLEX-RN
®
by graduates of one large public U.S. Midwestern
university school of nursing could be affected by implementing known success factors. Aspects
associated with NCLEX-RN
®
success identified from the review included: implementing
admission criteria, identifying at risk students, requiring above average exam and quiz scores,
using interactive teaching, incorporating analytical and synthesis level exam questions,
providing NCLEX-RN
®
material review and remediation, and facilitating student familiarity
with computerized testing. Assessors implemented the comprehensive standardized
computerized testing and remediation program developed by ATI consisting of pre-admission
screening assessments, RN content mastery series review modules, non-proctored and
52
proctored RN content mastery series examinations, and a RN Comprehensive Predictor
Examination™. No psychometric information was reported on the reliability or validity of the
ATI examinations. Evaluators reported that the NCLEX-RN
®
passage rates increased from
86% for three previous years to 92% for the first class graduating after the program instituted
the ATI comprehensive testing and remediation program.
In 2006, Mosser et al. evaluated the effect of progression testing using the ATI
computerized remediation and evaluation program at two Northeastern baccalaureate-nursing
programs to student achievement on the NCLEX-RN
®
. Researchers found that the program
attained at least an 80% pass rate for the subsequent three years with the highest pass rate of
96% attained in the third year of the ATI programs implementation. Investigators concluded
that progression testing was a key to promoting success on the professional nursing licensure
examination.
Newman and Williams (2003) appraised the use of a comprehensive computerized
systematic testing and review program developed by ATI in one nursing education program,
implemented to promote nursing school and post-graduation NCLEX-RN
®
success for all
students. Evaluators reported that the ATI testing program assessed students’ basic
competencies on admission and verified knowledge achievement at the completion of courses
with standardized content mastery exams. No psychometric data were reported on the
reliability or validity of the ATI testing instruments. Furthermore, the reviewers found that ATI
provided individually reported evaluations for students, providing specific information on areas
of content deficiency that could be used by faculty to guide remediation.
A retrospective descriptive study by Seldomridge and DiBartolo (2004) on a
convenience sample of 186 student nurses who graduated from 1998 through 2002 from one
53
rural public baccalaureate-nursing program was conducted to determine the variables that
predicted student achievement on the NCLEX-RN
®
. Data were collected using the National
League for Nursing Comprehensive Achievement Test for Baccalaureate Students
(NLN-CATBS) and student files. Researchers found that test average post medical-surgical
coursework and percentile performance on the NLN-CATBS predicted 94.7% of NCLEX-RN
®
passes and 33.3% of failures. Additional findings were that the NLN-CATBS percentile score
and the pathophysiology grade predicted 93.3% of NCLEX-RN
®
passes and 50% of failures.
Recommendations to programs who want to use evidence-based practices to facilitate student
success on NCLEX-RN
®
included initiation of student admission and progression criteria.
Suggested student admission and progression criteria includes a GPA of 2.5 or greater in
science coursework, a minimum grade of C in pathophysiology and medical-surgical nursing
coursework, and a computerized comprehensive nursing knowledge evaluation and remediation
program for all students enrolled in nursing courses.
Overall analysis of the literature on methods used to determine student readiness for
NCLEX-RN
®
achievement revealed five descriptive studies and a finding that the only
significant correlation to predict student readiness for NCLEX-RN
®
achievement came from
two content exams. No experimental or quasi-experimental studies were found exploring
student achievement and readiness methods. Furthermore, no psychometric data were reported
on the standardized exams evaluated in the located studies, exposing a gap in the literature.
Therefore, more research investigating methods used to determine student readiness for
NCLEX-RN
®
is needed using varied research designs, and reporting on the reliability and
validity information of the instruments used in the studies.
54
Analysis of the located studies reporting on methods used to assess student readiness for
NCLEX-RN
®
achievement revealed that standardized content specific testing is the evidenced
based practice used most by nursing education programs. Furthermore, this review found that
the ATI comprehensive remediation and standardized testing package was the most commonly
reported tool. In addition, the determined attributes of nursing education programs that prepare
graduates for NCLEX-RN
®
success were implementing student admission and progression
criteria of a 2.5 or greater GPA in science courses, a minimum grade requirement of a C in
pathophysiology and medical-surgical nursing courses, and a computerized comprehensive
nursing knowledge evaluation and remediation program for students in all nursing courses.
Other elements from this analysis determined to be associated with nursing education program
graduate success on NCLEX-RN
®
were identifying at risk students, requiring above average
exam and quiz scores, using interactive teaching, incorporating analytical and synthesis level
exam questions, facilitating student familiarity with computerized testing, and providing
NCLEX-RN
®
material review and remediation.
Competence
Competence refers to the information, skills, and actions that a professional needs to
perform a particular role (Competence, 2008; Competence, n. d.; U.S. Department of
Education, 2002). Thus, competence is multifaceted requiring various strategies for
development and evaluation (Piercey, 1995; Redfern et al., 2002). Clients of a continuously
changing US healthcare delivery system have mandated that schools of nursing provide
students with current and practical learning to achieve competency in the professional nursing
role (Pew Health Professions Commission, 1998). Because nursing schools have a
responsibility to develop competent students for entry into the profession and competence is
55
complicated, programs use a variety of means for assessment. Analysis of the literature reveals
five varied studies describing or exploring competency assessment in nursing education
(Piercey, 1995; Redfern et al., 2002; Sifford & McDaniel, 2007; Slezak & Saria, 2006; Yaeger
et al., 2004).
In 1995, Piercey evaluated current literature on ways nursing programs assess clinical
competence. The appraiser established that varied definitions of competency exist ranging from
a narrow focus of psychomotor skills in a vocation up to holistic interpretations incorporating
values, ethics, and reflective practice based on standards of a profession. Overall findings of the
evaluation were that the profession of nursing defines competency based on complex standards
and that nursing programs use mixed approaches of observation (i.e., critical incident
performance), written communication (i.e., examination, case studies, and journaling), and self-
evaluation for competency assessment.
Redfern et al. (2002) assessed the literature to determine the quality of the methods used
in assessing competence in nursing. The identified methods were questionnaire rating scales,
observation ratings, criterion-referenced rating scales, simulations, objective structured clinical
examinations, practice assessments and reflections, self-assessments, and multi-method
approaches. Conclusions were that the competency assessment methods used in nursing have
been inadequately evaluated and are lacking psychometric information prompting a need for
research to develop and determine objective, reliable, and valid means that are grounded in
theoretical frameworks. Furthermore, recommendation was made to nurse educators to take a
triangulation or multi-method approach toward competency assessment to enhance validity of
the evaluation and to capture the complex repertoire of cognitive, affective, and psychomotor
skills required of students.
56
In 2007, Sifford and McDaniel investigated 47 senior baccalaureate nursing students’
performance on a commercially available comprehensive NCLEX-RN
®
predictor exit exam
before and after students received a 15-week competency remediation course that included test-
taking strategies, anxiety reduction techniques, and weekly practice experiences. Results
indicated that student performance significantly improved following the intervention (p <.001).
Conclusions were that competency remediation instruction inclusive of practical experiences
improved student performance on a comprehensive exit exam in one nursing program.
Slezak and Saria (2006) designed and implemented a structured competency evaluation
and update session to 118 oncology nurses at one tertiary university-affiliated medical center
located in the Southwest region of the US. Researchers used a simulated clinical practicum, a
self-directed learning module, lecture-discussions, demonstration/coaching, case studies, and
video presentations over a 4-hour period to evaluate and remediate competence in oncology
staff nurses. Discussion determined that inconsistency was prevalent in the practice of
competency development among healthcare institutions and departments. Evaluation of the
project established that a structured competency validation process inclusive of a simulated
clinical practice scenario at one institution was effective in standardizing oncology-nursing
practice.
An analysis of the literature by Yaeger et al. (2004) was undertaken to reveal if nurse
educators could use simulation instruction to develop professional competence in nursing
students. The appraiser determined that Bloom’s Taxonomy of six hierarchical levels that
evolve from lower to higher levels of cognitive complexity provides a foundation to determine
student nurse competency needs. Using the taxonomy, the authors argued that student nurses
need an educational experience that includes development of learning from lower levels of
57
knowledge, comprehension, and application accomplished through traditional instructional
models of lecture, textbooks, and videos, to higher level learning experiences. Furthermore, the
reviewers maintained that the higher levels of learning development are essential to
professional nurse development because they facilitate student abilities to analyze, synthesize,
and evaluate content knowledge obtained at lower levels and must be included in nursing
education programs. Conclusions were that simulation instruction provided the means for nurse
educators to develop professional nurse competencies in students by providing increased
realistic practical experiences where students could improve performance and enhance
understanding of content in a safe environment.
