Content area
Aim
This study aims to develop the Mobile Simulation Program for Nursing Delegation (MSP-D) to enhance nurses’ delegation skills and evaluate its effects on nurses' preparedness to delegate, critical thinking disposition and role ambiguity reduction.
BackgroundEffective delegation is crucial for optimal patient care in nursing practice. However, many Korean nurses with insufficient delegation training in a new nursing model where they collaborate with nursing assistants.
DesignA randomised controlled trial with a pre–post-test design.
Participants and settingThe participants were 96 nurses from three general hospitals in South Korea, randomly assigned to either the experimental ( n = 48) or control group ( n = 48).
MethodsThe MSP-D is a mobile web-simulation and the experimental group used the MSP-D for three weeks. Data were collected pre- and post-intervention. The study was registered with the Clinical Research Information Service (KCT0007516) on 19 July 2022, with recruitment beginning on 20 August 2022.
ResultsThe experimental group showed significant improvements in preparedness to delegate ( p < 0.001), critical thinking (p = 0.038) and decreased role ambiguity ( p = 0.041). compared with the control group. Debriefing analysis revealed that participants’ reflections aligned with the learning objectives, indicating the study’s educational goals were met.
ConclusionThe MSP-D is an effective educational tool for improving nurses' delegation skills and may enhance job training for nurses collaborating with nursing assistants to improve nursing care quality in a new nursing delivery model. Mobile simulation education significantly improves effectiveness due to its high accessibility and flexibility.
The increasing demand for medical care and growing complexity of treatment procedures have created the need for more medical personnel in healthcare ( Blouin, 2023; Virkstis et al., 2019). In Korea, a new nursing model called Integrated Nursing Care Services is being implemented in approximately 700 healthcare institutions to enhance nursing efficiency and quality while reducing the financial burden of medical care ( Ministry of Health and Welfare (KR), 2023). This model supplants private caregivers with nurses and nursing assistants who provide integrated care and nursing services ( Ministry for Health and Welfare (KR) and National Health Insurance Service, 2023). For the successful implementation of Integrated Nursing Care Services, effective delegation of nursing tasks between nurses and nursing assistants is required ( Yi et al., 2022; Yi et al., 2024).
However, challenges such as role ambiguity and insufficient delegation training hinder nurses from fulfilling this requirement effectively ( Kim and Kim, 2020). Korean nurses providing integrated nursing care services have demonstrated a need to improve their readiness for delegation ( Wi and Kim, 2022). When nurses face difficulties with delegation, which leads to under-delegation, ultimately resulting in nurses performing more non-nursing tasks, decreased nursing service quality and increased workloads for nurses ( Crevacore et al., 2022; Park and Hwang, 2021). Increased workloads raise the risk nursing tasks will not be completed, thereby threatening patient safety ( Gravlin and Bittner, 2010). There is a critical need for delegation education that equips nurses with sufficient knowledge and skills to effectively and safely delegate tasks. Also, nurses must consider each patient's diverse needs and conditions in complex situations when delegating simple nursing tasks to nursing assistants ( Beckett et al., 2021; Campbell et al., 2020). However, nurses are delegating nursing tasks based on subjective judgment and work practices and developing their delegation skills through trial and error in practice ( Kim et al., 2016; Wi and Kim, 2022).
Education focused on delegation skills is essential for strengthening nurses' task delegation competency. Systematic delegation education is instrumental in enhancing the safety and quality of nursing practice ( Beckett et al., 2021; Crevacore et al., 2022; Kim and Kim, 2020). Nurses who have received delegation training are highly prepared to delegate tasks in nursing practice, as shown in studies by Kim and Kim (2020) and Wi and Kim (2022). These findings highlight the need for more structured and accessible delegation education programs in university curricula and clinical practice. Delegation education for nurses should encompass communication skills for task delegation and content that clarifies job definitions and responsibilities to resolve role ambiguity and conflicts ( Cengiz et al., 2021; Wagner, 2018; Yi et al., 2024). Fostering critical thinking skills through delegation education is essential, as task delegation is a complex decision-making process ( Hughes et al., 2017; Wi and Kim, 2022).
