The educational benefit of integrating genomic principles into an evolving simulation scenario

Evidence on simulations’ effectiveness as a teaching-learning modality has recognized validity, reliability, and legitimacy in nursing education. Studies on simulation demonstrates how it enhances student’s knowledge, skills and independent learning;^{[2, 3]} promotes professional attitudes and elevates confidence while decreasing anxiety;^[4] integrates theory to practice; promotes decision-making abilities, critical thinking and reasoning;^{[2, 4, 5, 6]} and fosters patient outcomes and safety.^{[7, 8]} Scenarios in emergency preparedness;^[9] Cystic Fibrosis integration;^[2] interprofessional teamwork and communication skills^{[10, 11]} are just a few examples of simulation in nursing education.

A quasi-experimental study explored simulation’s effectiveness in developing pediatric nursing students skills and clinical reasoning competency.^[5] Forty-five participants were evaluated with a pre/post and follow up assessment with results demonstrating their theoretical knowledge improved after simulation.^[5] One study explored nursing care skills of a five-month-old infant with bronchopneumonia, nasal obstruction, coughing and wheezing.^[12] Participants were randomly assigned to an experimental simulation experience (n = 23) and control (n = 34) groups. Significant statistical differences between the experimental and control groups were evident as well as the knowledge scores.^[12] Simulation training is beneficial to student’s overall knowledge, skills and confidence levels while enhancing their clinical application of nursing interventions. Twenty-four pre-licensure baccalaureate nursing students participated in a novel pilot study of a Cystic Fibrosis simulation scenario.^[2] Results revealed participants’ genetic comprehension of Cystic Fibrosis improved after simulation, enhancing learning outcomes, critical thinking and reasoning.^[2] Findings from an early post-test descriptive study of a simulation scenario incorporating Sickle Cell Disease showed that the 31 participants’ self-perceived genomic knowledge after simulation improved.^[13]

Cystic Fibrosis, a progressive autosomal recessive disease, affects the pulmonary system, pancreas, and other organs of every racial and ethnic group.^[14] According to the Cystic Fibrosis Foundation (CFF) Patient Registry, there are close to 40,000 children and adults living with CF in the United States. An estimated 105,000 people have been diagnosed with CF across 94 countries, with Ireland, United Kingdom and Belgium being the countries with the highest prevalence.^[15] There are approximately 1,000 newly diagnosed cases each year; more that 75 percent are diagnosed by age 2 and more than half of the CF population is 18 years old or older.^{[14, 16]}

Cystic fibrosis is caused by mutation in the gene that produces the cystic fibrosis transmembrane conductance regulator (CFTR) protein. Every individual inherits two CFTR genes, one from each parent. Individuals who inherit one variant CFTR gene and one unaffected CFTR copy are considered CF carriers. CF carriers do not have the disease but can pass their CFTR variant copy to their offspring. There is a 25 percent chance of transmitting CF to an offspring if the parents are both CFTR mutation carriers; a 50 percent chance the offspring will be a carrier of a mutated CFTR gene; and a 25 percent chance that the child will be a non-carrier.^[14] These statistics are for every pregnancy. Individuals who have CF can also transmit copies of their CFTR gene mutations to their children. Thus, if a parent with CF reproduces with an individual who is a CF gene carrier, there is a 50 percent their child will have CF and 50 percent chance the child will be a carrier.^[14]

A mutation in the CFTR gene leads to a dysfunctional CFTR protein. There are more than 1,700 known mutations of CF, the most common being F508del. Approximately 70 percent of CF patients are diagnosed with the F508del variant, a deletion of phenylalanine at residue 508 (delta F508) of the CFTR gene.^{[14, 17]} Symptomology includes salty-tasting skin; persistent unproductive cough; recurring pulmonary infections; wheezing and/or shortness of breath; poor growth/weight gain; steatorrhea; and constipation.^{[18, 19]} Males with CF (approximately 97%-98%) are infertile due to an absence of the sperm canal, known as congenital bilateral absence of the vas deferens (CBAVD).^{[14, 17, 20]} These men produce sperm, but the sperm does not make it into the semen, making it impossible to reach and fertilize an egg through coitus.^{[17, 20]}

Genomics is the study of the complete set of genes (the genome), how genes work, and epigenic interactions.^[21] It is a multifaceted interdisciplinary investigational science incorporating genetics, which is the study of how genes and traits are passed down from one generation to the next.^[21] The genomic-era has transformed the understanding of complex diseases, of genotype-phenotype relationships and how health information is constructed and translated into novel medicine and patient care practices.^[21] The genomic transformation of healthcare is underway and integration across nursing is required.^{[22, 23]} Recent studies have shown that genomic content in the core curriculum of undergraduate and graduate programs is insufficient^{[11, 22, 24]} and the global need to integrate genomics is warranted.^[25]

