Clinical Simulation in Nursing (2013) 9, e213-e218

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Featured Article

Testing Ajzen’s Theory of Planned Behavior

for Faculty Simulation Development
Amy L. Jones, RN, EdDa,*, Nancy Fahrenwald, RN, PhDb, Angie Ficek, MPHc
a
Mt. Marty College, Yankton, SD 57078, USA
b
South Dakota State University, Brookings, SD 57007, USA
c
Minnesota Department of Health, St. Paul, MN 55108, USA

KEYWORDS Abstract
Ajzen’s theory of Background: Ajzen’s theory of planned behavior (TPB) guided this evaluation of a Summer Simulation
planned behavior; Training Fellowship program for baccalaureate nursing faculty. The 2-day curriculum integrated
faculty development; simulation pedagogy with TPB-derived strategies.
simulation education; Methods: A 24-item survey measured preepost test changes in TPB-derived subscales. The dependent
simulation training t test was used (N ¼ 11).
Results: There were nonsignificant changes in the subscales. Intention to teach with SimManÔ in the
next year did not increase, but general intention to use simulation improved (p ¼ .005). There were
significant changes in individual subscale items.
Conclusions: The Summer Simulation Training Fellowship program needs further testing.

Cite this article:

Jones, A. L., Fahrenwald, N., & Ficek, A. (2013, June). Testing ajzen’s theory of planned behavior for
faculty simulation development. Clinical Simulation in Nursing, 9(6), e213-e218. doi:10.1016/
j.ecns.2012.01.005.
Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier
Inc. All rights reserved.

Background application in improving nursing student learning outcomes.

Nurse educators are implored to use innovative approaches
to train future nurses for the complexities of highly acute
care (American Association of Colleges of Nursing, 2008;
Coonan, 2008; Galloway, 2009; Institute of Medicine,
2010; National Council of State Boards of Nursing, 2005;
National League for Nursing, 2008). Patient care simulation
using a computerized manikin is an innovative teaching
approach with a growing body of evidence that supports its
All authors were employed by South Dakota State University, Brook-
ings, SD when the research study was performed.
* Corresponding author: amy.jones@mtmc.edu (A. L. Jones).
Many nursing programs are now using the pedagogy of
simulation as a teachingelearning technique, yet little
research exists on faculty development programs that could
assist the teacher to better use this instructional tool
(Hayden, 2010; Nehring, 2008). Lack of faculty develop-
ment programs has been cited as a barrier to simulation
use (Hayden, 2010).
One faculty development study applied the theory of
planned behavior (Ajzen, 1991) to understand and influence
teaching with simulation among associate degree nursing
faculty (King, Moseley, Hindenlang, & Kuritz, 2008).
Our research builds on this prior research by including
baccalaureate nursing faculty in the pilot test of a faculty

1876-1399/$ - see front matter Ó 2013 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ecns.2012.01.005
Testing Ajzen’s Theory of Planned Behavior e214

development initiative. The Institute of Medicine’s (2010)

