EVALUATING THE IMPACT OF FILMING ON THE NUMBER OF ERRORS COMMITTED BY NURSING STUDENTS TO DETERMINE THE EFFICACY OF SIMULATED CLINICAL SITUATIONS

Clinical simulaton as a training and knowledge technique allows people to experience a likely scenario with the aim of acquiring knowledge, abilites, and increased apttude. The flming of the staging represents a useful tool to review the decisions and actons taken, with the purpose of highlightng the strengths, weaknesses, and areas for improvement. To evaluate performance, nursing students are placed in clinical simulatons and flmed while facing life-like situatons. Some students have claimed that the camera might have caused them to commit more errors thereby hindering their overall performance. To test this, a study was designed in which half of the group would be evaluated using the method of flming while the rest would be evaluated without a camera present. This artcle details the study above carried out with second year nursing students and tries to evaluate the impact of flming on overall performance during clinical simulatons.


INTRODUCTION AND JUSTIFICATION 1.Current situaton
Spanish Universites, along with all European Universites, are modifying their educatonal systems with the goal of meetng the standards set out in the European Higher Educaton Space (EHES) (Gutérrez de la Horra, 2010).
Given the complexity of modern health care and nursing responsibilites, the range of environments where nursing training occurs, and the proliferaton of technology, it is essental that educatonal strategies are innovatve and research based if universites are to turn out high-quality, professional graduates (Halstead, 2006).For this reason nursing students need knowledge and skills in informaton technology and patent care to possess the necessary tools which enable them to be efectve (Grifn-Sobel, 2009).
Patent simulaton experiences are benefcial to students because they allow them to practce the skills (McConville & Lane, 2006) that must be used in real situatons, as they require them to act as though they are in real situatons with real patents (Wilford & Doyle, 2009).It Is also a tool that allows the teacher to work with the simulator and provide readings to students in preparaton (Wilford & Doyle, 2009;Faro, Isern, Sansalvador & Casas, 2008).

Simulaton and investgaton
This study demonstrates that such simulaton experiences, repettve and under controlled conditons, confrm the efectveness of the educaton in clinical care, which improves clinical thinking, stmulates confdence, and increases knowledge (Grifn-Sobel, 2009;Alinier, Hunt, Gordon & Harwood, 2006;Baker, Pulling, McGraw, Dagnone & Hopkins, 2008).The goal of this type of educaton is to transfer the knowledge from the classroom to real life situatons (Grifn-Sobel, 2009;Prion, 2008, Alfes, 2008).This type of simulaton has the potental to make signifcant changes to the curriculum in nursing programs by redefning clinical educatonal strategies and providing alternate tools of evaluaton (McConville & Lane, 2006).
There are not enough valid and reliable tools to evaluate the results, which limits the nursing simulaton educaton approach (Kardong-Edgen, Adamson & Fitzgerald, 2010).
In order to improve the quality of nursing programs, investgaton related to the human patent simulator (HPS) is needed to develop valid and reliable tools to measure performance.Knowledge, values, and skills are essental in nursing because they require efectve cognitve, and psychometric practces (Jefries & Norton, 2005;Oermann & Gaberson, 2006).

Filming and simulaton
Filmed videos can be useful pedagogical tools and have been used in diferent programs for many years.For example, videos can display recorded classes in order to facilitate discussion or recordings can be used to model good practce (McConville & Lane, 2006).
Much of the published research on this topic focuses on student self-assessment data in relaton to confdence and satsfacton.Recordings allow students to review their performances multple tmes thus enabling them to carry out a deeper analysis and identfy solutons to errors (Henneman et al., 2010).
What is not refected when students are being flmed is whether or not the flming has any impact on their overall performance.Students might make more mistakes while being flmed due to anxiety related to the camera.
As part of the evaluaton of the impact of flming on students, we hypothesize that students being flmed while simulatng clinical cases make more mistakes.To test this we created two groups, Experimental (students being flmed), and Control (second year students in other circumstances).Students were observed preparing antbiotc prophylaxis, the pipeline of a peripheral venous catheter, and the pre and post-surgery patent care according to the NIC (Nursing Interventons Classifcaton) Taxonomy.We then compared the mistakes made between the two groups.

