INTRODUCTION

Nursing education in Brazil is currently based on the National Curriculum Guidelines of the Undergraduate Program in Nursing, which guide the education of a nurse with generalist, humanist, critical, and reflective profile, based on scientific and intellectual rigor. It is based on ethics, linked with the abilities to act on health care, make decisions, communicate, lead, manage, and teach. Thus, its teaching must be centered in the student as active and participatory learning agent⁽¹⁾.

To meet these guidelines, several teaching methods have been implemented, with active methodologies standing out because they are pedagogical approaches that stimulate critical-reflective teaching-learning processes, in which the student starts to be an active and participatory learning agent and the professor acts as advisor, facilitator and mediator⁽²⁾.

Clinical simulation outstands among active methodologies, employing technological tools for teaching, such as low-, medium-, and high-fidelity simulators^(3-4). Nursing professors have used this strategy for student training as a way to provide knowledge and skills that are sometimes limited during clinical practice^(5-6). This occurs because not every student have the same opportunities to perform certain procedures with the patient, which can lead to a flawed clinical experience^(7-8).

The World Health Organization points out that simulated teaching can be a strategy to overcome training shortcomings, since it expands the clinical experiences of undergraduate students, being experienced in the laboratory of simulated practices. Therefore, it provides the development of skills in a safe care context, which, therefore, brings benefits for the training, the patient, and the institution⁽⁹⁾.

In the simulation laboratory, the diversity of scenarios can be simulated according to the learning objectives of a given moment. Thus, students develop the required knowledge, skills, and attitudes before clinical situations. From the point of view of patient safety, the simulation allows comprehensive training for students, minimizing the chance of errors during clinical practice⁽¹⁰⁾.

In addition, the simulation strategy may contribute to the emotional preparation of future nurses, because, by enabling students to practice their skills in safe environments, feelings, such as anxiety and stress, can be worked out and a better learning can be achieved⁽¹¹⁾.

Studies show that when nursing students practice health care, both in practice laboratory and in their first experiences with patients, they may present tremors, pallor, sweating, cold and clammy skin, emotional outburst, fainting and crying because of feelings of fear, insecurity, anxiety, and distress^(12-13).

Thus, the use of simulations can also be a stress reduction strategy for students. The first scholar to use the term stress in the health field was Hans Selye, who thus described it: nonspecific symptom from any demand on the body, be it mental or somatic effect; stressor is what leads to a stress reaction, and can be physical, mental, or emotional⁽¹⁴⁾.

Stress can lead to cognitive effects, such as decreased attention and concentration, deterioration of memory, increased rate of errors, difficulty and delay in response to stimuli. These factors are reflected in the teaching-learning process of students⁽¹⁵⁾.

A research conducted with 11 Brazilian nursing students evaluated the relationship between the stress of nursing students and patient safety⁽¹⁶⁾. The authors reported that, during the preparation of medication, the students’ nervousness led to flaws, which were corrected by the professor before being administered to the patient.

Before this scenario, seeking strategies that can reduce the stress of nursing students is a challenge to nursing professors, and may contribute to the safety of patients that will be met by these students during their training process.

OBJECTIVE

To evaluate and compare the perception of stressors of nursing students before and after high-fidelity clinical simulation or conventional laboratory class.

METHOD

RESULTS

The research included 54 participants: 13 in the second semester of 2015, 20 in the first semester of 2016, and 21 in the second semester of 2016. Participants were randomly allocated: 27 in the experimental group and 27 in the control group (Figure 1). During follow-up, two participants were excluded from the control group, one because of inadequate filling of the data collection instruments and another for abandonment of the program before the completion of the second phase of the research.

Figure 1 Flowchart of inclusion, randomization, and analysis of the groups, Curitiba, Paraná, Brazil, 2017 

The groups were homogeneous regarding sociodemographic variables. The average ages of the EG and CG were 20.32 ± 1.79 and 21.11 ± 2.47 years old, respectively (p = 0.1956). Women were predominant for both groups (85.19% - EG; 92.00% - CG). In both groups, most participants did not have another undergraduate degree (92.59% - EG; 100.00% - CG).

Table 1 presents the stressors answered by the groups according to KEZKAK, in the moments before and after the laboratory or simulation. We chose to present only the items with significant difference in the comparison between the different moments. The CG presented significant decrease in the perception of four items as stressors, while the EG presented significant increase in the perception of nine out of 31 items as stressors and significant decrease in one item.

Table 2 presents the comparison of stressors between the groups before and after the laboratory or simulation. Before the laboratory, the two groups differed significantly in two items, since the CG showed greater concern. After the laboratory, the two groups differed significantly in seven items. For the EG, six items (3, 4, 7, 18, 23, and 25) were considered significantly more stressful. The CG pointed only item 16 (“Seeing a patient die”) as significantly more stressful.

