1. Ketty Holt Nurse Educators’ Conference in the Rockies July 14, 2017
AFFECTIVE DOMAIN LEARNING IN HIGH-FIDELITY SIMULATION: STUDENTS’ PERSPECTIVES
Ketty Holt
Nurse Educators’ Conference in the Rockies
July 14, 2017

2. Session Disclosure 1) Approval Statement
This continuing education activity was approved by the Western Multi-State Division, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.
Arizona, Colorado, Idaho, and Utah Nurses Associations are members of the Western Multi-State Division. Approval # 72-17
2) Criteria for Successful Completion
To receive contact hours, participants must check-in to the session using the barcode scanner, attend the entire session and then complete both the session evaluation and full conference evaluation by July 31, 2017.
3) Conflicts of Interest
This educational activity does not include any content that relates to the products and/or services of a commercial interest that would create a conflict of interest.
4) Commercial Support
There is no commercial support being received for this session.

3. Understand the underlying research design
The research project

4. Purpose Explore affective learning from the student’s perspective
Investigate the developmental process of affective learning by comparing junior and senior level students
Identify the levels of affective learning as described by students

5. Affective learning
Defined as “attitudes, values, and beliefs about nursing”
Emphasizes “a feeling tone, an emotion, or a degree of acceptance or rejection”
Hard to teach and difficult to evaluate
Essential to develop nurses who are able to provide holistic care
Critical in self-care and retention of a healthy workforce

6. Methodology Qualitative paradigm
Facilitates understanding students’ perspectives
Encompasses multiple perspectives
Descriptive phenomenology

7. Methodology Two universities
Individual face-to-face or Skype/FaceTime interviews
Interviews followed semi-structured format, were audiotaped, transcribed

8. Sample

9. Data Analysis Significant statements had “feeling tone”
NVivo© and Word® files created
NVivo© nodes were developed using participant’s key word or phrase and facilitated theme development

10. Data Analysis Member checking of interview summaries Group essences
Affective learning was connected to statements from representative nursing authorities
Representative examples of the levels of affective learning were identified
Table 3
Affective Learning by Themes and Connected with Authoritative Nursing Source
Theme
Affective Learning
Authoritative Source
Anxious about not knowing
Emotional regulation as component of nursing role
ANA
Confidence to create meaning
Identification with professional nursing role
NCSBN, CCNE
Excited by growing and developing
Developing communication skills; developing healthy professional relationships; ability to evaluate self
ANA, CCNE
Enjoyed learning
Life-long learning; empathy; professional boundaries
ANA, CCNE, NCSBN
Pressured by being observed
Developing professional nursing role
Ambivalent when relating to the manikin
Practicing caring in awkward circumstances; emotional regulation
Affective learning outcomes
Communication skills; patient/family teaching; life-long learning; ethical considerations; empathy; self-confidence
ANA: American Nurses Association; NCSBN: National Council State Boards of Nursing; CCNE: Commission on Collegiate Nursing Education

11. Explore affective learning from the student’s perspective
Findings

12. Anxious about not knowing
Nervous anticipating simulation
Uncomfortable in the new environment
Shared anxiety
Worried about not knowing what to do or making mistakes
Persistent anxiety
Relief and perspective
Managing anxiety

13. Anxious about not knowing
“I think I was just really nervous that I’d do something wrong.” Leah (senior)
“Yep. I hated it. I freaked myself out. Gosh, I think even one time I caused myself to get sick my nerves always stayed with me all the way across.” Eva (senior)

14. Confident to create meaning
Connecting to previous experiences or learning
Applying learning to future clinical experiences
Connecting clinical experience to simulation
Discovering nursing role and scope of practice—the future

15. Confident to create meaning
“I did have autonomy in sim and it gives me confidence just like a little glimpse of what it will be when I’m done with school.” Yasmin (senior)

16. Excited by growing and developing
Grateful for feedback
From faculty
From peers
Challenged through personal critique
Comforted by the risk-free environment

17. Excited by growing and developing
“I love the collaboration of ideas. People have such different ideas about what you could have said, what you could have done.” Beth (senior)
“At the end of the day, I try to not take things personally, because you’re learning these things for the patients you’re going to take care of, and they’re the most important.” Reese (junior)

18. Enjoyed learning Being the nurse Watching others interact
Playing the family
member

19. Enjoyed learning
“I like it [observing] because it allows me to see a situation and act as if I'm being the nurse without being the one that's right there.” Zoe (junior)
“I’d much rather be a family member I just felt it was a really good inside look from the perspective of the family.” Olga (senior)

20. Pressured by being observed
By faculty who have expectations
By peers who were supportive or judgmental
Suggestions for decreasing pressure

21. Pressured by being observed
“I’m more comfortable messing up around them [peers], because they get it.” Faith (junior)
“I think it’s just knowing that they’re going to be watching you and evaluating you I want to do everything right, and not wanting to think ‘Oh no, you did this wrong and everyone saw.’” Morgan (senior)

