title: Comparison of standardized patients with high-fidelity simulators for managing stress and improving performance in clinical deterioration: A mixed methods study.
abstract: BACKGROUND
  The use of standardized patients in deteriorating patient simulations adds realism that can be valuable for preparing nurse trainees for stress and enhancing their performance during actual patient deterioration. Emotional engagement resulting from increased fidelity can provide additional stress for student nurses with limited exposure to real patients. To determine the presence of increased stress with the standardized patient modality, this study compared the use of standardized patients (SP) with the use of high-fidelity simulators (HFS) during deteriorating patient simulations. Performance in managing deteriorating patients was also compared. It also explored student nurses' insights on the use of standardized patients and patient simulators in deteriorating patient simulations as preparation for clinical placement.
  
  
  METHODS
  Fifty-seven student nurses participated in a randomized controlled design study with pre- and post-tests to evaluate stress and performance in deteriorating patient simulations. Performance was assessed using the Rescuing A Patient in Deteriorating Situations (RAPIDS) rating tool. Stress was measured using salivary alpha-amylase levels. Fourteen participants who joined the randomized controlled component then participated in focus group discussions that elicited their insights on SP use in patient deterioration simulations.
  
  
  RESULTS
  Analysis of covariance (ANCOVA) results showed no significant difference (p=0.744) between the performance scores of the SP and HFS groups in managing deteriorating patients. Amylase levels were also not significantly different (p=0.317) between the two groups. Stress in simulation, awareness of patient interactions, and realism were the main themes that resulted from the thematic analysis.
  
  
  CONCLUSIONS
  Performance and stress in deteriorating patient simulations with standardized patients did not vary from similar simulations using high-fidelity patient simulators. Data from focus group interviews, however, suggested that the use of standardized patients was perceived to be valuable in preparing students for actual patient deterioration management.
authors.affiliation: Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore 117597, Singapore. Electronic address: nurimjj@nus.edu.sg.
authors.forename: Jeanette
authors.initials: J
authors.lastname: Ignacio
authors.affiliation: Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands. Electronic address: d.dolmans@maastrichtuniversity.nl.
authors.forename: Diana
authors.initials: D
authors.lastname: Dolmans
authors.affiliation: Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands. Electronic address: a.scherpbier@maastrichtuniversity.nl.
authors.forename: Albert
authors.initials: A
authors.lastname: Scherpbier
authors.affiliation: Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands. Electronic address: j.rethans@maastrichtuniversity.nl.
authors.forename: Jan-Joost
authors.initials: JJ
authors.lastname: Rethans
authors.affiliation: School of Nursing and Midwifery, Faculty of Health and Medicine, University of Newcastle, Richardson Wing, Callaghan, NSW 2308 Australia. Electronic address: Sally.Chan@newcastle.edu.au.
authors.forename: Sally
authors.initials: S
authors.lastname: Chan
authors.affiliation: Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore 117597, Singapore. Electronic address: nurliaw@nus.edu.sg.
authors.forename: Sok Ying
authors.initials: SY
authors.lastname: Liaw
mesh_terms: D000328:Adult; D000704:Analysis of Variance; D002983:Clinical Competence; D004508:Education, Nursing, Baccalaureate; D005260:Female; D006801:Humans; D008297:Male; D008348:Manikins; D016544:Patient Simulation; D055291:Salivary alpha-Amylases / Q000032:analysis; D012720:Severity of Illness Index; D000066908:Simulation Training; D013315:Stress, Psychological; D013338:Students, Nursing / Q000523:psychology*; D055815:Young Adult
chemical_list: D055291:Salivary alpha-Amylases
keywords: Nursing education; Patient deterioration; Performance; Simulations; Stress