Nurse Education Today 31 (2011) 699704

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Nurse Education Today

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / n e d t

Exploring nursing students' decision-making skills whilst in a Second Life clinical simulation laboratory
Jacqueline McCallum , Valerie Ness 1, Theresa Price 2
School of Nursing Midwifery & Community Health, Govan Mbeki Building, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 0BA, United Kingdom

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Aim: To explore nursing students' decision-making skills through the use of a 3D virtual environment such as Second Life. Method: An exploratory qualitative evaluation of the students' experience of learning decision-making skills whilst in a Second Life clinical simulation laboratory. A convenience sample of ve third year student nurses entered a simulated world environment where they cared for six patients over 1 h. The written communication text from the Second Life scenario was saved into a Microsoft Word document. Additionally a semi-structured tape-recorded one to one interview was conducted immediately after the Second Life simulation in order to explore the students' decision-making skills. Results: The communication text illustrated that the majority of decisions (n = 21) were made in response to a situation or a patient request, therefore reactive rather than proactive (n = 9). Only one student carried out a vital signs assessment on a newly admitted patient (Willie). The interviews produced two themes, performing decision-making and improving learning. The absence of visual cues such as pre-operative checklists, vital sign observation charts and Nil by Mouth signs may offer a rationale for why students were more reactive. Conclusion: Further work is required for students to practice decision-making skills. With further development the innovative 3D virtual worlds such as Second Life could provide this experience. 2010 Elsevier Ltd. All rights reserved.

Article history: Accepted 10 March 2010 Keywords: Simulation Decision-making Virtual learning environment Second Life

Introduction The importance of teaching practical skills to ensure safe effective practice by the student nurse has become increasingly apparent. One of the key principles of the Nursing and Midwifery Council (NMC), the governing body for the United Kingdom, is that registered nurses have a duty of care to patients and clients, who are entitled to receive safe and competent care (NMC, 2008, p4). Historically, in order to learn the skills of nursing, student nurses practiced directly on the patients and clients. This was often referred to as the apprenticeship model of learning (du Boulay and Medway, 1999). Problems arose from this model as students had limited supervision due to the registered nurse's workload and they often failed to learn the theory underpinning their actions (Nicol and Glen, 1998). For more than a decade the tness for practice report by the United Kingdom Central Council UKCC (1999) identied that following qualication and registration there were a number of skill decits in newly qualied nurses. One of which is decision-making (Luker et al, 1996).

Worringly, Scholes et al (2004) in a review of nurse education in England found limited improvement. Since then the NMC (2004) has developed standards of prociency for pre-registration nursing education and the essential skill clusters (NMC, 2007) which include decision-making. Literature The goal of decision-making and the reason it is taught is to benet the patient (Harbison, 2001). However the skills involved and the process of decision-making are complicated (Garrett, 2005). It is widely recognised that there are two main theories to making decisions. One is the intuitive humanistic approach (Benner and Tanner, 1987) also known as the information processing theory (Lauri and Salantera, 1998) where experienced decision-making happens over time (King and Clark, 2002). The second is a systematic-positivist approach (Garrett, 2005), also known as analytical decision-making theory (Lauri and Salantera, 1998) based on systematic processes through analysis and deductive, inductive and abductive reasoning (Garrett, 2005). Consolidation of practical decision-making skills takes place in the classroom (Garrett, 2005). However it is argued this rarely happens (Croskerry, 2005) since decision-making is not a skill that is easily explained in a classroom (Ajjawi and Higgs, 2005). Instead, critical

Corresponding author. Tel: 0141 331 3068. E-mail addresses: jacqueline.mccallum@gcal.ac.uk (J. McCallum), v.ness@gcal.ac.uk (V. Ness), t.price@gcal.ac.uk (T. Price). 1 Tel: 0141 331 8813. 2 Tel: 0141 331 8786. 0260-6917/$ see front matter 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2010.03.010