22. Ambivalent when relating to the manikin
Awkward conversations with manikins
Disappointed by limitations
Surprised when experiencing connection with manikin and/or scenario
Emotionally affected by family interactions

23. Ambivalent when relating to the manikin
“You need to treat it like it’s a real situation. Once you have that mentality, the whole manikin factor just disappears because you know this is what I need to do, whether it’s a manikin or a patient.” Peyton (junior)
“With a manikin you get practice expecting not to get a response if that makes sense. So you walk into the room, you introduce yourself, and you ask for patient identifiers but you expect not to hear it.” Charlene (senior)

24. Affective learning outcomes
Communicating and working with teams
Teaching patients and families
Life-long learning through novel experiences
Confronting ethical issues
Empathy for patients, families and peers
Self-confidence

25. Affective learning outcomes
“The monitor [is] going and you can see your CPR causing a heart wave, and you’re just like wanting it to come back The doctor had talked to the family and decided that we need to cease CPR and we need to let her go, so then you feel the emotional side of it.” Deb (senior)
“It’s important to find a way to assess the patient and the family’s knowledge, and educate based on that and not just assume that they know things or they don’t know things.” Whitney (junior)

26. Investigate the developmental process of affective learning by comparing junior and senior level students
Comparison

27. Juniors A shared learning experience
Practicing nursing skills, observing peers, playing family members, and receiving feedback
Felt faculty feedback was most important and peer feedback was supportive
Increased confidence by providing practice in assessment, nursing treatments and teaching patients
Talking with the manikin was challenging because faculty were providing the voice

28. Seniors Collaborative learning experience
Responding as a nurse, observing and providing constructive feedback for peers, playing realistic family members
Safe environment to practice independent decision-making
Novel scenarios exposed them to ethical end-of-life dilemmas, surprising emotional reactions
Provided new perspectives, encouraged empathy, enhanced self-confidence

29. Contrasting 1st with final sim
Juniors
Seniors
More confident
Less anxious
Less checklist
More patient responsive
Easier to talk to the manikin
Better routine
Better prep
Less worried about mistakes
More confident
Less anxious
More about learning & less about performance
More patient responsive
Able to talk to providers & practice independently
Comfortable with environment & peer groups
Felt prepared; found their voice as nurses
Less critical of self

30. Affective learning levels
Identify the levels of affective learning as described by students
Affective learning levels

31. Levels of Affective Learning
Receiving
“So you’re just like sitting there staring at them and hoping they do well.” –Julia
Responding
“You get used to talking to the manikin as if it is an actual person.”—Sophia
Valuing
“I like getting feedback on things I need to work on, and then things like I did well on.”—Kylie

32. Levels of Affective Learning
Organizing
“If someone needs a straight cath[eter], you’re like, ‘Is there any chance you can go to the bathroom? Do you have any urge at all?’ those kinds of questions that you’re not asking [the manikin]. Because you’re like, they need a straight cath, so let’s just straight cath them. Things like that that you leave out.”—Beth
Characterization by a value or value set—not achievable as it develops over time

33. Implications—scenarios
End-of-life and cardiac arrest scenarios were highly effective in seniors
Patient and family teaching were effective in junior scenarios
End-of-life & CPR scenarios for seniors
Empathy
Ethical decisions about quality and quantity of care
Family attendance in cardiac arrest
Emotional regulation
Patient & family teaching for juniors
Patient and/or family centered teaching
Novel learning experiences to promote life-long learning

34. Barriers and strategies
Understand barriers to affective learning encountered by students during high-fidelity simulation
Describe potential strategies to enhance and individualize affective learning in high- fidelity simulation
Barriers and strategies

35. Barriers Persistent anxiety Observation pressure
Limitations of manikins

36. Strategies to reduce anxiety
Provide adequate orientation to environment
Refer to objectives in pre-briefing to help students understand expectations
Emphasize formative, student-centered learning
philosophy
Pre-briefing to assess emotional status, discuss and normalize anticipatory response
Encourage participants to volunteer for role

37. Strategies to reduce anxiety
Include reflective writing assignment post simulation
Individualized approach to participation to reduce anxiety levels
Consider referring students to counseling center

38. Strategies to reduce observation pressure
Emphasize formative, student-centered learning
philosophy
Reassure that perfection is not expected
Group prep to enhance peer support
Have peers share positive observations
Protect privacy
Who is in the control room?
Limit the number of observers (if possible)

39. Strategies to enhance created reality
Empathizing with family member
Focusing on the scenario and not the manikin
Identifying with the voice of the manikin

40. Conclusions
HFS creates anxiety in students; 6 of 25 reported persistent anxiety that sometimes interfered with learning
Debriefing was important to learning; some students feared giving criticism
Peer support enhanced the experience; negative interactions may have lasting implications to confidence
Affective learning in HFS is progressive in nature
HFS can support affective domain learning in the first 4 levels—receiving, responding, valuing, and organizing

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