The Effect of Faculty Debriefing Training on the Achievement and Satisfaction of

Pre-licensure Nursing Students Participating in Simulation

A Dissertation

presented to the Faculty of the College of Education

of TUI University

In Partial Fulfillment of the Requirements for the

Degree of Doctor of Philosophy in Educational Leadership

by

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Elizabeth Fentress Hallmark

TUI University
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Cypress, California

2010
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Defended August 4, 2010
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Approved by:

Dean, College of Education

Office of Academic Affairs

Committee Chair: Dr. Wenling Li

Committee Member: Dr. Sharon Dowdy

Committee Member: Dr. Marilyn Oermann

Director, PhD Program: Dr. Wenling Li

 UMI Number: 3431934

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a note will indicate the deletion.

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UMI 3431934
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 © Beth Fentress Hallmark 2010

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 Biographical Sketch

Beth Fentress Hallmark is an Instructor of Nursing at the Gordon E. Inman

College of Health Sciences and Nursing in Nashville, Tennessee where she is also the

Director of Simulation for the College. In addition to the Doctor of Philosophy in

Educational Leadership, she also holds an Associate of Science Degree in Nursing

from Samford University and a Bachelor of Science Degree in Nursing from Belmont

University. She also holds a Master of Science Degree in Nursing from Vanderbilt

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University.

Dr. Hallmark‘s clinical experience has focused on Pediatric Nursing with a

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specific interest in Pediatric Surgery. Beth‘s interests have expanded to simulation

education and specifically reflective thinking, situational awareness, and faculty

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training in simulation.
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 Dedication

I am honored to first dedicate this dissertation to Mr. Akins who always

encouraged me to learn. His death still to this day saddens me. Also, I dedicate this

work to my ―Mammaw‖ who was my biggest fan and would be so proud of this

project, I cannot wait to see her again in ―glory‖; she never, ever let me think I could

fail; no matter what life threw my way. To my mother who is my hero, she loves me in

spite of both my physical imperfections and my human frailties and made me believe

in myself. Also to my dad who prayed for me and supported me by helping transport

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and entertain children, a gift that was an immense help! To my sister Karen, who I
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know prayed without ceasing; I was sustained through many trials and God‘s strength

was my fortress. Finally and most importantly to my family, first to my husband,

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Brian, who loves me no matter what I say or do! Brian has washed clothes and paid

bills, missed hunting and fishing trips all to help me realize this dream. To my

children, Allison and Mack, who have given up so much and have tolerated me over
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the last three years …I love you all so much! To my co-workers and Dean Algren who

have picked up the slack when I was at my ―wits end‖ and wanted to quit; I thank you

from the bottom of my heart. I owe each of you an immeasurable debt of gratitude!

Finally to Debra Wollaber who never pushed but initially encouraged me to pursue

this PhD that I told her I would ―never‖ ever do…She was patient and ever supportive.

I love each of you very much!

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 Acknowledgment

I must first of all recognize my dissertation committee for guiding me through

this process of completing my dissertation. To Dr. Li for guiding me through the

entire progression of my doctoral program and for the final phase of my dissertation;

for helping me ―understand‖ the statistics and for being patient with me and my

adventurous life; to Dr. Dowdy for being an encourager and an ever present calming

presence, for her knowledge and wisdom; to Dr. Oermann for her expertise and

succinct feedback, for her patience with my novice writing skills and research

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experience. I could not have done this without each of you; you each brought
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individual gifts that helped me move through this long process. Thank you all!

I would also like to acknowledge those who supported my doctoral education

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financially: Belmont University, the Foundation of the National Student Nurses‘

Association Faculty Grant, and my family. In addition, I could not have completed

this research without the National League for Nursing and Laerdal who developed and
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supported the Simulation Innovation Resource Center and HESI Elsevier who

developed the test questions that I used to determine the cognitive measure within my

study.

Finally I would be remiss if I did not again mention the faculty and staff at

Belmont University School of Nursing. Your genuine love and support has helped

guide me not only through my doctoral studies but, you have supported me in times of

joy and in times of despair. Particularly, I would like to recognize Dr. Martha

Buckner and Mrs. Jean Blank who so willingly allowed me to perform my study in

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their courses; I know it was, at times, disruptive, thank you! Mrs. Kathy Jordan, Mrs.

