Improvement of nursing students' learning outcomes through scenario-based skills training

Abstract Objective: this study analyzed the influence of scenario-based skills training on students' learning skills. Method: the author evaluated the nursing skills laboratory exam papers of 605 sophomores in nursing programs for seven years. The study determined the common mistakes of students and the laboratory work was designed in a scenario-based format. The effectiveness of this method was evaluated by assessing the number of errors the students committed and their achievement scores in laboratory examinations. This study presents the students' common mistakes in intramuscular and subcutaneous injection and their development of intravenous access skills, included in the nursing skills laboratory examination. Results: an analysis of the students' most common mistakes revealed that the most common was not following the principles of asepsis for all three skills (intramuscular, subcutaneous injection, intravenous access) in the first year of the scenario-based training. The students' exam achievement scores increased gradually, except in the fall semester of the academic year 2009-2010. The study found that the scenario-based skills training reduced students' common mistakes in examinations and enhanced their performance on exams. Conclusion: this method received a positive response from both students and instructors. The scenario-based training is available for use in addition to other skills training methods.


Introduction
Nursing education is a compilation of theory and practice components, and covers cognitive, affective, and psychomotor learning fields (1) . The nursing skills laboratory (NSL) is the most important field for psychomotor skills training (2)(3) . The purpose of NSL work is to teach nursing students psychomotor skills and nursing care in a safe environment. The laboratory environment gives students the chance to "learn by practice". NSL is a controlled and safe learning environment (1,4) ; it gives students the opportunity both to learn psychomotor skills and combine theory with practice, allowing them to experience selflearning and helping them to enhance their readiness for an actual clinical environment (5)(6) . A variety of simulation methods are included in skills training during NSL. The use of simulations, mannequins and interactive videos, as well as critical thinking and making decisions by different techniques, such as role-playing, are the activities designed to demonstrate the skills and imitate an actual clinical environment (7) .
Simulation training not only teaches skills to students at a desired level, but also provides a positive learning experience (4) . One study defined the primary training and assessment methods used in NSL as low to high-fidelity simulators, Standardized Patients (SPs), scenario-based simulation, Objective Structured Clinical Examination (OSCE) and Audio-Visual (AV) recording. OSCE is a performance-based examination where students are observed while demonstrating various clinical behaviors (8) . The use of OSCEs facilitates the assessment of psychomotor skills as well as knowledge and attitudes (9) . Some of the methods used in the instruction of basic nursing skills are the use of static mannequins, low-fidelity simulation (LFS), case studies and role-playing (10) . It is reported in the relevant literature that using lowfidelity simulation and non-complex scenarios has a positive effect on the instruction and assessment of nursing skills (11)(12) . LFS and associated part-task training devices grant the user the opportunity to simulate an array of scenario based assessments and activities (12) . In one of the studies, LFS was considered as effective as high-fidelity simulation for technical skill acquisition, and both methods were significantly more effective than traditional didactic instruction (13) . The nursing school has been using static full-body mannequins as low-fidelity simulators in psychomotor skills training since its foundation (1994)(1995). The assessment method used in the school is performance-based nursing skills laboratory examination (NSLE), which was adapted according to OSCE. OSCE determines to what extent students have reached the competencies defined and targeted in skills training (14)(15)(16)(17) . Students are expected to put the skills they learned in lessons into precise practice in examinations. This practice is included in the third step of Miller's assessment pyramid, which is the "Shows How" step (15)(16) . Students may not always show the skill precisely in NSLE, yet they have to perform the essential steps of the skill. This is important for students' being accepted as successful in NSLE and their competencies in the practice of skills being considered at an acceptable level before they start working at clinics. It is particularly important that invasive procedures are correctly applied to real patients in terms of patient safety. For this reason, it is a necessity in educational practice that students' competencies in learning nursing skills are continually increased. Thus, the scenario-based simulation method was added to NSL practices in the academic year 2007-2008.
Learning theories indicate that students learn better when they practice the skills themselves in appropriate learning environments and participate in learning practices actively (18) . The best way to learn new things is to perform them and put them in practice (19) . A study was conducted that included three methods (scenario-based study groups with and without teacher, and simulation training) and found that scenario-based simulation training fits "learning by doing" the best (19) . According to the study developed with 12 health students; the study included four simulation scenarios and four short videos, and all students reported that they were satisfied with the training they were provided (20) .
A study was conducted using the Laerdal SimMan Universal Patient Simulator with the purpose of determining the influence of realistic scenariobased simulation on nursing students' competence and confidence, and this method was considered effective (21) . The experimental group was provided with scenario-based training and the OSCE results were better than those of the control group. In a study students trained by means of a simulation that included vignette scenarios, OSCE and written examinations (4) . A study was conducted using static mannequins, scenarios, computer-aided directions and different active learning demonstrations, showing that students' achievement rates in case study questions ranged between 93% and 100% and that they also successfully reached the skill targets created for the program (11) . www.eerp.usp.br/rlae 3 Uysal N.

Objective
This study aimed to determine nursing students' common mistakes in NSLE and evaluate the effect of scenario-based NSL practices on reducing students' mistakes in exams and NSLE achievement scores.

