Nurse Education Today 36 (2016) 298303

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

Perceived benets and challenges of repeated exposure to high delity

simulation experiences of rst degree accelerated bachelor
nursing students
Mahmoud Kaddoura a,, Olga Vandyke b, Christopher Smallwood c, Kristen Mathieu Gonzalez d
a

Duke University North Carolina, United States

MCPHS University Massachusetts, United States
c
University of Texas at Tyler Texas, United States
d
Northeastern University Massachusetts, United States
b

a r t i c l e

i n f o

Article history:
Accepted 17 July 2015
Keywords:
Simulation
High delity simulation
Multiple simulations
First degree accelerated nursing students
Critical thinking
Competence
Condence
Nursing education

s u m m a r y
This study explored perceptions of rst-degree entry-level accelerated bachelor nursing students regarding benets and challenges of exposure to multiple high delity simulation (HFS) scenarios, which has not been studied
to date. These perceptions conformed to some research ndings among Associate Degree, traditional nonaccelerated, and second-degree accelerated Bachelor of Science in Nursing (BSN) students faced with one to
two simulations. However, rst-degree accelerated BSN students faced with multiple complex simulations perceived improvements on all outcomes, including critical thinking, condence, competence, and theory
practice integration. On the negative side, some reported feeling overwhelmed by the multiple HFS scenarios. Evidence from this study supports HFS as an effective teaching and learning method for nursing students, along
with valuable implications for many other elds.
2015 Elsevier Ltd. All rights reserved.

Introduction
The complexity of the current healthcare environment poses challenges to students whose knowledge and skills are evolving. Educators
need opportunities for their students to practice clinical decisionmaking, but an inadequate number of appropriate clinical placements
limit students' experiences with real patients. Simulated clinical experiences can provide a largely risk-free approach to learning in an environment as close to reality as possible and allow students to construct
knowledge, explore assumptions, and develop psychomotor skills in a
safe setting (Foronda et al., 2013).
Numerous studies have measured outcomes from simulations after
exposing students to one or two scenarios. Yet, there is limited research
on simulations involving multiple scenarios, where instead of one or
two health scenarios evaluated in a single experimental session, this
study used seven different health scenarios evaluated consecutively in
Acknowledgment: The authors would like to acknowledge the support of DUKE
AHEAD writing team for their support and guidance. Special thanks are extended to Dr.
Marilyn Oermann for her motivation and constructive feedback that contributed to this
publication. Many thanks are also extended to Dr. Judy Hays, Duke University, for
editing and rening this paper.
Corresponding author at: 1560 Alemany Street, Morrisville, NC 27560, United States.
Tel.: +1 617 771 2605.
E-mail address: kaddoura123@gmail.com (M. Kaddoura).

http://dx.doi.org/10.1016/j.nedt.2015.07.014
0260-6917/ 2015 Elsevier Ltd. All rights reserved.

a single experimental session. Exposing students to multiple scenarios

all at once is important because multiple scenarios mimic actual nursing
practice better and provide a wider breadth of experience than one or
two scenarios. Additionally, simulation studies conducted in entrylevel nursing education have been limited to diploma, associate degree
nursing (ADN) programs, traditional 4- to 5-year Bachelor of Science in
Nursing (BSN) programs, and second-degree accelerated baccalaureate
nursing (ABSN) programs. Accelerated nursing programs, also known as
a second degree nursing program, are usually 1624 months in duration
offered for adult learners who have a prior non-nursing degree. The
rst-degree ABSN program, the setting of the study reported in this
paper, is designed for learners who have completed high school
(Goodstone et al., 2013; Kaddoura, 2013; Lucas, 2014). To-date, no simulation studies have been conducted in a rst-degree ABSN program,
adding to the uniqueness of this study.
This study lls gaps in previous research that evaluates the effectiveness of clinical simulation for entry-level nursing students by assessing
rst-degree ABSN students' perception of multiple simulated scenarios
in their rst medicalsurgical nursing course.
Review of Literature
The body of research on clinical simulation as a novel, supplemental
teachinglearning strategy in nursing education is growing. Students