Keary Dryden, Mrs. Sara Camp and Mrs. Martha Ezell who volunteered to be my de-

briefers; thank you each so much for the time you put into my doctoral work! In

addition I would like to thank Dr. Algren for not giving up on me! Finally I must

thank Beth Williams for keeping the labs running without her I could not have

completed this project.

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 Table of Contents

Chapter One. Introduction .............................................................................................. 2

Purpose ....................................................................................................................... 3

Chapter Two. Problem Statement................................................................................... 6

Research Questions .................................................................................................... 7

Qualitative questions ............................................................................................ 10

Chapter Three. Review Of The Research Literature .................................................... 11

Nursing Educational Outcomes ................................................................................ 11

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Debriefing ................................................................................................................. 13

Faculty debriefing/training ................................................................................... 14

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Linking debriefing to learning .............................................................................. 15

Linking debriefing or reflective thinking to critical thinking. .............................. 18

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Learning Theory ....................................................................................................... 18

Conceptual Framework ............................................................................................ 19

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Research Hypotheses ................................................................................................ 22

Chapter Four Research Methodology ........................................................................... 23

Research Design ....................................................................................................... 23

Quantitative Data ...................................................................................................... 24

Dependent variable: Achievement ....................................................................... 25

Dependent variable: Satisfaction .......................................................................... 26

Covariates: Reflective thinking inventory ............................................................ 27

Covariates: Age, Gender, Previous Education, and Pretest (pathophysiology

score) .................................................................................................................... 29
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 Independent variable: Faculty training. ................................................................ 30

Qualitative Measurement.......................................................................................... 31

Study Population ...................................................................................................... 32

Variables—Independent and Dependent .................................................................. 33

Summary................................................................................................................... 36

Chapter Five. Results.................................................................................................... 37

Quantitative Analyses ............................................................................................... 37

Descriptive data analyses ..................................................................................... 37

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Reflective Thinking Inventory ................................................................................. 42

Hypothesis 1 ............................................................................................................. 49
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Hypothesis 2 ............................................................................................................. 50

Hypothesis 3 ............................................................................................................. 51
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Hypothesis 4 ............................................................................................................. 51

Qualitative Data Analysis ......................................................................................... 52

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Introduction .......................................................................................................... 52

Demographics of qualitative data. ........................................................................ 63

Chapter Six. Discussion................................................................................................ 64

Introduction .............................................................................................................. 64

Descriptive Data ....................................................................................................... 67

Demographics ....................................................................................................... 67

Key variables. ....................................................................................................... 68

Demographic effects on HESI and satisfaction ................................................ 68

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Nursing Faculty Training ......................................................................................... 68

Debriefing training and student outcomes ............................................................ 70

HESI score comparison ........................................................................................ 71

Satisfaction Scores.................................................................................................... 72

Reflective thinking ............................................................................................... 73

Discussion of Qualitative Findings .......................................................................... 75

Introduction. ......................................................................................................... 75

Demographics ....................................................................................................... 75

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Key Variables/Themes ............................................................................................. 75

Communication .................................................................................................... 75
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Critical thinking .................................................................................................... 77

Confidence. ........................................................................................................... 78
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Awareness and reflection ..................................................................................... 79

Learning in simulation or debreifing .................................................................... 80

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Math skills ............................................................................................................ 83

Limitations and Assumptions ................................................................................... 85

Students. ............................................................................................................... 85

Reflective thinking continuum ............................................................................. 85

Inexperience and bias of researcher ..................................................................... 86

Measurement of learning ...................................................................................... 87

Faculty training ..................................................................................................... 87

Other limitations ................................................................................................... 88

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 References ................................................................................................................ 90

Appendix A: Test Blueprints ...................................................................................... 103

Appendix B: Fernandez Satisfaction Survey .............................................................. 108

Appendix C: Satisfaction Survey With Additional Questions ................................... 110

Appendix D: Reflective Thinking .............................................................................. 112

Appendix E: Demographic Data ................................................................................ 115

Appendix F: Qualitative survey.................................................................................. 116

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 List of Tables

Table 1 Six Stages of Reflection From Peltier, Hay, and Drago (2005) ...................... 28

Table 2 Demographics ................................................................................................. 33

Table 3 Hypothesis 1 .................................................................................................... 34

Table 4 Hypothesis 2 .................................................................................................... 35

Table 5 Descriptive Summary of Demographics: Gender ........................................... 38

Table 6 Descriptive Summary of Demographics: Age ................................................. 38

Table 7 Descriptive Summary of Demographics: Educational Level .......................... 39

