Nurse Education Today 36 (2016) 419421

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

Can nursing students' condence levels increase with repeated

simulation activities?,
Cynthia L. Cummings , Linda K. Connelly
University of North Florida, United States

a r t i c l e

i n f o

Article history:
Accepted 3 November 2015
Keywords:
Simulation
Clinical Education
Condence
Active learning
Nursing students
Competence
Scenarios

s u m m a r y
In 2014, nursing faculty conducted a study with undergraduate nursing students on their satisfaction, condence,
and educational practice levels, as it related to simulation activities throughout the curriculum. The study was a
voluntary survey conducted on junior and senior year nursing students. It consisted of 30 items based on the Student Satisfaction and Self-Condence in Learning and the Educational Practices Questionnaire (Jeffries, 2012).
Mean averages were obtained for each of the 30 items from both groups and were compared using T scores for
unpaired means. The results showed that 8 of the items had a 95% condence level and when combined the
items were signicant for p b.001. The items identied were those related to self-condence and active learning.
Based on these ndings, it can be assumed that repeated simulation experiences can lead to an increase in student condence and active learning.
2015 Elsevier Ltd. All rights reserved.

Three years ago, the adult health faculty at our university decided to
increase undergraduate nursing students' exposure to simulation activities. Two faculty members began a concerted effort to incorporate simulation into junior and senior year curriculums. This was done by
including two group and individual simulation experiences in adult
health I, adult health II and their capstone course, professional nursing
integration. We received permission from administration to utilize
these experiences as part of their clinical time. We exchanged 8 h of observation clinical for 8 h of simulated laboratory time. Once we decided
on the number of simulations, we began looking at different systems
and chose an online product that included pre- and post-quizzes, detailed patient information and a documentation system. We selected
scenarios to coincide with what was being taught in class and we scheduled students in groups of three to four for these sessions. The nal senior experience involved an individual scenario and was graded using a
rubric (Cummings, 2014). The seniors also attended a group role play
scenario involving delegation and interdisciplinary graduate students.
At the completion of these simulation experiences, the students
were asked to voluntarily complete a survey. The survey was made up
of 3 tools, the Student Satisfaction with Leaning Scale, Self-Condence
in Learning and the Educational Practices Questionnaire (Jeffries,
2012). The survey consisted of 30 items with answers scored on a Likert
I would like to acknowledge the support of the University of North Florida.
I received no funding for this research.
Corresponding author at: University of North Florida Brooks College of Health 1 UNF
Drive Jacksonville, Fl 32224, United States.
E-mail address: Cynthia.cummings@unf.edu (C.L. Cummings).

http://dx.doi.org/10.1016/j.nedt.2015.11.004
0260-6917/ 2015 Elsevier Ltd. All rights reserved.

scale from 15, with 5 being the highest. The Student Satisfaction with
Learning Scale consisted of 5 items with a reliability of r = 0.94. The
Self-Condence in Learning Using Simulation scale consisted of 8
items with a reliability of r = 0.87 and the Educational Practices in
Simulation Scale was made up of 16 items with a reliability identied
as r = 0.86 and 0.91 (Jeffries and Rizzolol, 2006). Approval for the survey was obtained through the National League for Nursing.
The study was approved by the Institutional Review Board (IRB)
from the University of North Florida. The survey was voluntary and
the students elected to participate if they desired. After one year, we
compared the mean averages for each item. Fifty-four students
responded, with 34 from the third semester or junior students and 20
from the fth semester or senior students. The means varied between
3.6 and 5, with a large number between 4 and 5. The mean averages
for each item were compared between junior and senior year students
using T scores for unpaired means. What we found was that 8 questions
had a condence level of 95% (Fig. 1). When the 8 questions were combined the signicance was p b.001 (Fig. 2). The questions found significant were:
1. I am condent that I am mastering the content of the simulation activity. (self-condence)
2. I am condent that this simulation covered critical content necessary
for the mastery of medical-surgical content. (self-condence)
3. I am condent that I am developing the skills and obtaining the required knowledge from this simulation to perform necessary tasks
in a clinical setting. (self-condence)

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C.L. Cummings, L.K. Connelly / Nurse Education Today 36 (2016) 419421

Fig. 1. Mean results for 8 Items.

4. I know how to use simulation activities to learn critical aspects of

these skills. (self-condence)
5. I actively participated in the debrieng session after the simulation.
(active learning)
6. I had the opportunity to put more thought into my comments during
the debrieng session. (active learning)
7. There were enough opportunities in the simulation to nd out if I
clearly understand the material. (active learning)
8. Using simulation activities made my learning time more productive.
(active learning)

These survey questions concerned condence and active learning.

Based on the student responses, it appears that the student identied
an improved belief in mastery of the content and condence in their
knowledge base for the required skills and critical content related to
adult health nursing. The simulation experiences all dealt with adult
health content, ranging from postoperative care to emergency situations. The students may encounter a patient having chest pain, an asthma attack, polypharmacy issues or diabetic education. Each scenario
addressed a specic adult health situation and the student was given
objectives to meet. The simulations required critical thinking and active
learning in a real world environment. They may be acting alone or in a
group and must decide on a course of action and then reect on their
performance.
The curriculum was adapted, so that in the junior year, the student
was exposed to 4 simulation activities that dealt with adult health I
and adult health II content. For adult health I, it could be a diabetic patient, a patient experiencing stroke symptoms or a postoperative client.
The students were in a group of 3 to 4 students and were required to
read about the scenario prior and to complete a pre-quiz on the topic.
Following the simulation, the students were debriefed on their experience and then were asked to document on a specied electronic health
record for that patient and to complete a post-quiz. For adult health II
simulations, the students also were in groups of 3 to 4, but the content
dealt with higher level acuity patients. The situations could be a patient
who had sepsis, a gun-shot victim, a patient experiencing a myocardial
infarction, a patient with an asthma attack, or a patient in respiratory
failure. The activities of preparation and documentation were the
same as in adult health I.
Senior year, the students participated in group simulations with the
obstetrics and pediatrics courses and then returned to their nal capstone course, professional nursing integration. In this course, each student attended a group simulation experience, in which they were
randomly assigned the role of oncoming or off-going nurse, patient
care technician or patient/family member. The students, who selected
the role of patient or family, followed a set script in which they called
for various needs throughout the morning. The student nurses were required to delegate and prioritize the care to these patients. The nal
simulation activity consisted of an individual performance on a randomly selected scenario. The senior student received report on their patient
and then entered the room as the nurse for the day. They were required