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J. McCallum et al. / Nurse Education Today 31 (2011) 699704 Table 1 Patient scenarios. May: 88 years old has been a patient on the ward for 3 weeks. She has been treated for a Urinary Tract Infection and is awaiting a bed in the care of the elderly unit for assessment. She has Alzheimer type dementia and is confused, disorientated and anxious. Laura 39 years old. She has a history of gastric reex and is awaiting an upper gastric endoscopy. William 56 years old. He was admitted 1015 minutes earlier with acute right sided upper abdominal pain. He was given Morphine 10mgs IM approximately 30 minutes go. Cholecystitis is suspected and the decision based on the abdominal ultrasound is awaited. Colin 22 year old professional rugby player who has just arrived back from theatre following a left knee arthroscopy. He is to remain non weight bearing until review by the medical and physiotherapy team tomorrow. Discharge planned following review. Priscilla 62 year old lady who is awaiting discharge following an appendicetomy. Discharge is planned at 11 am. An out patient appointment needs to be arranged for 68 weeks and she will require an appointment with the district nurse and a prescription for analgesia. Anne 44 year old lady who is 5 days post open cholecystectomy. Although up and about and eating well the wound is very red and moist in appearance. She is waiting for her MRSA screen results.

thinking skills are generally developed in the workplace with the guidance of a mentor (Garrett, 2005). However, due to constraints related to clinical placements and limited availability within clinical simulation laboratories, the focus is on nurse educators to provide innovative, interactive teaching, learning and assessment strategies to develop students' clinical decision-making (Standing, 2007). The use of simulation to help with the development and teaching of clinical skills is now well accepted throughout the world. However the research conducted in simulation is within a real life simulated clinical environment, and not the virtual one. There is therefore a need to carry out further research on the efcacy of the virtual world setting. Caledonian University has invested in the virtual environment market, and own an Island on Second Life. The university campus is situated with a realistic copy of the actual clinical simulation laboratory (CSL) where currently pre and post registration nursing students learn and become competent in skills. Second Life is a 3D virtual environment where Residents of the virtual world can socialise, participate in individual and group activities and create and trade virtual property in real time (Parker, 2008). Although there are medical (Danforth et al., 2009; Diener et al., 2009) and nursing (Skibra, 2007) publications explaining that Second Life can provide a unique and exible environment to enable simulation education without the constraints of distance and space and provide ward environments with real case patients there is limited research of its use as a learning and teaching strategy. Aims To explore nursing students' decision-making skills through the use of a 3D virtual environment such as Second Life. Method This study was a qualitative exploration of the students' experience of learning decision-making skills using the 3D virtual environment of Second Life. Following the activity the students were encouraged to reect on their experience through a one to one, semistructured, tape-recorded interview. The study Students assumed Avatars (a student nurse image in Second Life) and accessed the Clinical Simulation Laboratory within Second Life after changing into nursing uniform. Each student individually participated in a scenario-based activity. This involved communication and visual assessment of six patients (Table 1) prioritising their care and explaining their decisions. One of the research team acted as the students' mentor via their individual Avatar and provided feedback and guidance to the student Avatar. Study site, population and sample This was a case study undertaken in one Higher Education Institution (HEI) in Scotland where the researchers are lecturers. The population studied was convenient and consisted of all student nurses on a three year Diploma of Higher Education/Bachelor of Nursing or Bachelor of Arts in Nursing Studies (BANS) Adult Nursing course. The population was e-mailed through the Blackboard site (Virtual Learning Environment) with information about the study, and those interested were asked to reply. Twelve students replied and were sent detailed information about the study. Six students volunteered to take part in the Second Life training. Thereafter one student dropped out, leaving ve students to participate in the study.

Ethics Ethical approval was granted from the School Ethics Committee, informed consent was obtained from the students and the researchers handled all data according to the Data Protection Act of 1998. Data collection The written communication text from the Second Life scenario was saved into a word document and a semi-structured, tape-recorded, one to one interview was conducted with the student immediately after their experience on Second Life by one of the researchers. Semistructured interview guidelines allowing exibility were prepared, using open questions. This facilitated probing, reecting, and exploring new leads. Data analysis The communication text was rstly analysed by examining the decisions and determining whether they were initiated by the student, that is proactive, or in response to an evolving scenario, that is reactive. In addition, consideration was given to the activity of delegation to the mentor who was also on duty within the scenario. Further analysis of the communication text involved exploring the student's responses to the patient's comments or requests. Expected nursing care interventions for each patient were compiled. The decision or response made by the student to each of these interventions was then recorded. An analytical seven-stage process, as recommended by Deikelmann (1989), was utilised by one researcher to analyse the data from the interviews (Table 2). Barnett (2005) suggests that this particular framework can provide a good level of rigour, particularly trustworthiness. The interviews were transcribed and treated as text analogues for interpretive analysis using a computer-assisted analysis of qualitative data. Findings The communication text illustrated the decision-making activity that took place for each patient (Table 3). The majority of decisions

J. McCallum et al. / Nurse Education Today 31 (2011) 699704 Table 2 Deikelmann (1989) seven stages of analysis. 1. Reading the interviews, reective journal, literature and SD results to obtain an overall understanding. 2. Writing interpretive summaries and coding for possible themes. 3. Analysing selected transcripts as a group in order to identify themes. 4. Returning to the text or to the participants for clarication of disagreements in interpreting and writing a composite analysis of each text. 5. Comparing and contrasting texts to identify and describe shared practices and common meanings. 6. Identifying constitutive patterns that link the themes. 7. Eliciting responses and suggestions on a nal draft from a colleague familiar with the content and or methods of the study.