M. Kaddoura et al. / Nurse Education Today 36 (2016) 298303

engaged in clinical simulation may learn how to make sound decisions

in unpredictable health care situations that are time-sensitive and require critical thinking and advanced skills (Mills et al., 2014). Simulation
can be categorized as low-, moderate-, or high-delity, according to
how closely it represents a realistic situation (Meakim et al., 2013).
Sharp et al. (2014) dened high-delity simulation (HFS) as that
which exposes students to high-risk scenarios to which they are not
routinely exposed in traditional clinical settings. HFS commonly
employs role-play to foster affective, cognitive, and psychomotor domains of learning (Kaddoura, 2012; Kaddoura and Williams, 2012;
Lowenstein, 2014). The prevalence of HFS is growing in nursing education in response to a signicant gap between the demands of current
nursing practice and the nurses' education for that practice (Benner
et al., 2010). HFS may be a powerful educational tool that can narrow
this gap in a cost-effective and productive manner (Tawalbeh and
Tubaishat, 2014).
Research on simulations among non-rst-degree ABSN entry-level
nursing programs has focused on learner outcomes of satisfaction,
self-efcacy, self-condence, competence, critical thinking (CT), clinical
judgment, and knowledge gain. In that context, student response to HFS
has been reported as positive with high degrees of satisfaction (Sharp
et al., 2014; Tawalbeh and Tubaishat, 2014). Other researchers have reported increases in self-efcacy and self-condence after HFS experiences (Cardoza and Hood, 2012; Kaddoura, 2010; Lucas, 2014).
Clinical competence (Bultas et al., 2014; Lucas, 2014), critical thinking
(Goodstone et al., 2013; Kaddoura, 2010; Loke et al., 2014) and clinical
judgment (Bultas et al., 2014; Hao et al., 2014; Lucas, 2014) were also
shown to be higher after a HFS experience. Nursing students' knowledge acquisition and knowledge retention were found to signicantly
improve with HFS (Tawalbeh and Tubaishat, 2014). Immediate knowledge gain was not signicantly different between groups of students
participating in HFS and those exposed to case studies (Sharp et al.,
2014).
Critical thinking was found to have no signicant difference between
the simulated and traditional group of ADN students in the Health Sciences Reasoning Test posttest scores when an experimental pretest/
posttest design was used. Critical thinking was measured in 42 rstsemester ADN students using a two-group quasi-experimental design
in relation to an 8-hour simulated learning experience versus a traditional clinical experience for 45 second-year nursing students in a
maternalchild course (Rome, 2012). On the other hand, critical thinking difference scores increased from pretest to posttest when HFS experiences were evaluated in non-rst-degree ABSN entry-level nursing
students using Elsevier's Health Education Systems, Inc. (HESI) and
California Critical Thinking Disposition Inventory scores (Melenovich,
2012).
Clinical competence was evaluated in a quantitative experimental
study of the impact of HFS on fourth-semester ADN students: the experimental group completed an HFS experience plus a case study on delegation versus the control group that was exposed to the case study
only. Pretest and posttest scores were compared using the Nursing Assessment Decision Grid (NADG), and the experimental group NADG
scores improved signicantly more than the control group (Garneau,
2012). Conversely, in a longitudinal study of ADN and traditional nonaccelerated BSN students, participation in HFS for a portion of their clinical practicum did not signicantly improve their perceived clinical
competence, as measured by the Clinical Competence Appraisal Scale
(Sportsman et al., 2011).
The impact of HFS on knowledge gain was examined when six graduating ADN cohorts were compared using standardized exit examination scores to evaluate the impact of exposure to different amounts of
simulation on scores. No signicant differences were found on exit examination scores or graduating GPA when three years of seniors were
compared (Sportsman et al., 2011). Yet, statistically signicant knowledge gains were reported in groups exposed to HFS using a pretest/
posttest design. The use of simulation was examined in the classroom

