Lorem, Ipsum

Review Article

Repeated Simulation Experience on Self-Confidence, Critical Thinking, and Competence of Nurses and Nursing Students—An Integrative Review

Koukab Abdullah Al Gharibi, MSN1 and Judie Arulappan, MSc(N), PhD, DNSc2

Abstract

Background: Simulation is the most adopted teaching methodology in nursing education.

Objectives: This article investigated the outcome of repeated simulation experience on self-confidence, critical thinking,

knowledge, competence, and satisfaction of nurses and nursing students.

Methods: The Scholarly literature published in English for the period of 2011 to 2019 was reviewed.

Results: Repeated simulation enhances students’ self-confidence, knowledge, competence, critical thinking, and satisfaction.

Conclusions: Repetitive simulation experience is valued by the nurse educators as a valuable teaching methodology to

reinforce the student’s learning outcomes.

Keywords

nursing faculty, nursing students, undergraduate nursing programs, nursing theory, nursing simulation

Date received: 10 February 2020; Revised 6 April 2020; accepted 26 April 2020

During the past 20 years, simulation has become an

important part in nursing education, providing practical

training on nursing care for nursing students (Aebersold

& Tschannen, 2013). Beginning in the 1960s, simulation

has been used for educating health professionals and has

evolved over time due to the demand to provide high-

quality care, increased complexity of patients, and need

to minimize risks of care delivery for patients (Hall &

Tori, 2017). The National council of State Boards of Nursing

defines clinical simulation as a computer-based event

or activity imitating real clinical practice using

medium fidelity manikins, high-fidelity manikins,

clinical scenarios, standardized patients, skill stations,

role playing, and critical thinking components (Kim

et al., 2016). The International Nursing Association for

Clinical Simulation and Learning Simulation defines

simulation as a pedagogy using one or more

typologies to improve, promote, and validate a partici-

pant’s progression from novice to expert. International

Nursing Association for Clinical Simulation and

Learning Simulation designated three parts of simula- tion as prebriefing, scenario, and debriefing (Meakim et al., 2013).

In clinical nursing education, the theoretical knowl- edge is integrated into practical knowledge in real-life situations and the students are taught to develop problem-solving skills. The opportunities to provide direct patient care and to handle problem-based clinical situations have diminished due to rapid changes in clin- ical placements, patient safety issues, and ethical con- cerns (Kim et al., 2016). As the opportunities are decreased for the nursing students to practice the clinical

1Nursing Education Clinical Simulation Unit, College of Nursing, Sultan

Qaboos University, Al Khoud, Muscat, Sultanate of Oman 2Department of Maternal and Child health, College of Nursing, Sultan

Qaboos University, Al Khoudh, Muscat, Sultanate of Oman

Corresponding Author:

Koukab Abdullah Al Gharibi, College of Nursing, Sultan Qaboos University,

Al Khoud, P.O box-66, Postal code-123, Muscat, Sultanate of Oman.

Email: [email protected]

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and decision-making skills, there are mounting concerns that graduate nurses are not competent in basic psycho- motor skills. This requires the nurse educators to reeval- uate the methods that they use to teach these skills. Simulation in clinical nursing education allows the nurs- ing students to integrate the knowledge while practicing the skills (Ross, 2012). Nursing students get the oppor- tunity to practice their clinical and decision-making skills through varied real-life situational experiences without compromising the patient’s safety through simulation-based clinical education (Kim et al., 2016).

Simulation-based clinical education is an experiential learning technique, which involves placing the learners in patient care situations created by instructors in order to maximize the learning in real situations that learners may encounter. This involves an active preparation by the educators where the degree of realistic situation ranges from completely artificial to an actual real-life like situation. This includes many delivery methods that involve actors trained as standardized patients who play out specific situation, and artificial modes, which include basic low-fidelity simulators (LFS), mid- fidelity simulators (MFS), and high-fidelity simulators (HFS). With LFS, mannequin parts that simulate patient situations such as wounds, fractures, and arms for intravenous calculations are used. The MFS allows simulations that use mannequins with some, but not all features of human beings (Hicks et al., 2009). High- fidelity simulation refers to a simulation activity that integrates the use of a full body manikin that can be programmed to deliver the response which is physiolog- ical in nature to the actions of students (Blakeslee, 2019).

The use of simulation in health care has various ben- efits. It is well documented that simulation improves the psychomotor skills, assessment skills, communication, and management skills (Nestel & Bearman, 2015; Yuan et al., 2012). The simulation scenarios are created according to the knowledge and experience level of the participants (Motola et al., 2013). The skills are rehearsed and practiced by the participants in simulation for a better application in the real clinical practice (Dieckmann, 2009; Westwood, 2014).

