Thai nursing students' experiences when attending ...

YNEDT-02968; No of Pages 6 Nurse Education Today xxx (2015) xxx–xxx

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Thai nursing students' experiences when attending real life situations involving cardiac life support: A Phenomenological study Yaowarat Matchim ⁎, Waraporn Kongsuwan 1 Faculty of Nursing, Prince of Songkla University, Hat Yai, Songkhla 90112, Thailand

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Article history: Accepted 16 May 2015 Available online xxxx Keywords: Cardiac life support Nursing students' experience Phenomenological study Clinical teaching

s u m m a r y Background: During the last few years, manikin simulations have been used for cardiac life support training procedures in medical and nursing education. However, some nursing students have experienced attending real events involving cardiac life support during their clinical practice. Objective: This study aims to describe the meaning of experience of Thai nursing students when attending real situations of cardiac life support. Methods: A hermeneutic phenomenological study was used. Third and fourth year bachelor of nursing students at a university in the southern region of Thailand who had the experience of attending real situation of cardiac life support were purposely selected as the informants. The data were generated from individual in-depth interviews with eighteen nursing students. Van Manen's approach was used to analyze the data. Trustworthiness was established using the criteria set out by Lincoln and Guba. Results: Essential themes situated in the context of the four existential grounds of body, time, space, and relation emerged. These were: being worried and fearful while desiring to participate in cardiac life support procedures; enhancing self value; knowing each moment is meaningful for one's life; having time to understand the reality of life; being in a small corner; appreciating such opportunities and the encouragement given by nurses and the healthcare team; and feeling empathy. Conclusions: Besides learning in classrooms and practicing in labs, experiencing real situations is beneficial for nursing students in learning cardiac life support. This study provides information that can be used for clinical teaching management in the topics relating to cardiac life support. © 2015 Elsevier Ltd. All rights reserved.

Introduction Cardiac arrest is the leading cause of death in critical situations around the world. The Advanced Cardiac Life Support (ACLS) course is one dealing with the treatment of cardiac emergencies. The ACLS was created by the American Heart Association and is used in many countries to train medical and nursing staff to improve and ensure rapid survival after cardiac arrest (Field et al., 2010). Evidence shows that effective ACLS can save lives. In hospitals, the mortality and morbidity rates of cardiac arrest victims are directly affected by the ability of healthcare providers in using ACLS knowledge and skills effectively. ACLS competency has been defined as encompassing both the acquisition and retention of ACLS cognitive knowledge and psychomotor skills (Yang et al., 2012). ACLS training is important for healthcare professionals and health science students, especially medical and nursing students. ⁎ Corresponding author. Tel.: +66 74 28 6525; fax: +66 74 28 6421. E-mail addresses: [email protected], [email protected] (Y. Matchim), [email protected] (W. Kongsuwan). 1 Tel.: +66 74 28 6522; fax: +66 74 28 6421.

Through the nursing curriculum of the Faculty of Nursing, Prince of Songkla University (Faculty of Nursing, 2011), nursing students learned about cardiac life support. This program started with Basic Life Support (BLS), which is a core skill in which all healthcare professionals should be proficient. Lectures were also delivered in relation to BLS that demonstrated its importance and when and how it is performed. Individuals practiced BLS through simulation using manikins and this was undertaken in nursing laboratories. This started with assessment, asking for help, performing chest compression, and using a self inflating bag with a mask to help breathing. ACLS was taught in a later course after the BLS instruction had been given (Faculty of Nursing, 2011). These nursing students learned the principles of ACLS through course work. This included its importance, the way ACLS is performed, and the equipment and medication used in ACLS. A video of an ACLS situation taking place in clinics was provided for viewing. Nursing instructors explained and discussed the details of the ACLS procedures in the video. The nursing students were then assigned to groups of 10–12 persons. Each group was instructed about the way to practice simulated ACLS procedures using manikins in the laboratories. These procedures included assessment, EKG

http://dx.doi.org/10.1016/j.nedt.2015.05.010 0260-6917/© 2015 Elsevier Ltd. All rights reserved.

