Simulation Module for Patients with Hypoglycemia

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Development and Evaluation of Simulation Module for Patients with Hypoglycemia



Human patient simulator (HPS) has been used in medical education (Alinier, Hunt, Gordon, & Harwood, 2006) for almost four decades. Since simulation using high-fidelity has begun by applying crisis intervention training on nurse anesthetist  (Fletcher, 1995), over the past 10 years, simulation has been rapidly expanded in nursing education (Dunn, 2004).

Simulation education is not just about obtaining simple knowledge and techniques but rather have been considered as a kind of new education method that can train nursing care ability by reproducing real-like clinical situation in a safe environment (Hodge, Martin, Tavernier, Perea-Ryan, & Alcala-Van Houten, 2008; Steadman et al, 2006). Moreover, simulation education have been accelerated by shortening of the patient’s admission period and limited chances of nursing student’s participation due to elevated expectations on the medical staff by the patients.

Through simulation education, student carry out physical examination directly on simulator and immediately identify physiological changes on the monitor. After implementing the proper intervention, they can get feedbacks from results (Bremner,Aduddell,Bennett, & VanGeest, 2006). Therefore education using simulation is becoming the most important subject in current nursing education as a method that can improve problem solving ability and critical thinking of students in clinical situation (Corbridge, McLaughlin, Tiffen, Wade, Templin, & Corbridge, 2008; Feingold, Calaluce, & Kallen, 2004).

Since a simulation practice method has been introduced to the nursing practice educating in South Korea ten years ago, many study results on the effect of simulation education have been reported in the area of pediatric nursing (Yoo, 2013; Shin, Shim, & Lee, 2013), maternity nursing practicum (Kim, Ko, & Lee, 2012; Kim, Lee, & Chae, 2012; Lee & Kim, 2011), psychiatric nursing (Choi, 2012), and critical and emergency care unit (Kim, Choi, & Kang, 2011; Kim & Jang, 2011). Current scenario that can be used in simulation education is not still developed variously in sub-major nursing areas in Korea. Therefore case is not appropriate to situation so there is a difficulty of having simulation practice. Especially, diabetes mellitus is prevalent disease in middle ages. However, it can be controlled by both concrete assessment for differentiation and anticipatory management. And because patients with diabetes mellitus should always manage blood glucose in their life, nursing education to prevent hypoglycemia is essential education contents. In nursing student education, simulation practice for critical thinking training to identify symptoms and plan nursing care as priority due to hypoglycemia is effective and important nursing problem.

In this study, we tried to test the applicability of the simulation by developing simulating education scenario based on the case of hypoglycemia and evaluating student’s performance after using it. The study was done to improve nursing students’ critical thinking on nursing problems and clinical decision-making ability by developing scenario with high-fidelity SimMan simulator based on clinical real situation. The purpose of this study is to develop a scenario and evaluate students’ performance and satisfaction in simulation learning of care for patients with hypoglycemia.



This study used a mixed method design which captured both quantitative and qualitative data to evaluate degree of performance and satisfaction as development and applying simulation module with hypoglycemia. In disciplines such as nursing, the phenomena studied are often complex and mixed-method approaches can expand the impact and enhance the flexibility of research designs (Sandelowski, 2000)


A convenience sample of 55 nursing students participated from a university located in Seoul, South Korea. We have decided that third year nursing students who have enough basic knowledge on pathophysiology will not have difficulty in applying simulation education on patient with hypoglycemia and developed simulation scenario targeting them. The inclusion criteria to attain hypoglycemia included (a) junior nursing students, (b) completion of fundamental and endocrine system nursing course with the same credits and textbook, and (c) no prior participation in a simulation class focused on diabetes mellitus.

The participants ‘ ages ranged from 21 to 25 years. The majority of students 89% were women.

Ethical considerations’

Approval to conduct this study was obtained from the Sahmyook university institutional review board (SYUIRB-2013-074). Written informed consent consist of issues of voluntary participation, anonymity, and confidentiality. It explained the purpose of study, the researchers’ credentials, and information regarding confidentiality. Collected data will be managed in the researcher’ office and will be shredded after coding. The IRB proved that there were no factors to this study that would deprive human ethical right, and that all contents and processes confirm to proper research ethics.

Process of module development

Scenario development

Contents of scenario were developed based on real patient’s situation which admitted to emergency unit with shock symptom due to hypoglycemia. In addition, we searched more information on nursing care for hypoglycemia from nursing textbook and protocol. Scenario was focused on developing of student’s ability about assessment and problem identification by critical thinking. For this, the purpose of scenario formulation was to differentiate the origin of shock symptom between hypoglycemia and increasing of intracranial pressure. For testing of validity, five experts consisted of three nursing professors, two nurses who have worked in emergency unit over 10 years reviewed contents of scenario. The scenario was pilot tested using five students (not included in the present study) to determine feasibility and clarity of instructions. No problems were identified.