The practice of skills in the simulation laboratory provides a safe and effective environment for undergrad- uate students to acquire the clinical skills (Lynagh et al., 2007). This training improves the knowledge, skills, and behavior of students as compared with the direct clinical training. The training of the skills in the simulation lab- oratory enables the students to perform the skills faster and in an accurate manner (Lund et al., 2012).

The practice of skills deliberately in the simulation laboratory using LFS, MFS, and HFS results in an improvement of procedural skill acquisition of students. The practice of skills in the laboratory along with inter- mittent feedback results in better and smoother

performance. Furthermore, the training of the students in the skills laboratory leads to higher scores in Objective Structured Clinical Examination (Bradley & Bligh, 1999; Herrmann-Werner et al., 2013; Junger et al., 2005).

Simulation-based nursing education increases the clinical competency of nursing students. However, the repetitive practice of skills through simulation results in long-term retention of both low- and high- complexity skills (Ericsson, 2007; Lammers, 2008). Repeated simulation experience also enhances the tech- nical skills and critical thinking skills (Abe et al., 2013). Similar findings are reported by many authors across the world (Boling & Hardin-Pierce, 2016; Bowling & Underwood, 2016; Lubbers & Rossman, 2016; Cummings & Connelly, 2016; Kaddoura et al., 2016; Shin et al., 2015; Ko & Kim, 2014; Abe et al., 2013; Mould et al., 2011; Brewer, 2011; Guhde, 2011).This makes it very evident that repetitive simulation enhances the clinical competence of nursing students.

Having the evidence that repetitive simulation enhan- ces the clinical competence of nurses and nursing stu- dents, the authors of this article reviewed the existing literature on the effect of repeated simulation experience on nurses and nursing students’ competence, self- confidence, knowledge, critical thinking, and satisfaction with learning. Delivery methods and type of fidelity are also included to add more relevance to the article. Findings could help nurses, nursing students, and nurse educators to be aware of the potential impact of simulation and may imply that simulation education is a best practice. Furthermore, conclusions could help edu- cators to value or adopt simulation experiences as an effective teaching methodology in nursing education.

Methods

Integrative review of literature was done through a sys- tematic process in an attempt to understand the effect of repeated simulation experience on nurses’ and nursing students’ competence, self-confidence, knowledge, criti- cal thinking, and satisfaction with learning of nurses and nursing students. With the existing available qualitative and quantitative literature, an integrative review method was utilized. The CINAHL, Medline, and ProQuest data base were searched using combination of keywords such as nursing education, simulation experience, debriefing, effect, self-confidence, undergraduate nursing students, and nursing. The peer-reviewed literature published in English between January 1, 2011 and December 30, 2019 was used for the review to find the most updated literature.

Initially, 60,618 results were obtained with the use of simulation experience and its related keywords. After this, the search was narrowed down to nursing (Figure 1). A total of 11,445 articles were retrieved. Thereafter

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400 articles were obtained when the keywords were fur- ther limited to repeated simulation experience. Although single simulation experiences were studied in many articles, those were rejected to conserve the main focus of repeated simulation experience. These articles were hand searched and those with general information, com- mentary, speech/lecture, biography, and instructional material/guideline were excluded. The use of limiters such as timeframe from January 1, 2011 to December 30, 2019, English language, peer-reviewed journals, and nursing and ProQuest data base reduced the number to 25. All 25 articles were further analyzed based on the availability of keywords repeated simulation experience and nurses and nursing students’ competence, self- confidence, knowledge, critical thinking, and satisfaction with learning. This resulted in 11 articles for the analysis.

The rigor and bias were addressed as follows: the authors screened the titles and abstracts of each relevant article in the first step after the elimination of duplicates. In the second step, the authors independently evaluated each relevant full texted article for eligibility and dis- agreement was settled by consensus. The authors inde- pendently carried out data extraction. In the third step, the authors collected relevant data from the articles and consolidated it into an article review matrix.

The narrative analysis was done to interpret the text in this article as only limited literature was available to generate the evidence of effect of repetitive simulation on nurses and nursing students’ competence, self- confidence, knowledge, critical thinking, and satisfaction with learning.

Results

The detailed information of the articles analyzed through narrative analysis is appended in online Appendix A, Article Review Matrix. The outcome var- iables analyzed in this article included nurses and nurs- ing students’ competence, self-confidence, knowledge, critical thinking, and satisfaction with learning. However, the authors have included the findings of two other variables which are delivery of simulation and type of fidelity. The authors felt that these variables would add more value to the article as these are more relevant to the simulation experience.