299

with 45 ADN students. Results showed that signicant learning occurred. Student perceptions of the classroom simulation were measured
using a Likert scale, along with open-ended comments. Students perceived their knowledge had improved by integrating simulation into
the classroom (Beyer, 2012).
Self-condence and self-efcacy gains through HFS were measured
in non-rst-degree ABSN entry-level nursing programs, and research
ndings have been consistent in showing a positive effect (Garrett
et al., 2011; Mould et al., 2011; Sportsman et al., 2011). Students felt
more condent in their ability to care for their patient after participating
in the simulation activity (Garrett et al., 2011). Competence and condence were found to improve with HFS, and the scores were highly correlated (Mould et al., 2011). Similarly, measurements for competency
signicantly improved after HFS experiences (Sportsman et al., 2011).
Thus, where simulations of one to two scenarios have been tested,
HFS has shown improved outcomes such as students' satisfaction, selfefcacy, clinical judgment, self-condence, and clinical competence.
On the other hand, outcomes such as critical thinking and knowledge
gain were found to show no signicant difference between groups in
traditional and simulated clinical experiences where one to two scenarios have been examined. All of these ndings were reported among
ADN, non-rst-degree ABSN, or traditional BSN students. The purpose
of this study is to expand the science base by exploring the following research question: Are these outcomes similar or different among rstdegree entry-level accelerated nursing students exposed to multiple
scenarios?
Methods
Study Design
An exploratory qualitative research design using open-ended survey
methods was used to explore the perceptions of rst-degree ABSN students about their perceived benets and challenges of repeated exposure to HFS. The descriptive exploratory design was consistent with
the authors' intent to uncover and provide an accurate description of
the subjective HFS experiences of students. The exploration of multiple
scenarios may provide for a better understanding of participants' perceived benets and challenges of repeated exposure of students to
HFS scenarios and explore factors that may inuence their experiences.
It also allows for better assessment for how different scenarios may inuence students' capacities to learn new information and provide a better platform for improving HFS experiences of students. This design may
also help the researchers determine the best methods to be used in a
subsequent study (Patton, 2015).
Sample and Setting
The convenience sample (N = 107) consisted of all rst semester
senior-level nursing students enrolled in a 32-month, rst-degree
ABSN program for high school graduates at a private university. The
rst year of the program consisted of a strong science foundation and
required general education courses, and subsequently two years focused on fullling ABSN requirements. This program consistently produces more than 50 new graduates annually. If its student outcomes
prove robust, such a program could provide an important model for
contributing to the overall pool of available professional nurses across
the globe. The sample was assessed at the beginning of the medicalsurgical nursing course during the rst semester of the third year. The sample of students had never been assigned to a clinical setting and had no
previous exposure to HFS.
Procedures
Following approval of the University's Institutional Review Board
(IRB), participants were invited to participate in the study during the

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M. Kaddoura et al. / Nurse Education Today 36 (2016) 298303

rst week of class by the principal investigator who provided information and answered students' questions regarding the study. Firstsemester students in the senior year who volunteered to participate in
the study signed an informed consent. It was emphasized to the students that the simulations were primarily prepared for instructional
purposes rather than for assessment purposes. To ensure that the
study was free of any risks, the consent form was administered by a clinical teaching assistant who was not associated with the participants.
Ethical behavior by the researchers was highly emphasized and concrete steps were taken to protect the study participants. None of the researchers were involved with teaching their own students who
consented to participate in the study. Students were assured that anonymity and condentiality would be maintained and that their participation would not affect any of their rights as a student. Contact details
of student support groups were provided for anyone who felt distressed
about any of their experiences during this study and who needed
support, but none were used. The researchers actively monitored the
students for signs of distress and the students were afforded the opportunity to openly talk about any potential concerns about their study
experiences.
The clinical lab instructors for the Medical Surgical Nursing course
conducted the clinical simulation. Groups of ve students participated
in each of seven 15-minute HFS scenarios, followed by 15 min of
debrieng to reect on the experiences, reinforce important concepts,
and clarify any difcult issues. The high-delity mannequins were controlled through a two-way mirrored glass window that is located adjacent to the simulation space in the lab. This mirror is used for viewing
students from the control room, which separates the nursing instructor
from the students during simulation. The mirrored glass screen assists
in creating a more effective simulation in a realistic-appearing hospital
room. The faculty can observe and facilitate the scenario without
disrupting the participant or inuencing or increasing their stress during the scenarios. Instructors can also operate simulators from the control room to modify the simulation in progress and provide a voice for
the patient through the manikin. One lab instructor was the voice for
each patient, and a second lab instructor interacted with and guided
the students through the scenarios, which played out according to script
design, with participants unaware of the patient's ultimate diagnosis.
After each scenario, a trained facilitator debriefed the participants
and engaged them in dialogue about their experiential learning in the
scenarios and actual practice setting. During debriengs, students' discussions were facilitated to connect the diagnosis, assessment ndings,
treatments, nursing care, safety issues, and any other concerns.
Although students were informed that the main goal of the HFS experience was not an assessment, but rather to create a valuable learning
opportunity for the participants, some students may still feel anxious
about being observed by a lab instructor who will provide them with
constructive feedback along with their peers. This is often referred to
as simulation anxiety syndrome (Blazeck, 2011).