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(n = 21) made were in response to a situation or a patient request, therefore reactive. For example, the decision to change a wound dressing was in response to Ann's request. Similarly, discharge drugs were ordered as a result of Priscilla making a statement about going home. Nine proactive decisions were made in total. Student two made the most proactive decisions which included undertaking the pre-operative checklist with the patient called Laura and completing a pain assessment with the patient called William. Table 4 summarises the care interventions which the students undertook. May: The response to May's behaviour and questions were mixed. Not all students recognised that May had left the ward or had prevented her from leaving the ward. Also there was a mixed response for the need to provide constant reassurance. Only two students saw May as having a high priority in terms of overall care delivery. Laura: One student did not recognise that Laura should be fasted, no one explained to her what would happen to her during the procedure and one did not complete her pre-operative checklist. Furthermore the need to complete the checklist was in response to Laura's request or by the assisting mentor. William: Only one student carried out a vital signs assessment on a newly admitted patient. The patient complained throughout the scenario of acute pain and nausea. Most students undertook a pain assessment but for two students this was in response to a medical request for a pain score. Only one student appeared to recognise that the patient was deteriorating and needed an Early Warning Score (EWS) to be calculated (Department of Health, 2009). This task was

delegated to the assisting mentor. However all students recognised their own limitations and requested assistance for care intervention. Colin: Post operative observations were not undertaken by any of the students. Only one student recognised the need to provide food and uid, however the remaining students did respond to the patient's request. All students recognised the need for Colin to remain on bed rest and attended to personal care needs. Priscilla: All students managed to arrange the discharge drugs but this was in response to the patient and or the assisting mentor's prompts. Most did not arrange an outpatient appointment or determine the expected time of arrival of the ambulance to take the patient home. Anne: All but one student recognised that the patient may have MRSA and tried to restrict Anne's contact with other patients and her movement around the ward. However only one student gave Anne an explanation of why she was restricted. All responded to Anne's request to have her dressing changed and considered the possibility that the wound was infected. The one to one interviews produced two themes relating to decisionmaking, which were performing decision-making, and improving learning. Theme one performing decision-making The students were able to discuss how they learned about decision-making from two perspectives the theory from being in class, as well as gaining experience from clinical practice. Student ve I knew how to make the decision from my classes, lectures and practices as well as the CSL. Also from my experience of watching what was happening on placement, yes. So I am putting all of that together. The students could identify learning from theory, which included clinical guidelines and instruction on how to care for certain patients. Student four I think it was William again when he was pain and everything I felt I brought a lot of theoretical knowledge into it. But they also recognised that some of the charts to help them with decision-making were not present, such as early warning scoring systems, and pre-theatre checklists. Student one: The EWS wasn't there so I forgot about it. The students reected on the decisions they made during the simulation and felt they were the same as if it were a real scenario. Student two even though it's a computer programme I think really you make the decision that you would make anyway. I am pretty sure that the decisions I made are still the decisions that I would have made if I was out on the ward. One student expressed that they had limited experience of making decisions on clinical placement. Student four I suppose there has been times when I've done decision-making on a ward or clinical placement, yeh, I have. I don't know, I wasn't really that conscious of it at the time. The remaining students stated that they had no experience at all of making decisions on clinical placement. Student one I think this is mainly the only time that I have had practice at making decisions. Because of this, some students felt scared at having to make decisions, Student two I mean you know all the stuff from the 3 years, but do you have the condence to go out and actually make the decisions. However the Second Life experience gave the students some condence that they were able to make decisions at this stage in their programme. Student one So it gave me more experience of dealing with more patients. But I felt I coped. I feel I could now do it in the real situation. Student one Eh I think it's provided more of an insight into what I'll be doing in the wards. The students commented that being able to practice delegation gave them more condence in doing it in clinical placement,