All pre-licensure nursing students were assigned to a simulation experience as part of their clinical rotation with their clinical educator as the simulation facilitator. Each educational clinical group had approximately 8-10 students. The researcher did not enroll students into their clinical placement. The researcher, who was the Simulation Coordinator for the School of Nursing (SON) and was responsible for the simulation schedule at the time of this study, assigned all students to a simulation experience based on their clinical day. The researcher created the four CF simulation scenarios that were assigned to three different educational levels: (a) sophomore (2nd yr); (b) junior (3rd yr) and (c) senior (4th yr). The four evolving CF simulation scenarios were developed to complement the core educational didactic course which had a corresponding required clinical.

All students and experienced clinical nurse educators received the simulation schedule and prebriefing preparatory material in advance, which was developed by the researcher. All students prebriefing preparatory material consisted of explanations of the various roles during the simulation, YouTube videos; social/medical history; scenario information; laboratory results; medication orders and simulation learning objectives. All clinical educators separately received their prebriefing preparatory material as it was extremely detailed with information intended only for the educator. In addition to the students prebriefing preparatory information being embedded, instructors received a detailed overview of the simulation scenario; expected student assessments and patient/family education; proposed correct treatment plan with time-frames; comprehensive debriefing/guided reflection content; pathophysiology; genetic content and genomic inheritance patterns; symptomology; treatment modalities and numerous potential nursing diagnoses.

The researcher assigned the CF simulation scenarios to experienced nurse educators, given their familiarity with the simulation process and having conducted simulations in prior semesters. As such, the scenarios were assigned based on the educators’ simulation expertise and students’ educational clinical level. Given that students were randomly assigned to a clinical rotation, random participant allocation method was the approach. All but the junior level were traditional four-year track students. The junior level (3rd yr) had both traditional and accelerated educational track students. Accelerated students already have a Bachelors’ degree and were enrolled in the nursing program to obtain their RN license at a quicker educational pace. Both the junior level accelerated and the traditional students’ simulation scenario were assigned either the 3 week old or 6 year old simulated scenario. Traditional and accelerated students had their own assigned clinical experiences and students were not combined.

3.1.1Evolving cystic fibrosis simulation scenarios

3.1.2Participants

3.2.1Pre/post simulation learner survey of cystic fibrosis knowledge

3.2.2Learner survey of cystic fibrosis knowledge survey

3.2.3One open-ended qualitative question

Quantitative data were coded and entered into an SPSS database for analysis. A priori power analysis was conducted using G*Power (version 3.1.9.7) to estimate the minimum sample size required to detect a medium effect size (Cohen’s d = 0.50) with a statistical power of 0.80 and an alpha level of 0.05. Results indicated that a total sample size of 50 participants was sufficient to detect statistically significant differences between two independent groups using a two-tailed independent samples t-test. The final sample consisted of 103 participants in the intervention group and 46 participants in the control group.

An analysis of variance (ANOVA) revealed a statistically significant group difference (p = .04), with a corresponding 95% confidence interval and an effect size of Cohen’s d = 0.50, thereby strengthening the internal validity and interpretability of the findings. Descriptive statistics, including mean percentage of correct responses and associated standard deviations, were tabulated to compare performance across student groups. Post-simulation knowledge gains in genomic literacy were evaluated using item-level analysis of survey responses.

Qualitative data from open-ended survey items were analyzed using thematic analysis, incorporating inductive coding and cluster-based pattern recognition to identify emergent themes. From this analysis, data-driven suppositions were generated through a systematic and objective interpretative process.

The instruments employed in this study had been previously validated in similar educational and clinical contexts. Their psychometric properties, established through prior testing, support both construct validity and internal consistency reliability. Instrument selection was closely aligned with the research objectives, target population, and measured constructs, thereby ensuring methodological rigor and facilitating comparability between pilot data and the current study. Potential biases in data collection were mitigated through the use of pre-validated instruments that had undergone prior evaluation for content validity and error susceptibility.^[2]

A significant limitation was that data collection from the respondents on the pre/post simulation learner survey of Cystic Fibrosis knowledge and the learner survey of Cystic Fibrosis knowledge did not allow for pairing to a particular individual, thus only the averages of the group data was obtained and not paired analyses. An additional limitation may be the size of the control group (n = 46) being less than half the size of the intervention group (n = 103). As this study occurred at one campus location of a university, only those students assigned to the CF simulation scenarios were eligible, minimizing generalization. Students’ self-perceived knowledge can be viewed as a constraint as it was not actual knowledge. Possible confidentiality violation could be perceived as surveys were completed prior to post-conference. There was no privacy expectancy as the clinical group may have been aware of any individual who chose not to partake. However, this limitation was discussed in the information sheet and no identifiable data was collected. The quasi-experimental design, with a comparison group and both quantitative and qualitative data collection, promotes evidence triangulation, thereby enhancing the reliability of the findings and the depth of the analysis.