medical surgical coursework, develop skills, and clarify values. The students were required to identify patients' various needs, perform regular
nursing procedures efciently, and demonstrate therapeutic communication skills in conjunction with their management of crisis situations.
Data Collection and Analysis
Data were collected using pencil and paper surveys. Ten open-ended
questions explored students' perceptions of the benets and challenges
of HFS experiences. The questions' general scope focused on how the
students applied what they learned in the Medical Surgical Nursing
course through their interactions with the simulated patients.
Content-analysis method was used to analyze the data and derive
themes to make sense of participants' responses. The Atlas.ti version7.5.3 qualitative data analysis software was used to code the data.
Data coding was done individually by the primary investigator and
then by another coder. Over 90% consistency on the codes was identied by both coders. Codes were then categorized to generate the
themes.
Results
Demographic Findings
Of the 107 participants, 96 were female and 11 were male. The
participants' ages ranged between 20 and 42 years old with a mean of
23.5 years (SD = 3.86 years). Most participants were Caucasian (N =
61), 18 were Asian, 17 were African-American, and two had unidentied race categories. None of the participants had any college education
prior to their ABSN program, and none had participated in simulations
with a HFS before this study.
Themes
HFS was perceived by students as promoting ve attributes: critical
thinking, condence, competence, theorypractice integration, and
knowledge decit identication. A few students perceived that repeated
experiences with HFS were challenging as they revealed their lack of
prior knowledge helped lead to feelings of being overwhelmed.
Critical Thinking Skills Development
Most participants perceived that HFS contributed to the development of critical thinking skills. For example, one student stated, The
scenarios were complex enough to get me thinking on my feet about
the big picture. I was able to reason clinically and make sound clinical
judgments. Another student reported that HFS advanced his ability to
interpret data and make inferences and reasonable clinical decisions
to stabilize a patient. Some students stated that repeating HFS sessions
helped them learn to prioritize patient needs and think about alternate
options for care.

Simulations
The simulation sessions were conducted in a simulation laboratory.
High-delity mannequins with simulated breath sounds, pulses, and
the ability to respond verbally to questions from health care professionals were used. The simulator used was the Laerdal SimMan High
Fidelity Simulator. The seven scenarios used in this study included
(1) acute coronary syndrome, (2) asthma exacerbation, (3) diabetes,
(4) fractures, (5) stroke, (6) geriatric patient with urinary tract infection, and (7) delirium/dementia.
For each simulation scenario, students were presented with an acute
or chronic patient problem with concrete learning objectives that drove
the parameters of each scenario. Students were asked to demonstrate
cognitive and psychomotor skills to solve each patient's problem.
Students were engaged in direct life-like experiences and focused
reection to apply understanding of the theory presented in their

Clinical Competence Development

Many students perceived that repeated exposure to HFS allowed
them to develop their clinical competence. As an example, a student
said, The HFS helped me become competent in skills like Cardiopulmonary Resuscitation (CPR), debrillation, and team work. Some students
reported that learning from their own mistakes and from their peers
and faculty boosted their competence. Another student stated, The
HFS prepared me well to be competent when I take care of patients
with stroke, asthma, and Chronic Obstructive Pulmonary Disease
(COPD). I am capable now of handling skills I was previously afraid of
doing.
Self-condence Development
Participants perceived that repeated exposure to HFS fostered their
self-condence in providing safe nursing care for patients with altered