Overall analysis of the literature on competency assessment in nursing education
revealed four descriptive and one quasi-experimental study. No experimental studies were
found. Conclusions are that more research is needed in nursing exploring competency
assessment methods especially studies reporting psychometric information on objective,
reliable, and valid tools. Further analysis revealed the recommendation to nurse educators to
use a multi-method approach for competency assessment to enhance validity using observation
(i.e., simulations), written communication (i.e., examination, case studies, and journaling), and
self-evaluations.
Opinion
An opinion is defined as a view, judgment, or appraisal formed in the mind of a person
about a particular matter (Opinion, 2008). For example, a student forms an opinion about the
various instructional strategies encountered as a learner. Opinions have been used in other
studies for data collection (Blatchley, Herzog, & Russell, 1978; Nehring & Lashley, 2004).
Therefore, an educator who wants to elicit information about an instructional method that was
58
used to deliver medical-surgical content determined from the NCLEX-RN
®
Test Plan and
tested on NCLEX-RN
®
can use a student opinion question on how that strategy affected
learning to gain insight and depth on the intervention.
When a person forms a belief or judgment about a specific matter, they are forming an
opinion based on their individual assessment (Opinion, 2008). Student opinion or evaluation
has been used as a source of data collection using open-ended surveys and questionnaires to
solicit in-depth insight into students’ values, satisfaction, beliefs, feelings, and perceptions.
Analysis of the literature on opinions and nursing content revealed two studies conducted using
this technique (Blatchley et al., 1978; Nehring & Lashley, 2004).
Blatchley et al., (1978) conducted a mixed method longitudinal study on the effects of
self-study on achievement in medical-surgical nursing courses with a convenience sample of
359 medical-surgical nursing students enrolled in six consecutive classes at one higher
education institution. Measurement of student opinions using a questionnaire with an open-
ended comment section and knowledge using pre-test and post-test written examinations were
used for data collection. Researchers reported that self-study methods were as effective as
traditional methods of lecture for medical surgical content delivery since students receiving the
most self-study scored significantly better on the posttest than those receiving the least amount.
Furthermore, investigators found that students reported greater satisfaction with independent
study due to the pace, ability to repeat content as needed, and flexibility compared to traditional
lecture.
In 2004, Nehring and Lashley administered an international survey to 21 nursing
schools to examine student opinions regarding the use of the human patient simulator (HS) in
their nursing education. Data collection on student assessments of simulation for instruction
59
was gathered from evaluations, specific surveys, and verbal reports with open-ended questions
soliciting student opinions. Analysis revealed students found simulation to be enjoyable,
interactive, safe, practical, a means for content remediation, and realistic.
Analysis of the literature on opinions and nursing content revealed the finding that
student and faculty opinions generate information about teaching and learning methods.
Furthermore, the most common way that opinion data has been collected is from open-ended
questions on surveys or questionnaires.
Summary
Chapter 2 contains a review of the pertinent literature and research related to this study.
Analysis revealed that evidence measuring student outcomes to guide nurse educators on the
use of gaming simulation instruction is limited. However, findings are optimistic, establishing
that, teaching/learning is positively impacted when simulation is used as an instructional
strategy revealing student improvements in content retention, motivation, fun, problem-solving
ability, accuracy, confidence, stress reduction, experience, realism, values, decision-making,
and clinical skills. Research methods used to evaluate the cognitive learning of students
engaged with simulation instruction included quasi-experimental and descriptive designs.
However, no studies could be located exploring virtual clinical gaming simulation instruction
applied using digital media software. Furthermore, research instruments measuring student
achievement varied and psychometric information on the reliability and validity of the tools
was rarely reported, impairing generalizations of findings. Implications of this review are that
adoption of virtual clinical simulation instruction using educational gaming software suitable
for today’s digital native nursing students is impeded without further evidence on student
learning of nursing content mastery areas due to the risks for negative consequences to students
60
and programs for poor NCLEX-RN
®
performance. The conclusion is that more research
investigating the use of simulation instruction and its effects on student learning is needed,
especially when it is applied using virtual clinical gaming simulation software.
61
CHAPTER THREE: RESEARCH METHODS
Identification of the techniques and measures used to perform this research is the aim of
this chapter. The research design, population and sample, intervention, instrumentation, and
data analysis used to answer three research questions are described.
Research Questions
The research questions addressed in this study were:
1. What are the differences in post-instruction exam achievement scores on the
Assessment Technologies Institute Content Mastery Series 2.1 Medical-Surgical
Exam™ among higher education medical-surgical nursing students taught with and
without virtual clinical simulation instruction during the fall 2006 through fall 2008
semesters?
2. What are the differences in pre/post-instruction exam achievement scores on the
Assessment Technologies Institute Content Mastery Series 2.1 Medical-Surgical
Exam™ among higher education medical-surgical nursing students taught with and
without virtual clinical simulation instruction during the fall 2008 semester?
3. What are the differences in pre/post-instruction perceived competence summative
scores on the Medical-Surgical Nursing Self-Assessment Survey among higher
education medical-surgical students who received virtual clinical simulation instruction
during the fall 2008 semester?
Research Design
A quantitative causal comparative descriptive design was used to address the research
questions because all sought to describe the differences and infer causes in variables among
62
two or more groups (Burns & Grove, 2001) taught with and without virtual clinical simulation.
Moreover, independent and dependent variables were determined for each research question to
aid with description of the differences in variables among groups.
Research Question One
For research question one, the independent variable was instructional strategy
manipulated by groups from the 2006 to 2008 semesters (i.e., after traditional (TI) or after
virtual clinical simulation instruction (VCSI)). The dependent variable was achievement
measured using the ATI CMS 2.1 MS Exam™ scores.
Research Question Two
Instructional strategy manipulated by groups (i.e., before/after TI and before/after
VCSI) from the 2008 semester was the independent variable in research question two. The
dependent variable was achievement measured using the ATI CMS 2.1 MS Exam™ scores.
Research Question Three
The independent variable was instructional strategy manipulated by groups (i.e.,
before/after VCSI) for research question three. Perceived competence was the dependent
variable for research question three measured as summative scores (i.e., pre/post-VCSI
perceived competence summative scores) from the Medical-Surgical Nursing Self-Assessment
Survey (Appendix B).
Population and Sample
The population for this study was 138 higher education undergraduate nursing students
from one private university enrolled in medical-surgical nursing courses for the purpose of
learning essential medical-surgical content, skills, and behaviors needed by entry-level nursing
graduates during the fall 2006 though fall 2008 semesters. The sampling technique was non-
63
probability purposive sampling. A non-random sample of 98 fluent English speaking medical-
surgical students with a grade point average (GPA) of 2.5 or greater in nursing who completed
the ATI CMS 2.1 MS Exam™ during the fall 2006 through fall 2008 semesters was obtained
and purposively placed into sample subgroups based on the instructional method used for
delivering medical-surgical nursing content.
Research Question One
For research question one, the sample was 98 medical-surgical student subjects who
received VCSI or TI from the fall 2006 through fall 2008 academic semesters. Subjects were
part of four post-instruction sample subgroups including:
1. fall 2006 after TI group, n = 30,
2. fall 2007 after VCSI group, n = 22,
3. fall 2008 after TI control group, n = 29, and
4. fall 2008 after VCSI treatment group, n = 17.
Research Question Two
The sample for research question two was 46 medical-surgical student subjects who
received VCSI or TI from the fall 2008 semester. Subjects were placed into pre- and post-
instruction subgroups. The sample subgroups included:
1. fall 2008 before TI control group, n = 29,
2. fall 2008 before VCSI treatment group, n = 17,
3. fall 2008 after TI control group, n = 29, and
4. fall 2008 after VCSI treatment group, n = 17.
64
Research Question Three
The sample of subjects for research question three was 17 medical-surgical students
who received VCSI from the fall 2008 semester. Subjects were placed into pre- and post-
instruction sample subgroups. The sample subgroups were the:
1. fall 2008 before VCSI treatment group, n = 17 and
2. fall 2008 after VCSI treatment group, n = 17.
Intervention
The intervention in this study was VCSI used to deliver medical-surgical nursing
content. The particular partial reality virtual clinical gaming simulation software used was
Virtual Clinical Excursions (VCE) 3.0 a CD-ROM developed by Elsevier, Inc., specifically for
the medical-surgical textbook adopted in a medical-surgical nursing education course. VCE 3.0
is an educational gaming package that contains 24-simulated multimedia enriched interactive
virtual patient care practical application situations on a CD-ROM accompanied by a
corresponding student guidebook and course textbook. Each simulation begins with reading
and writing activities outlined in the guidebook that direct students to review content in the
course textbook. At the conclusion of the guidebook exercises, students are directed to start the
VCE 3.0 CD-ROM and select certain patients and/or timeframes to initiate an interactive
virtual clinical simulation experience enriched with visual and auditory cues from patient and
peer actors to apply the medical-surgical content just reviewed using the nursing process. VCE
3.0 is a computer-based 2D interactive partial virtual reality clinical simulation delivered using
a computer screen, speakers, mouse and printer that stimulates at least two senses i.e., hearing
and vision (Stanford University, 2009). Thus, VCE 3.0 aids students in developing critical
65
thinking skills and clinical judgment through realistic or practical application in nonclinical
settings such as classrooms (Tashiro, 2006).
