INTRODUCTION:

Nursing is a practical profession which requires significant combination of institutional content and practical ability.¹The main purpose of process of nursing education is to gain some cognitive, psychomotor and attitudinal behaviors to students², to have the students internalize ethical standards relating their own disciplines, and to contribute making these a part of their behaviors.

The most effective methods in gaining the students required knowledge, skills and behaviors are the interactives ones which provide active participation of students to learning processes.^1,3,4 Of these methods, simulation training provides opportunity for students to use their own knowledge and skills in the learning processes.³

Simulation means performing something which exists in reality by imitating.² In healthcare, simulation is defined as a method in which a clinical case is represented as realistic as possible and thus a virtual experience is obtained without taking a risk so that when said case is encountered in real clinical practice, it is easily understood and managed.^2,5 In the education of nurses, the skills and practices, which are developed in preclinical and clinical environment, are important for turning the theoretical knowledge learned in the class environment into practice. Clinical practices offer students important opportunities for turning their theoretical knowledge, skills and attitudes related to patient care into practice.⁶ Due to recent increase in sensitivity towards patient safety and patient rights, increased number of students in nursing programs, limited space in clinical practice areas, decrease of time for which patients stay in hospital and the students spending less time in the clinic as a result of the problems arising from the education system, it is not always possible for students to gain proper clinical experience.^7,8These kinds of problems show us the necessity to increase clinical sufficiency in virtual environment or in the lab where the necessary technical equipment and hardware are located for students of nursing before the real patient care environment.⁶This situation made use of simulation the most required learning and teaching strategy in terms of nursing standards and sufficiency.⁹

Simulation training which is developed in the field of health provides active participation of students to teaching and learning process.^5,10Simulation applications provide many opportunities to students in a safe and controlled environment such as self-learning of patient care standards, critical thinking, problem solving, developing necessary skills for clinical reasoning, turning theoretical knowledge into skills in an integrated way and correcting the difficulties experienced by the students in the clinical environment.^5,9-11 In a study conducted by Bremner et al. (2006) on student nurses, the student nurse group stated that the training provided with simulator increase their self-esteem on skills in evaluating the patient, and that it must be compulsory in nursing training.

One of the fields in which complicated health services that require strong knowledge, problem solving, critical thinking and advanced technology use is obstetrics and gynecology. Simulation can be used as a strong teaching strategy in order to provide safety and increase quality of the care provided in terms of health of both prospective mother and the fetus in the preparation of students to clinical practice in the educational field of women's health nursing. In the educational field of women's health nursing, with simulation training, advanced skills like basic and complicated technical and behavioral skills training regarding all routine and urgent obstetrics and gynecological clinical cases, team work and teaching of clinical decision making process can be evaluated.^13-16 Additionally, it also provides the students with the chance to encounter more real obstetric - gynecological cases and to practice, and to repeat the operations without harming the individual and to gain experience from his/her mistakes, and to ensure that the students overcome stressful situations such as the anxiety of making mistakes, fear of harming the patient, and feeling of inadequacy, and it develops the skill of critical thinking.¹⁵For example, students may be able to use their experience on the emergency situations like simulated articular postpartum hemorrhage when they encounter with a real incident. With the use of simulation, educational practices which would be performed on patients by inexperienced students are prevented.¹⁶

As a result, it is believed that the use of simulation training methods will contribute to students’ skills in clinical environments, students will overcome the fear of harming the patient, will attempt confidently, and that these methods will contribute to training nurses with self-confidence. This study was conducted to assess the simulation training within the scope of Nursing Department Obstetrics - Women's Health Nursing course.

MATERIAL AND METHODS:

This study was conducted as descriptive in order to investigate simulation training activity within the scope of Obstetrics -Women's Health Nursing Course during 2016-2017 academic year in one university. 48 students (34 participant, 14 observer) who took the course participated in the study. By using simple random number table, opinions from 5 students in the participant group and 5 students in the observing group were included. Students were asked the questions of "What are the advantages of training with simulations? How did you feel during and after the simulation? What were the applications you were afraid to perform during the simulation? What are the differences of simulation training from the clinical applications?". Opinions of participant and observer groups were assessed separately and qualitatively. The data of the study were collected with questionnaire form which included students’ basic characteristics. Questionnaire form was composed of questions that express socio-demographic data of the individuals and their feelings related to the simulation. All procedures in the study were performed in accordance with the ethical standards of the institutional committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Permission from ethics committee and written institution permissions have been obtained for the research. Informed verbal consent was obtained from all individual students included into the study.