M. Kaddoura et al. / Nurse Education Today 36 (2016) 298303

physiological and mental health conditions. As a case in point, one student stated, The HFS taught me how to condently talk to patients,
family members, and healthcare providers. Some students reported
that the repeating HFS experiences helped them adapt to the clinical
practice as they felt better prepared to deal with similar real-life situations with less anxiety. One student said, The HFS experiences boosted
my condence as I feel that I am able to be calmer and more exible in
stressful situations.
Theory Integration into Practice
Many participants perceived that HFS helped them integrate the
knowledge they learned in class into practical clinical situations. For instance, one student stated, The repeated exposure to HFS aided me to
put the content I learned in the medicalsurgical class into practical
context and apply it. Many reported that course content that lacked a
meaningful context made sense only when simulations assisted them
with imagining how theory was applicable to practice.
Knowledge Decit Identication
Students reported that repeated experiences with HFS revealed their
lack of knowledge about clinical practice. For example, one student stated, Repeated exposure to HFS established that I was unable to consider
what my nursing actions in a given situation might be. I did things the
way I learned in class, but I was challenged with what I didn't learn
and what I should have learned. Another student reported that he
lacked an understanding of why to perform certain interventions and
how assessment components linked together.
Feelings of Being Overwhelmed
Finally, some participants felt overwhelmed during the simulations.
One student stated, I was overwhelmed with the acute changes some
of my simulated patients had, and I did not know what to do rst. Another student said, I felt there was added pressure to do all steps in
each scenario perfectly because I was aware that the faculty member
was watching from behind the two-sided mirror.
Discussion
The study ndings showed that students getting a rst college degree in an accelerated nursing program faced with multiple complex
simulations perceived that HFS experiences improved their critical
thinking, clinical competence, condence, and theory practice integration skills. A key strength of good qualitative research is a discussion
of which contextual factors in a given setting or system may have had
an impact on a successful (or failed) implementation of clinical practices
and treatments. The current study was the rst to be conducted in the
context of a rst-degree, entry-level accelerated program for nursing
students.
The participants in this study reported that they were able to think
critically about their simulation experiences in valuable ways. These
participants' perceptions of HFS as an effective method of learning
that aided in developing critical thinking skills are consistent with
Kaddoura (2010) who found the same results in traditional, nonaccelerated nursing students. They are also consistent with the ndings
of Garrett et al. (2011) and Sportsman et al. (2011) who found out that
HFS augments the critical thinking of non-rst-degree ABSN entry-level
nursing students faced with 1 to 2 complex simulations. On the other
hand, these perceptions are contradictory to the ndings of Hao et al.
(2014) and Loke et al. (2014), who have demonstrated that simulation
does not increase non-accelerated nursing students' abilities to think
critically. These inconsistent ndings suggest that the methods of
these studies are appreciably different and that future research is needed to continue exploring HFS impact on nursing students from different
programs.
Participants of this study perceived that HFS promotes clinical competence, which has been uniformly reported in the context of other