Method
This is a retrospective and quasi-experimental The NSLE can be done in two stages: a short written exam (WE) and a performance exam in which students perform nursing skills under the supervision of an instructor, except for skills with a low difficulty level.
Instructors assess each student's performance based on the control lists prepared specifically for each skill, and score them as "Done: 1 point" or "Not Done: 0 points".
The NSLE success criterion is to get at least 70 out of 100 points.
The nursing school has been providing psychomotor skills training to students in NSL since its foundation (1994)(1995). The instructors used mannequins and demonstration methods, such as a low-fidelity simulator in the laboratory. At the school of nursing, students and instructors provide their written and verbal feedback at the end of each semester for evaluation. The feedback indicated that the psychomotor skills training in the laboratory was focused on skills, and students and instructors began to regard it as a mechanical practice.
According to the feedback provided by instructors who study with students in the skills laboratory and clinical practices, the students did not use critical thinking and problem-solving skills in the laboratory, did not want to spend too much time there, thought that the process was boring, and had problems in using their skills in the implementation area (22) . The NSL training process was re-structured for sophomore students in the academic The author wrote specific study directions for each skill in order to achieve standardization among the small study groups in the laboratory. The author also held meetings with all the instructors who would deliver the laboratory courses a week before the laboratory studies.
After each laboratory study, the author held meetings in order to receive feedback from the instructors.
The author distributed the skill checklists to the students, along with the scenarios specifically written for each skill, such as printed materials and video, a week before the courses, and asked them to prepare before coming to the course. The laboratory study proceeded with the instructor showing how to perform the skill and students worked on it until they managed to perform it.
Then, the students role-played the clinical scenario and were asked to offer solutions for the problem in that scenario. After the study was completed, the students filled out the NSL feedback forms and provided their verbal feedback.
The author evaluated students' performance in the skills they learned in NSL using the NSLE, which

Data collection and data analysis
The exam control lists used for each skill in the

Results
The total number of NSLE mistakes the students

The most common mistakes in IM injection
The distribution of students' mistakes in IM injection practice was as follows: the most common mistake in

The most common mistakes in SC injection
The distribution of the most common mistakes by students during SC injection was: in the same order of the

The most common mistakes in IV accesss
The students' mistakes in the practice of IV access were distributed as follows: in the same order of the

Feedback received from the students and instructors
According to written and verbal feedback received from the students and instructors at the end of each semester, students said that scenario-based skills training helped their learning and made their knowledge permanent, which made it easier to remember on examinations, enabled them to have fun during laboratory studies. They felt readier since they had seen the problems they would encounter in the clinic.
The instructors said that the scenarios made students curious, which facilitated their learning and prevented the skills training from being mechanical.

Discussion
An analysis of the students' most common mistakes revealed that the most common was not following the principles of asepsis for all three skills (IM and SC injection, IV access) in the first year of the scenario-based training. Mistakes such as forgetting to tell patients to take deep breaths during the injection or forgetting to untie the tourniquet after the IV process can be explained by the fact that the mannequin the procedure was applied on did not give the reactions or response expected from a real human being, along with exam anxiety. In a study, 65% of the participants described OSCE as stressful (14) . In this study, the participants stated in their written feedback after the examination that the NSLE was very stressful and that that was why they forgot the steps of the skill. The Alinier, Hunt, Gordon and Harwood found that OSCE 2 scores were higher in the experimental group that received scenario-based training than in the control group (23) . A study was conducted using the Laerdal SimMan Universal Patient Simulator to determine the influence of realistic scenario-based simulation on nursing students' competence and confidence, and it was found that the experimental group had a greater improvement in skill performance than the control group (21) . Another study found that using simulated scenarios was an effective tool to evaluate clinical performance and to make a distinction between the students with high and low performances (24) . It was reported that the students who received simulation was not enough discussion about the rationales and scenarios in the NSL. In their feedback, the students indicated that they preferred to be informed by the instructors instead of coming to the laboratory without any preparation. According to a study by Mete and Uysal, which was conducted in the same school, the instructor gave the lowest scores to the items "writing rationales, discussing rationales and scenario and peer contribution" in the evaluation of the 2009-2010 fall semester laboratory studies (22) .
The positive feedback provided by the students and instructors at the end of each semester concerning the scenario-based skills training was similar to the results of a study in the literature (25) . Their study reported that the scenario-based simulation method in the fundamental nursing skills laboratory attracted the students' attention and was valuable for clinical experiences. In a study, students stated in their verbal feedback that they were satisfied with the laboratory study (11) . The students' and instructors' feedback instructors had positive opinions about the scenariobased training (22) .

Study limitation
This study was developed with the second- year students at a nursing school. The study could be developed to include all years at the schools. In addition, the study could include other nursing schools and different training methods.

Conclusion
Nowadays, advanced technology makes it possible to commonly use high-fidelity simulators. However, the use of low-fidelity simulation in the instruction of non-complex nursing skills cannot be disregarded. The results of this study support the argument that scenariobased skills training in NSL is beneficial for students. This