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Table 8 Descriptive Summary of Demographics: Students Debriefed by Trained or
Untrained Faculty ........................................................................................................ 39
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Table 9 Satisfaction Scores of Students Comparing Debriefing Groups of Trained or
Untrained ...................................................................................................................... 40

Table 10 HESI Scores of Students Comparing Debriefing Groups of Trained or

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Untrained ...................................................................................................................... 40

Table 11 Rotated Component Matrix ........................................................................... 44

Table 12 Summary of Results of ANOVA for Faculty Debriefing Training as a

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Predictor of Cognitive Achievement: HESI Score ........................................................ 49

Table 13 Summary of Results of ANCOVA for Faculty Debriefing Training as a

Predictor of Cognitive Achievement: HESI Score While Controlling for Level of
Reflective Thinking ....................................................................................................... 50

Table 14 Summary of Results of ANOVA for Faculty Debriefing Training as a

Predictor of satisfaction ............................................................................................... 51

Table 15 Summary of Univariate Analysis of Variance for Faculty Training as a

Predictor of Satisfaction; Covariates of Age, Gender, Pathophysiology Pretest Score
and Educational Level .................................................................................................. 52

Table 16 HESI Score With Coded Data ....................................................................... 55

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Table 17 Comparison of Students in Trained or Untrained Debriefing Group With
Coded Qualitative Data ................................................................................................ 56

Table 18 Comparison of Student: Reflective Thinking Versus Habitual Thinking

Groups With Coded Qualitative Data .......................................................................... 58

Table 19 Qualitative Themes Identified ....................................................................... 60

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 List of Figures

Figure 1. Conceptual framework. ................................................................................ 21

Figure 2. Study design. ................................................................................................ 24

Figure 3 . Simulation model © NLN, 2007. ................................................................ 71

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 List of Abbreviations

HESI Health Education Systems, Inc.

NCLEX-RN National Council Licensure Examination-Registered Nurse

RT Reflective Thinking

HT Habitual Thinking

CCNE Commission for Collegiate Nursing Education

BSN Bachelor of Science in Nursing

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NLN National League for Nursing

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 Abstract

Nursing educators are utilizing high fidelity simulation technology to meet the

objective of preparing competent entry level nurses. Examining the effect of

simulation on achievement while considering how the faculty has been trained to work

with the students during the debriefing was the one of the goals of this project.

Eighty- four students participated in two National League of Nursing scenarios and

subsequently participated in debriefing sessions, resulting in 166 subjects. The

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students were randomized to one of two groups where a trained or an untrained faculty

member led the debriefing session. This study examined how preparing nursing
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educators to debrief students effectively theoretically leads to higher achievement

scores on questions directly related to the simulation content; in addition, a student‘s

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satisfaction survey was conducted. The student‘s age, gender, previous education and

their level of reflective thinking were controlled in the study. Discovering how faculty
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preparation was linked to student outcomes was imperative as this pedagogy is

integrated throughout nursing curricula across the country. Not only is faculty training

imperative, but the faculty must have an understanding of how students use reflective

thinking to learn during debriefing. The quantitative outcomes supported the theory

that the students were more satisfied with the faculty members who had been through

the training course. There was a not, however, a significant effect when considering

the training of the faculty and the cognitive outcomes of the students. The qualitative

data provided a glimpse into the student‘s feelings relating to the experience with the

simulation and with the faculty debriefing. The student‘s comments revealed an
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increase in self-confidence, improved situational awareness, improved critical thinking

skills and improved communication skills. In order to measure the cognitive outcomes

a HESI exam was created for each simulation. The HESI exams were developed using

a test blue-print and the simulation objectives. The results of the study did not support

the research hypotheses in terms of the cognitive outcomes. A limitation of the study

was the HESI exams in terms of the global nature of the questions. The simulations

and subsequent debriefing sessions had narrow outcomes; it was thus difficult to align

the HESI test questions that in turn encompassed more global content. Questions that

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were written specifically for the simulations would have provided a more accurate

view of the student‘s actual knowledge of the simulation content and objectives.
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Another limitation of the study was the satisfaction tool that was chosen. Although

the tool had been used in simulation in pharmacy education and was modified for this
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study, a tool that was written for nursing and validated would have provided more

succinct data that would have been more applicable to this population. The qualitative
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data did provide student feedback that supported improved critical thinking, increased

situational awareness, enhanced communication skills and enhanced confidence. The

student feedback was not however supported by the cognitive outcomes of the study.