301

types of programs. The ndings of the current study are consistent

with Bultas et al. (2014), Kaddoura (2010), and Mills et al. (2014)
who found that learning through simulation enables traditional, nonaccelerated nursing students to develop clinical competence. They
are also consistent with the ndings of Garrett et al. (2011) and
Sportsman et al. (2011), who reported that HFS has been used to augment non-rst-degree ABSN entry-level nursing students' competency
in psychomotor learning opportunities in low- and high-risk clinical environments and populations.
Students of this study perceived HFS as a valuable method of learning
that fosters self-condence. These perceptions of simulations as a means
of helping students to learn condently to be nurses are consistent with
second-degree entry level accelerated students whose condence level
was found to signicantly increase after exposure to one to two simulations (Lucas, 2014; Cardoza and Hood, 2012; Parker et al., 2011; Rush
et al., 2012; Slager et al., 2011). They are also similar as Kaddoura
(2010) who found that HFS has been showing an overwhelmingly positive effect on increasing traditional, non-accelerated nursing students'
condence levels. On the other hand, they are inconsistent with Liaw
et al. (2012) and Yuan et al. (2012) who found that simulation had no
effect on self-condence of traditional, non-accelerated nursing students faced with one to two complex simulations.
Participants of this study perceived that HFS facilitated the integration of nursing knowledge acquired in class and its application to practice for the caring of patients and their families in clinical settings.
Participants explicitly reported theorypractice integration was demonstrated through transfer of learning and application of their knowledge and skills. They reported HFS afforded them the opportunity to
make connections between concepts through their active engagement
in the learning process, and integrate knowledge from class to practice
and skills from the HFS clinical setting to the traditional clinical setting.
These perceptions conform to the ndings of Gates et al. (2012), Liaw
et al. (2012), and Yuan et al. (2012) who reported a signicant gain in
knowledge of traditional, non-accelerated nursing students after participation in a simulation exercise with one to two complex simulations.
Conversely, they are inconsistent with Cardoza and Hood (2012) and
Parker et al. (2011) who have found lack of clear evidence indicating
that the knowledge gained during the simulation transfers of seconddegree entry level accelerated students to the clinical setting.
Despite its perceived benets, a few participants had a negative attitude toward HFS, regarding it as an unfavorable method of learning that
incites unpleasant emotions, humiliation, and overwhelming feelings.
This is consistent with Davis et al. (2014), who found that simulation
highlighted decits in traditional, non-accelerated, undergraduate students' knowledge and understanding of vital nursing skills after exposing them to one to two simulations. Even though different students
experienced the same simulation, their reactions were not identical.
Some students felt humiliated and embarrassed when they performed
poorly in front of their instructor or peers. Such concerns decreased
the interest of non-rst-degree ABSN entry-level nursing students
faced with one to two complex simulations (Sharp et al., 2014; Cook
et al., 2013). Providing students with simulation-based learning without
consideration for students' academic background and learning styles
can result in a negative effect on students' learning experiences, despite
potential advantages (Cook et al., 2013).
Even though participants reported discomfort being observed during simulation, they recounted that anxiety during simulation did not
change their learning outcomes. HFS allows learners to experience clinical scenarios without risks to patients (Oermann and Gaberson, 2014).
Anxiety, an overwhelming feeling of uneasiness from a real or perceived
risk, might interfere with the ability to think critically. Despite offering a
safe place to practice patient care without harm to real patients, the experience of learning in simulation laboratories is not stress-free, and
many nursing students report signicant anxiety associated with simulation practice (Gantt, 2013). When a learner shows signs of overwhelming feelings during a simulation, it should be suggested to them

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to rely on the expertise of professionally trained laboratory staff. It is