Instrumentation
Data collection instruments used in this study included both an examination and a
questionnaire. The examination used to collect data on student achievement for research
questions one and two was the nationally normed standardized ATI CMS 2.1 MS Exam™
constructed from the NCLEX-RN
®
blueprint to assess student mastery of medical-surgical
content that is tested on the NCLEX-RN
®
(ATI, 2004). The ATI CMS 2.1 MS Exam™ is
considered a reliable and valid tool based on the following data. Using a group of 1,681
medical-surgical students, ATI initially calculated the Cronbach’s alpha reliability coefficient
to establish internal consistency of the instrument as α = .695 demonstrating sufficient internal
reliability that the tool was dependable and consistent in measuring medical-surgical elements
(ATI, 2004). Subsequently, the Cronbach’s alpha reliability coefficient was recalculated by
ATI two years later using a new group of 1,627 medical-surgical students and was found to be
α = .716 again demonstrating a sufficient internal consistency or reliability of the tool (ATI,
2006).
In addition, validity of the tool was determined using construct and content validity
methods. Construct validity was established by an extensive review of the NCLEX-RN
®
Test
Plan (ATI, 2004; NCSBN, 2004, 2007). Content validity was determined using a panel of
nursing experts and a sampling of nursing schools. Based on the findings from the construct
and content validity reviews the instrument was determined to be valid for measuring medical-
surgical content needs of nursing students (ATI, 2004).
66
The questionnaire used in this study to collect data for research question three was the
Medical-Surgical Nursing Self-Assessment Survey. The Medical-Surgical Nursing Self-
Assessment Survey is a researcher designed self-report questionnaire consisting of
demographic queries, an open-ended item, and medical-surgical content information questions.
Construct validity was determined by an extensive review of the NCLEX-RN
®
Test Plan. A
panel of undergraduate nursing education experts including a school of nursing Dean, Program
Chair, Doctoral Faculty Survey Researcher, and Medical-Surgical Nursing Faculty members,
established content validity (Appendix C) .
Data Analysis
Data were acquired from participant ATI CMS 2.1 MS Exam™ scores for research
questions one and two. In addition, data for research question three were gained from
participant Medical-Surgical Nursing Self-Assessment Survey responses related to
demographic information and medical-surgical content questions. Statistical analysis on
gathered data was conducted using SPSS
®
15.0.
Research Question One
Data collected for research question one were analyzed using descriptive statistics and
one-way analysis of variance (ANOVA) to determine significant differences in the post-
instruction ATI CMS 2.1 MS Exam™ mean scores among medical-surgical nursing students
taught with or without VCSI during the fall 2006 to fall 2008 semesters. An effect size measure
was computed because significance was found. Moreover, a mean score plot graphic and
descriptive data frequencies and measures of central tendency tables were created to provide
relevant visuals of the descriptive data output.
67
Research Question Two
The data acquired for research question two were analyzed using descriptive statistics
and one-way ANOVA to determine significant differences in the pre-instruction and post-
instruction ATI CMS 2.1 MS Exam™ scores among the treatment (VCSI) and control (TI)
groups during the fall 2008 semester. A p value of .05 was set beforehand as the test of
significance. An effect size measure was computed because significance was found. Relevant
descriptive data frequencies and measures of central tendency were placed into tables to
visualize output.
Research Question Three
Data for research question three were analyzed using descriptive statistics and two-
related samples Wilcoxon matched-pairs signed-rank test. The two-related samples Wilcoxon
matched pairs-signed rank test was used because the sample size was small (n = 17) and
Wilcoxon replaced observed differences with ranks, which offsets the severity of an effect for
outliers, or large differences. Results of the descriptive analysis consisting of measures of
central tendency were placed into a table to visualize output. Response data from one open-
ended question on the Medical-Surgical Nursing Self-Assessment Survey were analyzed to
identify common themes. Themes, reported as ancillary findings, were summarized.
Summary
This chapter outlined the overall quantitative causal comparative design and research
procedures that were used in this investigation. The research population for this study was
higher education undergraduate nursing students from one private university enrolled in
medical-surgical nursing courses for the purpose of learning essential medical-surgical content,
skills and behaviors needed by entry-level nursing graduates from the fall 2006 though fall
68
2008 semesters. A non-random sample of 98 fluent English speaking medical-surgical students
with a grade point average (GPA) of 2.5 or greater in nursing who completed the ATI CMS 2.1
MS Exam™ during the fall 2006 through fall 2008 semesters was used. Students were
purposively placed into sample sub groupings. Data were collected from the standardized ATI
CMS 2.1 MS Exam™ and the Medical-Surgical Nursing Self-Assessment Survey both
constructed from the medical-surgical content found in the NCLEX-RN
®
Test Plan. Data
analysis included statistical analysis of quantitative examination and questionnaire data.
Relevant ancillary findings from participant responses to an open-ended item on the Medical-
Surgical Nursing Self-Assessment Survey were also analyzed. Major findings and ancillary
findings are reported in Chapter 4.
69
CHAPTER FOUR: FINDINGS
This study was designed to determine whether the use of virtual clinical gaming
simulation has an effect on the learning outcomes of medical-surgical nursing students.
Descriptive data and statistical analysis are presented in this chapter for the following three
research questions:
1. What are the differences in post-instruction exam achievement scores on the
Assessment Technologies Institute Content Mastery Series 2.1 Medical-Surgical
Exam™ among higher education medical-surgical nursing students taught with and
without virtual clinical simulation instruction during the fall 2006 through fall 2008
semesters?
2. What are the differences in pre/post-instruction exam achievement scores on the
Assessment Technologies Institute Content Mastery Series 2.1 Medical-Surgical
Exam™ among higher education medical-surgical nursing students taught with and
without virtual clinical simulation instruction during the fall 2008 semester?
3. What are the differences in pre/post-instruction perceived competence summative
scores on the Medical-Surgical Nursing Self-Assessment Survey among higher
education medical-surgical students who received virtual clinical simulation instruction
during the fall 2008 semester?
Population and Sample
The population for this study was 138 higher education undergraduate nursing students
from one private university enrolled in medical-surgical nursing courses for the purpose of
learning essential medical-surgical content, skills, and behaviors needed by entry-level nursing
70
graduates from the fall 2006 though fall 2008 semesters. The sampling technique was non-
probability purposive sampling. A non-random sample of 98 fluent English speaking medical-
surgical students with a grade point average (GPA) of 2.5 or greater in nursing who completed
the ATI CMS 2.1 MS Exam™ was obtained and purposively placed into sample subgroups
based on the instructional method used to deliver medical-surgical nursing content.
For research question one, the sample consisted of 98 medical-surgical student subjects
who received virtual clinical simulation instruction (VCSI) or traditional instruction (TI) from
the fall 2006 through fall 2008 semesters. Subjects were placed into four post-instruction
sample subgroups including: fall 2006 after TI group (n = 30), fall 2007 after VCSI group (n =
22), fall 2008 after TI control group (n = 29), and fall 2008 after VCSI treatment group (n =
17).
The sample for research question two was 46 medical-surgical student subjects who
received VCSI or TI from the fall 2008 semester. Subjects were placed into pre- and post-
instruction subgroups including: fall 2008 before/after TI control groups (n = 29) and fall 2008
before/after VCSI treatment groups (n = 17).
The sample of subjects for research question three was 17 medical-surgical students
who received VCSI during the fall 2008 semester. Subjects were placed into pre- and post-
instruction sample subgroups: fall 2008 before/after VCSI treatment groups (n = 17).
Major Findings
Data were obtained from the standardized ATI CMS 2.1 MS Exam™ scores for
research questions one and two and the Medical-Surgical Nursing Self-Assessment Survey
(Appendix B) for research question three. Using SPSS
®
15.0, the data were analyzed using
descriptive and inferential statistics. Results for each research question are reported.
71
72
Research Question One
What are the differences in post-instruction exam achievement scores on the Assessment
Technologies Institute Content Mastery Series 2.1 Medical-Surgical Exam™ among higher
education medical-surgical nursing students taught with and without virtual clinical simulation
instruction during the fall 2006 through fall 2008 semesters? In order to answer research
question one, data from 98 medical-surgical student subjects were analyzed using descriptive
statistics and one-way analysis of variance (ANOVA) to determine differences.