The American Nurses Association (2012) emphasises that delegation education should be developed using simulations tailored to various situations. Education through simulations reflecting actual situations is essential for enhancing nurses’ understanding and performance ( American Nurses Association and National Council of State Boards of Nursing, 2019). Particularly, theory-based education design in nursing education helps develop programs systematically ( Wilson et al., 2014). This study applies Kolb’s (1984) experiential learning theory (ELT) as a theoretical framework for simulation education to effectively integrate knowledge through experience ( Davitadze et al., 2022; Kobiske and Deprey, 2022). The simulation debriefing design is based on Tanner’s (2006) clinical judgment model (CJM) to help nurses make appropriate delegation decisions in complex clinical situations.
While face-to-face simulation education has spatiotemporal limitations (i.e., constraints related to specific times and locations; MacKenna et al., 2021), mobile simulation education offers benefits in accessibility, mobility and learning extension, learning extension allows learners to search for information or acquire additional knowledge anytime and anywhere, thereby enhancing learning accessibility for shift-working nurses ( Chen et al., 2020, Han and Jin, 2024). Mobile simulation education is an effective method for enhancing practical competence by allowing users to experience situations indirectly ( Chen et al., 2020; Hester et al., 2021). This innovative approach supports the development of delegation skills necessary for increasingly complex healthcare environments and contributes to improving nursing quality and the safety of Integrated Nursing Care Services. This study aims to develop the ‘Mobile Simulation Program for Nursing Delegation’ (MSP-D), adhering to Trifonova and Ronchetti (2003) guidelines for mobile learning and evaluate its effectiveness.
2 MethodThis study comprises two steps: (1) development and (2) effectiveness evaluation of the MSP-D
2.1 Development of the MSP-DIn this study, the MSP-D was developed according to the systematic instructional design framework consisting of Analysis, Design, Development, Implementation and Evaluation (ADDIE) ( Branch, 2009).
2.1.1 AnalysisA literature review was conducted to develop the MSP-D and educational materials from domestic and international studies were analyzed to identify the educational needs of nurses. The researchers searched academic journals and reports from the Korea Research Foundation until 30 May 2022, using search engines that included the Cumulative Index to Nursing and Allied Health (CINAHL Database), Web of Science (WOS), Medical Literature Analysis and Retrieval System Online (MEDLINE) via PubMed, Cochrane Library, Research Information Sharing Service (RISS), Korean Medical Database (KMBASE), Korean Studies Information Service System (KISS) and National Digital Science Library (NDSL). The search terms included ‘delegation’, ‘nursing’, ‘registered nurse’, ‘nursing assistant’, ‘education’, ‘nursing tasks’ and ‘integrated nursing care services’.
To select materials relevant to the research objectives, the researchers read the titles and abstracts of each document and selected those that matched the educational focus of this study. Then, the researchers conducted a detailed analysis to ensure alignment with the educational requirements. A total of 20 documents were selected and the researchers comprehensively analyzed the educational requirements, presented them and integrated overlapping elements (Supplementary 1). The final educational content was systematically categorised into three items: Delegation principles and consideration of delegation (aspects of work, people and the environment); Delegation instructions and communication, including supervision and feedback; Nurses’ legal liabilities for delegation and ineffective delegation (under-delegation, over-delegation, inappropriate delegation), with teamwork among nursing staff (Supplementary 2).
2.1.2 Design2.1.2.1 Curriculum design based on experiential learning theory and the clinical judgement model
The curriculum covered in the MSP-D is structured according to Kolb’s (1984) ELT and comprises four stages ( Fig. 1). First, learners gain concrete experiences through pre-learning and simulation. Second, they reflect on and evaluate their learning experiences through self-report debriefings based on Tanner’s (2006) CJM, which includes the stages of noticing, interpreting, responding and reflecting; helping learners understand situations; and making knowledge-based judgments. Third, the program organises knowledge related to task delegation to expand each learner’s knowledge base. Finally, based on the previous steps, learners enhance their readiness and critical-thinking skills for delegation in clinical settings, thereby improving their delegation competence.
