The Effect of Simulation-Based Education on Patient Training Correct Inhaler Technique of Nursing Students: A Randomized Controlled Trial

Abstract

Introduction

Teaching inhaler techniques to nursing students is crucial.

Objective

This study aimed to investigate the effect of simulation-based education on patient training correct inhaler technique in nursing students.

Methods

This is a single-blind, randomized controlled trial in which nursing students are randomly allocated into two groups of control (n = 41) and intervention (n = 40). The students’ mean score of correct inhaler technique was measured before and one week after intervention, using checklists of inhaler techniques.

Results

The mean score of control group was significantly lower than the intervention group (p < .001). The results also revealed that there was no significant difference in students’ level of confidence regarding the ability to educate patients on inhaler techniques before the intervention, while all students were shown to have higher levels of confidence in this term after the intervention.

Conclusions

Simulation is an effective way to train nursing students in the correct inhaler techniques.

Keywords

education inhaler technique Iran nursing student simulation

Introduction

Asthma and Chronic Obstructive Pulmonary Disease (COPD) are the most common chronic respiratory conditions and the most important causes of morbidity and mortality worldwide (Milenković et al., 2011). In Iran, the prevalence rate of asthma and COPD is about 5.57% and 8.80%, respectively (Varmaghani et al., 2016). Inhaled medicines are one of the most common measures in the treating respiratory disorders and they are also known as the cornerstone of pharmaceutical treatment in patients with lung diseases (Rogliani et al., 2017). Various inhalers such as dry powder inhalers and metered-dose (e.g., Turbuhaler and Diskus) are usually used to deliver inhalation drugs to patients (Basheti et al., 2014; Roche & Huchon, 2000). Each inhaler has specific properties to deliver optimal inhalation to patients (Rogliani et al., 2017). In general, it has been shown that the administration of drugs through inhalation allows the correct use and direct delivery of drugs to the desired area and reduces systemic absorption and possible adverse effects (Dolovich et al., 2005; Hess, 2008).

The effectiveness of inhalation therapies largely depends on the correct use of inhalers (Vincken et al., 2010) and the amount of drug deposition at the target organ (Chow et al., 2007). The biggest problem, however, is the misuse of inhalers due to the lack of education on how to correctly use and inhale therapeutic aerosols (Ibrahim et al., 2015). The results of studies have shown that about 14–90% of patients with respiratory diseases misuse inhalers (Price et al., 2013). In addition, it has been shown that only 15–69% of health care providers (i.e., physicians and nurses) can train correct inhaler techniques (Price et al., 2013). The results of a systematic review indicated that 25% of patients with asthma and COPD were not given any training on how to use inhalation drugs by nurses. (Lavorini et al., 2008). On the other hand, most nurses do not have the necessary knowledge about the correct use of inhalers (De Tratto et al., 2014; Fink, 2005). Therefore, due to the complexity of using different types of inhaler, adequate inhaler technique education will be essential and helpful to ensure optimal drug delivery (Beatty et al., 2017), improve treatment outcomes, and promote the quality of patient care (Adeyeye et al., 2015).

Different teaching methods have different learning outcomes and the existence of conflicting results may be due to the type of teaching methods used (Leiva-Fernández et al., 2012). For instance, many training strategies, particularly small-group training, demonstration, and computer-based learning, have been used to optimize the use of an inhaler and also have led to the appearance of better training techniques. However, they have not been sufficient to completely satisfy needs in this regard (Basheti, 2014). Toumas et al. (2009) indicated that small-group training and self-directed internet-based learning both were equally effective in improving students’ inhaler techniques (Toumas et al., 2009). Therefore, health care providers need to acquire these skills efficiently in order to provide a better patient education (Podlinski, 2016).

In order to improve the education status, lecturers have developed and proposed new methods for theoretical and practical education, one of which is simulation-based learning (Callahan & Switzer, 2013). Simulation-based learning is a valuable educational strategy (Teixeira & Felix, 2011) and it is known as an essential part of clinical education in nursing since it can provide a safe learning setting, and a real clinical experience for nursing students in clinical practice (Podlinski, 2016). Simulation-based education is one of the highly efficient types of educational strategies. This method creates more stability in gaining experience (Gordon et al., 2006a) and enables students to have comprehensive and experiential learning (Knowles, 1990) since the student is not only the recipient of educational content but also an active participant in the sessions (Hughes, 2008).