Table 3 Decision-making and delegation activity across scenarios. Patient May Proactive decision Reactive decision Delegated Laura Proactive decision Reactive decision Delegated William Proactive decision Reactive decision Delegated Colin Proactive decision Reactive decision Delegated Pricilla Proactive decision Reactive decision Delegated Anne Proactive decision Reactive decision Delegated Student 1 No Yes Yes No Yes Yes Yes No yes No Yes Yes No Yes Yes Yes No Yes Student 2 No Yes Yes Yes No Yes Yes No Yes No Yes Yes No Yes Yes Yes No Yes Student 3 No Yes Yes No Yes Yes No Yes Yes No Yes Yes No Yes Yes Yes No Yes Student 4 No Yes No No Yes Yes No Yes Yes No Yes Yes Yes No yes No Yes Yes Student 5 Yes No Yes Yes No Yes No Yes Yes No Yes Yes No Yes Yes No Yes Yes

702 Table 4 Student communication text results of patient scenarios. Patient Interventions or behaviours

J. McCallum et al. / Nurse Education Today 31 (2011) 699704

Student 1 Action taken

Student 2 Action taken No No Yes Medium Yes Yes Yes Yes No No Yes Yes Yes Yes Yes No No Yes Yes No Yes No No Yes Yes Yes

Fiona 3 Action taken No No No Med/low Yes No No No No Yes No No (medic request) No No (Medic request) Yes No No (given on request) Yes Yes Yes Yes No No Yes Yes No

Student 4 Action taken Yes No No Low Yes Yes No No No No No No Yes No Yes No No Yes Yes Yes Yes No No No Yes No

Student 5 Action taken Yes Yes Yes High Yes Yes No No No No No (medic request) Yes No No Yes No Yes Yes Yes No Yes Yes No Yes Yes No

May Questions answered Given reassurance Prevented from leaving the ward Priority of care Laura Fasted for uids and food pre-operatively Pre-operative checklist complete Prepared for theatre/endoscopy Smoking advice (prevent pre-operatively) Procedure explained to patient Time for theatre allocated William Assessment of vital signs (routine intervention ) Pain assessment Pain and nausea managed Recognition of a sick patient use of EWS Got help Colin Post operative observations of vital signs Food and drink offered post operatively Personal care provided Maintained on bed rest Priscilla Outpatient appointment arranged Discharge drugs arranged Arrive of ambulance time Reassurance given Anne MRSA recognise strategies to limit spread Wound dressing changed Explanations given about MRSA status

Yes Yes Yes High No (given water) Yes Yes Yes No Yes No Yes Yes No (EWS medic request) Yes No No (given on request) No request made Yes No Yes No Yes Yes Yes (request by patient) No

Student three I've probably gained the most about being able to ask somebody to do things. You know the delegation side of it. Theme two improving learning All the students explained that the simulation helped them learn better. Also the simulation made them test themselves. It made the students aware of what they could do. Student two I am actually surprised that I know that much. I think. I actually think that it actually showed me that I can actually go out and make the right decisions in a ward setting. Even after careful consideration prior to making decisions, mistakes can be made but the students recognised this as helping their learning. Student four You know no-one would get hurt if I made a bad decision, so it was kind of ok. There were specic things that the students had problems with. One student gave Laura, who was waiting to go to theatre a drink, although they realised their error on reection. Student one The hiccups (errors) were mainly the ones with em, well, one of the patients going for a test, for the endoscopy, and giving them a drink of water. All but one of the students virtually ignored May, who was an elderly patient with dementia. Student four I didn't quite realise that May had absconded off the ward. Em partly I wasn't seeing it and partly just other things just kept coming up. The students explained some reasons as to why they found some things difcult. Student three I wasn't switched on enough to be looking at the screen, or being in the wrong position on the screen to actually see that she had gone out. Student two I didn't like that you couldn't actually do the skills.

Discussion When developing the simulated ward based scenario with the six patients, we had an expectation of some of the nursing decisions that would be made whilst caring for these patients. Surprisingly, a large number of these were unfullled. One of our main observations was that the students were more reactive than proactive in their care. We had an expectation that they would make decisions about the patient's care, prioritising who needed care rst and then carrying this out. In reality, most of the care that took place was reactive, and from hints, cues and requests from the patients and the mentor. We made William the sickest patient, and most of the students recognised this. The students were able to discuss how they had learned about decision-making from two perspectives, the theory from being in class, as well as gaining experience from clinical practice. This links with the two major discourses of clinical decision-making discussed by Garrett (2005) which are the intuitive humanistic approach (Benner and Tanner, 1987; Thompson, 1999) and a systematicpositivist approach (Ellis, 2002; Bench-Capon, 1990; Putzier et al., 1985; Elstein et al., 1981). The students were able to identify both learning in practice as well as learning in theory and used tools to help their learning in a Bayasian way such as the EWS charts. This is in agreement with literature that supports that nursing decision-making involves both analytic and intuitive processes (Thompson, 1999; Lauri and Salantera, 1998). Since the students were relatively inexperienced, and therefore novices (Benner, 1984) we thought they would use a more systematic-positivist approach to their decision-making. However this was not what we observed in the simulation. The students did not ask for any EWS scores, did not perform them, and in fact did very little in the way of collecting any vital sign information for the patients. Rather worryingly, the students commented that this