Please cite this article as: Matchim, Y., Kongsuwan, W., Thai nursing students' experiences when attending real life situations involving cardiac life support: A Phenomenological study, Nurse Educ. Today (2015), http://dx.doi.org/10.1016/j.nedt.2015.05.010

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Y. Matchim, W. Kongsuwan / Nurse Education Today xxx (2015) xxx–xxx

interpretation, preparing an endotracheal tube, and the medication used in ACLS. Each student had to practice all these procedures and demonstrate them in turns. All the practice took place and evaluation conducted in the laboratories. In clinical practice, as nursing students are a part of the health care team, some nursing students have a chance to attend real situations involving cardiac life support at some points during their clinical practice. In an evaluation of a course for practical adult nursing, nursing students stated that studying cardiac life support in a real situation is quite different from studying it in the laboratory. These nursing students emphasized that being given the opportunity to attend real situations involving ACLS on clinical practice enabled them to understand and memorize the procedures of ACLS more clearly. However, no existing study has been found that examines the experience of nursing students studying ACLS in real-life situations. Thus the present study aimed to explore nursing students' experiences of attending real-life events involving cardiac life support during their clinical practice. Understanding such experiences could assist nursing instructors develop appropriate teaching and learning strategies. These could enhance nursing students' positive learning outcomes relating to cardiac life support and also increase their satisfaction about how they have learned.

Literature Review A review of educational theory suggests that hands-on activities or real experiences can lead to greater cognitive gains (Clark et al., 2010). When undertaking hands-on practice, students can integrate theory and practice, experience success and failure, and work in learning environments that help them develop their mental strength. Hands-on practice, incorporated with real time feedback, has been identified as the best method for teaching cardiopulmonary resuscitation (Plant and Taylor, 2013). However, in medical and nursing education, appropriate real-life situations in clinical practice are not always available for students to engage in hands-on practice. When developing training courses it has been assumed that the more realistic the scenario, the more the related skills improve, and the greater the knowledge that is retained. It is of interest to note that one study reported on the use of live actors to create realistic scenarios or role play. However, this did not improve the retention of knowledge (Miotto et al., 2008). A comparative study has shown that real-patients problem-based learning (RPBL) is better than digital problem-based learning (DPBL) and paper problem-based learning (PPBL). RPBL is even better than traditional lecture-based learning (LBL) to help students achieve critical assessment and management skills in a dermatology course (Li et al., 2013). This study reported that cases involving real patients were more effective, compared to digital and paper cases, in helping students develop self-directed learning skills, improving their confidence about future patient encounters, and encouraging them to learn more. One study evaluated the impact of a computer-based educational intervention on teamwork behaviors and patient care performance. It reported that computer-based team training positively impacts on teamwork and patient care during simulated patient resuscitations (Fernandez et al., 2013). Regarding cardiac life support, few studies have been found that deal with students experiencing it in real situations. Price et al. (2006) examined the effects of attending a cardiac arrest situation and cardiac life support among medical students. This study reported that medical students' confidence about being involved in resuscitation procedures changed positively after participating in them. No existing study has been found that examined the effect among nursing students on attending a cardiac life support event. Therefore the purpose of this present study was to explore the experience of nursing students when attending real situations dealing with cardiac life support in hospitals.

Methods Study Design Hermeneutic phenomenology was used to explore the meaning of the lived experience of Thai nursing students when attending real situations involving adult cardiac life support in their clinical practice. The research question that this study intends to address is, “What are the experiences of attending real situation involving cardiac life support of Thai nursing students?” Setting and Samples The study was conducted in Songkhla province, southern Thailand. The settings of the study included adult medical, surgical, and intensive care wards in three tertiary hospitals. Nursing students who had experienced practical study were recruited to be participants and to be interviewed about the study. Eighteen nursing students who met the inclusion criteria were selected to participate in this study. The inclusion criteria were: (1) to be a third or fourth year nursing student at a university in Songkhla province; (2) to have had experience of attending real life situations involving cardiac life support in hospitals; (3) to be able to verbally express their recollections of cardiac life support procedures and situation that they observed; and (4) be willing to participate in the study. Ethical Consideration This study was approved by the Research Ethical Committee of Faculty of Nursing, Prince of Songkla University (REC approval number: PSU 604.2/040). A detailed description of the study, the risks and benefits, the matter of confidentiality, and the informed consent procedures followed were explained to the potential participants during the initial contact. The consent form was signed before the interviews. The real names of the participants were not used in any verbal or written presentations and/or reports. Data Collection The data were collected between October, 2011 and February, 2013. A purposeful snowball-sampling method using word-of-mouth contact was employed to recruit the participants. In addition, flyers inviting participation in the study were announced in classrooms and other places in the school of nursing. After contacting the participants, the researchers and each participant mutually agreed upon the setting for the interview. All interview settings were quiet, private, comfortable, and in convenient locations. The interviews took place in the researchers' office as it was accessible to both the researchers and the participants. These individual face-to-face interviews were conducted in the Thai language. They were tape recorded and took from 45 to 90 min for each participant. The set of questions used in the interviews were: “Please tell me your experience of having attended real situations involving cardiac life support during your clinical practice.”; “What was it like for you attending real situations involving cardiac life support during your clinical practice?”; and “How did you feel about attending real situation involving cardiac life support?” In order to encourage further reflection, follow-up prompts were given, such as: “Please tell me more”; and “Can you give an example?” During the interviews the researcher also observed the behavior and facial expressions of the participants and entered these in a field note journal. Each interview continued until the participant reported that she had nothing more that she wished to share. In the first year of collecting data, only 10 nursing students had experiences of interest and the data did not meet saturation point. Thus the data collection continued after the practicum course was completed in the next academic year. The data derived from the