Delivery of Simulation

Across studies, there are variations in timing and design of simulations. In terms of the total time of simulation experience, a period of 7 to 9weeks is sufficient to achieve desired outcomes for undergraduate nursing stu- dents (Bowling & Underwood, 2016; Cummings & Connelly, 2016; Kaddoura et al., 2016; Smith & Roehrs, 2009).In contrast, Abe et al. (2013) required

6months to conduct simulation training for cardiovas- cular nurses in a hospital. These nurses participated in two to three case scenarios during the 6-month training. These data inform us that a minimum of 7 to 9weeks of simulation experience is adequate to achieve the desired outcome among nursing students.

Type of Fidelity

Some studies were conducted to compare the effects of LFS versus HFS experiences. For instance, Bowling and Underwood (2016) examined the difference in the simu- lation outcome between MFS and LFS. They found that the knowledge, self-confidence, and skill performance outcomes improved following simulation, but there was no difference in the outcomes between the two types of simulation. In addition, Guhde (2011) found that all participants scored high means on critical think- ing, assessment, and satisfaction with teaching following the simple and complex case scenario simulations (M¼ 4.74, SD ¼ 0.50), and there were no significant differences between the simple and complex in improv- ing the learner’s knowledge (p> .05). It appears that sim- ulation, ranging from low to high fidelity, is considered a good strategy for enhancing student outcomes.

Competence, Self-Confidence, and Knowledge of Nurses and Nursing Students

Several studies examined the effect of repeated simula- tion scenarios on nursing students’ competence and self- confidence. For example, in a survey of 54 baccalaureate students, Cummings and Connelly (2016) found that the students reported that their mastery of skills and critical thinking improved after repeated simulation experience. Students reported that they experience active learning and active participation during simulation, which enhanced their competence.

In addition, in a classic experimental study by Mould et al. (2011), students were evaluated on perceived con- fidence and competence after repeated simulation sce- narios. The tested intervention was a series of 27 case scenarios delivered over 9weeks; each student experi- enced 17 to 18 simulations. The authors found a stati- cally significant increase from baseline in perceived level of student confidence (63% increase) and perceived com- petence (48% increase).

Ko and Kim (2014) evaluated the effectiveness of multimode simulation learning on 65 junior nursing stu- dents’ problem-solving, critical thinking, and clinical competence. Authors found that multimode simulation learning improved the clinical competence and problem- solving process of nursing students. The problem-solving process in the experimental group who participated in multimode simulation increased by 0.32 points, whereas

Al Gharibi and Arulappan 3

the scores of control group increased by 0.03 points which indicates a statistically significant difference between the groups (t¼ –2.39, p¼ .020). The clinical competence scores of experimental group increased by 0.29 points and the scores of control group decreased by 0.03. This shows a significant difference between both the groups (F¼ 12.76, p¼ .001). There was no significant effect on critical thinking disposition.

In a nonequivalent control group pretest–posttest study, Bowling and Underwood (2016) compared the effects of MFS and LFS simulation on self-confidence, knowledge, and skill performance in 77 baccalaureate students enrolled in pediatric nursing course. Skill per- formance was measured with a mini Objective Structured Clinical Examination; self-confidence was measured by a self-reported questionnaire and knowl- edge was measured by 15 items knowledge question- naire. The MFS simulation experience lasted 30minutes, followed by 20-minute group debriefing; the LFS was a paper and pencil case study. The LFS group scored higher on self-confidence (t¼ 2.213, df¼ 71, p¼ .03) than the MFS group. Both groups exhibited significantly increased postsimulation skill per- formance (p< .0001), with no difference between the LFS and HFS groups (p¼ .123).

Using a quasi-experimental pretest/posttest design, Lubbers and Rossman (2016) studied the effects of a pediatric community simulation experience on self- confidence among 54 senior baccalaureate students. The study took place in a private institution in the Midwestern, United States. The simulation experience was given once a week for approximately 3.5 hours each week for 7 weeks. The intervention involved approximately 1 hour spent in simulation and debriefing which was preceded by presimulation and followed with postsimulation exercises included within the Simulation Learning System. Self-confidence was measured using a survey developed for the study to measure self- confidence and the author included four subcategories as a part of the students’ self-confidence which included students’ knowledge, skill, communication, and docu- mentation. The study showed significant increase in overall self-confidence (t¼ 20.70, p< .001).