Review of the Literature

Patient-based simulation training also applies the student's prior knowledge to complete clinical practice and develops critical thinking, clinical decision-making, and psychomotor skills in a safe setting without posing potential risks to the actual patient (Hughes, 2008). Moreover, simulation-based learning is considered as a complement to conventional learning methods. Basheti (2014) involved pharmacy students with actual asthma patients in a simulated scenario and taught them the correct inhaler technique, according to his study the simulation-based intervention led students to better implement the inhaler techniques (Basheti, 2014). Nonetheless, based upon a comprehensive search of related databases, no study has been conducted on the effect of simulated patient-based education on nurses and nursing students’ ability to provide education about inhaler techniques in the social and cultural context of the Iranian educational system. Considering the critical role of nurses in optimizing the use of inhalation drugs in respiratory patients, using this educational method can add a new and important perspective to education. Therefore, regarding the high prevalence of chronic respiratory diseases in all countries, the widespread use of inhaled medicines, the high incidence of improper use of the inhaler by patients and even health care providers, and the lack of sufficient researches in this regard, the present study aimed to investigate the effect of simulation-based education of nursing students for patient training in correct inhaler technique.

Methods

Study Design

This is a single-blind, parallel-group, randomized controlled trial conducted at teaching hospitals affiliated to Urmia University of Medical Sciences.

Research Question

What is the effect of simulation-based education on patient training correct inhaler technique in nursing students?

Setting and Samples

The study population included all fourth- and fifth-semester students of Urmia School of Nursing and Midwifery who had passed the theory course of respiratory care. Accordingly, a total of 81 eligible nursing students were included in the study. The CONSORT reporting guidelines were used in this study (Schulz et al., 2010).

Intervention and Control

After random allocation, all students attended the pretest phase, during which a brochure containing information on the correct use of inhalation drugs was given to the students and they were given 15 min to read it. Then they were asked to display the correct technique of using inhalers. At this phase, none of the participants was trained on using inhalers or using the information provided in the brochures. During the display of the technique, the assessor first evaluated and then scored participants’ performance based on the standard checklist provided for all three devices. The assessor was a nurse with a bachelor's degree in nursing who was blind to the allocation process. The score obtained in this phase was considered as the base score. If the student did each step correctly, he/she would receive a score of 1 and if not, he/she would receive a score of 0 (Figure 1).

Figure 1.

Data collection procedures.

Participants in the control group only received lectures-based, hands-on, and peer assessment/education, while participants in the intervention group, in addition to the above, received simulated patient-based education and related scenarios.

In the intervention group, a number of 3 patients who had a respiratory disease were recruited to simulate the inhaler techniques. In this study, simulated patients were selected from those eligible patients referred to Imam Khomeini Hospital, Urmia, Iran. Eligibility criteria for patients included the following: (a) being over 18 years of age, (b) having an exact diagnosis of a respiratory disease confirmed by a doctor, (c) using one or more inhaled medicines, (d) voluntary acceptance to participate in the study, and (e) having the ability to perform inhaler techniques well. Written informed consent was also obtained from these patients prior to the beginning of the study.

Both the control group and the intervention group were given 20 min to receive in-group hands-on education on the correct technique of using the devices and the peer education was then conducted for them. In the practical section of the education program, each student showed other students how to use one of the devices randomly allocated to him/her under the researcher's supervision. Students then taught each other the correct inhaler technique in pairs, evaluated each other's performance, and corrected each other's errors using the inhaler checklist.

In the intervention group, three patients were recruited to conduct the intervention. Students and patients in each group were first introduced to each other and then each student taught the correct inhaler technique to patients in the same group. Students in each group were randomly selected to train the technique of using one of the devices and the rest of the students observed the patient education process, which included a verbal explanation and hands-on implementation of the inhaler technique. Each student was given 5 min to provide the necessary education for the patient. This part of the intervention process lasted about 40–60 min. During the education process, patients acted in accordance with the scenarios designed by the researcher so that they intentionally performed one or more steps of the technique in the wrong way. First, a scenario was randomly selected and run from three scenarios and then the student had to identify and correct the incorrect inhaler technique of the patient using verbal explanation and hands-on implementation. Then one of the researchers provided the necessary feedback and explanations for the students of the same group about the mistakes made by each of the students or patients.