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interviews with the 18 participants reached the saturation point when no new information emerged from the interviews.

lived body: “Being worried and fearful while desiring to participate in cardiac life support procedures”; and “Enhancing self value.”

Data Analysis

Being Worried and Fearful While Desiring to Participate in Cardiac Life Support Procedures

All the interviews were transcribed verbatim. Codes were assigned to participants to ensure confidentiality. The data were analyzed following Van Manen's approach (Van Manen, 1990). The processing and data analysis were as follows. First, the field notes and transcription for each participant were read several times to gain clear understanding. Second, phrases and statements that appeared to describe the participants' experiences when attending real situation involving cardiac life support were selected. Meanings were then formulated from these statements and phrases. The formulated meanings were organized into themes. Decisions about including the data in themes, formulating meanings and significant statements were examined by the two researchers and any contradictions were resolved. None were found. Third, phrases showing conceptually similar thematic descriptions were identified and compared with those of other participants. Such themes were interconnected and reflected the interpretation of the participants' experience. Fourth, themes were rephrased and described. Selected statements of the participants were attached to the themes with continuous writing and rewriting. Finally, the essential themes were placed within Van Manen's four lived worlds: lived body (corporeality); lived time (temporality); lived space (spatiality); and lived relations (relationality). After analysis and the writing of descriptions, each participant was asked to review the themes and descriptions. No new data were revealed during validation. All analyzed data and descriptions were presented as aggregate data. These data were translated into English and were reviewed by two nursing professors who were bilingual (fluent in both English and Thai). Rigor of the Study The rigor of the qualitative research was established by using the criteria created by Lincoln and Guba (Lincoln and Guba, 1985). These included credibility, transferability, dependability, and confirmability. Credibility was accomplished by recruiting participants who were able to describe their experiences while attending a real situation involving cardiac life support in hospital. Transferability was sought by providing the audience with rich in-depth descriptions. Dependability was achieved through another researcher being able to follow the decision trail of the study process without contradicting the findings. Confirmability was established by using the audit trails that demonstrated the thought processes that were followed. Results There were 16 female and 2 male nursing students who took part. The average age was 21.6 years. There were 6 third year nursing students and 12 fourth year nursing students. Five students reported that they had attended real situations involving cardiac life support twice. The rest of the participants reported attending real situations involving cardiac life support once. Most patients who were resuscitated died, and only two patients were revived. The average time participants took in attending the cardiac life support events was 30–60 min. Based on the lived body, lived time, lived space, and lived relations, the essential themes described the experience of attending real situation involving cardiac life support of the Thai nursing students are as follows:

Participants stated that initially they were excited to know that they were attending a real life situation involving cardiac life support. They understood that all procedures involving cardiac life support had to be done as quickly and effectively as possible to save the patient's life. Most participants reported that was their first time to attend a real situation involving cardiac life support. Although they had learned cardiac life support in classrooms and practiced these procedures in the laboratories, participants were excited, worried, and fearful. At the same time they wanted to help and join the healthcare team in performing cardiac life support. As one participant described it: I was very excited. I wanted to help the patient. I knew we have practiced these procedures in the labs. I could do well in the labs, but in the real situation I was not sure. I was afraid that I might make the team delay which may harm the patient. (P1) Similarly, one participant who was assigned to care for a critically ill patient during her clinical practice in ICU, was fearful and worried in knowing that her patient had developed cardiac arrest. As she expressed it: My patient had septic shock, his blood pressure started to drop one day before I was assigned to care for him. He was treated by inotrope, fluid challenge, and antibiotics. When I assessed this case in the morning, a staff nurse told me that the patient may develop a severe condition. So, I prepared to care for him carefully. I observed the patient closely. Then in the late morning the patient developed cardiac arrest. It happened very fast. The CPR started promptly. I was shocked, my hands were shaking. I wanted to help the patient, but I didn't know what I should do. (P2)