report on the future of nursing recommends that 80% of
all nurses be prepared at the baccalaureate level by 2020.
It is critical to test approaches to enhancing the application
of human patient simulation (HPS) in nursing education
with the faculty members
who will teach the next
Key Points generation of nurses. The
 The SSTF program purpose of this study was to
intervention had a sig- examine the efficacy of
nificant, positive im- a summer simulation train-
pact on all four ing program on baccalaure-
mesures of Ajzen’s ate nursing faculty attitudes,
theory of planned be- subjective norms, perceived
havior, with the most behavior control, and intent
impact on the mea- to use simulation as a teach-
sure of perceived be- ing strategy.
havioral control.
 Faculty self-reported
competence and con- Theoretical
fidence in using HPS Framework
improved however Figure 1 Ajzen’s theory of planned behavior applied to Sum-
the SSTF program Researchers have applied mer Simulation Training Fellowship program.
made faculty mem- a variety of theories from
bers realize that social psychology to under- personal control that the individual has over the behavior.
teaching with HPS re- stand and facilitate behavior For this research, perceived behavioral control relates to
quires extra prepara- change among nurses. a faculty member’s perceptions of preparation time, ease
tion time. Ajzen’s (1991) theory of of use, time needed to teach using HPS, and whether the
 Further exploration of planned behavior (TPB) has available resources are sufficient. Application of the TPB
both reliability (in- guided recent research to im- in this research study is depicted in Figure 1. Each of the
cluding test-retest) prove infection control by TPB constructs was applied in the intervention activities.
and validity is needed nurses (Smith, Kirksey, Actual performance of teaching with HPS was assessed in
as the instrument Fac- Becker, & Brown, 2011), to a follow-up evaluation at the end of the academic year that
ulty Attitudes and In- understand nurses’ com- followed the faculty development initiative.
tent to Use Related puter use (Shoham &
to the Human Patient Gonen, 2008), and to under-
Simulator becomes stand nurses’ intentions to Method
more established. provide continuous labor
support to childbearing Design
women (Payant, Davies, Graham, Peterson, & Clinch,
2008). The TPB posits that intention is the most important The Summer Simulation Training Fellowship (SSTF)
determinant of actual behavioral performance. Intention is program was pilot-tested using a preepost test single group
influenced by three constructs, attitudes, subjective norms, design. The independent variable was participation in
and perceptions of behavioral control. Attitude reflects an the SSTF program. The five dependent variables were
overall evaluation of the behavior. For use of HPS in teach- preepost program changes in faculty attitudes, perceptions
ing, attitude includes a faculty member’s evaluation of the of behavioral control, subjective norms, behavioral in-
ease of use of the technology and associated comfort level tentions, and actual teaching with simulation during the
with the technology, the level of competence required, per- next academic year. All participants took the same 24-item
ceptions of teaching effectiveness with HPS, and the reality survey before and after the intervention.
of the clinical experience that HPS provides. The construct
called subjective norms reflects an individual’s perceptions Sample and Setting
of social pressure to perform a behavior. Subjective norms
are influenced by a faculty member’s perceptions of whether The SSTF program was delivered in the Clinical Simula-
the use of HPS in teaching is supported, or viewed favorably, tion Laboratory. Complete preepost test data from nursing
by college administrators, peers, and students. The third con- faculty members were used in the analysis (N ¼ 11). Lab-
struct, perceived behavioral control, refers to the degree of oratory assistants (N ¼ 3) participated in the training but

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Testing Ajzen’s Theory of Planned Behavior e215

Table 1 Summer Simulation Training Fellowship Program

Day 1 Schedule
Program overview
Simulation overview
Simulation pedagogy
Debriefing and self-reflection
in simulation
Components of a simulation scenario
Simulation video and debriefing
Curriculum integration of simulation
Day 2 Schedule
Expected student learning outcomes
Small-group simulation scenario
development
View and debrief simulation scenarios
Logistics of simulation implementation
Hours Activities
2 Review of agenda and dialogue about perceived barriers to
implementing simulation.
Review of adult learning and change theory.
Review of initiatives of agencies involved in simulation.
Overview of terminology used in literature.
Orientation to general operation of high-fidelity manikins.
3 Key components of debriefing.
Review of a debriefing framework.
Small groups: Pick LaerdalÔ (2007) medicalesurgical scenario choice
for next-day videotape session.
3 Watch video of an entire simulation, including the debriefing.
Examine and use Jeffries (2007, Chapter 5) operational plan.
Student panel discussion with faculty of aspects of simulation
helpful to learning.
Hours Activities
1 Discuss Tanner’s integrative model of clinical judgment (2006).
Review Lasater’s Clinical Judgment RubricÓ (2007).
4 Small groups work on a LaerdalÔ medicalesurgical scenario of choice
for implementation within next academic year.
Small groups enact the scenarios developed.
Videotape and debrief in small group.
2 View each group’s video of simulation scenario and debrief.
Participate in small-group debrief and large-group discussion.
1 Discuss logistics of each campus simulation lab.
Discuss expectations for work to be completed by each group and
follow-up assignments due prior to implementation with students.
Collect evaluations from each module from participants.