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was because the charts were not on display. It was only when the mentor asked the score that they then delegated this task. The absence of visual cues such as pre-operative checklists, vital sign observation charts and Nil by Mouth signs may offer a rationale for why students were reactive or did not make certain important decisions. One of the areas of concern was the lack of response from the students in assessing the patient William when his condition began to deteriorate. In the interviews following the scenario, student one noted that the EWS chart wasn't there, and suggested that this was a reason why they did not perform a vital sign assessment on a deteriorating patient. This would imply that it was not the patient's explanation of how he felt that triggered a response by the student, but the presence of a chart that represents severity of illness. However there are other cues that would alert the nurse to a deterioration in a patient's condition such as; a change in the patient's colour or breath sounds and rate, or the temperature and feel of the skin. These visual and auditory cues were not used in the scenario and are difcult to replicate. Instead however, attempts were made through the use of text. For example I feel really sick. .I have been sick all over the bed..groan. I am in pain. Nevertheless only one student offered medication to alleviate William's nausea and two needed a medical request before a pain score was calculated. The visual cue of a prescription chart or pain score was missing but the patient was clearly distressed. This is worrying when you consider that student two commented that she was sure that decisions she made during the simulation would be the same ones she would make on the ward. Communication skills are an essential part of the decision-making process (Garrett, 2005). It would be expected that year three students would be able to communicate effectively and use the information to make decisions about patient care (NMC, 2004). However little attempt was made to reassure or talk to May and she was allowed to leave the ward unchallenged. Laura was not prepared for theatre and received no explanation of the procedure she was about to have and Colin did not have any post operative observations performed. Student three noted that in the real situation you may be talking and listening to one patient but can hear and see what is happening to other patients nearby. All this information is used to make an assessment of the situation (Lauri and Salantera, 1998). A further explanation of their observed poor communication skills may be because they had to type rather than speak. This was felt to be distracting, particularly by those with less computer experience, as it required them to focus on the key board and not on the screen. May or Laura may have left the ward during a text exchange with another patient or nurse. Therefore the form of communication used within Second Life may in itself be a confounding variable that impacts on the students' performance and condence in decision-making within the scenario. A third factor that could explain the students' lack of proactive decision-making was the difculty in undertaking motor skills within the scenario. Student nurses within the rst two years of their programme learn through performing psychomotor skills such as taking blood pressures, administering medications, completing documentation and wound assessment (NMC, 2007). However within the second life scenario this was not possible. Student three noted that she felt that she should be doing something and didn't really move around the room. She also felt inexperienced with the hands on skills needed to run an avatar on Second Life. The simulation did make the students realise that they could perform decision-making. The students actually saw that they were prioritising care, making decisions and delegation. The students however were not sure that they had ever performed this on clinical placement, even though almost all the care they provide would have involved some form of decision-making. Therefore this simulation made it clear to the student what was involved in decision-making.

Study limitations A limitation of the study was its small sample size; however, this was an exploratory study examining the possibility of using Second Life for decision-making skills with a larger group of students. Secondly, Second Life does not lend itself to psychomotor skills due to the limited ability to control the Avatars movements other than walking, lying, sitting, which could have inuenced the students' decision-making processes. Conclusions This small scale exploratory study supports previous ndings that decision-making is still a skill that students nd difcult to learn. Learning and teaching strategies are required that are interactive, immersive, real and which link theory and practice. Second Life could be valuable in providing the practice that students require. Further development and research is required to explore the possibilities of using Second Life in different clinical settings as an innovative learning and teaching strategy to enhance a variety of nursing skills such as decision-making. Acknowledgments The authors would like to thank Andy Whiteford, Ferdinand Francino and Steven Lang at Glasgow Caledonian University for their help in the development and upkeep of the virtual clinical environment on Second Life and in the training of the students. References
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