recommended that simulation facilitators should consider the psychological impact of any potentially stressful scenario. Exit interviews
with students to monitor their psychological and emotional state are a
potential solution to this problem.
Overall, clinical competence would seem to be the single outcome
that is consistently showing change for the better, related to HFS,
among students in all types of programs. The other outcomes all show
inconsistent ndings: some signicant improvement and some insignificant change, although the students in this study uniformly perceived
HFS positively on all dimensions related to clinical competence.
Limitations
One limitation is that the study only used a convenience sample
from a single nursing program. Another limitation was that only selfreported perceptions were assessed; a more comprehensive assessment
might have included observations by faculty raters or quantitative
knowledge examinations. Some of the students mentioned that they
felt pressure during the simulations due to the knowledge that they
were being watched by a researcher. Future studies should include at
least a small control group where the impact of knowledge of being
watched while performing a simulation could be measured. For the
HFS procedural aspect, future studies would benet from studying the
differences in student performance based upon the order of the individual scenarios. Given the large number of scenarios being tested, it would
be ideal to obtain a better understanding of student attention span and
whether or not knowledge retention and performance are better closer
to the beginning, middle, or end of a session.
Implications
This study provided additional evidence to support HFS as an effective teaching learning method. The integration of HFS into nursing curricula gives students the chance to practice newly learned skills and
reinforce prior knowledge in a safe patient care environment. Condence to participate in rendering care to different patients during HFS
increased because the participants felt they knew what to expect and
what was expected from them after being faced with multiple complex
simulations.
The ndings provided evidence that students getting a rst college
degree in an accelerated nursing program are able to integrate and
transfer knowledge and skills learned in class to the HFS clinical setting
and practice. These ndings provide support to program directors and
nursing educators in rst-degree entry-level accelerated programs as
they work to offer evidence that the nancial investment of HFS is
worth the dividend of helping to produce competent nurses.
Based on the ndings of this study, it is suggested that nurse educators use simulations for students with no other post-secondary education who nd themselves in a time-limited three-year program. It is
recommended that faculty teaching in rst-degree accelerated nursing
programs consider assigning more time in their curriculum to integrate
HFS education as an adjunct to teaching and learning methodologies.
HFS should be used in conjunction with learning acquired from traditional clinical training and didactic instruction. There are no limitations
for use of simulations for these types of non-traditional students. Faculty might calculate the number of simulations in the rst medical
surgical course based on various factors, including content that students
may not encounter in their clinical practice as well as the availability of
clinical sites for the students.
It is crucial to concede that some learners may experience overwhelming feelings beyond the usual level felt by most learners in the
same situation. It is recommended that the best practice guidelines for
simulated clinical activities should include an awareness of the possibility that some learners may experience unusual stress and anxiety responses (Willhaus et al., 2014).

Although this study was done with nursing students in a rst degree
nursing program, the ndings are applicable to using simulation in
other types of programs and specialties worldwide. While the focus on
nurse educators showed the value of this study in teaching, it also has
many other valuable uses in other nursing elds. This could include
retraining or testing programs for nurses who have already completed
their degrees. This would be valuable for nursing elds with very little
margin of error for keeping patients alive, such as nurse anesthesiology,
as it could eventually be used to monitor the professional competency
of these nurses in a controlled setting. Further research should be conducted both nationally and internationally to explore the application
of HFS across programs.
It is further recommended that faculty use multiple simulations in
the laboratory prior to sending students to clinical practice. It is essential
to apply a wide variety of scenarios developed for use in simulationbased education in the area of not only medical surgical nursing, but
also maternity, pediatric and other clinical nursing courses. The simulation scenarios need to be thoughtfully written, but can range from simple to complex, and build on previous knowledge sets so that
simulations can be gradually increased in difculty over the nal year
in a way that is most benecial to the education of the student.
Conclusion and Recommendations
The study ndings indicate that most of the participating students
perceived HFS to be an effective teaching learning tool that contributes
to the development of critical thinking, clinical competence, selfcondence, and integration of knowledge by bridging the theory
practice gap. A few participants perceived that repeated experiences
with HFS were challenging, as they revealed the student's lack of knowledge and led to feelings of being overwhelmed.
The ndings could be used as a cornerstone for application of HFS for
students with no other post-secondary education who nd themselves
in a time-limited three-year program, as an adjunct to clinical practice
and to replace clinical experiences in healthcare settings. Based on the
challenges participants perceived about the HFS, it may be helpful to examine students' individual learning styles and individualize simulation
experiences based on those styles. Simulation provides the opportunity
to carry over into practice those theories learned in lecture to clinical
simulation laboratory in a safe, controlled environment, enabling the
student to recreate real-life situations, thus bringing them closer to an
understanding of the professional nurse's role.
Based on the ndings of this study, it is recommended that further
studies be done that use quantitative measures to evaluate the impact
of simulation on critical thinking, self-condence, and clinical competence. Replication with a larger representation of nursing programs
and expansion of the simulation scenarios to include additional nursing
courses are recommended paths forward.
Recommendations for future research include comparing more than
one nursing program to make ndings more generalizable to all nursing
students. This design would provide a better representation of the
student nursing population. Continued research efforts are needed to
develop valid and reliable measurement tools to measure learning outcomes of simulation and compare HFS and clinical experiences in various clinical courses.
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