were not part of the study. Seven faculty participants did
not complete either the pre- or the posttest data collection.
Participants received a $500 cash honorarium for participa-
tion in the training intervention and completion of study
instruments.
Instrument
The name of the survey used was Faculty Attitudes and
Intent to Use Related to the Human Patient Simulator. The
survey was employed as a pre- and posttest measure of the
TPB constructs of attitude, subjective norms, perceived
behavioral control, and intent to teach with HPS (King
et al., 2008). A 5-point Likert-type response scale (from
1 ¼ strongly disagree to 5 ¼ strongly agree) was used
with single items. Four subscales measured TPB constructs
related to teaching with simulation. There were eight
attitude items that explored faculty beliefs and perceptions
related to teaching with simulation. Six items measured
subjective norms by examining the social impetus from in-
fluential others (peers, administrators, or students) to teach
with simulation and the importance of student and faculty
opinions about a faculty member’s teaching. Perceived
behavioral control was measured by eight items that exam-
ined perceptions of teaching with simulation, including
preparation time, ease of use, time to be proficient, and
training resources. Intention was measured by two items
that asked about a faculty member’s intention to use simula-
tion as a teaching tool during the upcoming academic year
and general intent to use simulation as a teaching tool. Com-
posite scores were obtained by combining the responses
from items within each subscale. To compare the composite
means between constructs on a 5-point scale, summed com-
posite scores were divided by the number of items within
each construct. In the instrument development study, multi-
ple regression analysis indicated that 49.3% of the variance
in intent to use simulation teaching was predicted by the
TPB subscales (King et al., 2008), supporting the construct
validity of the instrument. This was reported as an overall
strength of association. The report did not reflect which
particular construct was associated with intent. Testeretest
reliability for the tool was not measured. Cronbach’s alpha
was used to estimate internal consistency reliability of the
subscales. The resulting alpha values were .49 for behavioral
control, .76 for attitude, and .82 for subjective norms
(C. King, personal communication, March 6, 2009).
InterventiondSSTF Program
The SSTF program took place on two consecutive days. The
educational program was developed to strengthen faculty
members’ attitudes, build a sense of behavioral control, and

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Testing Ajzen’s Theory of Planned Behavior
communicate supportive social norms that are intended to
improve intention to teach with a high-fidelity simulation
manikin. The simulation content that was integrated in the
program was derived from recommendations made by an
experienced simulation researcher (Suzan Kardong-
Edgren, personal communication, May 28, 2008) as well
as best practices for simulation (Jeffries, 2007). The 2-day
educational intervention included 1- to 2-hour modules on
simulation application and pedagogy, essentials of debrief-
ing and self-reflection, components of a simulation scenario,
curriculum integration of simulation, student learning out-
comes, and logistics (Table 1). There were longer sessions
on development, implementation, and evaluation of simula-
tion scenarios. Each of the modules integrated progressive
exposure to the technology, demonstration, and guided
practice. Faculty members were given a common structure
for the design of a simulation scenario to use in a course
taught in the same level of the curriculum. Each faculty
group adapted a LaerdalÔ scenario, participated in the
scenario (which was videotaped), and participated in a de-
briefing. Strategies for modifying common attitudes, percep-
tions of behavioral control, and social norms were included
in all aspects of the program.
Procedures and Human Participants
Institutional review board approval for human participant
research was obtained prior to the study. Faculty members
were sent a letter asking for their participation in this
research project and were asked to e-mail the primary
investigator if they were interested. Those who expressed
interest received a pretraining survey. Consent to partici-
pate in the study was implied by completion of the online
pretraining survey.
Data Analysis
Data were collected via online survey and stored securely as
an Excel spreadsheet. Results were analyzed with the
Statistical Package for the Social Sciences, Version 16.0.
Composite subscale scores were obtained by adding the
responses from each TPB construct (i.e., attitudes, subjective
norms, and perceived behavioral control) and dividing the
total for each construct by the number of items within each
construct. Behavioral intention was measured in two ways,
specific intention to teach with simulation in the next year
and general intention to teach with simulation. Each
approach to measuring intention was measured with a single
item. To examine changes in the TPB constructs as a result of
participating in the SSTF intervention, a paired t test was cal-
culated using pre- and postsurvey results for each subscale
and for each item within the subscales, replicating the ap-
proach employed by King et al. (2008). Internal consistency
reliability for each subscale (perceived behavioral control,
attitude, and subjective norms) was calculated on both the
pre- and posttest scores with the use of Cronbach’s alpha.
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e216
Results
In all, 11 participants (52%) completed both the pre- and
postsurveys. Nursing faculty experience ranged from 4 to
26 years (M ¼ 12.0, SD ¼ 7.9), and 9 respondents (82%)
were full-time faculty. Respondents’ primary area of clini-
cal expertise was medicalesurgical (36%), pediatrics
(27%), critical care (18%), and obstetrics and gynecology
(18%). Two thirds of respondents had previous hands-on
training with SimManÔ, and more than half (55%) had
attended an educational program. Three fourths (75%) of
the participants had used SimManÔ as a teaching tool
with students, on an average of three times during the
past academic year.
Attitudes
The composite mean attitude score increased from 4.17 (SD
¼ 0.75) on the presurvey to 4.59 (SD ¼ 0.52) on the post-
survey. This change was not statistically significant, t(10) ¼
1.513, p ¼ .07. There were statistically significant (p < .05)
and favorable changes in three of the eight items (Table 2).
Cronbach’s alpha was .81 for the presurvey and .73 for the
postsurvey.
Subjective Norms
The composite mean subjective norm score changed from
4.26 (SD ¼ 0.65) on the presurvey to 4.45 (SD ¼ 0.56) on
the postsurvey. The overall change was not statistically
significant, t(10) ¼ 0.713, p ¼ .23. There was a statistically
significant (p ¼ .05) positive change in only one item,
‘‘Other faculty members want me to use HPS’’ (Table 2).
Cronbach’s alpha was .71 for the presurvey and .67 for
the postsurvey.
Perceived Behavioral Control
The composite mean perceived behavioral control score
increased from 3.78 (SD ¼ 0.67) to 3.91 (SD ¼ 0.63) from
pre- to posttest; however, this increase was not statistically
significant, t(10) ¼ 0.613, p ¼ .32. There were statistically
significant (p < .05) improvements in five of the eight
subscale items (Table 2). Cronbach’s alpha was .72 for
the presurvey and .80 for the postsurvey.
Behavioral Intention
Intention to use SimManÔ in teaching during the upcoming
academic year was explored with a single item (Table 2).
The pretest mean was 4.73 (SD ¼ 0.47), and the posttest
mean was 4.82 (SD ¼ 0.40). This change was not statisti-
cally significant, t(10) ¼ 0.512, p ¼ .46. Participants’ gen-
eral intention to use SimManÔ in their teaching was
evaluated with a 10-point scale, higher scores reflecting
Testing Ajzen’s Theory of Planned Behavior e217