Repeated simulation has also been evaluated among practicing registered nurses. Abe et al. (2013) evaluated repeated simulation scenarios during a 6-month training program for 27 cardiovascular critical care nurses work- ing in a Tokyo hospital. The baseline scores after the first simulation showed low levels of self-reported self- confidence and competence. As the number of simula- tion scenarios increased, rubric scores of competence and confidence increased.

In a systematic review to examine the effect of HFS training among critical care providers, Boling and Hardin-Pierce (2016) did a meta-analysis for self-

confidence and knowledge of critical care providers. Of the 17 studies included in the review, 13 examined the effect of simulation on provider self-confidence. In most articles, self-confidence was measured by self-rated survey. All studies showed that repeated simulation training improved self-confidence of nurses. It had been found that, confidence level was consistently higher in the experimental groups who participated in the simulation exercise. Seven studies focused on partic- ipant’s knowledge as an outcome. In all seven studies, participants rated their knowledge as greater following the simulation intervention. The researchers concluded that HFS is a valuable means for improving knowledge and confidence among critical care workers and advised inclusion of simulation in critical care training curricula.

Critical Thinking

The effect of simulation on Critical Thinking (CT) has also been studied. Shin et al. (2015) studied the effect of repeated simulation scenarios on 237 baccalaureate stu- dents’ CT level (N¼ 237). In this experimental study, a control group of students experienced one scenario, an experimental group of students had two different simu- lation sessions, and another experimental group had three different simulation sessions. Yoon’s Critical Thinking Disposition tool (2008) was used in this study to measure the CT of the students. The authors found that CT scores varied according to the number of exposures to simulation experiences. The results showed that students who had three simulations showed more CT gains in the subcategories of prudence and intellec- tual eagerness. The students who were exposed to two simulation scenarios also had improved scores in CT when compared with students who underwent one simulation.

To compare the effect of complex versus simple human patient simulation scenarios on CT and learner satisfaction, Guhde (2011) conducted a quasi- experimental, quantitative study among134 junior nurs- ing students. Simulation scenarios were delivered over 6weeks. During the first 4weeks, a simple one-event sce- nario was implemented. On Week 5, the students were evaluated. On the last 2weeks, students were doing a complex role-playing scenario. On Week 7, students’ responses showed a high mean CT scores (M¼ 4.69, SD¼ 0.53). The means were slightly, but not significant- ly, higher on the complex scenarios compared with the simple case scenario. The researchers concluded that HFS can heighten CT.

Student Satisfaction With Learning

Student’s learning satisfaction also were investigated by many researchers. For example, in a qualitative study,

4 SAGE Open Nursing

Kaddoura et al. (2016) interviewed nursing students

(N¼ 107) to explore the perception of first-degree

Bachelor of Science in Nursing (BSN) students about

their perceived benefits and challenges of repeated expo-

sure to HFS in the first medical-surgical nursing course.

The exposure of students to seven different health sce-

narios were evaluated consecutively in a single experi-

mental session. They found that most of participating

students were satisfied with the knowledge; they gained

post simulation confidence and perceived HFS as an

active teaching pedagogy that contributes to their CT,

clinical competence, self-confidence, and integration of

knowledge by bridging the theory-practice gap. Using a quasi-experimental design, Lubbers and

Rossman (2016) also studied student satisfaction with

learning. Student satisfaction with the learning experi-

ence was measured by a 1 to 5 point Likert-type scale

with 5 indicating very satisfied. Students also reported a

high level of satisfaction with their simulation experience

(M¼ 4.36, SD¼ 0.50). Their finding is consistent with

others (Abe et al. 2013; Kaddoura et al., 2016; Smith

& Roehrs, 2009). For example, Smith and Roehrs

(2009) reported that all nursing students were satisfied

(M¼ 4.5; SD¼ 0.5) with the knowledge they gained

because of simulation, concluding that students were sat-

isfied with teaching pedagogy. The mean satisfaction

with learning knowledge score for students with clinical

experience was 4.5 (SD¼ 0.5) compared with 4.6

(SD¼ 0.4) for students without any clinical experience,

that was found to be insignificant (p¼ .05).

Discussion

In the evidence, participants were junior and senior

undergraduate BSN students or staff nurses. The level

of confidence, competence, CT, satisfaction with learn-

ing, and knowledge were measured before and after the

simulation training. Sample sizes, which varied, involved

either convenience or random sampling. The students

were exposed to multiple different simulation experien-

ces throughout semesters and were provided with expe-

riential sessions and simulation debriefing sessions.