Descriptive statistics. Fall 2006 through fall 2008 post-instruction ATI CMS 2.1 MS
Exam™ results – mode, median, mean, and standard deviation – are displayed in Table 1. The
fall 2006 after TI group mean score was 63.2 (SD 9.35). For the fall 2007 after VCSI group, the
mean score was 69.9 (SD 8.33). For the fall 2008 after TI control group, the mean score was
54.9 (SD 5.65). The fall 2008 after VCSI treatment group mean score was 80.9 (SD 5.66).
Other measures of central tendency – mode and median – revealed similar results. In each case,
students taught with VCSI scored higher than those taught with TI.
Table 1: Research Question One - Descriptive Statistics.
Groups
n
Mode Median Mean
SD
Fall 2006 after TI 30 60.0 61.7 63.2 9.35
Fall 2007 after VCSI 22 63.3 67.3 69.9 8.33
Fall 2008 after TI Control 29 51.1
54.4
56.7
57.8
58.9
55.6 54.9 5.65
Fall 2008 after VCSI Treatment
17 76.7
78.9
83.3
78.9 80.9 5.66
Total Post-Instruction 98 60.0 63.3 65.3 11.68
One-way analysis of variance. Data were analyzed using one-way ANOVA to determine if
differences between groups were significant. The hypotheses were:
1. Null hypothesis: There are no differences in the post-instruction achievement mean
scores on the ATI CMS 2.1 MS Exam™ among higher education medical-surgical
nursing students taught with and without VCSI during fall 2006 through fall 2008
semesters.
2. Alternate hypothesis: There are differences in the post-instruction achievement mean
scores on the ATI CMS 2.1 MS Exam™ among higher education medical-surgical
nursing students taught with and without VCSI instruction during the fall 2006 through
fall 2008 semesters.
Levene’s test of homogeneity was obtained to determine equal variance among groups.
Based on the p = .148, homogeneity of variance was assumed. The obtained F ratio (45.490)
73
shown in Table 2, reveals a significant effect among the groupings. The magnitude of that
effect was moderately large as noted by the Eta Squared of .592.
Table 2: Research Question One - ANOVA.
Mean
Groups SS df Square
F
Sig.
Eta
Squared
Between Groups 7838.296 3 2612.765 45.490 .000* .592
Within Groups 5398.931 94 57.435
Total 13237.227 97
*Significant at the .05 level.
To know which of the groups were significantly different, a post hoc comparison was
obtained using the Bonferroni procedure. Note these effects in Table 3. There were significant
differences between the fall 2006 and fall 2008 TI groups (p = .000) and between the fall 2007
and fall 2008 VCSI groups (p = .000). Significant differences were also found when post-
instruction TI groups (fall 2006 and fall 2008) were compared to post-instruction VCSI groups
(fall 2007 and fall 2008). The smallest difference in post-instruction scores was between the
fall 2006 TI and fall 2007 VCSI groups (p = .013).
Table 3: Research Question One - Bonferroni Post Hoc Test.
(I)Semester
Year
(J)Semester
Year
Mean
Difference
(I-J)
SE
Sig. 95% Confidence Interval
Lower
Bound
Upper
Bound
Fall 2006 (TI) Fall 2007 (VCSI)
Fall 2008 (VCSI)
Fall 2008 (TI)
-6.6833
-17.6363
8.3063
2.1273
2.3007
1.9736
.013*
.000*
.000*
-12.417
-23.837
2.987
-.950
-11.435
13.626
Fall 2007
(VCSI)
Fall 2008 (VCSI)
Fall 2008 (TI)
-10.9529
14.9897
2.4473
2.1427
.000*
.000*
-17.549
9.215
-4.357
20.765
Fall 2008
(VCSI)
Fall 2008 (TI) 25.9426 2.3150 .000* 19.703 32.182
* Significant at the .05 level.
74
75
In summary, one-way ANOVA and Bonferroni post hoc tests reveal that there is a
significant difference in post-instruction ATI CMS 2.1 MS Exam™ scores among students
taught with and without VCSI from fall 2006 to fall 2008. Therefore, the null hypothesis was
rejected, and the alternate hypothesis was accepted. Further exploration of post-instruction
group mean score data, conveyed in Figure 1, illustrates that students taught with VCSI earned
higher group mean scores (69.9 in 2007 and 80.9 in 2008) than those taught by TI (63.2 in 2006
and 54.9 in 2008).
Semester Year Groups
Post TI Cn Fall 2008 Post VCSI Tx Fall 2008Post VCSI Fall 2007Post TI Fall 2006
Mean Scores
80.00
70.00
60.00
50.00
54.91
80.85
69.90
63.22
54.91
80.85
69.90
63.22
Figure 1: Research Question One - Mean Score Plot.
Research Question Two
What are the differences in pre/post-instruction exam achievement scores on the
Assessment Technologies Institute Content Mastery Series 2.1 Medical-Surgical Exam™
among higher education medical-surgical nursing students taught with and without virtual
clinical simulation instruction during the fall 2008 semester? The sample for research question
two consisted of 46 medical-surgical student subjects who were taught with TI (n = 29) or
VCSI (n = 17) during the fall 2008 semester. Descriptive statistics and one-way ANOVA were
completed to determine differences.
Descriptive statistics. Pre- and post-instruction ATI CMS 2.1 MS Exam™ results –
mode, median, mean and standard deviation – from fall 2008 control and treatment groups are
displayed in Table 4. The mean score for the fall 2008 before TI control group was 51.2 (SD
6.33). The fall 2008 before VCSI treatment group averaged 56.4 (SD 8.42). The fall 2008 after
TI control group had a mean score of 54.9 (SD 5.65). The fall 2008 after VCSI treatment group
mean score was 80.9 (SD 5.66). Other measures of central tendency, including the mode and
median, revealed the same pattern; students taught with VCSI scored higher than those taught
with TI.
76
Table 4: Research Question Two - Descriptive Statistics.
Groups
n
Mode Median Mean
SD
Fall 2008 Before TI Control Group 29 47.9
48.9
50 51.2 6.33
Fall 2008 Before VCSI Treatment Group 17 53.3
58.9
62.2
65.6
58.9 56.4 8.42
Fall 2008 After TI Control Group 29 51.1
54.4
56.7
57.8
58.9
55.6 54.9 5.65
Fall 2008 After VCSI Tx Group Mean Score 17 76.7
78.9
83.3
78.9 80.9 5.66
One-way analysis of variance. Data were analyzed using one-way ANOVA to
determine if differences between groups were significant. The hypotheses were:
1. Null hypothesis: There are no differences in the pre/post-instruction achievement mean
scores on the ATI CMS 2.1 MS Exam™ among higher education medical-surgical
nursing students taught with and without VCSI from the fall 2008 semester.
2. Alternate hypothesis: There are differences in the pre/post-instruction achievement
mean scores on the ATI CMS 2.1 MS Exam™ among higher education medical-
surgical nursing students taught with and without VCSI instruction from the fall 2008
semester.
Levene’s test of homogeneity was obtained to determine equal variance among groups.
Based on the p = .113 homogeneity of variance was assumed. The obtained F ratio (83.992)
77
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shown in Table 5, reveals a significant effect among the groupings. The magnitude of that
effect was large as noted by the Eta Squared of .714.
Table 5: Research Question Two - ANOVA.
Mean
Groups SS df Square
F
Sig.
Eta
Squared
Between Groups 10486.968 3 3495.656 83.992 .000* .714
Within Groups 3662.471 88 41.619
Total 14149.438 91
*Significant at the .05 level.
To know which of the groups were significantly different a post hoc comparison was
obtained using the Least Significant Difference (LSD). Note these effects in Table 6. Analysis
shows that there were significant differences between students in the VCSI treatment group and
TI control group before instruction (p = .010). There were also significant differences in scores
received by VCSI and TI groups after instruction (p = .000). Further review shows that both TI
(p = .030) and VCSI (p = .000) groups made significant gains between pre- and post-
examination. Although, the level of significance was greater for students taught with VCSI.
Scores for the pre-instruction VCSI treatment group and post-instruction TI control group were
non-significant.
Table 6: Research Question Two - Least Significant Difference (LSD) Post Hoc Test.
(I)Semester
Year
(J)Semester
Year
Mean
Difference
(I-J)
SE
Sig. 95% Confidence Interval
Lower
Bound
Upper
Bound
Pre Fall
2008 (VCSI)
Pre Fall 2008
(TI)
(VCSI)
(TI)
5.2172
-24.4529
1.4897
1.9706
2.2128
1.9706
.010*
.000*
.452
1.301
-28.850
-2.427
9.133
-20.056
5.406
Pre Fall
2008 (TI)
(VCSI)
(TI)
-29.6702
-3.7276
1.9708
1.6942
.000*
.030*
-33.586
-7.094
-25.754
-.361
Post Fall
2008 (VCSI)
(TI)
25.9426 1.9706 .000* 22.026 29.859
*Significance at the .05 level.
