The effect of simulation practice with a live subject on the anxiety level and perceived competence level of paramedic candidates in approaching a trauma patient

2.1 Research type and study group

A total of 72 second-year Paramedic students of the Gazi University, Vocational School of Healthcare Services participated in this study, which was designed as an intervention study. A criterion for participating in the study was to have taken Trauma and Advanced Life Support courses. An exclusion criterion in the study was to have been diagnosed with anxiety and depression in the last year. A total of 24 teams (3 people in each team) were formed for the competition. Two persons whose information was missing in the data set were excluded from the study and data analysis was carried out with 70 people.

2.2 Data collection form

The data collection form used in the study consisted of three parts. The first section included six questions regarding the socio-demographic characteristics of the participants.

In the second part, a self-efficacy form was used in approaching trauma patients. To measure the perception of self-efficacy, statements regarding diagnosis and treatment that could occur in 20 different trauma patients were stated and the participants were asked how competent they were for these statements. For situations where self-efficacy was questioned, a three-point Likert scale with answers such as “agree”, “partially agree” and “disagree” was used. To measure the self-efficacy of the participants, 20 situations were created by the researchers and expert opinions were obtained from five academicians who are experts in their field.

In the ultimate part, the Worry and Anxiety Scale (WAS) was used. This self-assessment scale was developed by Dugas et al.[10] (2001) and adapted into Turkish. The WAS measures the diagnostic criteria of Generalized Anxiety Disorder (GAD) as defined in DSM-IV (Diagnostic and Statistical Manual of Mental Disorders-IV) according to American Psychiatric Association The scale, consisting of a total of 11 items, is a nine-point Likert scale (0–8). The score that can be obtained from the scale is between 0 and 80. The WAS measures anxiety issues, the excessive and uncontrollable aspect of concern, duration and frequency of the disorder, somatic symptoms, worry and helplessness due to anxiety and its interference in one’s life. The scale score is calculated by adding the scores from all items except the first item. The scale has good test-retest reliability (r = 0.75; for a 9-week test-retest). The scale has a good sensitivity (89.5%) in distinguishing between people who meet and do not meet GAD diagnostic criteria. The Cronbach’s Alpha value for the Turkish adaptation of the scale is 0.891 [11].

2.3 Procedure

For the study, a competition named “trauma rally” was organized for Paramedic students of the Gazi University, Vocational School of Healthcare Services, consisting of pre-hospital approaches to injured live subjects. In this competition, participants were asked to intervene in a traffic accident with a person in a vehicle, a fall from a height, an injured person under rubble, and a patient whose heart has stopped, according to the scenario. The competition was held on 30 December 2022 at the Gazi University, Vocational School of Healthcare Services. The trauma and advanced life support issues included in the checklists to be used in the competition have been prepared in line with the ERC 2021 guide and preliminary preparations have been completed. The surveys were administered by the research conductor through face-to-face interviews. The checklists were used during the competition by researchers who are experts in their field and who received the necessary training on how to apply the checklists. The checklists included the patient/injured person’s history, vital signs, patient’s medical history, the physical injury findings of the patient, preliminary diagnosis of the patient, interventions to be performed on the patient, and instructions for use of the stretchers. The survey form was filled out just before the competition, after the competition and 30 days after the competition.

Scenario 1: Adult advanced life support; According to the scenario, a British tourist at the scene, calls in ambulance services for his father, whose heart stopped due to an electric shock in a hotel room.

Scenario 2: Traffic accident with a person in a vehicle; An accident took place with a vehicle carrying a married couple and a baby. The responding team is expected to, based on clues, find a baby who went through an open window due to the accident and to treat all three injured persons.

Scenario 3: Falling from a height; An ambulance is called in when a person climbing a tree to pick apples falls. Competitors arriving at the scene are asked to approach the injured person with multiple trauma.

Scenario 4: Intervention in narrow areas; Intervention is requested for an injured pregnant woman who has gone into labor and who is trapped under the rubble after an earthquake hit.

2.4 Statistical analysis

In the study, the data were evaluated with the SPPS 20.0 statistical program (IBM, Westchester, NY, USA). The socio-demographic variables of the participants are expressed in numbers and percentages. Before proceeding with the pre-test, post-test and retention test analysis, it was examined whether the WAS and self-efficacy score averages were normally distributed. Kurtosis and skewness values were checked for normality tests. The results showed that the data were normally distributed (+1.5 to −1.5) [12]. The Cronbach’s Alpha value calculated for this study was found 0.941.