2.1.2.2 Mobile learning designThe study followed the three guidelines for mobile learning reported by Trifonova and Ronchetti (2003). First, the MSP-D was designed with short modules that allow learners to study by reading small amounts of text and taking quizzes. Second, the MSP-D was developed as a Hypertext Markup Language 5 (HTML5) web application to optimize for mobile environments while enhancing educational accessibility. This approach ensures easy access from various devices, such as personal computers (PCs), tablets and mobile phones, without requiring complex procedures such as app installation. Additionally, the content is designed in an animated format to engage learners within a short time. Third, the content is organised into three sessions by learning topics, allowing learners to select the desired topic at their convenience, regardless of the order.
2.1.3 DevelopmentThree educational topics were selected based on the educational needs analysis: ① What should nurses consider when delegating nursing tasks? ② How should nurses delegate, supervise, evaluate and give feedback? ③ What are the legal obligations of nurses and the barriers to delegation? Each session consists of 10 minutes of pre-learning, 10 minutes of simulation and 10 minutes of debriefing. Table 1 shows the detailed learning title, objective, content for each session and content validity index (CVI). The learning content in Table 1 represents the topics covered during both the pre-learning and simulation phases. The program is designed for learners to complete pre-learning on these topics before proceeding to the simulation.
Six experts evaluated the validity of the completed content presented in Table 1 using a 5-point Likert scale (1 = not valid at all, 5 = very valid) and providing written feedback. The expert group consisted of three clinical nurses with over five years of experience in integrated nursing care and three nursing professors. The researchers calculated average scores and revised the content based on the experts’ feedback, including removing redundant content, adjusting the difficulty level of the lectures, clarifying terms, controlling the narration speed for better comprehension and modifying quizzes to reflect variations in task performance across medical institutions. The revised content was reviewed and confirmed by the experts, who confirmed that no further modifications were necessary. Module-specific simulation scenario overviews and quiz examples have been presented (Supplementary 3).
The completed simulation scenarios and quizzes were designed using storyboards and produced as educational videos by the mobile web education production company, DUNET ( www.dunet.kr). Pre-learning used voice narration and the simulation scenarios were animated with character dialogues and voice narration, enabling learners to engage with the scenarios and complete quizzes based on the situations presented. The researchers design final debriefing based on the CJM to be used on a mobile device and completed as a self-report reflection questionnaire. During the program development process, the researchers continuously reviewed the progress and communicated with the program developers to identify and correct any parts that did not accurately reflect the researchers' intent, thereby ensuring the program’s successful completion.
2.1.4 ImplementationThe developed MSP-D was hosted on a mobile website ( www.nursecaseprogram.com) and optimised for viewing on mobile devices, tablets and PCs. Learners could access the homepage using their preferred device, click on the relevant lecture, register and engage in the educational simulation. To ensure thorough online learning, the learners could not skip or fast-forward through the content and each part needed to be completed before proceeding to the next. The researchers could monitor learners’ progress to confirm their participation and encourage continued learning.
2.1.5 EvaluationBoth experts and learners used Yi’s (2007) educational program evaluation tool to assess the MSP-D. Six nursing professors with simulation education experience participated in the expert evaluation and six nurses working in integrated nursing care conducted the learner evaluation. The expert evaluation tool included ten items: one item on topic consistency, one on learning objective consistency, six on content appropriateness, one on video accuracy and one on terminology accuracy. The learner evaluation included nine items: one on system convenience, two on system structure, four on information appropriateness and two on information usefulness. Each item was rated on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating better program development.
Additionally, seven experts with master’s degrees or higher in information technology evaluated the mobile usability of the MSP-D was evaluated using Nielsen’s (1994) mobile usability evaluation tool, which consists of 10 items. Answers were provided on a Likert scale as follows: ‘0 = no usability problems’, ‘1 = cosmetic problem, no need for changes’, ‘2 = minor usability problem, low priority for changes’, ‘3 = major usability problem, high priority for changes’ and ‘4 = usability problem, must be changed’. Scores range from 0 to 4, with a score of 2 or higher indicating a need for changes and higher scores representing higher priority for revisions. A score of 4 indicated a critical usability issue that must be addressed.