One week after completing the intervention, all students were asked to attend the posttest. The post-test phase was conducted the same as the pretest phase by the very same assessor using the inhaler technique checklist. Eventually, all students were asked to complete a questionnaire related to students’ viewpoints on their level of confidence regarding their ability to educate patients on inhaler techniques.

Inclusion and Exclusion Criteria

Inclusion criteria included the following: (a) voluntary acceptance to participate in the study, (b) attending no similar courses and educational programs during the study period, (c) having no personal experience in the use of inhalers for oneself or a family member, and (d) having no clinical work experience in general respiratory wards (except for internships).

Exclusion criteria included the following: (a) lack of presence in the pretest or post-test phase of the study and (b) Refusal to continue participation in the study.

Outcome

The expected outcome was students’ correct implementation of the inhaler technique, which was evaluated and approved using a standard checklist developed by Basheti (2014) (Basheti, 2014). The psychometric properties of this checklist were also evaluated and confirmed by other researchers in some studies (Al Ammari et al., 2016).

Randomization

Considering the results of a study by Erfanian and Khadivzadeh (2008) and in order to achieve a test power of 80% and a confidence interval of 95%, the minimum sample size was calculated to be 39 (Erfanian & Khadivzadeh, 2008). After informing the director of the nursing department, the researchers first enrolled a number of 82 eligible nursing students and then divided them into 11 groups, of which six were randomly allocated to the intervention group (n = 40) and the rest were allocated to the control group (n = 41). Of 82 participants, one was not able to attend the pretest phase due to contracting COVID-19 and thus was excluded from the study. A nurse who did not participate in any of the study stages assigned the students to the intervention and control groups (Figure 2). Moreover, necessary explanations about the purpose of the study were provided to the participants, and before beginning the study, written informed consent was obtained from them.

Figure 2.

Consort diagram.

Data Collection Procedure

Data were collected using a two-part instrument. The first part included items on demographic characteristics, including age, gender, student Grade Point Average (GPA), semester, and residence status. The second part was made up of the standard checklist of correct inhaler techniques for three inhaled medicines. Basheti (2014) gave the checklist to three clinical pharmacists and 15 pharmacy students to evaluate and approve its face and content validity (Basheti, 2014). After making initial corrections, the validity of the checklist was approved. The test-retest reliability was utilized to assess the reliability of the checklist. In this regard, the Spearman correlation coefficient was calculated to be 0.93, which indicates the acceptable reliability of the checklist. Moreover, the inhaler technique checklist was given to five faculty members, who approved its qualitative content validity.

The checklist of Metered-Dose Inhalers (MDIs), Turbuhaler (TH), and Diskus (DIS) consisted of 10, 11, and 10 steps, respectively. According to the checklist, some of these steps were considered essential and some were considered non-essential (required). At the final stage of using each inhaler, a step entitled “Rinsing the mouth after using the devices” was added to prevent oral thrush (Gardenhire et al., 2017). If the student did each step correctly, he/she would receive a score of 1 and if not, he/she would receive a score of 0. The total score for all three devices ranged from 0 to 31. Furthermore, students’ perceptions of their confidence in their ability to educate patients on correct inhaler techniques were assessed using a 5-point Likert scale from “I am completely able = 5” to “I am not able at all = 1”.

Statistical Analysis

Data were first entered into the SPSS Statistics for Windows, version 17.0 (SPSS Inc., Chicago, IL., USA) and then analyzed using the Student's t-test. The normality of the data distribution was assessed using the Kolmogorov-Smirnov test. The p-value of less than 0.05 was considered.

Results

Sample Characteristics

The results showed that there was no significant difference in the mean age and GPA of the students between the intervention and the control group. In other words, the two groups were homogeneous in terms of quantitative background variables (Table 1).

Table 1.

Comparison of Quantitative and Qualitative Demographic Characteristics Between the Control and Intervention Groups.

Group Variable
		Control (n = 41)		Intervention (n = 40)
		Frequency	Percentage	Frequency	Percentage
Gender	Male	14	34.1	13	32.5
	Female	27	65.9	27	67.5
Residency Status	Native	14	34.1	13	32.5
	Non-native	27	65.9	27	67.5
Semester	4^th	16	39	25	62.5
	5^th	25	61	15	37.5
Age		22.4 ± 1.71		22.6 ± 2.01
GPA		16.8 ± 0.81		16.8 ± 0.93

Research Question Results

There was no significant difference in the mean score of correct inhaler techniques between the intervention group compared to the control group before the intervention (simulated patient-based education), but this difference was found to be statistically significant after the intervention (p = 0/001). There was also a statistically significant difference between the baseline and the post-intervention mean score of correct inhaler techniques in both groups (p = 0/001). Nonetheless, this difference was shown to be more significant in the intervention group (Table 2).