In summary, one-way ANOVA and LSD post hoc tests reveal that there are significant
differences in pre- and post-instruction ATI CMS 2.1 MS Exam™ scores among students
taught with and without VCSI during fall 2008. Specifically, there were significant differences
between students in the VCSI treatment group and TI control group before instruction (p =
.010) and after instruction (p = .000). Additionally, both TI (p = .030) and VCSI (p = .000)
groups made significant gains between pre- and post-examination, but the level of significance
alternate hypothesis was accepted. Further exploration of post-instruction group mean score
data, conveyed in Figure 2, illustrates that students taught with VCSI earned higher group mean
scores than those taught by TI. Specifically, means scores for the treatment group increased by
24.5 points (from 56.4 to 80.9), while students in the TI control group only gained 3.7 points
(from 51.2 to 54.9) between pre- and post-examination.
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Fall 2008 Semester Test Times
PostCn Fa08PostTx Fa08PreCn Fa08PreTx Fa08
Mean Scores
90.0
80.0
70.0
60.0
50.0
54.9
80.9
51.2
56.4
Figure 2: Research Question Two - Mean Score Plot.
Research Question Three
What are the differences in pre/post-instruction perceived competence summative
scores on the Medical-Surgical Nursing Self-Assessment Survey among higher education
medical-surgical students who received virtual clinical simulation instruction during the fall
2008 semester? Data were collected for research question three from the pre- and post-
instruction Medical-Surgical Nursing Self-Assessment Survey completed by 17 baccalaureate
medical-surgical student subjects. The mean age was 26 (SD 7.04) with a median age of 22.
The mean years of gaming experience was seven (SD 5.87) and the median was four. Students
also identified their preferred learning style as “Doing” (88.2%) when asked to select between
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“Doing”, “Hearing” (0%) and “Seeing” (11.8%). Survey results were analyzed using
descriptive statistics and the two-related samples Wilcoxon matched-pairs signed-rank test.
Descriptive statistics. Based on students’ Medical-Surgical Self-Assessment Survey
pre- and post-instruction perceived competency summative scores (mode, median, mean and
standard deviations) are displayed in Table 7. Scores are based on a rating scale of 1 = none, 2
= low competence, 3 = moderately low competence, 4 = moderately high competence, and 5 =
high competence. The pre-instruction VCSI treatment group perceived competence mode was
4, median was 4, and mean was 3.47 (SD = .717). As noted by a mean score of 3.47, students
perceived their competence as moderately low prior to instruction. The post-instruction VCSI
treatment group perceived competence mode was 5, median was 5, and mean was 4.82 (SD =
.393). Based on the mean score of 4.82, students felt they had achieved high competence in
medical-surgical content.
Table 7: Research Question Three - Descriptive Statistics.
n
Mode Median Mean
SD
Fall 2008
Before-VCSI
Treatment
Group
17 4 4 3.47 .717
Fall 2008
After-VCSI
Treatment
Group
17 5 5 4.82 .393
Two-related samples Wilcoxon matched-pairs signed-rank test. Data were analyzed using
the two-related samples Wilcoxon matched-pairs signed-rank test to determine the size of the
difference in mean ranks among paired subjects. The hypotheses were:
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82
1. Null hypothesis: The mean rank is similar among the pre- and post-instruction groups
perceived competency Medical-Surgical Nursing Self-Assessment Survey summative
scores during the fall 2008 semester.
2. Alternate hypothesis: The mean rank is not similar among the pre- and post- instruction
groups perceived competency Medical-Surgical Nursing Self-Assessment Survey
summative scores during the fall 2008 semester.
Table 8: Research Question Three - Mean Rank.
n
Mean
Rank
Sum of
Ranks
After VCSI
Perceived Competency Score
Negative Ranks 0
.00 .00
Before VCSI
Perceived Competency Score
Positive Ranks
17
9.00 153.00
Ties 0
Total 17 9.00 153.00
The positive ranks or cases for which the post-instruction perceived competency
summative score increased over the pre-instruction perceived competency score was 17 and the
mean rank was nine (see Table 8). There were no reported negative ranks or ties. The obtained
z statistic was -3.758 (displayed in Table 9) revealing a significant effect (p = .000) between
pre- and post-instruction.
Table 9: Research Question Three -Two-Related Samples Wilcoxon Matched-Pairs
Signed-Rank Test.
After VCSI PCS Group – Before VCSI PCS Group
Z
-3.758
Asymp. Sig. (2 –tailed)
.000*
*Significant at the .05 level.
In summary, the two-related samples Wilcoxon matched-pairs signed-rank test reveals
that there was a significant difference in students’ perceptions of competence between pre- and
post-instruction. Furthermore, the gains were all positive with students indicating an increase
from moderately low competence (3.47) before instruction to high competence (4.82) after
instruction. Therefore, the null hypothesis was rejected and the alternate hypothesis was
accepted.
Ancillary Findings
Students in the VCSI treatment group responded to the following open-ended question
located on the Medical-Surgical Nursing Self-Assessment Survey: “In your opinion, how has
virtual clinical gaming simulation affected your learning of medical-surgical content?” Thirteen
of 17 or 76.4% of students in the VCSI treatment group responded (see Table 10).
Table 10: Ancillary Findings - Student Opinion Analysis.
n
Missing Total Themes Frequency Percent
17 4 13 Experience 10 76.6%
Understanding 7 53.9%
Safety 4 30.8%
Enjoyment 3 23.1%
Convenience 2 15.4%
Motivation 1 7.7%
The most frequently reported benefit was experience mentioned by 10 of 13 students
(76.6%). Experience was expressed as doing or practice. For example, one student reported that
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virtual clinical simulations (VCS) “give me a chance to learn by doing without the fear of
harming someone. They really helped me learn the medical-surgical content.” Another reported
that VCS “helped me to practice skills, be flexible and learn from my mistakes.”
Understanding was the second most frequent benefit conveyed by seven of 13 students
(53.9%) in the VCSI treatment group. For example, one student reported, “virtual clinical
simulation games have had a great influence on my understanding of medical-surgical content”.
The other emergent but less frequently stated themes were that VCSI promoted safety,
convenience, enjoyment, and motivation. Many student comments cut across themes. For
example, in this comment, “I got to practice at home which makes it convenient, better to make
mistakes in the game because it’s safer than in a live clinical!” both the themes of convenience
and safety were highlighted.
Summary of Findings
This chapter reported findings from the descriptive and inferential statistical analysis of
data collected from the ATI CMS 2.1 MS Exam™ and the Medical-Surgical Nursing Self-
Assessment Survey to answer the three research questions. Research question one findings
from the one-way ANOVA shows the differences between TI and VCSI are statistically
significant (p = .000) with post hoc analysis revealing significance between each group.
Further review of mean scores and other measures of central tendency shows that students
taught with VCSI scored significantly higher than TI students from fall 2006 through fall 2008
semesters. The effect of VCSI accounted for 59.2% of the total variability. Research question
two findings from the one-way ANOVA shows the differences between TI and VCSI are
statistically significant (p = .000) with post hoc analysis revealing significance between pre-
instruction groups (TI versus VCSI), between post-instruction groups (TI versus VCSI), and
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between pre- and post-instruction groups (TI versus TI and VCSI versus VCSI). Further review
of mean scores and other measures of central tendency shows that students taught with VCSI
scored significantly higher than TI students during the fall 2008 semester. The effect of VCSI
accounted for 71.4% of the total variability. Research question three findings show that
differences in pre- and post-instruction perceived competence summative scores of students
who received VCSI during the fall 2008 semester increased significantly for all students.
Finally, ancillary findings from thematic analysis of student responses to an open-ended
question revealed the most frequent benefits of VCSI to learning were experience and
understanding. Other reported, but less frequently mentioned, themes were safety, enjoyment,
convenience, and motivation.
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CHAPTER FIVE: SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
The purpose of this study was to determine if the use of the instructional strategy of
virtual clinical simulation instruction (VCSI) to deliver medical-surgical content had a
significant effect on the learning outcomes of students in higher education medical-surgical
nursing education courses. The specific student learning outcomes of medical-surgical content
exam achievement scores and perceived competency were explored for differences with the
following three research questions:
1. What are the differences in post-instruction exam achievement scores on the
Assessment Technologies Institute Content Mastery Series 2.1 Medical-Surgical
Exam™ among higher education medical-surgical nursing students taught with and
without virtual clinical simulation instruction during the fall 2006 through fall 2008
semesters?