Fig. 2. Combined T score for all 8 items had a p b.001.

C.L. Cummings, L.K. Connelly / Nurse Education Today 36 (2016) 419421

to perform an assessment, call the physician for orders, follow through

with the orders and then reevaluate the patient condition and make
any changes. Following their performance, they debriefed the situation
and were required to document fully on an electronic record system.
The patient scenarios selected for this individual performance were
very similar to ones they had been exposed to during junior year. The
scenarios were posted at the beginning of the semester, so that students
could review them if they so desired. The simulation survey was posted
through an online system and the students were asked to voluntarily
participate at the completion of each semester. The results were anonymous and there was no connection to individuals through this system.
In addition to condence levels, another critical area identied as
improving, is the active learning environment. The students noted
that their participation in debrieng improved, as well as their opportunity for comments, understanding of content, and productivity. As they
went through the simulations over time, they became more open and
reective with their comments and questions. The same faculty members debriefed the students throughout and the students were aware
of the type of questions and reections that maybe discussed during
this time. They did not view the debrieng sessions as a negative area,
but more as a safe environment in which to express their opinions.
Therefore, it can be assumed that repeated simulation activities can
increase student condence levels. Yet, can we translate condence into
competence? In Bandura (1997), p. 393 work on self-efcacy, he refers
to self-condence as an individual's belief in themselves and their ability to succeed. Self-efcacy is a person's belief that he or she can succeed
at a specic task or range of task. The more condence the student has,
the greater the chance that they will partake in a task and succeed.
Benner et al. (2008) often speaks on critical reection with clinical experiences and the need for nurses to reect on performance and determine best practice. The greater the opportunity for an active learning
experience, the greater the ability the student has to assimilate this information. Vygotsky (1978) proposed that learning cannot be separated
from the real world. Students must experience accommodation and assimilation of ideas in an active learning environment. The instructor acts
as a support, providing a scaffold by which the student can build on
knowledge. The student's metacognition is either changed by accommodating this information into previous knowledge or assimilating
this as new knowledge. For meaningful change to occur, the student
must be an active participant in a real world scenario. This is where simulation activities can provide student engagement that leads to enhanced knowledge and a framework for future experiences.
So, why is this important? It is very difcult to measure clinical competence. We attempt to do this with walk through exams and clinical
evaluation. However, all clinical experiences are different and involve
a variety of variables. If we can control for these variables and expose
students to structured situations, then we can provide them a method
by which they can incorporate these scenarios into their clinical experiences. Most of the simulated experiences deal with emergent or high
stress situations. These often are the very situations in which students
do not have exposure because of the critical nature within the hospital
setting. Tosterud et al. (2013) noted that it is vital for students to receive
training on assessment, prioritization and actions under conditions in
which patient safety is not a threat.
Critical thinking ability is one of the most basic competencies of
nursing and is crucial to performance (Chang et al., 2011; Fero et al.,
2010; Garrett et al., 2010). The greater the exposure to critical situations, the increased ability the nurse has for clinical reasoning (Billings
and Halstead, 2009). Tseng et al. (2006) discussed the need to focus
on problem-based learning to enhance motivation, critical thinking
ability and problem-solving abilities. Rodgers (2007) stated that learner
feelings of self-condence tend to be improved when simulation based.
Using high-delity simulation as a tool to develop practical communication and collaboration skills has been proven to increase the student's
satisfaction and self-condence (Thidemann and Soderhamn, 2013).
Park et al. (2014) stated that the likelihood of students gaining

421

competence and critical thinking skills for practice is limited, while

Goodstone et al. (2013) revealed that simulation over time can improve
critical thinking scores. In a study by Kaddoura (2010) ten new nursing
graduates reported that clinical simulation improved their condence
and decision making abilities. Bambini et al. (2009) noted that simulation introduces novice students to the process of being able to perceive
aspects of patient care and promote condence and self-efcacy.
This study provides some insight into the benet of simulation for
active learning and also condence levels. While the study was limited
to our population and the scenarios to which the students were exposed, the results are similar to many others previously discussed. In addition, the method of incorporating simulation activities into the
curriculum follows an educational pattern for social cognitivism. It
would benet the faculty to continue to survey student satisfaction
and condence levels and attempt to understand which activities may
show greater student condence and learning. In general, the students
expressed satisfaction with most activities, with mean scores between
4 and 5 on the items. Simulation therefore, provides an opportunity to
structure knowledge and to supply crucial content, as well as critical
thinking experiences. The more students are presented with critical
thinking situations, whether in simulated activities or other instructional methods, the greater their ability to rene and build on their performance strategies. As an educator, it is our responsibility to incorporate
these methods and guide our students in their role development. Ultimately, any process which can increase a student's condence through
active learning situations will be a benet in producing better prepared
nurses.
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