DISCUSSION

This research had a predominance of young adults - with average age of 20.32 ± 1.79 (EG) and 21.11 ± 2.47 (CG) - and women - 85.19% (EG) and 92% (CG). The latter feature appears in undergraduate programs in nursing throughout the world, as shown by national and international studies. In a study carried out in Turkey⁽²⁰⁾, 88.5% (n=52) individuals were women, with average age of 23 years old. In the United States of America⁽²¹⁾, 89% (n=134) of the nursing students were women, with average of 23 years old. In China⁽²²⁾, 92.5% (n=80) were women aged between 18 and 20 years old. In Brazil⁽²³⁾, a study showed that 77% (n=206) students were women aged between 18 and 21 years old. In Sweden⁽²⁴⁾, 85% (n=361) were women, with average age of 23 years old.

Most participants - 92.59% (EG) and 100% (CG) - do not have another undergraduate degree, as corroborated by other authors, who found 96.6% (n=84) and 98.1% (n=102) participants attending their first undergraduate program^(25-26). We highlight that this feature is related to the age range found in this research, of young adults who are mostly in their vocational training phase.

Nursing training involves associating theory and practice since the early years of the program. This feature requires students to deal with complex situations, including the need to take care of someone who is becoming ill, with insufficient resources to meet the existing stressors. The previous experiences of each student will affect the perception of stressors: as a threat, leading to negative emotions, such as fear, anxiety, and anger; or as a challenge that will allow coping and overcoming⁽²⁷⁾.

One of the objectives of this research was to evaluate whether the teaching strategy used (high-fidelity clinical simulation) affects the perception of stressors. After the laboratory class, the CG presented a significant reduction in the perception of stressors related to lack of competence and impotence/uncertainty to meet the needs of the patient. The CG showed no significant increase in any factor when comparing the moments before and after the laboratory.

In analyzing the EG in the moments before and after the simulation, we observed a significant increase in the perception of factors related to lack of competence, not controlling the relationship with the patient, emotional involvement, and contact with suffering as stressors for the students after the simulation. Only item 1 had significant reduction after the laboratory class.

When comparing the moment before and after laboratory in the CG and EG, we verified an increase in the number of stressors, with significant difference after the laboratory class in the EG. Before the laboratory class, the CG was more worried about items 16 and 31. Item 16 remained worrisome for the CG after the laboratory. After the laboratory class, the EG was more worried than the CG with factors related to lack of competence and to interpersonal relationships with patients, multidisciplinary team, and colleagues.

We highlight that the CG laboratory practice was held in pairs, in a relaxed and safe environment for students, since they knew each other. The results of reduction of stressors after the laboratory may be linked to the fact that these students did not experience something new. The EG, in turn, participated in a high-fidelity simulation scenario, in a new education strategy for students. Thus, the simulation may have changed students’ critical thinking and provided increased awareness of their responsibility and of the required skills to meet patients. In contrast, the conventional class produced little interference in the students’ perception of stressors.

Thus, it is evident that the clinical simulation allowed students to experience a near-real situation that made them think about the importance of scientific knowledge, of skills, and of their responsibility to provide the nursing care that patients need. Authors⁽¹¹⁾ confirm this, stating that the high-fidelity simulation strategy allows approximation to reality, as well as critical reflection of attitudes by students and professors.

In this research, the perception of factors related to lack of competence, contact with suffering, relationship with professors, colleagues, and patients prevailed as significant. Studies that sought to know stressors for nursing students in clinical practice also found lack of competence as one of the main stressors at the beginning of practical training^(28-31). No studies evaluating the stress of nursing students in skill laboratory were found.

The beginning of clinical practice causes important changes in the emotional state of nursing students. Lack of competence, difficulties in the relationships with professors, team, and patients, and work overload are factors that contribute to a lower learning yield⁽³²⁾. Knowing the main stressors and applying strategies to decrease their intensity may improve students’ satisfaction and promote a quality and safe care^(33-34). In this context, the simulation strategy has been described as able to encourage the acquisition of skills, clinical reasoning, decision-making, and critical thinking^(19,35-36).

CONCLUSION

Our findings showed that the high-fidelity simulation strategy increases the perception of stressors related to lack of competence and to interpersonal relationships with patients, multidisciplinary team, and colleagues compared with the conventional practice class in skill laboratory. This increase was related to the students’ capacity for self-evaluation and critical reflection concerning their responsibility to learn and the need to acquire the required skills for patient care.