2. What are the differences in pre/post-instruction exam achievement scores on the
Assessment Technologies Institute Content Mastery Series 2.1 Medical-Surgical
Exam™ among higher education medical-surgical nursing students taught with and
without virtual clinical simulation instruction during the fall 2008 semester?
3. What are the differences in pre/post-instruction perceived competence summative
scores on the Medical-Surgical Nursing Self-Assessment Survey among higher
education medical-surgical students who received virtual clinical simulation instruction
during the fall 2008 semester?
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Population and Sample
The population for this study was 138 higher education undergraduate nursing students
from one private university enrolled in medical-surgical nursing courses for learning essential
medical-surgical content, skills and behaviors needed by entry-level nursing graduates from the
fall 2006 though fall 2008 semesters. The sampling technique was non-probability purposive
sampling. A non-random sample of fluent English speaking medical-surgical students with a
grade point average (GPA) of 2.5 or greater in nursing who completed the ATI CMS 2.1 MS
Exam™ was obtained and purposively placed into sample subgroups based on the instructional
method used to deliver medical-surgical nursing content.
For research question one, the sample consisted of 98 medical-surgical student subjects
who received VCSI or traditional instruction (TI) from the fall 2006 through fall 2008
semesters. Subjects were placed into four post-instruction sample subgroups including: fall
2006 after TI group (n = 30), fall 2007 after VCSI group (n = 22), fall 2008 after TI control
group (n = 29), and fall 2008 after VCSI treatment group (n = 17).
The sample for research question two was 46 medical-surgical student subjects who
received VCSI or TI from the fall 2008 semester. Subjects were placed into pre- and post-
instruction subgroups including: fall 2008 before/after TI control groups (n = 29) and fall 2008
before/after VCSI treatment groups (n = 17).
The sample of subjects for research question three was 17 medical-surgical students
who received VCSI during the fall 2008 semester. Subjects were placed into pre- and post-
instruction sample subgroups: fall 2008 before/after VCSI treatment groups (n = 17).
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Methods
A causal-comparative descriptive research design was used for this study. Partial
reality virtual clinical simulation using the computer-based gaming simulation software Virtual
Clinical Excursions 3.0 by Elsevier was the intervention. The independent variable was the
type of instructional method (i.e., TI or VCSI) used to deliver medical-surgical content to
students. The dependent variables were the student learning outcomes of achievement (i.e., ATI
CMS 2.1 MS Exam™ scores) for research questions one and two and perceived competence
(i.e., Medical-Surgical Nursing Self-Assessment Survey perceived competency summative
scores) for research question three.
Summary of Findings
For research question one the one-way ANOVA and Bonferroni post hoc tests revealed
that medical-surgical students taught with VCSI had significantly different content mastery
post-instruction mean scores than groups taught with TI (p = .000) from the fall 2006 through
fall 2008 semesters. Additional exploration of post-instruction group mean score data,
conveyed that students taught with VCSI earned higher group mean scores (69.9 in 2007 and
80.9 in 2008) than those taught by TI (63.2 in 2006 and 54.9 in 2008). The effect of VCSI on
mean scores accounted for 59.2% of the total variability.
Regarding research question two the one-way ANOVA and LSD post hoc tests revealed
that there were significant differences in pre- and post-instruction ATI CMS 2.1 MS Exam™
scores among students taught with and without VCSI from fall 2008. Specifically, there were
significant differences between students in the VCSI treatment group and TI control group
before instruction (p = .010) and after instruction (p = .000). Additionally, both TI (p = .030)
and VCSI (p = .000) groups made significant gains between pre- and post-examination, but the
88
level of significance was greater for students taught with VCSI. Further exploration of group
mean score data illustrated that students taught with VCSI earned higher group mean scores
than those taught by TI. Specifically, mean scores for the treatment group increased by 24.5
points (from 56.4 to 80.9), while students in the TI control group only gained 3.7 points (from
51.2 to 54.9) between pre- and post-examination. The effect of VCSI on mean scores accounted
for 71.4% of the total variability between VCSI and TI groups.
For research question three the two-related samples Wilcoxon matched-pairs signed-
rank test revealed that there was a significant difference (p = .000) in students’ perceptions of
competence between pre- and post-instruction. Furthermore, the gains were all positive with
students indicating an increase from moderately low competence (3.47 out of 5) before
instruction to high competence (4.82 out of 5) after instruction.
Ancillary findings from an open-ended student opinion question provided students’
perceptions regarding benefits of learning with VCSI. The most frequently mentioned
advantages were categorized as experience and understanding. Experience was expressed as
doing or practice, articulated as VCS “give[s] me a chance to learn by doing without the fear of
harming someone. They really helped me learn the medical-surgical content.” The link of
understanding to learning was conveyed in comments like this: “virtual clinical simulation
games have had a great influence on my understanding of medical-surgical content.” Other
expressed benefits related to issues of safety, convenience, enjoyment, and motivation.
Findings Related to the Literature
Findings from this study were compared to published investigations exploring gaming
instruction, simulation instruction and gaming simulation instruction. The review revealed
other studies with similar and dissimilar results.
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Major Findings
Research questions one and two in this study revealed that students taught with VCSI
had significantly higher post-instruction content mastery scores than students taught with TI.
These findings were similar to other studies reporting significant differences in post-instruction
content mastery or comprehension results in groups taught with simulation instruction (Alinier
et al., 2006; Farnsworth et al., 2000) and gaming instruction (Cessario, 1987; Cowen &Tesh,
2002). Furthermore, for research question three, this examination discovered that medical-
surgical nursing students’ perceived their competency to be significantly higher after
instruction. This was also similar to other studies that established that student beliefs about
content learning or knowledge were increased after receiving nursing curriculum delivered with
simulation instruction (Bearnson & Wiker, 2005; Bremner et al., 2006) and gaming instruction
(Sisson & Becker, 1988).
The finding that students taught with VCSI had significantly higher post-instruction
content mastery scores than students taught with TI also differ from a few studies. For instance,
some investigations exploring differences in groups taught with gaming instruction and TI
found no significant difference in post-exams (Bays & Hermann, 1997; Ingram et al., 1998) or
that TI instruction groups scored significantly higher than gaming instruction groups on post-
exams (Montpas, 2004).
Ancillary Findings
Student opinion analysis of responses to the open-ended survey question revealed six
benefits of VCSI to learning: experience, understanding, safety, convenience, enjoyment, and
motivation. These findings are similar to other studies where doing or practice of nursing using
the nursing process and technical skills were acknowledged by students taught with simulation
90
instruction (Bearnson & Wiker, 2005; Bremner et al., 2006; Feingold et al., 2004; Kidd &
Kendall, 2006; Morton, 1997; Nehring et al., 2001; Nehring & Lashley, 2004) and gaming
instruction (Ward & O’Brien, 2005). Additionally, other studies also found that student
understanding or cognitive knowledge was significantly improved with gaming instruction
(Berbiglia et al., 1997; Gruending et al., 1991; Royse & Newton, 2007; Sisson & Becker, 1988)
and simulation instruction (Morton, 1997; Nehring & Lashley, 2004; Rodgers, 2007). Safety or
safe environments were connected with simulation instruction (Aronson et al., 1997; Larew et
al., 2006; Morton, 1997; Nehring & Lashley, 2004) and gaming instruction (Gruending et al.,
1991; Henry, 1997; Schmitz et al., 1991; Ward & O’Brien, 2005). Enjoyment, fun, and
relaxation comments were linked with simulation instruction (Aronson et al., 1997; Nehring &
Lashley, 2004; Rowell & Spielvogle, 1996) and gaming instruction (Berbiglia et al., 1997;
Cessario, 1987; Gruending et al., 1991; Henry, 1997; Kuhn, 1995; Sisson & Becker, 1988;
Ward & O’Brien, 2005). Finally, other research confirms that motivation was associated with
the use of gaming instruction (Cessario, 1987; Royse & Newton, 2007; Walljasper, 1982).
Benefits to learning not identified in this study but discussed in other studies were
found. For example, a simulation was deemed an event that fosters decision-making or critical
thinking skills (Bremner et al., 2006; Butler et al., 2007; Feingold et al., 2004; Kidd & Kendall,
2006; Nehring and Lashley, 2004), boosts confidence (Bremner et al., 2006), and stimulates
interest for specialty practice similar to the experienced event (Butler et al., 2007).
Additionally, simulation instruction is a means for a structured (Larew et al., 2006) or varied
multimedia environment (Agazio et al., 2002) where feedback (Agazio et al., 2002),
communication and reflection (Kidd and Kendall, 2006) emerge. Gaming instruction
experience promoted learning from involvement and interaction (Kuhn, 1995; Nehring &
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Lashley, 2004; Ward & O’Brien, 2005), diversity (Henry, 1997), feedback (Henry, 1997),
attentiveness (Kuhn, 1995) and critical thinking (Kuhn, 1995). Gaming instruction affects
learning by stimulating thinking from competition, cooperation, creativity and variety
(Berbiglia et al., 1997). Another study discovered learning was affected through technical skill
practice and critical event management with simulation instruction (Nehring & Lashley, 2004).