Table 2 Paired t-Test Differences between the Pre- and Postsurvey

Mean Difference SD Significance
Attitude measures
I feel competent using HPS as a teaching tool. 1.10 0.99 .007
I feel comfortable using HPS as a teaching tool. 1.09 1.30 .02
Using HPS is an effective teaching strategy. 0.36 0.50 .04
HPS fits well into the nursing course(s) I teach. 0.27 0.47 .08
Using HPS provides a realistic patient care experience. 0.36 0.67 .10
Providing students a realistic patient care experience 0.09 0.54 .59
is important to me.
I feel comfortable using different instructional technologies, 0.00 0.45 1.00
such as PowerPoint.
I choose teaching strategies based on their effectiveness. 0.00 0.45 1.00
Subjective norm measures
Other faculty members want me to use HPS. 0.55 0.82 .05
The opinions of the CON administrators are important to me. 0.27 0.65 .19
The opinions of students are important to me. 0.18 0.60 .34
Students want me to use HPS. 0.18 0.75 .44
The CON administrators want me to use HPS. 0.00 0.63 1.00
The opinions of other faculty members are important to me. 0.00 0.77 1.00
Perceived behavioral control measures
Using HPS requires a lot of extra preparation time for me. 2.27 0.79 <.001
I would use HPS more if an easy and simple instructor’s guide 0.73 0.65 .004
was available to me.
The amount of time it takes to be proficient in using HPS exceeds 1.27 1.42 .01
its educational effectiveness.
The ease of use of teaching strategies is important to me. 0.36 0.50 .04
HPS is easy to use. 0.64 0.92 .05
When deciding to use a specific teaching strategy, the amount 0.18 0.40 .17
of preparation time required is important to me.
It is important that the time it takes to become proficient using 0.20 0.63 .34
a particular teaching strategy does not exceed its educational effectiveness.
I’m confident I can become proficient in using HPS with more experience. 0.10 0.57 .59
Behavioral intention measures
Intention to use HPS as a teaching tool. (scale, 1-10) 0.91 0.53 .005
I intend to use HPS as a teaching tool during the upcoming session 0.09 0.54 .59
of the academic year. (scale, 1-5)
Note. CON ¼ college of nursing; HPS ¼ human patient simulation.