Table 2.

Comparison of the Mean Scores of Overall, Essential, and Non-Essential Inhaler Techniques Between and Within the Control and Intervention Groups.

Group Data	Control (n = 41)		Intervention (n = 40)
Group Data	Before	After	Before	After
Overall (mean ± SD)	24.29 ± 4.05	26.26 ± 3.41	24.17 ± 4.41	29.27 ± 1.89
Essential inhaler technique (mean ± SD)	10.56 ± 1.80	10.73 ± 1.79	10.18 ± 2.02	12.13 ± 1.11
Non-essential inhaler technique (mean ± SD)	13.73 ± 2.78	15.54 ± 2.12	14.00 ± 3.11	17.15 ± 1.39

The difference between the pre-test scores in the control and intervention groups was not statistically significant, but the difference between the post-test scores in the control and intervention groups was all statistically significant (p < .001).

The results of the independent-samples t-test showed that the mean scores of overall, essential, and non-essential inhaler techniques were not significantly different between the two groups before the intervention. Nevertheless, there was a significant difference in this term between the two groups after the intervention (p = 0/001). The results of the paired-samples t-test also indicated that the difference between the baseline and the post-intervention mean scores of overall and non-essential inhaler techniques was statistically significant in the control group (p = 0/001). However, this difference was not found to be statistically significant in terms of essential inhaler technique in the control group. Moreover, the difference between the baseline and the post-intervention mean scores of overall, essential, and non-essential inhaler techniques were shown to be statistically significant in the intervention group (p = 0/001) (Table 2). The results also revealed that there was no significant difference in students’ level of confidence regarding the ability to educate patients on inhaler techniques before the intervention, while all students were shown to have higher levels of confidence in this term after the intervention so that they considered themselves capable in educating patients on inhaler techniques (Table 3).

Table 3.

Comparison of the Mean Scores of Students’ Confidence in Their Ability to Educate Patients.

	Group	Control (n = 41)		Intervention (n = 40)
Variable		Frequency	Percentage	Frequency	Percentage	p-value
Students’ confidence in their ability to educate patients	Before the intervention	3.43 ± 0.83		3.00 ± 1.17		t = 1.93
						p = .056
						df = 79
	After the intervention	5		5		—

Discussion

The present study aimed to investigate the effect of simulated patient-based education on nursing students’ ability to train correct inhaler techniques. This study showed that the mean scores of the correct inhaler technique increased significantly in both groups after the intervention, although this increase was shown to be significantly higher in the intervention group than the control group.

The goal of educational strategies and methods is to facilitate learning and improve performance. In this regard, simulation-based education can lead individuals to achieve this goal. Furthermore, this method of education is an effective way to change learners’ attitudes and improve their critical thinking and clinical decision-making (Sajadi & Farsi, 2015).

In a study by Andrea & Kotowski, nursing students declared that they feel better in teaching real patients after simulation training (Andrea & Kotowski, 2017). Another study has shown that with the simulation training, students had successful behavioral strategies (Dwyer et al., 2015). Also, Basheti (2014) indicated that a significant number of pharmacy students who had been trained in the correct inhaler technique using simulation-based education had learned this skill well (Basheti, 2014).

In a study by Erfanian and Khadivzadeh (2008) about the effect of simulation-based and traditional training methods on performing pelvic exams, it was found that both training methods lead to a significant increase in students’ learning levels, although the level of learning was significantly higher in the simulation group compared to the control group. In their study, the students in the simulation group stated that this training method leads to better learning and faster recall of the technique (Erfanian & Khadivzadeh, 2008).

In a randomized controlled trial, Gordon et al. (2006a, 2006b) compared the effects of simulation-based and traditional training methods. They came to the result that there was no significant difference between the simulation and the lecture group, although the post-intervention mean scores were higher than the baseline ones in both groups (Gordon et al., 2006b).

Inconsistent with our study Kleinman et al. (1996) found that the use of standardized patients for instructing pelvic exams had no advantage over routine training methods (Kleinman et al., 1996), this discrepancy can be attributed to the lack of accurate assessment method, use of inappropriate tools, and dissimilarity between educational content and goals.