2.2 Effectiveness evaluation of MSP-D2.2.1 Design
This study used a randomised controlled pre-test–post-test design ( Fig. 1). The study followed the CONSORT guidelines and was registered with the Clinical Research Information Service (KCT0007516) on 19 July 2022, with the first recruitment beginning on 20 August 2022. Study details are available online: https://cris.nih.go.kr/.
2.2.2 Participants and settingThis study targeted nurses working on integrated nursing care wards at three general hospitals in a metropolitan area of South Korea. The study focused on nurses engaged in task delegation, excluding those not directly involved in providing patient care. The required sample size was calculated using G*Power 3.1.9.2 based on Cohen's power analysis. The effect size of 0.71 was derived from a study of Chyn et al. (2015) using an independent samples t-test. Chyn et al. (2015) implemented simulation-based nursing education and assessed critical thinking disposition by comparing the pre- and post-test score differences between two groups using an independent t-test. Our study involves an educational intervention for nurses, measuring critical thinking disposition and applying the same statistical analysis as Chyn et al.'s study. This makes their study a highly appropriate reference for deriving the effect size used in our research. The appropriateness of this reference was thoroughly reviewed and approved during the Institutional Review Board (IRB) process. In this study, the significance level was set at.05, power (1-β) at.90 and two-tailed testing was used, resulting in a minimum sample size of 44 per group, for 88 participants in total. If the effect size were assumed to be larger or smaller than 0.71, the required sample size would change accordingly. For example, assuming a smaller effect size would require a larger sample size and this possibility was considered during the study design phase. Considering a dropout rate of 10 %, the final sample size was set at 48 per group and 96 participants were recruited through in-hospital notices at each medical institution. The researchers instructed the research assistant to randomly assign participants to the experimental and control groups in a 1:1 ratio using random numbers generated by the ‘RAND()’ function in Microsoft Excel (2018). To maintain double-blinding, the researchers did not receive the assignment results until the intervention was completed. The research assistant divided the 96 participants into groups of 20:20 for Hospital D, 8:8 for Hospital H and 20:20 for Hospital S. The research assistant created an open chatroom using Kakao Talk, a mobile message application in Korea, where participants could join anonymously using nicknames to receive research instructions. The research assistant provided pre- and post-survey links to the participants and were not informed of the participants’ assigned groups.
2.2.3 InterventionThe control group completed pre- and post-tests before the experimental group’s intervention started and received no intervention for three weeks. The control group was provided with the Effective Nursing Delegation eBook after the study was completed and provided access to the MSP-D in the same way as the experimental group. The experimental group participated in learning using the MSP-D, completing three modules—30 minutes per module, 90 minutes in total—over three weeks after the pre-test. The MSP-D was designed to allow learners to access the educational program freely from PCs, tablets and mobile phones without time and space constraints. The education period was set to three weeks to accommodate the shift schedules of the nurse participants, ensuring sufficient learning time during their personal hours. This period was determined based on previous studies that applied online education to clinical nurses ( Lim and Yi, 2021). Program progress and completion were monitored and confirmed through the homepage admin privileges. During the learning period, the research assistant monitored the participants' progress and used social media to send motivational message cards or provide guidance on their learning progress. Additionally, the debriefing results were submitted via the survey link to the Korean Social-science Data Centre Database (KSDC DB) at https://www.ksdcdb.kr following the mobile learning session was verified. Feedback on the debriefing was provided after all three modules had been completed, as the learning content is interconnected and the debriefing completion time varies for each learner.
2.2.4 Data collectionThis study recruited participants through internal recruitment notices at three general hospitals in the metropolitan area from 10 July 2022 to 10 August 2022. Data were collected from 20 August to 1 October 2022. The study was not conducted until the researchers had received online consent from all participants who voluntarily agreed to take part in the study. The control group completed the pre-test, followed by the post-test after three weeks, minimising the spread of the experiment. All 48 members of the control group participated. The experimental group also initially included 48 participants; however, one participant withdrew before starting the training program and two participants were lost to follow-up, resulting in 45 participants in the experimental group. Thus, data from 93 participants (48 in the control group and 45 in the experimental group) were used for analysis (Supplementary 4).