RESULTS:

Results regarding the socio-demographic characteristics of students in the study were shown in Table-1. It was determined that of the students included in the study, the average age was 20.70±0.98, 70.8% there of were participant and 29.2% thereof were observer; 87.5% were female and 12.5% were male; 87.5% were normal high-school and 12.5% were vocational high-school graduates.

Table-1: Demographics of Students Participating in Simulation (n:48)

Sample Characteristics	Mean (SD)
Age	20.70(0.98)
	N (%)
Participation status in simulation
Participant	34(70.8)
Observer	14(29.2)
Gender
Male	6(12.5)
Female	42(87.5)
Educational Status
Normal high school	42(87.5)
Vocational high-school	6(12.5)

Results regarding the simulation moods of students included in the study were shown in Table- 2. About simulation, of the students included in the study 25.0% stated that they experienced fear, 72.9% stated that they experienced excitement, 39.6% stated that they experienced anxiety, and 25.0% stated that they experienced complicated feelings.

Table-2: Mood Situations of Students about Simulation (n:48)

Mood Situation	N (%)
Fear
Yes	12(25.0)
No	36(75.0)
Excitement
Yes	35(72.9)
No	13(27.1)
Anxiety
Yes	19(39.6)
No	29(60.4)
Complicated feelings
Yes	12(25.0)
No	36(75.0)

Participant opinions;

1^st participant “I think that training with simulation has many contributions to reinforce knowledge in terms of measuring, evaluating and practicing theoretical knowledge and experience. During the simulation I felt a little excited and anxiety due to being observed. However, with the start, I put everything aside and focused on my work. I fear to be the one that manages the situation during highly critical incidents. In clinics, we are able to perform practices very comfortably since we are under nurse observation. However, in simulation all liability and application is within our responsibility, so I believe it provides a much realistic environment. When I see an application that I did right or my friends or mentors point at it, I became happy. When I saw my faulty applications or when I forgot about an application, rather than being upset I became aware of them. I did not fear since I had a long time to make up for it”.

2^ndparticipant “It allowed us to practice our theoretical knowledge. I felt as I had really experienced the incident. It helped me gain experience as a player. Now I know what to do if I encounter with a similar incident at a hospital. I became aware of things that I should not do. My self-confidence increased. I was very excited. It was not like a role but reality. Even my legs shook. The patient was fully under my responsibility. For this reasons, I tried so much to be useful. During the simulation, I feared of wrongly treating the patient, not having the full control on the patient, and forgetting the necessary attempts that we are supposed to perform. We have a change of making mistakes in simulation. There is no real patient to get harmed when we make a mistake. However, in the clinic every wrong treatment will do harm to the patient. I still feel excited after the game. Now I know what to do if I encounter with a similar case. I feel confident now."

3^rd Participant "As a real environment is established, the rate of benefit and seeing cases increases. I think it is useful in terms of professional autonomy. It is comforting that I can experience a possible event in advance and that it decreases the anxiety and the risk of making mistake in said event. After the simulation, I believe that learning how to correct performed applications will help me avoid making wrong applications. Being able to approach possible future incidents with more experience and being better is quite relieving from a humanistic perspective. Practicing doctor’s request without checking as if it is correct though it is not, performing in a haste without considering the consequences, performing voluntary or involuntary practices without empathizing with the patient may make us unease since they can harm the patient. In simulation we have a chance to correct our mistake. However, in the clinical environment, the process we perform must be correct and timely."