In future research aligning the cognitive measure with the simulation theoretically may

reveal results that would align with the qualitative comments.

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 Chapter One

Introduction

Healthcare in the United States was forever changed in 1999 when the Institute

of Medicine (IOM, 1999) published its report ―To Err is Human.‖ This report

illuminated the many medical errors that are made each year in our healthcare system.

Since this report, the incidences of preventable medical errors has only improved by

one percent each year (Quality Forum, 2007) while some sentinel events have actually

increased over the last calendar year (Joint Commission, 2008). In addition to medical

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errors that result in death or harm to the patients, there has been an alarming shortage
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of nursing staff and faculty. Nursing education has been forced to explore ways to

increase the nursing graduates and the pool of educators. Historically nursing
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education has evolved into a profession that is well respected and considered rigorous

in academic settings.

Clinical sites are also scarce in many regions of the country, leading the
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administration of both academic institutions and their practice partners to seek

alternatives to inpatient clinical rotations (Seropian, Brown, Gavilanes, & Driggers,

2004). The current economic crisis has led to many nursing schools being left without

adequate faculty and staff even in the midst of the well documented nursing shortage.

In an effort to address the increased incidences of medical errors and the resulting

injury and/or death of patients, advocacy groups and accreditation bodies such as the

Joint Commission, the National Quality Forum and the National Patient Safety

Foundation have all supported projects that improve patient safety and the education
of nurses related to patient safety. Educating patients, and the staff that care for the

patients, must be purposeful and directed in order to address the errors and knowledge

gap that exists. The overall goal was of course, reducing harmful medical errors in

order to keep the patient population safe and healthy. Education cannot ignore this cry

for change.

Nursing faculty have answered the call by vigorously seeking new technology

and cutting edge pedagogy. Simulation is one such pedagogy and provides for active

learning methods that afford the students a ―hands on‖ experience that resembles the

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actual clinical area. Clinical instruction in nursing education consists of nursing

students caring for patients in healthcare settings. The lack of available clinical sites,
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and the shortage of nursing faculty, has mandated alternatives to ―practicing‖ on live

patients. The ability to mimic life like situations in a lab setting using simulation has
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afforded nursing students with the opportunity to care for patients that they may never

have the option to care for in the clinical area. Nurse educators have used simulation
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for decades. Early on, nurses injected water into an orange to simulate the skin of a

real person. Nursing education has come a long way since those first rudimentary

simulations.

Purpose

Today‘s high fidelity simulators provide the student the opportunity to perform

invasive procedures such as endotracheal intubation and chest tube insertion. The

computerized technology allows the faculty to program these simulators to mimic a

real patient situation and ultimately assess the student‘s ability to respond to changes

in patient conditions. Subsequent to the completion of the actual bedside simulation

event the debriefing occurs. Training faculty to use this technology effectively and

facilitate the debriefing is imperative to the successful integration of this pedagogy.

Research in the area of high fidelity simulation within nursing education is in the

infancy stages. The purpose of this study was to investigate how the training of

nursing faculty to debrief students effectively will lead to a student with higher

achievement scores and how the faculty training will in addition affect the satisfaction

of the student. The study sought to clarify the relationship that the student‘s

chronological age, gender, previous education, and reflective thinking level have on

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the achievement of students.

The gold standard for identifying acquisition of knowledge in the student nurse
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is the NCLEX-RN standardized exam. All applicants for licensure must pass the

NCLEX in order to successfully become a registered nurse. The construction of

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course exam questions in nursing programs is typically modeled after the NCLEX-

RN. Preparing nursing students to be successful on application and analysis questions

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is essential in the preparation for NCLEX success. Using the same level of thinking in

terms of measuring outcomes of knowledge is consistent with the use of the NCLEX

exam. This supports the endeavor to determine academic and clinical success of the

nursing student. Prion, in her 2008 article entitled ―A Practical Framework for

Evaluating the Impact of Clinical Simulation Experiences in Pre-licensure Nursing

Education‖ discusses various methodologies for assessing the outcomes of simulation.