METHODOLOGY AND EMPIRICAL APPLICATION
A community "pilot" study was designed (randomizaton of groups, not of individuals).This study was conducted in the second semester of the 2009-2010 academic year, in clinical simulaton laboratories, with the second year students in the Surgical Nursing.Adult I class, during a simulaton case evaluaton.
The study populaton was made up of second year students registered in the nursing course listed above, who were being evaluated through clinical simulaton.Each student had to give writen consent to partcipate in the study and atend a training session explaining the study.Students who did not sign the consent form were excluded from the study.
A clinical scenario was set up and students were asked to prepare for a case dealing with a patent who was about to undergo knee prosthesis surgery.
The interventon was organized in three phases: • PHASE 1: Analysis and planning of the case.Students organized the dates based on a care model.In this phase they had to identfy possible problems while working independently and as part of a team, and prepare objectves and acton plans.They also studied the therapeutc use of prescripton drugs in medical treatment and evaluated the hourly dose of medicaton.
• PHASE 2: Scientfc knowledge and professional practce.This phase consisted of applying the scientfc evidence and integratng the research into the practce.By reading and analyzing relevant literature, they could answer questons applying the best scientfc evidence.This had to be refected in the third phase of the simulaton.
• PHASE 3: Dummy simulaton.It consisted of applying the pre and post-surgical nursing care they had already planned in the frst phase, and the best scientfc evidence studied in the second phase.
We carried out our study during the third phase.
Students were asked to divide themselves into groups of 28.Afer this we divided the groups into two diferent groups at random: the Control Group, who did the simulaton without being flmed, and the Experimental Group, who were being flmed during the simulaton.
The ones chosen to be evaluated were: • Interventon 2314: preparaton and administraton of intravenous medicaton • Interventon 4190: intravenous puncture • Interventon 2930: surgical preparaton To document our fndings, we created a sheet of paper per interventon and per student, which included demographic informaton such as the student's age, sex, country of residence, and place of origin.We also noted if they worked in healthcare (if so, we specifed the shif), and if they were part of the Control or Experimental Group.
The nursing interventons were evaluated using the Likert Scale, assigning a score 1-5 to each of them.
Interventons with a score between 1 and 3 were considered incorrectly performed, while interventons with a score between 4 and 5 were considered correctly performed.
First we prepared two identcal simulaton laboratories.Both had a nurses' staton and a hospital room.The diference between the laboratories was the recording camera, which was only present in the Experimental Group lab.
Students were called prior to the simulaton, but were not told which group they were in untl they arrived at the laboratory.
The study variables were: • Dependent variables: • the number of mistakes that each student made during the simulaton in each NIC interventon • Independent variables: • Member of the Experimental or Control Group • Demographic details: age, sex, country of residence, place of origin • Professional status: if they worked in health care (shif specifed) • Academic experience: if they had partcipated in simulatons or in an internship previously • Psychological state: Spielberger's State-Trait Anxiety Inventory (STAI) Each student arrived at the laboratory at the specifed date and tme and was then informed as to which group they belonged (Spielberg, Gorsuch & Lusherne, 1982).Afer that they completed the State-Trait Anxiety Inventory.The State part of the inventory evaluates the student's current anxiety levels while the Trait part evaluates basal anxiety.
Following the questonnaires, the students started the evaluaton for which they had a maximum of 30 minutes to complete.During the 30 minutes two teachers were observing them while flling in the assessment grid.

RESULTS
The results of comparing the characteristcs of the members of the Control Group and the Experimental Group, indicate that there are no statstcally signifcant diferences in any of the variables, so the two groups can be considered comparable (Table 1).

Control Group Experimental Group p
Age 23.6 (22.2-25.0) 23.9 (22.5-25.4In terms of the anxiety assessed with STAI, we have notced that there was no diference in scores between the groups. Regarding the interventons performed during the simulaton, the statstcal analysis highlights the following results (Table 4): • Interventon 2314: administraton of intravenous medicaton.In subsecton 2314.1, correct preparaton of the medicaton administraton equipment, the test xi2 shows p=0.034, the Experimental Group having performed beter than the Control Group.
• Interventon 4190: intravenous puncture.Only in subsecton 4190.2, clean the area with the appropriate product, there is a signifcance diference of p=0.013, the Control Group having performed beter than the Experimental Group.
There were not any diferences with regard to interventon 2870 nor in the other sectons of the above interventons.

CONCLUSIONS
The results of the study confrm that the number of errors that students commited while being flmed is not a result of being flmed.Filming does not cause errors.
These results provide evidence that flming should contnue to be used during simulaton, knowing that it does not negatvely impact the assessment of the student.Filming is intended to improve the use of clinical simulaton as a learning, training and evaluaton method in a controlled environment, which increases the student's knowledge, skills, and abilites while also enabling them to refect on errors and to learn from mistakes and experience.It was not possible to compare our experience with other equivalent experiences, as the literature reviewed highlights the importance of flming to learn diferent aspects and subsequently analyze and critcize the performance, but does not refect whether it causes students to make more mistakes.
The points highlighted above, along with the training that we have done on the clinical simulaton method, allowed us to improve the process in the following ways: • Defne beforehand all the competences students should meet during the simulaton • Prepare the clinical case scenario to simulate as realistc an environment as possible • Give relevance to debriefng (tme to refect on what was done and why) and to feedback • Use the recording only when there are points of confusion during debriefng, because a video can help solve diferences in recollecton In the 2012-2013 academic year we changed objectves by competences and we incorporated the debriefng immediately afer every simulaton.
In the 2013-2014 academic year we have spent more tme debriefng and giving feedback (double the amount of tme the students used for the interventon in the simulaton), making sure to emphasize strengths while also notng areas needing improvement.We have currently started another study to evaluate the student's perceptons of the use of debriefng and feedback, the results of which will be forthcoming.

Table 1 .
Results of comparing the Control and the Experimental GroupsIf we contrast the scores of the State inventory (the Test of Kolmorogov Smirnov suggests normal distributon [p>=0.05])with a T Student, we do not identfy signifcant statstcal diferences between the flmed group and the not flmed group (Table2).

Table 2 .
Results of the State inventoryIf we contrast the scores of the Trait inventory (the Test of Kolmorogov Smirnov suggests normal distributon [p>=0.05])with a T Student, we do not identfy signifcant statstcal diferences between the flmed group and the not flmed group (Table3).

Table 3 .
Results of the Trait inventory

Table 4 .
Summary table of statstcal tests performed (probability values for each test)