4^th participant "When we encounter with a sample incident, we understand how we may approach. We practice the theoretical knowledge we learned in class. I was very excited and nervous. I felt like the case was real and I was very worried about the patient. I felt relaxed after the simulation and thought about my rights and wrongs during the simulation. I felt happy for the practices I performed correctly. If I encounter with a similar incident later, I believe I will perform little/no mistakes. Practices with vital risks were my nightmare. I was afraid of not performing and ignoring little but important practices. In the simulation, we have a chance to see our mistakes and most importantly we are able to learn from these without anybody getting harmed. We see errors with feedback we make. In the clinic, there is no going back from the mistake and these mistakes may cost the patient's life."

5^th Participant "We learnt how to be cold-blooded, understood how important the communication is within the team, and realized defects. I got excited during the simulation. Of course, I had complicated feelings such as anxiety and not knowing what to expect. I think that each group should enter the simulation and experience this. When I put myself into the patient’s shoes, I was scared to experience what the patients were experiencing. Not being informed as a relative of the patient increased the anxiety even more. We have a chance of being directly included in the case during the simulation training. We are left a little outside during the clinical practices."

Observer opinions:

1^st observer “I understood that it is hard to practice what we have learnt in theory. It was easy to say those in theory one by one. I felt excitement, fear, and a little joy. I had complex feelings. When I saw the state of the patient during the simulation, I understood that nurses panicked. I saw that practice is a lot different than theory. I would be afraid of performing a n inadequate or wrong practice in the simulation. It is reliving to know that the incident is not real but animated. Since we are able to manage the practices individually, I believe that they are more lasting than clinical practices.”

2^nd observer "Exhibition of realistic fictions in simulation training makes us experience the real meaning of seizing the moment. What I felt was excitement, fear and, of course, complexity of feelings. During this type of practices, it must be hard to act cold-blooded. After the simulation, there is a comfort of overcoming, yet the person still questions himself/herself. Did I perform the practices correctly? How it should have been? I believe it was a good opportunity to evaluate ourselves. My biggest fear in the simulation would be to harm the patient by performing wrong practice. One realizes that he/she cannot control his/her feelings. Practices that we perform both in the school and internship are limited and correct-practice oriented since they are performed with a supervisor or an assistant. I believe that along with undertaking the whole liability in the simulation, since it a study whose objective is to learn the truth, and yet in which the mistakes are evaluated in the foreground, its contribution is remarkable.”

3^rd observer "Simulation practice may help us perform emergency action in a more cold-blooded and faster way by using our knowledge and practical experience when we encounter an incident. I observed what my friends would do, whether they were making any mistakes, and in which issues they were careful. I saw the mistakes made and the practices ignored and my chances of ignoring these reduced by emphasizing them later on. If I encounter a similar incident with a real patient, I think that my excitement and panic state will decrease. I believe that simulation practice is quite advantageous in terms of being catchy. In the simulation, I would be afraid of making a wrong practice, and not informing patient relatives sufficiently and correctly. In the clinic, we are student nurses and we are removed from the room so that we do not crowd the place. During emergencies, even though we are present on site, we are just observers. Here we learnt what to do more or less. Our friends in the foreground are lucky, I wish we were too."

4^th observer "Encountering and experiencing a possible incident before hospital at the simulation center is a great contribution to our professional life. I did not play a role, and I was an observer, yet I felt excited while watching. After the simulation, I realized that practice is a lot different than theory. During the simulation, I would be afraid of performing wrong drug administration and confusing the procedure due to excitement. While the mentors, guiding nurses, interns etc. were present in the clinic, autonomy was in the foreground during the simulation practice."

5^th observer “Reducing the chance of mistake on a live patient and the chance of anxiety and experiencing this beforehand without real patient is a very different experience. Although I was an observer I felt excited as much as my friends did. After the simulation, I believe that the feedbacks of our friends and mentors made great contributions to us. During the simulation, I would be afraid of not fulfilling my responsibilities. Simulation practices will help us become more active for the incidents which we may encounter in the clinic. I think that theoretical knowledge is crowned with the simulations."