Simulation instruction was linked to collaborative inquiry, critical thinking, decision-making,
and problem solving (Aronson et al., 1997).
Detriments to learning were not found in this inquiry. However, other studies have been
completed that identify learning impediments with simulation and gaming instruction such as:
stress, time intensity, inconsistency as an evaluation tool, competition, high development costs,
and reliance upon orientation and debriefing periods (Bremner et al., 2006, Haskvitz & Koop,
2004, Kuhn, 1995).
Conclusions
Effect sizes, ranging from 59 to 71% indicate that a considerable portion of content
mastery variability can be attributed to the intervention – virtual clinical simulation instruction
using digital media software. Since similar results were found from other gaming simulation
instruction studies (Alinier et al., 2006; Cessario, 1987; Cowen &Tesh, 2002; Farnsworth et al.,
2000) support exists for integrating this method in nursing classrooms to provide practical
experiences related to teaching/learning essential medical-surgical skills and content. However,
no evidence was found in this study or in related literature exploring virtual clinical simulation
instruction to deliver other nursing curriculum content.
In addition to scoring well on the medical-surgical content mastery exam, student
nurses perceived that their achievement would be high. It may be concluded that while the
92
acquisition of a professional content knowledge base is no doubt a major training objective, the
related perceptions and beliefs about one’s ability and motivation to acquire learning are
important interactive effects that merit future perception and opinion research.
Lastly, all students reported positive open comments regarding the benefits of virtual
clinical simulation instruction to their learning, and no detriments were identified. In short, it
can be concluded that since differential assessments of professional knowledge and competence
indicate the growth of medical-surgical nursing knowledge by these undergraduates then it
provides additional support for using the method.
Implications
Today’s nursing students are digital natives who prefer learning similar to the way they
have gained information in life, interactively, using digital technology enriched with audio,
visual, and kinesthetic media different from previous generations. These contemporary students
are also adult learners who like practical experience with new content delivery similar to
previous generations of students. Software like Virtual Clinical Excursions 3.0 (VCE) by
Elsevier, Inc. that stimulates hearing and visual senses with multimedia for practical application
in medical-surgical nursing courses should be appealing to digital native adult learners.
Additionally, the findings of this study contributed to a developing knowledge base in
nursing education literature regarding the effects of VCSI on student achievement and
perceived competence in medical-surgical content mastery by adding new information to the
body of evidence related to gaming simulation instruction. Furthermore, nursing stakeholders
(i.e., nursing education accreditors, administrators, program chairs and faculty) responsible for
decision-making on whether to adopt VCSI for use to deliver nursing curriculum can empower
themselves with evidence- based results from this study in their decision-making.
93
The results from this study imply that:
1. Nursing instructors who teach medical-surgical nursing content knowledge using VCSI
resources can increase the probability that their students will have greater content
retention and related understanding of essential nursing knowledge. This is an important
basis for future applications and synthesis of such concepts in day-to-day nursing
practice.
2. There appears to be a concurrent, affective effect or by product of VCSI training related
to virtual experiences, which engage all of one’s senses in the learning context. An
increased sense of self-efficacy may emerge from “doing nursing” via virtual clinical
simulation or related kinds of resources.
3. Additionally, teachers can promote psychomotor learning and the technical skills, tasks,
and procedures of medical-surgical nursing using VCSI. This consequence is based on
the finding in this study that partial virtual reality clinical simulations were reported by
students as safe, convenient, and motivating learning environments for repeated practice
and doing of skills, independent of instructor and clinical laboratory availability.
Recommendations for Future Studies
The findings of this study are significant but limited, providing opportunity for
additional research. Recommendations for future study include:
1. Purposive sampling resulted in small and varied disproportional sample sizes for sub
groups. Conducting future studies using random sampling techniques with larger and
proportional sample sizes would aid in generalizing findings to other nursing
populations.
94
2. The partial virtual reality clinical simulation used in this study stimulated the senses of
hearing and vision and is only one kind of virtual reality simulation. Additional studies
are needed using other partial reality or full reality virtual clinical simulations to
determine if there are differences in student learning when two different, or more than
two, senses are stimulated.
3. Virtual Clinical Excursions 3.0 for medical-surgical nursing content is only one version
of this type of software for delivering nursing content with VCSI. More studies using
VCE software versions for other nursing content areas like newborn nursing, mental
health nursing, and pediatric nursing are needed to determine the effects on student
learning in these content areas to build the body of evidence on the method.
4. Results of this study revealed a significant increase in student achievement on the
standardized ATI CMS 2.1 MS Exam™ for students instructed on medical-surgical
content with VCSI compared to TI. Future studies using other standardized ATI content
mastery series exams for students instructed with VCSI on other nursing content areas
required for entry-level practice and tested on NCLEX-RN
®
are needed to build the
body of evidence in best-educational practices in nursing education.
5. Undergraduate higher education medical-surgical nursing students from one private
university were used as the subjects in this study, limiting generalizability of the
findings. Replication of this study using other medical-surgical nursing student samples
like those found in diploma programs, practical nurse programs, community colleges,
and public higher education institutions would aid in generalizing findings.
6. Future studies are needed to explore explained and unexplained variance in ATI CMS
2.1 MS Exam™ means scores identified in this study among pre- and post-instruction
95
96
groups taught with VCSI and TI. Identifying factors associated with student learning
and achievement in mastering essential content in nursing curriculum would further
benefit nursing education stakeholders with decision-making related to adopting
instructional practices and methods that facilitate competence in entry-level nursing
practice.
7. Further research is needed to establish the reliability of the Medical-Surgical Nursing
Self-Assessment Survey instrument in other studies exploring medical-surgical nursing
perceived competence.
8. More research with different and larger samples may uncover additional benefits or
detriments of VCSI to learning not expressed by those in this study.
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APPENDICES
109
APPENDIX A: PARTICIPANT LETTER
110
Dear Student:
In an effort to learn more about the effects of the teaching strategies used in your medical-
surgical nursing course, please complete the attached survey. There are two sections to this
survey. In the first part, respond to general questions about who you are. For the second part,
rate your current competence level in medical-surgical nursing practice. The purpose of the
survey is to collect data for my dissertation research study.
This survey will take approximately 10 minutes to complete. Participation is voluntary and
your consent is implied by your response. The information you supply is confidential. The
results of the survey will be determined by the answers you provide and not by any personal
information. Individual responses will not be identified. Data will be reported in aggregate
form.
The results from this survey will assist in determining best educational strategies to use in
teaching medical-surgical nursing. If you have additional questions about the study, please
contact me Robin Lewis at 304-357-4837 or by email at [email protected]. If you have
questions concerning your rights as a research participant, you may contact the Marshall
University Office of Research Integrity at 696-4303.
Sincerely,
Robin A. Lewis, MSN, FNP-BC, CCRN, RN
Graduate Student
Marshall University Graduate College
111
APPENDIX B: PARTICIPANT SURVEY
112
Medical-Surgical Nursing
Self-Assessment
Survey
Part I. Demographic Information
Please respond to the following general questions about who you are.
1. How old are you? _____
2. How many years have you played video games? _____
3. How do you prefer to learn? Check One
Doing
Hearing
Seeing
4. In what type of undergraduate nursing education program are you enrolled?
Check One
Associate
Baccalaureate
Diploma
5. In your opinion, how has virtual clinical gaming simulation affected your learning of
medical surgical content?
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________.
Continue to the next page→.
113
Part II. Competence Level Information
Using the scale below, circle the number after
each statement that best corresponds to your
current level of skill in medical-surgical nursing
practice.
1 = None
2 = Low competence
3 = Moderately low competence
4 = Moderately high competence
5 = High competence
None
Low
Moderately
Low
Moderately
High
High
1. Perform a nursing assessment. 1 2 3 4 5
2. Perform safe medication administration. 1 2 3 4 5
3. Perform patient education. 1 2 3 4 5
4. Prioritize patient care. 1 2 3 4 5
5. Delegate patient care. 1 2 3 4 5
6. Develop a nursing care plan. 1 2 3 4 5
7. Participate in performance improvement. 1 2 3 4 5
8. Document a nursing note. 1 2 3 4 5
9. Perform nursing interventions. 1 2 3 4 5
10. Determine nursing diagnoses. 1 2 3 4 5
11. Interpret diagnostic tests. 1 2 3 4 5
12. Interpret cardiac rhythms. 1 2 3 4 5
13. Interpret lab values. 1 2 3 4 5
14. Interpret vital signs. 1 2 3 4 5
15. Interpret central venous pressures. 1 2 3 4 5
16. Interpret pulmonary artery catheter values. 1 2 3 4 5
17. Interpret intracranial pressure values. 1 2 3 4 5
18. Identify patients in shock. 1 2 3 4 5
19. Treat patients in shock. 1 2 3 4 5
20. Interpret arterial blood gas values. 1 2 3 4 5
Developed by Robin A. Lewis © 2007
Thank you for your time!