Open-ended question surveys and Likert-type scales

were used to evaluate self-confidence, competence,

knowledge, learning satisfaction, and CT. The objective

measurement tools reported were self-efficacy

Records identified through database searching

(n = 60,115 )

Sc re

en in

g In

cl ud

ed

E lig

ib ili

ty

Id en

ti fi

ca ti

on Additional records identified

through other sources (n = 503 )

Records after duplicates removed (n = 14,567 )

Records screened (n = 11,445 )

Records excluded (n = 7,445 )

Full-text articles assessed for eligibility

(n =400)

Full-text articles excluded, with reasons (n = 375 )

Studies included after the use of limiters (n = 25 )

Studies included in narrative analysis

(n =11 )

Figure 1. PRISMA Flow Diagram.

Al Gharibi and Arulappan 5

assessment tools (Boling & Hardin-Pierce, 2016), Simulation Learning System (Lubbers & Rossman, 2016), and Yoon’s Critical Thinking Scale (Shin et al., 2015). However, most of the outcomes were self- reported measures. This indicates the need to develop objective measurement tools to assess the competence, self-confidence, knowledge, CT, and satisfaction with learning.

None of the investigators measured the practice of the nurses and nursing students on their direct clinical prac- tice after the exposure to repetitive clinical simulation. Therefore, future research is needed to determine the competence, critical thinking, and self-confidence of nurses and nursing students to indicate that simulation enhanced the skills and confidence level of the nurses for a better practice in the actual clinical setting. Investment in terms of simulation in nursing curriculum will improve the clinical practice of nurses; therefore, the quality of patient care will be improved.

Most of the evidence shows that simulation using dif- ferent case scenarios each time over a semester of a course enhanced students’ self-confidence, competence, and CT. Moreover, students were satisfied with their learning and believed that the simulation experiences enhanced their knowledge. In addition, evidence showed that a range of simulation fidelity enhanced stu- dents’ self-confidence, competence, knowledge, and crit- ical thinking. The use of LFS, MFS, and HFS with repeated simulation experiences is found to be the best teaching practices until now. Therefore, the authors highly recommend integrating the use of LFS, MFS, and HFS with repeated simulation experiences in nursing curriculum to enhance the nursing students’ self-confidence, competence, knowledge, and critical thinking. Also, the nurse’s competence will definitely be improved with the use of repeated simulation experiences.

Limitations

The authors have reviewed and summarized the litera- ture pertaining to both nurses and nursing students although the knowledge, skills, attitudes, and behaviors vastly differ across these groups as very limited literature is available. However, the authors intended to convey that repeated simulation enhances both the nursing stu- dents and nurses’ self-confidence, competence, knowl- edge, and critical thinking. Despite the abundance of literature available about simulation in undergraduate nursing students, researchers have yet to study the effect of repeating the similar simulation experience after debriefing with facilitators. This aspect merits investigation because there are two possible outcomes from practicing the same experience after debriefing with instructors. First, students may be more confident

because they will be able to correct their mistakes done

during the first simulation experience while improving

their skills. A second possible outcome is that immediate repetition of the same simulation experience will be a

waste of time because students could benefit more

from practicing in different experience.

Priorities for Future Research

Therefore, the authors would recommend a study to

evaluate the effect of repeating same simulation practice post debriefing on students’ learning outcomes.

Future research could be directed toward determining

the competence, critical thinking, knowledge, and self-

confidence of nursing students and nurses in the real

clinical setting after exposure to repetitive simulation experience. Moreover, future studies are required to

develop objective tools to measure the competence, crit-

ical thinking, knowledge, and self-confidence of nursing

students and nurses.

Highlights

• The review concluded that simulation enhances nurs- ing students’ and nurse’s self-confidence, competence,

knowledge, critical thinking, and satisfaction. • Repetitive simulation experience shall be valued and

adopted as an effective teaching methodology in nurs- ing education by the nurse educators.

• Repetitive simulation enhances the nurse’s compe-

tence and knowledge while providing nursing care.

Author contributions

Koukab Abdullah Al Gharibi conceived, designed, and per-

formed the study. He also analyzed and interpreted the data

and wrote the initial draft of the article. Judie Arulappan

reviewed, edited, and finalized the article.

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.

Funding

The author(s) received no financial support for the research,

authorship, and/or publication of this article.

ORCID iDs

Koukab Abdullah Al Gharibi https://orcid.org/0000-0003-

2773-8067 Judie Arulappan https://orcid.org/0000-0003-2788-2755

Supplemental Material

Supplemental material for this article is available online.

6 SAGE Open Nursing

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