DISCUSSION:

Simulation trainings provide students opportunity of participation in training process actively, working in cooperation with peers, taking role and making practice in training process in safe environment. Use of simulation in nursing trainings ensures increase in self-confidence and developing clinical decision making skills by offering experience-based learning means.^17,18All students specified in the study that use of simulation is beneficial in clinical practice. Terzioglu et al. (2012) detected that all students considered that these trainings were beneficial for them when they were asked about their opinions on performance of clinical practice skills training in virtual environment by using scenario/ computer and models (simulation). Also in other studies carried out in similar manner, students specified that these trainings were beneficial for them when their opinions on simulation trainings were asked.^19,20 It is significant that the skills and practices developed during nursing education are to be integrated with theoretical knowledge learnt. Practice scenarios can be prepared as desired in simulation trainings and all possible situations can be tested. In such an educational environment, it is provided to transfer the things learnt to clinical ambient with the help of appropriate skills training methods. Majority of the students who actively participated in and watched (three students participated actively and three students watched) the simulation stated in the study performed that they experienced how the theoretical information they had learnt and practical application would become integrated by means of simulation training. Similarly, in the study of Lendahls and Oscarsson (2017), it is said that simulation trainings establish bonds between theory and application that are facilitating learning skills of students.

Clinical practices may create fear and anxiety for bachelor’s degree nursing students. Performance of nursing applications on patients in the first instance, concern for making mistake and fear for giving harm to patients and many other suchlike reasons stress students out. Khalaila (2014) stated in his study that simulation training carried out before first clinical experience reduces the anxiety of students in meaningful extent, and increases self-confidence and caring skills. As for the study conducted by Howard et al. (2011), it was indicated that students were too nervous in simulation training; however, their anxiety decreased while caring the same incident in clinic. Participant students in the study mentioned about their stress with these expressions: ‘‘I got excited during simulation and anxious about being watched, I was too excited.” ‘‘I got too excited and anxious.” ‘‘I experienced some complex feelings during simulation such as excitement, anxiety not knowing what will happen.”, and viewer students said: “I got excited as much as my friends despite being viewer”, “I felt excitement, fear and a little bit joy. I felt complex emotions”.

Simulation trainings before clinical applications on patients increase self-confidence of students. Reid-Searl et al. (2012) set forth in their study that simulation trainings reduce the fear and concerns of students and increase their self-confidence and create feeling of readiness for clinical practice. In the study Terzioglu et al. (2012), it was stated that students think that simulation trainings to be received before performing application to patient will increase their self-confidence. The students who attended a similar study (one participant, one viewer) expressed that they develop more autonomy and self-confidence about what to do when they confront with a case similar to the simulation training during practice and simulation training before clinical application is beneficial although they feel anxious due to the fact that all responsibility is taken by them.

Ensuring patient safety in nursing applications performed is quite important. Simulation trainings are applications enabling students gaining experience without giving harm to anyone, performing again and again, making mistakes and learning from mistakes. In the study of Ozkal and Cayir (2016), 87.5% of students agreed with the following opinion: ‘‘enables students gaining experience without giving harm to anyone, performing again and again, making mistakes and learning from mistakes’’. 3 of participant students and 4 of viewers said in the study that the practices carried out in simulation trainings allow them know what to do when they confront with the same case in clinic, and this will reduce or prevent faulty applications, and they can learn the correct way giving harm to no one. Anxiety for making mistake and fear for giving harm to patient stress students out. Simulation provides opportunity for transfer of things learnt to clinical ambient by means of appropriate skills and training methods.

CONCLUSIONS:

As a result of the study, it is seen that the students are in fear, excitement, anxiety and complex feelings. When the students’ views which are evaluated qualitatively are revised, participant students evaluated simulation practices as a teaching process for having a chance to practice their theoretical knowledge without the risk of harming the patient. The observer students stated that even while observing the scenario from outside their anxiety levels increased, and they revised their theoretical knowledge during the steps of practice, and evaluated themselves.

In accordance with these results, it is concluded that it is important to practice without harming the patient in realistic virtual settings in terms of safety of patient and the employee. Regulations towards the active use of simulation applications in nursing training may be suggested.

ACKNOWLEDGMENTS:

We would like to thank the students who participated in the study. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Received on 25.02.2019 Modified on 18.04.2019

Int. J. Nur. Edu. and Research. 2019; 7(3):299-304.

DOI: 10.5958/2454-2660.2019.00069.3