114
APPENDIX C: PANEL OF EXPERTS
115
Panel of Experts
Dr. Sandra Bowles, EdD - Dean, Bert Bradford Division of Health Sciences, Division Chair,
Department of Nursing, University of Charleston, Charleston, West Virginia.
Dr. Ronald B. Childress, EdD - Professor, Marshall University Graduate School of Education
and Professional Development, South Charleston, West Virginia.
Dr. Laura Festa, EdD - Program Chair, Baccalaureate Science in Nursing Program, University
of Charleston, Charleston, West Virginia.
Dr. Debra Kay Mullins, EdD - Associate Professor, Baccalaureate Science in Nursing Program,
University of Charleston, Charleston, West Virginia.
Lisa Ramsburg, MSN - Assistant Professor of Nursing, Associate Degree in Nursing Program,
St. Mary’s Hospital, Huntington, West Virginia.
Dr. Paula Reilley, PhD - Associate Professor of Nursing, West Virginia State Community and
Technical College, Institute, West Virginia
116
APPENDIX D: PARTICIPANT LETTER WITH MARSHALL UNIVERSITY
INSTITUTIONAL REVIEW BOARD APPROVAL
117
118
APPENDIX E: MARSHALL UNIVERSITY INSTITUTIONAL REVIEW BOARD
APPROVAL
119
120
CURRICULUM VITAE
ROBIN A. LEWIS
EDUCATION
Marshall University
Doctor of Education in Curriculum and Instruction, EdD, 2009
West Virginia University
Master of Science in Nursing, 2002
West Virginia University
Bachelor of Science in Nursing, 1999
University of Charleston
Bachelor of Science in Biology, 1990
University of Charleston
Associate in Arts in Nursing, 1989
CERTIFICATION
American Academy of Nurse Practitioners, Family Nurse Practitioner, NP-C
American Association of Critical Care Nurses, Adult Critical Care Nursing, CCRN
American Heart Association, West Virginia Region, Basic Cardiac Life Support Provider
American Nurses Credentialing Center, Family Nurse Practitioner, FNP-BC
State of West Virginia, Department of Health and Human Services, Clinical Laboratory
Practitioner, Point of Care Technician
West Virginia Board of Examiners for Registered Professional Nurses, RN
PROFESSIONAL EXPERIENCE
1989-1990 Staff Nurse, Relief Charge Nurse, Telemetry Unit, Saint Francis Hospital,
Charleston, West Virginia
1990-1994 Staff Nurse, Relief Charge Nurse, Intensive Care Unit, Saint Francis Hospital,
Charleston, West Virginia
1994 Shift Coordinator, West Virginia Dialysis Facility, Charleston, West Virginia
1994-1996 Director of Nursing, West Virginia Dialysis Facility, Charleston, West Virginia
1996 Telemetry Unit Shift Coordinator, Saint Francis Hospital, Charleston, West
Virginia
1996-2001 Education Coordinator, Saint Francis Hospital, Charleston, West Virginia
1997 Interim Nurse Manager Telemetry Unit, Saint Francis Hospital, Charleston,
West Virginia
1998-1999 Nurse Supervisor, Putnam General Hospital, Hurricane, West Virginia
1998-1999 Nurse Supervisor, Saint Francis Hospital, Charleston, West Virginia
1999-2000 Interim Chief Nursing Officer, Saint Francis Hospital, Charleston, West Virginia
2001-2002 Clinical Director Intensive Care Unit, Putnam General Hospital, Hurricane,
West Virginia
121
2002-Present Assistant Professor of Nursing, Baccalaureate Nursing Department, University
of Charleston, Charleston, West Virginia
2002-2004 Nurse Practitioner Trauma Services, Charleston Area Medical Center,
Charleston, West Virginia
2002-2004 Nurse Practitioner Emergency Department Services, Charleston Area Medical
Center, Charleston, West Virginia
2004-2006 Kaplan NCLEX-RN Teacher, Kaplan Inc., Louisville, Kentucky
2004-Present Nurse Practitioner, Women’s Health Center, Charleston, West Virginia
2008-Present Nurse Practitioner, Medical Weight Loss Clinic of Charleston, Charleston, West
Virginia
HONORS AND RECOGNITION
1999 West Virginia University, Outstanding RN-BSN Student
2000 West Virginia Nurses Association, Legislative Leader
2000 West Virginia University, Clinical Preceptor
2001 West Virginia Nurses Association, State of West Virginia Health, Policy and
Legislative Committee, Legislative Leader
2002 West Virginia University, Outstanding MSN Student
RESEARCH
2000 A comparison of weight changes in older and younger persons undergoing
CABG surgery. Funded by American Society for Parental and Enteral Nutrition,
Rhodes Research Foundation, Richard Fleming Grant, $5000.00. PI: R.
DiMaria-Ghalili, PhD, RN, CNSN. Activities performed include data collection,
and data base entry (Research Assistant)
2000 Post Operative Weight Loss & Depressive Symptoms in Older Elective CABG
Patients. PI: R. DiMaria-Ghalili, PhD, RN, CNSN. Under supervision of the PI
performed a review of literature, secondary data analysis of previously collected
data on the unexplored relationship between the phenomena of depressive
symptomatology and weight loss in older elective CABG clients (Research
Assistant)
2000 Post-operative Weight Loss and Depressive Symptoms in Older Elective CABG
Patients, Sixth National Nursing Research Conference, White Sulfur Springs,
West Virginia. (Co-presenter, Poster).
2001 Post Operative Health Outcomes and Depressive Symptoms in Older Clients
Recovering from Elective CABG Surgery, 2001: A Nursing Research Odyssey
Alpha Rho Chapter of Sigma Theta Tau, Morgantown, West Virginia. (Co-
presenter, Poster)
2001 Post Operative Health Outcomes and Depressive Symptoms in Older Clients
Recovering from Elective CABG Surgery, West Virginia University-Charleston
Division Research Division, (Co-presenter, Poster)
2002 Post Operative Health Outcomes and Depressive Symptoms in Older Clients
Recovering from Elective CABG Surgery, 2002: A Nursing Research Odyssey
122
123
Alpha Rho Chapter of Sigma Theta Tau, Morgantown, West Virginia. (Co-
presenter, Poster)
2003 Concept Analysis of Well-Being, American Association of Critical Care Nurses
Research Forum, Greater Charleston Area Chapter, Charleston, West Virginia
(Presenter, Paper)
2003 Weight Loss and Depressive Symptoms During CABG Recovery
2003: A Nursing Research Odyssey Alpha Rho Chapter of Sigma Theta Tau,
Morgantown, West Virginia (Co-presenter, Paper)
2003 Weight Loss and Depressive Symptoms During CABG Recovery, Seventeenth
Annual Conference of the Southern Nursing Research Society, Orlando, Florida.
(Co-presenter, Poster)
2004 State of the Science of Well-Being, Eighteenth Annual Conference of the
Southern Nursing Research Society, Louisville, Kentucky (Presenter, Poster)
2004 Weight Loss and Depressive Symptoms During CABG Recovery
2004 Research Forum Xi Tau Chapter of Sigma Theta Tau,
Charleston, West Virginia (Co-presenter, Paper)
2007 Technology Use and Professional Growth through the Residency Portfolio,
Virtual Clinical Excursions: Practical Use of Gaming Simulation Software,
Society for Information Technology & Teacher Education, San Antonio, Texas
(Co-Panel Presenter)
2007 Virtual Clinical Excursions: Gaming and Simulation in Higher Education, 2007
West Virginia Statewide Technology Conference, Charleston, West Virginia
(Presenter, Paper)
2007 Virtual Clinical Excursions: Gaming and Simulations in Nursing Education,
Infusing Technology into Nursing Education, Association of Deans and
Directors of Nursing Education Conference. University of Charleston,
Charleston, West Virginia (Presenter, Paper).
2008 Online Teaching and Learning Panel – Q & A. Online Leaning/Technology
Conference. Saint Mary’s Hospital, Huntington, West Virginia (Co-Panel
Presenter).
2009 The Effects of Virtual Clinical Gaming Simulation on Student Learning
Outcomes in Medical-Surgical Nursing Education Courses. Let the games
Begin! 2009 Research Forum Xi Tau Chapter of Sigma Theta Tau,
Charleston, West Virginia (Presenter, Paper)