Based on the results of the present study, before the intervention, the difference between the overall scores of the intervention group and control group was not high, but the intervention group was slightly better, and after the intervention because of attending the training courses caused participants in both groups to consider themselves capable of educating patients on correct inhaler techniques.

The results of post-test statistical analyses showed that the viewpoints of the participants in the control group on their level of confidence regarding the ability to educate patients were somewhat false and incorrect. This false level of confidence can probably be attributed to participating in training sessions, observing the performance of other students, repetition and practice, and peer feedback. The assessor approved the intervention-group students’ ability to educate patients on inhaler techniques since they showed this ability nicely. Based on the results of this study, the main reason for this true confidence can probably be attributed to the use of simulated patients in education.

In a study conducted by Labrague et al. (2019) demonstrated that students’ self-confidence was improved after a simulation-based activity, and directly affect their communication, knowledge, skills, assessment, and engagement (Labrague et al., 2019).

In another study by Tiffen et al. (2011) on the effect of the simulated patient on nursing students’ confidence in assessing the cardiovascular system, no significant difference was found between the two groups (Tiffen et al., 2011), that not consistent with our results and the reason for this discrepancy can be associated with the type of skill taught as well as the simulation approach used.

Gaba (2004) emphasizes that finding the right combination of traditional training, simulation-based training, and actual patient care experience is a fundamental challenge in education (Gaba, 2004). To make the simulation more effective, it is necessary to focus on key goals and skills, be careful in preparing scenarios, provide personal feedback and performance appraisal, conduct guided clinical practice, and tailor the simulation to the students’ learning needs (Salas & Burke, 2002).

Strengths and Limitations

In the present study, methods are similar to other studies conducted in this regard with the difference that three different scenarios were used all three patients had their own inhaler device, and also mouth washing step was added in the scenarios. Also, in this study, a 5-point Likert scale was used for self-confidence, which can evaluate self-confidence more accurately, while in other studies (for example, Basheti, 2014) a 3-point Likert scale (very confident, confident, and not confident) with two positive options and 1 negative option are used, which may force students to provide answers that do not fully match the answers.

Given that, this research was required the involvement of real patients in educating students, which resulted in more cost and time consumption. Moreover, repetition of scenarios by patients at different times led them to be exhausted and this might make it difficult for them to display the desired scenario. The small sample size was another limitation of this study since it may limit the generalizability of the findings.

Implications for Practice

Considering the fact that nurses are more involved in patient care, respiratory patients are a high percentage of patient's admission to the hospital, and given that the results of this study that simulated patient-based education affects the students’ motivation and confidence. Thus, simulation-based training and use of standardized patients in the education process can improve the quality of care.

Conclusions

The results of this study showed that the use of simulated patient-based education, creation of an environment similar to the clinical settings, hands-on practice with placebo devices, observation of errors, and the provision of feedback by students and supervisors cause learners to be more active and better learn and perform the correct inhaler techniques. The use of standardized patients in the education process increased students’ motivation and confidence in learning and positively affected the study results. The students also stated that attending simulation-based training courses not only was a new and enjoyable experience for them but also provided them with quick feedback and gave them a full understanding of the technique, so that they could have better learning without the anxiety and stress of endangering patient safety.

Footnotes

Acknowledgements

We, the authors, are so grateful to the students, patients, clinical instructors, and the officials of Urmia University of Medical Sciences for helping us to conduct this study. We also express our deep gratitude to Mr. Ali Sadeghian for the translation and editorial service.

Authors’ Contributions

M.A. and L.A. wrote the conception, methodology, design and writing original draft. A.F. wrote the analysis, interpretation of data and supervision. All authors reviewed the manuscript.

Availability of Data and Materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Consent for Publication

Not applicable.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Considerations

This study was approved by the Regional Research Ethic Committee at the Urmia University of Medical Sciences (Ethics No. IR.UMSU.REC.1399.203). The present study was also registered on the Iranian Registry of Clinical Trials (Registry No. IRCT20120409009422N10. 03/01/2022). All the participants completed informed written consent, and all of them could withdraw from the study whenever they desired. All methods were performed in accordance with the Declaration of Helsinki.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Urmia University of Medical Sciences

ORCID iD

Mahnaz Abdali

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