This study descriptively compared averages of the groups of students who were assigned the CF intervention simulation scenario. A total of 103 pre-licensure students completed the anonymous voluntary nine-item pre/post simulation learner survey of CF knowledge. Twenty-eight traditional sophomore level students (2nd yr) completed the young adult CF scenario. Nine accelerated and 15 junior (3rd yr) students completed the 3 week old CF scenario. Ten accelerated and 23 junior students completed the pediatric 6 year old CF scenario while 18 senior students (4th yr) completed the older adult CF scenario. Forty-six students comprised the control group and completed only the nine-item learner survey of CF knowledge. Of those, eight sophomore (2nd yr) completed the young adult CF survey. Six accelerated and eight traditional (3rd yr) students completed the 3 week old while nine accelerated and seven traditional students (3rd yr) completed the pediatric 6 year old survey. Finally, eight senior (4th yr) students completed older adult CF survey.

As shown in Table 1, all of the six collective intervention groups total post-simulation knowledge averages improved or remained the same as pre-simulation CF knowledge. Comparatively, all total post-simulation CF knowledge averages were considerably higher than the control group CF knowledge averages, which is shown in Table 3.

Twenty-eight sophomore students’ pre-simulation average was 74.6 with a post-simulation average of 78.9. The corresponding control group (n = 8) average was 60. Fifteen traditional juniors who had the 3 week old simulation pre/post average remained the same at 83.3 while the control group of eight student was 77.5. The 23 traditional students who had the pediatric 6 year old scenario averaged 77.4 for pre-simulation and had an increase to 81.3 post-simulation. The corresponding seven control group students had an average of 78.57. The nine accelerated students assigned to the 3 week old simulation had a pre-simulation average of 73.3 which increased to 81.1 post-simulation while the six control group averaged 80. The 10 accelerated students assigned to the pediatric 6 year old case had a pre-simulation average of 82 with a post-simulation average of 86. The corresponding nine students in the control group averaged 75.6. Finally, the 18 seniors pre/post simulation CF knowledge remained the same at 78.9 while the eight control group students’ averaged 68.75.

As shown in Table 2, only the groups receiving the simulation intervention completed this tool and the data was derived from their perceptions. All five survey items had the majority of participants strongly agreeing/agreeing improvement in their genomic knowledge post simulation. Self-perceived genetic knowledge was 87.4 (n = 90); ability to provide pertinent CF information to patient/family had 92.3 (n = 95); CF comprehension to provide appropriate nursing care and interventions effectively and efficiently was 93.2 (n = 96); critical thinking skills improved 87.4 (n = 90) while clinical judgment improved 89.8 (n = 92).

Participants were asked to share if they felt that their assigned scenario enhanced their overall ability to integrate genomics into their knowledge base of nursing and nursing care. Three major themes emerged from the rich qualitative data with seven sub-themes. Improved knowledge and comprehension of genomics in nursing had 42.8% which described the value in applying knowledge from didactic education in a simulation experience. Simulation was able to solidify comprehension of genomics in a clinical learning environment. Two sub-themes were identified: understanding CF and applying nursing interventions and critical thinking skills. The second theme, family and patient education skills in nursing demonstrated how students embraced the importance of understanding the genomics and disease process of CF. They learnt to effectively explain the process of CF with confidence while providing thorough patient and family care. Three sub-themes were revealed: patient-centered care; confidence and teaching and explaining. Lastly, students expressed their appreciation for an opportunity to apply hands-on skills in a controlled clinical learning setting in the theme of valuing the clinical experience in nursing with sub-themes of experience and communication.

It is essential that educators continue to expound on creative and innovative educational strategies to proactively engage students to achieve their highest learning potential. Engaging students with an interesting and novel approach to learning genomic content is an important aspect for educators. Combining pedagogical methodologies and core competencies is a beneficial teaching strategy to meet learning outcomes. The use of evolving clinical cases throughout the semester stimulates clinical reasoning, contextual learning, and knowledge transfer to practice, which are key features of competency-based education.