Development of evaluation checklist

The evaluation checklist focused on the attainment of critical thinking ability rather than implementation skill and was divided into three categories: assessment, problem identification, and interventions. Finally, 4 items were deleted and 16 items reached by consensus (Table 1). The items were selected, reviewed, and analyzed by a seven expert panel including two nursing professors, five advanced practice nurses.

Process of debriefing

Debriefing questions were also developed focused on critical thinking as three phase process. Description phase : ‘What decision did you make when patient complains dyspnea? Why did you do?’; Analysis phase : ‘Did you have an enough understanding about nursing care for patient with hypoglycemia after this simulation practice?’; and Application phase: ‘How can you cope real nursing situation in future through what you learned?. These three phases for debriefing are based on clinical judgment model by Tanner (2006). After taking simulation practice, students had debriefing time for about 20~30 minutes per group of four students. The nursing students were encouraged to reflect on their critical thinking.

Data collection procedure

Data were collected from May6, 2013 to June 28, 2013. The study’s purpose and its procedures were explained to the participants prior to obtaining informed consent. All participants enrolled in this study voluntarily and anonymously, were made aware that there was no disadvantage to nonparticipation as well as information regarding confidentiality. In addition, the data would be reported as a whole and not individually. The ratio of participation was 98%.

Before the simulation, students received an orientation that included how to operate the simulator, simulation learning objective, the scenario information, and patient’s health status. Four nursing students have teamed up to have a discussion of the simulation scenario. Students were asked to wear uniforms and to treat these as actual professional situations. The simulations were scheduled in simulation rooms in which the high-fidelity patient simulators were used. One operator and one instructor observed the simulations from the control room. Each simulation lasted 20 minutes, with the simulation module including debriefing taking about two hours per group. The evaluation checklist was evaluated as a group and was handed to two instructors in a sealed envelope. After simulation module, student satisfaction was measured using the Satisfaction of Simulations Experience (SSE).


The evaluation checklist tool using 3-point Likert scale (1: not fulfill, 2: partially fulfill, 3: fulfill) was a researcher-developed tool designed to assess simulation-based performance. The higher the evaluation checklist score, the better the performance. Content validity was conducted from nurse educators, simulation experts, and clinicians (n=10). The results of the content validity index were above 80% (Waltz and Bausell, 1981). Inter-rater reliability between two independent raters was established using Cohen’s kappa.

Satisfaction which students felt about simulation practice was measured just after finishing the debriefing session using the Satisfaction of Simulations Experience (SSE) scale developed by Levett-Jones and colleagues (2011). This scale consists of 18 items in the area of debrief and reflection (9 items), clinical reasoning (5 items), and clinical learning (4 items). Each item was scored on a 5-point Likert scale. Higher scores indicated higher satisfaction. Cronbach’s alpha coefficient in this study was .94.

Data analysis

The evaluation checklist and the SSE were analyzed using SPSS 18.0 for Windows to calculate descriptive statistics including means and standard deviations. Debriefing data were analyzed using the Matrix Method (Garrad, 2007). Four researchers was analyzed all papers related to debriefing. It were photocopied and organized as a review matrix that, once labeled appropriately, would serve as a structured abstract of all of the documents. The 3C’s (i.e., codes, categories, and concepts) of analysis was used to capture key characteristics of interest, thereby summarizing a large amount of textual information into meaningful themes (Lichtman, 2006).


Scenario of simulation-based hypoglycemia

The patient’s case was developed based on scenario objectives and performance measures. The simulated patient was a 55-year-old man admitted via the emergency unit complaining of dizziness and sweating. The algorithm proceeded as follows: assessment, problem identification, intervention (Fig. 1).

Evaluation Checklist

The evaluation checklist consisted of three categories and 16 items. To identify a statistical measure of inter-rater agreement for items, Cohen’s kappa was measured. Cohen’s kappa for the evaluation checklist was 0.61, good strength of agreement, and each category ranged from 0.33 to 0.97.

The mean score of each category and item is shown in Table 1. The mean score is average of numbers of two measurers. The total mean score was 2.68 (±.129). The mean score of assessment was 2.56 (±.199), problem identification was 2.91 (±.193), and intervention was 2.71 (±.192).


Student comments about the simulation experience were grouped 2 categories, 9 subcategories, and 303 significant statements using content analysis (Table 2). The categories were as followed: Self-reflection and Improvement of competency. The most frequent subcategories, in order, were nursing intervention, coping ability deficiency, perception of real situation, clinical thinking deficiency, knowledge deficiency and communication.

Satisfaction with simulation experience

The SSE scale was used to assess participation in the simulation experience. The total mean score of SSE was 4.15 (±.68). The mean score for debrief and reflection was 4.21 (±.58), clinical reasoning was 4.09 (±.50), and clinical learning was 4.08 (±.46). The highest score item in SSE was “I received feedback during the debriefing that helped me to learn”, and the lowest was “The facilitator made me feel comfortable and at ease during the debriefing” (Table 3).

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