Enhancing Self Value Lived experience when attending the real situation involving cardiac life support was described as enhancing the feeling of pride in oneself. This phenomenon occurred after the participants were allowed to join the cardiac life support team. Even though some procedures that they were required to follow did not provide direct care to the patients, the participants were very proud to be a part of the team. For example, the procedures that the participants were allowed to do included checking vital signs, helping breathing by using self inflating bags, drawing medication from vials, and operating suction. As one participant said: I helped the nurse in drawing medication from the vials. I was very proud to be a part of the CPR team. I felt like my heart was bigger. Although eventually, the patient died, at least we tried our best to help him. (P3) Similarly, another participant explained: I think it is challenging to save someone's life. We can use knowledge and skills about cardiac life support that we have learned and practiced from class to help someone. I was very proud while I was helping the team. After attending this event, I felt like having more confidence about performing cardiac life support procedures. (P15)

Lived Body Lived Time This lived world refers to participants' perceptions regarding their physical body, emotions, and feelings while attending the real situation involving cardiac life support. Two themes were selected to reflect the

Lived time reveals participants' perceptions regarding time while they were attending the real situation involving cardiac life support.


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Two themes were selected to reflect the lived time: “Knowing each moment is meaningful for one's life”; and “Having time to understand the reality of life.” Knowing Each Moment Is Meaningful for One's Life Participants stated that attending a real situation involving cardiac life support helped them realize that time is very important in one's life. As one participant described it: What I have learned from attending the cardiac life support?… I started to realize that every moment is very important. Each moment might mean for one to be alive or to die. As we care for patients, we have to do the best to make sure that each one is saved. If we do something wrong in performing cardiac life support procedures, it might harm someone's life. (P2)

Having Time to Understand the Reality of Life Participants also explained that attending a real situation involving cardiac life support helped them learn about life and death. This phenomenon occurred mostly when the CPR team could not save the patient's life. Witnessing the lives and deaths of their patients, participants had more understanding of the reality of life; in that a person is born, becomes old, and ultimately dies. This is normal for every life. Cardiac life support procedure and life-sustaining technologies could not help the person if his/her time of death had come. As one participant explained: Anytime, when we were doing cardiac life support and the patient died, I was sad. I always had a question “Why even though we did our best, we could not help the patients?” Then I learned this is the reality of life. Everybody who was born in the world has to grow old and die. Attending the real situation involving cardiac life support is like an opportunity to understand the reality of life. (P6)

Lived Space Lived space reflects participants' perceptions regarding a place or area while attending a real situation involving cardiac life support. The selected theme situated in the lived space is “Being in a small corner.” This theme reflected participants' feeling about being a student working among experts or senior staff during a crisis situation. At this busy moment, staff may not have time to pay attention to the student. As one participant expressed it: I had a chance to attend the real situation involving cardiac life support when I had clinical practice in ICU. One patient had complicated problems and the CPR was performed promptly. While taking part as the CPR team worked, I felt like I was being in a small corner surrounded by experts. Everybody looked serious. No one talked or explained anything to me. Sometimes they communicated with medical terms and language that I was not familiar with. (P11)

Lived Relations Lived world refers to the participants' perceptions regarding their relationships with others while attending the real situation involving cardiac life support. Two themes were selected to represent lived relations: “Appreciating such opportunities and the encouragement given by nurses and the healthcare team”; and “Feeling empathy.” Appreciating Such Opportunities and the Encouragement Given by Nurses and the Healthcare Team

On this theme participants stated that although they wished to help and join the CPR team, they were not confident about offering themselves. This opportunity and the encouragement given by nurses and the healthcare team were important in influencing participants on being confident about performing cardiac life support procedures in a real life situation. As one participant pointed out: Although we have learned and practiced CPR procedures in the labs, when in the real situation I didn't know how to start. Fortunately, a staff nurse told me to help the breathing by using the self inflating bag. I really appreciated the staff nurse giving me an essential opportunity. (P5) Similarly, another participant said: I was confident doing CPR procedures with manikins in the lab. However, in the real situation I was not sure. While I was observing the team for a while, one doctor allowed me to do chest compression after he knew that I had had CPR training. After doing these procedures in the real situation, I realized that I could do it. I also wanted to thank the doctor who kindly gave me an opportunity to do CPR procedures in the real situation. I will always remember him. (P12)

