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Description of the postoperative nursing simulation: The purpose of this simulation was to allow students to observe postoperative patients and learn to assess patients accurately using available information on them. The educator informed students that they would see a patient one hour after the patient’s tracheal tube had been removed within the operating room. Students were further instructed to observe the patient’s condition and position of the patient’s body, and to pay attention to the patient’s respiratory condition. In addition, the students were asked to conduct a medical interview with the manikin. After explaining this process to the students, the educator was waiting in another room next door. The educator observed the students through a one-way mirror window in the next room from which the educator could see the students, but the students could not see the educator. The educator observed students’ performance on the observation of respiratory condition, which included confirmation of position of the patient’s body, oxygen dose, auscultation of respiratory sound, thorax movement, respiratory frequency, respiratory pattern, and respiratory rhythm. The simulation was progressed into the following phases: 1). introduction (5 minutes; students were given basic information on the patient and setting); 2). a 5-minute break (hereafter, “the break”); 3). patient care (about 10 minutes; the student examined the manikin through auscultation, inspection, and palpation); 4). reporting (5 minutes; student reported on patient care); and 5). debriefing (10 minutes). In the patient care phase, they mainly confirmed the patient’s breathing frequency, breathing sound, cyanosis, and peripheral circulation. In addition, they confirmed that the oxygen tube was not bent and that the dose of oxygen was correct. The debriefing was conducted in a separate room from the patient’s room and was based on the following five guidelines by Decker et al. : (1) facilitated by an individual competent in the debriefing process; (2) conducted in an environment conducive to learning and that supports confidentiality, trust, open communication, self-analysis, and reflection; (3) facilitated by a person(s) who observed the simulated experience; (4) based on a structured framework for debriefing; and (5) congruent with the students’ objectives and outcomes of the simulation-based learning experience [17]. The educator gave feedback about the patient care phase for students. The simulation lasted for about 30 minutes from introduction to debriefing (Table 1).
Table data removed from full text. Table identifier and caption: 10.1371/journal.pone.0195280.t001 Simulation phases. A high-fidelity manikin was installed within the patient’s room. The temperature, relative humidity, and illumination conditions were controlled. The patient was simulated using a life-size manikin for advanced life support training (Laerdal Co., Ltd). This manikin is capable of issuing (and attenuating) a breathing sound and can be set to have specific a heart rate, blood pressure, and respiratory rate in realistic scenarios. The patient simulated was a 53-year-old male who had undergone total gastrectomy for the treatment of gastric cancer. The scenario was set such that the patient’s tracheal tube had been removed within the operating room one hour before the student saw him. The patient had fully recovered consciousness after the operation and was outfitted with a central venous catheter, an oxygen mask with a flow of 3 liters of per minute, a nasogastric tube, a urethral catheter, a sheet of gauze for protection of the celiotomy wound, an indwelling abdominal drain, and an electrocardiogram monitor. We set the manikin’s physiological parameters as follows (heart rate, 62–70 bpm; blood pressure, 120–128/66–70 mmHg; and respiratory rate, 16–20 min).
Third-year students enrolled in a 4-year nursing university course were recruited as volunteers in this study. All students had acquired the credits for all lecture-based lessons before participation in the study. None of the students had used a high-fidelity manikin before. They had two weeks’ experience of practicing in a hospital setting before this study, during which they had only taken charge of a single patient. None of them had begun surgical nursing practice, and all were unfamiliar with the observation of a real surgical patient. Therefore, a simple and easy-to-resolve scenario was required. Students with hypertension, heart disease, diabetes mellitus, or kidney disease, or who were receiving routine oral medication, were excluded from this study. All students were advised to avoid consuming alcohol and caffeine the day before the study and to sleep well on the night before. Overall, 74 eligible students who provided informed consent for participation and were given an explanation of the ethical considerations enrolled in the study.
Before students entered the patient’s room, the researcher connected students to a Holter electrocardiography system (GLLERT Lab Tech Co., Ltd.) and then gave students an explanation of the setting of the simulation. They were also given a 5-minute break (the break phase) to stabilize their autonomic nervous system. During the break phase, students were advised to take deep breaths while sitting on the chair in a quiet room with the curtains drawn. Five minutes later, students entered the patients’ room with the educator to begin the patient care phase. This phase ended when the student said “completed.” Upon completion of patient care, students reported to the educator what they had observed and assessed with regard to the patient’s condition (the reporting phase). The educator observed the students in a booth connected to the patients’ room, which was blinded from view while in the patients’ room. After being disconnected from the Holter system, the student was interviewed about his/her reflections on the simulation, with emphasis being put on what the student had said of the simulation.
The Holter system records were used to calculate heart rate, as well as the HF and LF/HF components of HRV. The simulation was divided into five phases, although HRV was only compared between the following four: (1) break, (2) patient care, (3) reporting, and (4) debriefing. Significant differences in heart rate and the HRV components were determined using the Mann-Whitney U-test with SPSS Statistics 22 (IBM Corp., Armonk, NY). The statistical significance level was set at p < 0.05. In addition, we analyzed the meaning of students’ remarks and counted the number of occurrences of certain remarks.
Each student received an explanation from the researcher about the ethical considerations related to the study, including the freedom of the student to participate in the study at her/his own discretion and to cancel participation at any time after the start of the study, and the fact that participation (or lack thereof) would have no influence on the student’s school performance. If students considered these terms acceptable, they were asked to give their written consent. This study was carried out with the approval of the Research Ethics Committee at Chubu University to which the researcher belonged.
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