Objective: To examine the relationship between patient-type simulator and undergraduate nursing students’ previous professional role exposure to individuals in high crisis on psychological and physiological stress.
Methods: The quantitative, quasi-experimental study involved analysis of physiological and psychological stress in 159 participants observing or actively providing care to a simulated end-of-life care patient. Further analysis involved assessing the impact of previous professional background exposure to individuals in high crises on stress levels. Psychological stress was analyzed through percentage changes in the State Trait Anxiety Inventory (STAI), Form Y-1; physiological stress was analyzed through percentage changes in heart rate, systolic and diastolic blood pressure.
Results: Overall greater psychological stress occurred when patient care involved the high-fidelity mannequin. Whereas, the greatest change in heart rate occurred in those with no professional exposure to individuals in high crises when care involved the standardized patient. However, the greatest percentage change in blood pressure occurred in those engaged with the care of the standardized patient.
Conclusion: There was a relationship between undergraduate nursing student stress, choice of patient simulator, and previous professional role exposure to individuals in high crises.
Keywords: End-of-life Care; Simulation; Nursing Education; Stress
However, end-of-life care simulation research that has examined nursing student stress is scant [9, 11- 13]. Analyzing the relationship between nursing student stress, simulators, and their working backgrounds is lacking in the literature.
Stratified random sampling, through randomization software, was used to determine simulated patient-type and learner-type. Patient-type was either a high-fidelity mannequin or standardized patient. Learner-type was either an active or observing learner where the active learner provided care to the dying simulated patient and the observing learner watched the care being provided during the simulation.
The a priori calculations identified that a minimum participant sample size was 120. This study had 159 total participants, involved with or observing the care of the high-fidelity mannequin [n=79] or standardized patient [n=80] [19]. Prior to the simulation, participants were given a demographics form. The demographics form requested participants provide the number of professional roles in which they were exposed to individuals in high crises. Examples of such professional roles included: veteran of armed forces, patient care technician, emergency care technician, police officer, certified nursing assistant, etc.
After the participants filled out the demographics form and randomization of simulated patient-type and learner-type occurred, participants filled out the STAI Form Y-1 and Y-2. For this analysis, State Anxiety, Y-1 was used. From there, participants partnered-up, took each other’s heart rate and obtained blood pressure per automated blood pressure cuff. Each participant documented their own heart and blood pressure findings in the table.
At that point, participants were given report on the 24 yearold, simulated patient dying of hepatic cancer and complications of Hepatitis C. Participants cared for or observed the care of either the high-fidelity mannequin or standardized patient. The simulation lasted 30 minutes. The patient required palliative care, did not have family at the bedside, and participants were required to provide post-mortem care including placing the simulated patient in a body bag. Extra care for the standardized patient occurred as participants placed a static mannequin in the body bag when post-mortem care was completed. The simulation was concluded once the body bag was zipped up and participants left the room.
Upon completion of the simulation, all participants obtained heart rate, systolic and diastolic blood pressure, and filled out the STAI Form Y-1 again. To compensate the participants for their participation, each was given a $10 coffee shop gift card. After that, 30 minutes of debriefing occurred including discussion about nursing self-care coping strategies that can be utilized when providing palliative and end-of-life care to patients.