stronger intentions. These scores increased from a mean of
8.73 (SD ¼ 1.19) at pretest to 9.64 (SD ¼ 0.81) at posttest,
which was statistically significant, t(10) ¼ 4.59, p ¼ .005.
Behavior Change
The final outcome was actual change in faculty behavior,
which was an assessment of whether the participants would
actually teach with simulation in the next academic year.
Of the 11 faculty participants, 8 (78%) reported they would
use a simulation scenario with students during the next
academic year.
Discussion
The purpose of this pilot study was to examine the efficacy
of the SSTF program on baccalaureate nursing faculty
attitudes, subjective norms, perceived behavior control, and
intent to use simulation as a teaching strategy. Paired t test
differences between the pre- and postsurveys indicated
the SSTF program intervention had a significant, positive
impact on all four measures, with the most impact on the
measure of perceived behavioral control. This study builds
on prior work by King et al. (2008) by including baccalau-
reate nursing faculty. Both studies report improvements in
the TPB constructs of attitudes, subjective norms, percep-
tions of behavioral control, and intention to teach with
simulation after a 2-day training program. This study
reports that intention to teach with simulation in general,
and specifically in the next semester, improved from pre-
to posttest. King et al. (2008) reported that there was
a significant gain in general intention to teach with the
simulator, but not in specifically using the technology in
the next academic year. Our findings may have been
influenced by prior exposure to an educational program

pp e213-e218  Clinical Simulation in Nursing  Volume 9  Issue 6

Testing Ajzen’s Theory of Planned Behavior
on simulation or even using simulation as a teaching tool
in the past. Two thirds of faculty members reported previ-
ous hands-on training with SimManÔ and more than half
(55%) reported they had attended an educational program
on simulation. Additionally, three fourths (75%) of the
faculty members reported they had used SimManÔ as
a teaching tool with students during the past academic
year.
While the SSTF program clearly improved faculty
self-reported competence and confidence in using HPS as
a teaching tool, it also made the faculty members realize
that teaching with HPS required extra preparation time.
These results relate to the findings of a study by Katz,
Peifer, and Armstrong (2010), who reported that faculty
development was a chief barrier to the full utilization of
simulation manikins. Demanding teaching loads, combined
with a steep learning curve for the use of HPS and the lack
of a designated simulation coordinator, were additional
barriers. The authors stated, ‘‘This is a paradox in nursing
education, the desire to incorporate the latest technology
but not dedicating faculty time to develop it to its greatest
potential’’ (p. 49).
Strategies for modifying common attitudes, perceptions
of behavioral control, and social norms (Ajzen, 1991) were
supported by the presence of two simulation experts who
were given some limited work release to assist participants
during the course of the year. Also, other ‘‘simulation
cheerleaders’’ who evolved from the SSTF program have
assisted several other faculty members to start using HPS.
This pilot study is not without limitations. Baseline scores
on the survey items and scales were high, thereby limiting
our findings. The pre- and posttest survey had acceptable
internal consistency at both times for the attitude and
perceived behavioral control subscales, and at one time for
the subjective norms subscale (with a criterion of 0.70 for
a newer scale). Further exploration of both reliability
(including testeretest) and validity is needed as the in-
strument becomes more established. Faculty members who
chose to participate were already favorably inclined toward
teaching with simulation. The study included a convenience
sample of baccalaureate nursing faculty from one university.
Because of the rural logistics of the state and a limited travel
budget, a randomly selected group of participants was not
possible. Another limitation was the small sample size of
18 participants, of whom 11 completed the pre- and posttest
surveys. This pilot study represents one college of nursing;
therefore, the results are not generalizable.
Acknowledgments
There was no commercial financial support. Dean Roberta
Olson awarded Dr. Jones a Dean’s Development Grant as
seed money to assist in developing research for faculty
pp e213-e218  Clinical Simulation in Nursing  Volume 9  Issue 6
e218
development in simulation at the college. This money en-
abled Dr. Jones to pay a stipend to summer simulation
training fellowship participants for completion of the 2-
day program.
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