She notes that one such tool is the pretest posttest that can be administered to evaluate

the students learning during the simulation. This research study uses a posttest design

to determine the difference in the control and experimental group‘s knowledge gain or
achievement. The posttest scores were compared to the student‘s course grade in

Pathophysiology. Educational institutions must prepare nursing students to be

successful on standardized tests and must prepare the nursing student to think

critically and use their reflective thinking in their practice. The use of simulation and

the component of debriefing encourages‘ nursing students to participate in an active

learning exercise and to use reflective thinking to bring all the pieces of the puzzle

together. Theoretically the nursing student should use the learning that takes place

within the period of debriefing to impact their ability to think critically, applying their

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learning to not only actual clinical situations but to application and analysis questions.

Students who participate in a debriefing session that is facilitated by a faculty member

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whom has not been formally trained to debrief will theoretically not show improved

achievement. Examining the link between the student‘s level of RT and the student‘s
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achievement will allow the researcher to identify factors that mediate the learning.
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Chapter Two

Problem Statement

Cantrell (2008) clearly identifies the importance of the facilitator and how this

affects learning. She recommends looking closely at the interactions between the

student and the faculty in order to see how learning is affected. This study took this a

step further by investigating how training the faculty to be effective facilitators affects

learning, addressing the gap in the current literature regarding how training affects

outcomes. Eliminating the unknown for the faculty, not knowing where to start or

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how to actually lead the students into reflection and critical thinking theoretically

leads to learning.
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Kardong-Edgren, Anderson, and Michaels (2007) examined fidelity and its
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effect on test scores. The outcome of this pilot study revealed that the fidelity of the

simulation did not in-turn affect the scores of the students on NCLEX type questions.

Examining the training of the faculty in terms of debriefing may reveal the key to
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learning during simulation: the debriefing, and how well prepared the faculty is to

facilitate this process of learning. Identifying the connection between faculty training

on debriefing and student outcomes encourages nurse educators to effectively prepare

to utilize this methodology.

This study also examine how the students with a previous degree and the

traditional student compare in terms of reflective thinking level and achievement

scores. Hallman (2007) concluded in her study that accelerated nursing students did

not perform better on the NCLEX but instead on their nursing course work. This study
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will add to the body of knowledge surrounding the accelerated nursing student and the

outcomes of this group. Ouelett, MacIntosh, Gibson and Jefferson (2008) found

students who graduated from an accelerated program were as well prepared for

practice and the NCLEX as traditional students. Finally the affect of gender and age

on the student‘s learning has been well documented in the research; however, the

research has not examined the effect on achievement related to debriefing (Grady et al,

2008). Examining how gender and age have a relationship to achievement and how

the reflective thinking level of the student influences achievement is of interest to

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nursing faculty as they construct learning experiences that will be beneficial to all

students regardless of their age and gender.

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Research Questions
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The research related to simulation and the learning that takes place within

simulation began in the field of aviation and has, over the last decade, moved into the

medical and nursing arena. Research provides a critical link between the practice
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setting and the academic setting. Discovering how students utilize the tool of

simulation and debriefing to learn is the goal of this project. The variables within this

study all create a pathway to determine the affect or lack of affect that simulation

learning has on achievement and more specifically how the training of the faculty to

lead the debriefing component will have an effect. In addition the study examines

how the training of faculty to effectively debrief influences the satisfaction level the

students have related to the debriefing and the simulation. As a covariate the study
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explores how the student‘s level of reflective thinking interacts with the faculty

training when achievement and satisfaction were measured.

Nursing educators have traditionally been faculty from traditional nursing

backgrounds with little experience in educational theory and training (Baragagliotti,

2008). Purposefully instructing those who are experts in the content area on how to

teach, or in the case of this study how to teach through debriefing, is crucial. Bartels

(2007) states that ―by effectively focusing on student learning as the goal of the

teaching role, faculty will be in a better position to encourage students to become more

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precise, reflective, flexible thinkers in the discipline‖ (p.155). The students came to

the simulation and debriefing using a certain level of reflective thinking (RT);
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determining their level of RT prior to the simulation and debriefing provides the
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researcher with a window into how RT interacts to influence learning that occurs with

the faculty debriefing. Learning or achievement in nursing education is defined

quantitatively through the National Licensure Exam or NCLEX. This study used a
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posttest, similar in format and taxonomy to the NCLEX, to measure learning. The

tests will be developed by HESI Elsevier. The students completed a posttest related to

the objectives of the simulations. How the faculty training affects the performance of

students on traditional achievement measures is important as nursing education

continues to develop into a profession with rigorous academic standards. Building

upon the already delineated need for training as described by Bartles, this study gives

nursing educators evidence that supports the goals of faculty preparation for teaching.