Number of Professional Fields |
n |
% |
None |
88 |
55.3 |
Low |
58 |
36.5 |
Medium |
13 |
8.2 |
Total |
159 |
100 |
Patient-types |
Physiological Stress (p value) |
Psychological Stress (p value) |
|
High-Fidelity Mannequin (n=79) and Standardized Patient (n=80) |
Heart Rate |
t(157)-0.23, p=0.82 |
t(157)=2.16, p=0.03 |
Systolic Blood Pressure |
t(157)=0.96, p=0.34 |
||
Diastolic Blood Pressure |
t(157)=1.25, p=0.21 |
Patient Type |
Number of Professional Roles Exposed to Individuals in High Crisis |
M, SD |
N |
High-Fidelity Mannequin |
None |
2.05, 11.19 |
40 |
Low |
6.81, 14.40 |
32 |
|
Medium |
4.07, 9.50 |
7 |
|
Total |
4.15, 12.53 |
79 |
|
Standardized Patient |
None |
6.95, 16.14 |
48 |
Low |
-1.18, 9.47 |
26 |
|
Medium |
-1.61, 12.76 |
6 |
|
Total |
3.67, 14.50 |
80 |
|
Total |
None |
4.72, 14.25 |
88 |
Low |
3.23, 12.97 |
58 |
|
Medium |
1.45, 11.03 |
12 |
|
Total |
3.90, 13.52 |
159 |
Patient Type |
Number of Professional Roles Exposed to Individuals in High Crisis |
M, SD |
N |
High-Fidelity Mannequin |
None |
2.79, 10.36 |
40 |
Low |
3.80, 16.73 |
32 |
|
Medium |
-2.93, 8.75 |
7 |
|
Total |
2.69, 13.19 |
79 |
|
Standardized Patient |
None |
-0.66, 8.84 |
28 |
Low |
1.18, 10.34 |
26 |
|
Medium |
11.61, 20.83 |
6 |
|
Total |
0.86, 10.86 |
80 |
|
Total |
None |
0.91, 9.65 |
88 |
Low |
2.62, 14.17 |
58 |
|
Medium |
3.78, 16.61 |
13 |
|
Total |
1.17, 12.07 |
159 |
Patient Type |
Number of Professional Roles Exposed to Individuals in High Crisis |
M, SD |
N |
High-Fidelity Mannequin |
None |
4.01, 10.82 |
40 |
Low |
6.15, 13.45 |
32 |
|
Medium |
1.39, 3.44 |
7 |
|
Total |
4.64, 11.55 |
79 |
|
Standardized Patient |
None |
1.93, 7.99 |
48 |
Low |
5.20, 7.96 |
26 |
|
Medium |
-2.24, 5.76 |
6 |
|
Total |
2.68, 8.03 |
80 |
|
Total |
None |
2.87, 9.38 |
88 |
Low |
5.72, 11.25 |
15 |
|
Medium |
-0.28, 4.83 |
13 |
|
Total |
3.66, 9.95 |
159 |
Patient Type |
Number of Professional Roles Exposed to Individuals in High Crisis |
M, SD |
N |
High-Fidelity Mannequin |
None |
30.45, 37.84 |
40 |
Low |
31.07, 42.28 |
32 |
|
Medium |
17.44, 21.24 |
7 |
|
Total |
29.55, 38.41 |
79 |
|
Standardized Patient |
None |
18.98, 31.07 |
48 |
Low |
16.85, 24.80 |
26 |
|
Medium |
15.20, 19.44 |
6 |
|
Total |
18.00, 28.19 |
80 |
|
Total |
None |
24.19, 34.59 |
88 |
Low |
24.70, 35.95 |
15 |
|
Medium |
16.41, 19.61 |
13 |
|
Total |
23.74, 34.05 |
159 |
When the researcher observed students working with the standardized patient, the students appeared more anxious. Often times, the students, particularly without exposure to end-oflife care, appeared confused and laughed nervously with each other, including when calling the physician to pronounce the standardized patient as deceased. It is possible that this anxiety led to the increase in physiological stress with the standardized patient. In addition, it is possible that previous memories in the participants who worked in two professions with individuals in high crisis led to a greater fight-or-flight response. A future qualitative component would promote greater understanding regarding the specific stressors of each patient-type.
New graduate nurses have described feeling anxious, uncertainty, and stressed to the point of choosing to leave the profession within the first year of practice [1, 20, 21]. The nursing profession has pushed to incorporate palliative care in nursing education through programs, such as the End-of-Life Nursing Education Consortium [ELNEC] [5]. Given this and understanding the results of this study, incorporating end-of-life care education as a simulation is necessary. Going forward, when nursing faculty implement an end-of-life care simulation experience, this research can offer insight into selecting a student-centered patient simulator based upon their students’ working backgrounds.
• Ethical approval: This research was IRB-approved.
• Clinical trial registration: Written consent has been obtained.
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