Feeling Empathy While attending a cardiac life support event and the patient was dying or the family members were grieving, the participants developed a sense of feeling of empathy. As one participant described it: I was sad when I knew that we could not help the patient. He was going to die soon. I was thinking of his daughter who would lose her father in a few minutes. I understood how she felt and I also felt very sad with her. At that moment, I felt like I lost my father. (P2) Similarly, another participant shared her experience: After we did ACLS for about 30 minutes and the patient's condition was worse, the doctor told the family that we could not save the patient's life. Then I saw the family hold the patient's hands and cry. I was sad and I cried. In the evening when I told the story to my roommate, I cried again. I felt like I was a family member who lost her father. (P14n

Discussion Previous studies have suggested that manikin simulation (Sahu and Lata, 2010) and multimedia computer-based teaching (Fernandez et al., 2013) are effective methods for teaching cardiopulmonary resuscitation. However, participants in the present study tended to report positive learning experience in attending cardiac life support in real situations. This was especially so for participants who obtained opportunities and encouragement from a healthcare team. This included verbal support or being given the chance to participate in performing the procedures, even though in small tasks which might not provide direct care to the patient. Having these opportunities and receiving feedback from a healthcare team facilitated nursing students' learning in clinical practice. As reported above, the nursing students reported feeling that they were being empowered when they were valued as learners and team members during their clinical practice. At the beginning of being in the lived world in a clinic, it is true that students may feel worried and fearful while facing difficult situations. However, students who were accepted as team members and obtained the chance to perform cardiac life support procedures in a real life situation reported positive learning experiences. These were expressed in terms of understanding the concept of cardiac life support more clearly, being more confident about performing life support procedures in real situations, and understanding more about life. These feelings were displayed in the following



themes: “enhancing self value”; “knowing each moment is meaningful for one's life”; “having time to understand the reality of life”; and “feeling empathy.” Positive learning experience in clinical practice can be a foundation for achieving successful practice; this encourages students to become great professional nurses (Yang, 2013). In clinical practice, positive learning experiences might be established by creating a good learning environment. This involves clinical practice preparation, the hospital atmosphere, and the relationships and understanding between nursing instructors and healthcare professionals working in that unit. It is of interest that the present study revealed that the nursing students were well trained in cardiac life support procedures in the laboratories. However, they were not as confident as they wanted to be about performing these procedures in real life situations. Several reasons were given that showed their worries, fears, and emotional stress. These findings are similar to those of one study which reported that nursing students experienced simultaneous feelings, including excitement, fear, a sense of embarrassment, and uncertainty during their first clinical practice (Yang, 2013). Similarly, in another study, nursing students reported about lacking confidence and feeling fear during their clinical practice (Oflaz et al., 2010). In addition, nursing students viewed their clinical practice as “initial clinical anxiety” regarding their lack of confidence, lack of knowledge, fear of the hospital environment, and being anxious about clinical practice (Sharif and Masoumi, 2005). This information indicated that, in their initial clinical practice, nursing students may feel a lack of confidence, fear, worry, and anxiety, especially when faced with difficult situations, such as a cardiac life support event. In order to deal with these situations, students need support, encouragement, and acceptance from healthcare teams and ward staff. As found in the present study, participants who were given opportunities to participate in performing cardiac life support procedures reported positive learning experiences and pride in being a part of the healthcare team. In addition, gaining this experience helped participants to realize that each moment is meaningful for one's life. It also encouraged participants to learn and accept the reality of life. This phenomenon that participants touched on is deeper than the knowledge and experience they obtained from lectures and practice with manikins in the laboratories. On the other hand, some participants who had attended real situations involving cardiac life support had not been given encouragement and support when participating in performing life support procedures. They reported their negative learning experiences as like “being in a small corner.” This suggests that these nursing students felt they were not recognized or were ignored at some points when cardiac life support was being given. This phenomenon occurred when the healthcare professionals were busy and no one paid attention to the nursing students. This might be a normal situation if this event lasted a short period of just a few moments. The sense of not being recognized seems to hamper students' motivation to learn. This finding is congruent with another study which disclosed that students could not learn in places where they felt not welcome (Levett-Jones and Lathlean, 2008). Similarly, one study explored Australian nursing students' perception on their clinical practice and reported that nursing students viewed “ignoring” as an unhelpful behavior by nurses (Jackson and Mannix, 2001). In the present study, nursing students were taught concepts and skills for cardiac life support by providing lectures on concepts and theory in a classroom. Demonstration was given in performing procedures involving cardiac life support with manikin simulations in the laboratories. Lastly, nursing students learnt these procedures in their clinical practice. However, the opportunity for nursing students to be involved in performing nursing procedures in real life situations, even though not directly giving care to patients, mostly depends on a hospital's atmosphere and relationships and understanding shown by nurses and healthcare teams. In order to help nursing students to obtain such opportunities, nursing instructors should encourage nursing students