A correlation analysis was performed to determine the relationship between age, GPA (Grade Point Average), self-efficacy score and WAS score. The one-way ANOVA (Analyze of Variance) test was used to compare WAS and self-efficacy score averages according to the pre-test, post-test and retention tests. Least Significant Difference (LCD) was used as a post-hoc test. The results were evaluated at a 95% confidence level, and p < 0.05 was considered to be statistically significant.

4.1 Simulation and anxiety level

Experiencing a decreased level of anxiety with increasing simulation experience may be associated with how well participants prepared. With increased preparation for the simulation, participants’ anxiety may decrease even before the simulation [18]. However, there are studies showing that well-prepared participants still experience high anxiety [19]. This may be because participants were expecting something extraordinary to happen during the simulation. In our study, there was a decrease of approximately four points in the average WAS score of the participants between the pre-test, post-test and retention test averages, but this decrease was not significant. Being peer reviewed during emergency care caused anxiety. This has also been described in previous studies [20]. Fear of criticism, both positive and negative, is associated with increased anxiety levels of participants [18]. Participants become anxious when a caregiving action is performed incorrectly or when they do not know what to do while being observed by their peers [21]. It is thought that being observed by peers was effective in finding high pre-test scores. The competitive nature of the simulation studies may have increased students’ anxiety, which may then decrease. In addition, the high anxiety of the participants in the pre-test may be due to reasons such as not having had any previous simulation experience or fear of making the wrong intervention.

When the literature was examined, similar results were encountered. In the study conducted by Torné-Ruiz and colleagues, who planned to reduce anxiety levels in nursing students with simulation training, it was observed that the anxiety levels of nursing students were high before the simulation application and that there was a significant decrease in anxiety levels after the training [22]. In a study by Couarraze and colleagues examining how simulation-based training given to critical care healthcare workers would affect their anxiety levels in the short term, it was observed that simulation-based training reduced the anxiety levels of the participants. They explained that the most important reason for the decrease in the participants’ anxiety was that they understood the clinical situations better and the treatment was organized correctly [23]. In a study conducted by Roseland et al. [24] with nurses, nurses were given simulation-based training for pediatric patients requiring critical care. After the training, an approximately 24% decrease in the anxiety levels of the nurses was found [24].

4.2 Simulation and self-efficacy level

The best learning in adult education is achieved through active participation in the education process and taking part in the education process. Through this way of learning, the student gains experience by including his existing knowledge and experiences. Simulation, which is among the active participation methods, is effective in developing both the cognitive, psychomotor and attitudinal knowledge and skills of students by providing them with a realistic learning environment in which they experience real life situations [25]. In our study, there was a significant increase of approximately five points between the average self-efficacy score of the participants in the pretest and the average self-efficacy score in the retention test. In the training conducted by Attoe and colleagues to reduce newborn deaths, a 40% decrease in neonatal mortality was detected in a one-year study period following the implementation of simulation training [25]. According to the results of the study planned by Guerrero et al. [26] to examine the improvements in knowledge, skills, self-efficacy, confidence and satisfaction of nurses after simulated clinical experience in providing care to a patient undergoing chemotherapy; a significant increase in self-efficacy was found in nurses after the simulation. When Tucker and colleagues examined the effects of simulation-based resuscitation training given to nursing students on their self-efficacy levels, an increase in students’ self-efficacy levels was found after the simulation training, but this increase was not statistically significant [27]. According to the research conducted by Kassabry on Palestinian nursing students, which examined the effect of simulation-based advanced life support training on the students’ self-efficacy, it was concluded that the participants felt statistically significantly more competent after the simulation training [28]. In a study conducted by Afni and his colleagues in Indonesia, participants were trained with a traffic accident simulation. Participants were subjected to a traffic accident simulation and then asked to provide first aid. At the end of the training, there was a statistical increase in the participants’ self-efficacy [29].

4.3 Anxiety and self-efficacy level

According to the correlation result, it is observed that there is a negative, moderate and statistically significant relationship between the self-efficacy average and the WAS score average. In the study by Al-Ghareeb et al. [30], which examined the effect of simulation on the anxiety levels of nursing students, it was observed that students with low levels of anxiety performed best and that performance decreased with medium to high anxiety levels. The participants’ belief that they had low self-efficacy may have increased their anxiety levels. Participants with low self-efficacy may have become anxious because they thought they could make more mistakes.

4.4 Limitations of the study

The study was conducted at Gazi University School of Health Services. A budget request was requested from the unit that was the funding source for the study to be conducted here. This study may form the basis for future studies.