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to establish good relationships with ward staff (Oflaz et al., 2010). In addition, a good clinical learning environment can be established through good co-operation between the school and the clinical staff. It is of interest that nursing students also reported that humor and joy are important for their clinical learning although the workload may be heavy (Papp et al., 2003). Limitation The participants in this study were recruited from the nursing students enrolled in one institution. The findings of this study should not be generalized to apply to all nursing students in Thailand. Conclusion The present study explored nursing students' experiences while attending real life situations involving cardiac life support during their clinical practice. They had studied the required procedures in classrooms and practiced them in laboratories. However, this lived experience demonstrated that, having the opportunity to participate in performing cardiac life support procedures in real situations is highly beneficial for nursing students. This was so even when they did not provide direct care to patients. They reported they obtained positive learning experience when practicing challenging procedures in a good clinical learning environment. Understanding, encouragement, and support from healthcare teams are critically important. This may include verbal support or being given the chance to participate in performing some procedures, even small tasks which might not provide direct care to the patient. All these help motivate learning by nursing students and cultivate good attitudes towards their future profession. A good clinical learning environment can be created by basing this on good co-operation among the school, nursing instructors, and the clinical staff. Acknowledgment The authors express gratitude to the Faculty of Nursing, Prince of Songkla University for financial support in conducting this study. References Clark, R.W., Threeton, M.D., Ewing, J.C., 2010. The potential of experiential learning models and practices in career and technical education and career and technical teacher education. J. Career Tech. Educ. 25 (2), 46–62. Faculty of Nursing, 2011. Nursing science: curriculum. Faculty of Nursing. Prince of Songkla University, Songkhla. Fernandez, R., Pearce, M., Grand, J.A., Rench, T.A., Jones, K.A., Chao, G.T., Kozlowski, S.W., 2013. Evaluation of a computer-based educational intervention to improve medical teamwork and performance during simulated patient resuscitations. Crit. Care Med. 41 (11), 2551–2562. http://dx.doi.org/10.1097/CCM.0b013e31829828f7. Field, J.M., Hazinski, M.F., Sayre, M.R., Chameides, L., Schexnayder, S.M., Hemphill, R., Vanden Hoek, T.L., 2010. Part 1: executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 122 (18 Suppl. 3), S640–S656. http://dx.doi.org/10.1161/ CIRCULATIONAHA.110.970889. Jackson, D., Mannix, J., 2001. Clinical nurses as teachers: insights from students of nursing in their first semester of study. J. Clin. Nurs. 10 (2), 270–277. Levett-Jones, T., Lathlean, J., 2008. Belongingness: a prerequisite for nursing students' clinical learning. Nurse Educ. Pract. 8 (2), 103–111. http://dx.doi.org/10.1016/j.nepr. 2007.04.003. Li, J., Li, Q.L., Li, J., Chen, M.L., Xie, H.F., Li, Y.P., Chen, X., 2013. Comparison of three problem-based learning conditions (real patients, digital and paper) with lecturebased learning in a dermatology course: a prospective randomized study from China. Med. Teach. 35 (2), e963–e970. http://dx.doi.org/10.3109/0142159X.2012. 719651. Lincoln, Y.S., Guba, E.G., 1985. Naturalistic Inquiry. Sage Publications, Newbury Park, CA. Miotto, H.C., Couto, B.R., Goulart, E.M., Amaral, C.F., Moreira Mda, C., 2008. Advanced cardiac life support courses: live actors do not improve training results compared with conventional manikins. Resuscitation 76 (2), 244–248. http://dx.doi.org/10. 1016/j.resuscitation.2007.07.031. Oflaz, Fahriye, Arslan, Filiz, Segmen, Esra, Uzun, Senay, Ustunsoz, Ayfer, 2010. An insight into the experiences of nursing students during first clinical practices. Balk. Mil. Med. Rev. 13 (1), 17–23.


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