2.2.5 Outcome measurements2.2.5.1 Preparedness to delegate
Preparedness to delegate was measured using a 15-item Korean version of the delegation preparedness measurement tool by Kærnested and Bragadóttir (2012), adapted and validated by Kim et al. (2016). Permission to use the tool was obtained from the author via email. This tool consists of four domains: delegation skills (4 items), understanding of task content (5 items), task differentiation (2 items) and understanding of delegation content (4 items). Scores are measured on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicating greater preparedness to delegate. Regarding reliability, Cronbach's α was.63 in Kærnested and Bragadóttir (2012),.85 in Kim et al. (2016) and.82 in this study.
2.2.5.2 Critical thinking dispositionCritical thinking disposition was measured using a 27-item tool for nurses developed by Yoon (2004), with permission obtained from the author via email. This tool comprises seven subdomains: intellectual eagerness/curiosity (5 items), prudence (4 items), confidence (4 items), systematicity (3 items), intellectual fairness (4 items), healthy scepticism (4 items) and objectivity (3 items). Each item was measured on a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree), with higher total scores indicating greater critical thinking. Cronbach's α was.84 at the time of development and.80 in this study.
2.2.5.3 Role ambiguityRole ambiguity was measured using a 6-item tool developed by Rizzo et al. (1970), validated by Schuler et al. (1977) and adapted into a Korean version by Lee et al. (2002). Permission to use the tool was obtained from the author via email. Items are measured on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree); lower scores indicate less role ambiguity. Reliability was demonstrated with Spearman–Brown corrected Kuder–Richardson 20 = .78 at the time of development and Cronbach's α = .76 and.89 in Lee et al. (2002) and this study, respectively.
2.2.5.4 Debriefing journalThe debriefing was conducted through a self-report tool based on Tanner’s (2006) CMJ. Table 4 shows debriefing questions according to each module. The questions were tailored to the educational topics covered in each session.
2.2.6 Data analysisData analysis was conducted using SPSS 25.0 software. The general characteristics, preparedness to delegate, critical thinking and role ambiguity of the two groups were described using frequencies, percentages, means and standard deviations. The homogeneity of the variables between the groups was tested using independent t-tests, χ2-tests and Fisher’s exact tests. The normality of the distribution of the dependent variables was assessed using the Kolmogorov–Smirnov test. Pre-test–post-test differences within groups were compared using paired t-tests and between-group differences post-intervention were analyzed using independent t-tests.
Qualitative content analysis was conducted on the debriefing content participants provided after the simulation practice. Content analysis is a systematic method for categorising and investigating recorded information ( Krippendorff, 2019). This study used content analysis to verify whether participants’ responses reflected that they had effectively achieved the learning objectives in each module. Following content analysis procedures, the researchers repeatedly read and reviewed the collected data to extract categories. An inductive approach was used to identify themes and patterns, grouping responses with similar meanings and expressions for each debriefing question ( Elo and Kyngäs, 2008). Initial codes were generated from the data, which were then refined into broader categories through iterative analysis. To enhance coding reliability, two researchers independently coded the data, compared their results and resolved discrepancies through repeated discussions until consensus was reached. Frequencies and percentages of each response were calculated using quantitative content analysis techniques.
2.3 Ethical considerationsDuring the program development stage, the researchers applied for and received a review exemption from the IRB (No. blind). The same committee subsequently reviewed and approved the program’s effectiveness evaluation stage and the study was conducted following this approval (No. blind).
3 Results3.1 Development of the MSP-D
The MSP-D was developed as a three-module simulation educational program ( Table 1) and evaluated by experts and learners for its usability and mobile accessibility. The MSP-D received an average score of 4.82 ± 0.44 out of 5 in the expert evaluation and an average score of 4.45 ± 0.52 in the learner evaluation, respectively.
Usability issues identified by experts based on a score of two or higher were addressed to complete the program. For ‘user control and freedom’, modifications were made to improve the visibility button on the homepage used to access the lectures. To ‘help users recognise, diagnose and recover from errors’, a support board was implemented to facilitate error resolution. These modifications resulted in an improved the learning program with enhanced usability.
3.2 Effectiveness evaluation of the MSP-D3.2.1 General participant characteristics and homogeneity test
The results of the homogeneity test showed no significant differences between the experimental and control groups in demographic and clinical characteristics, such as age, gender, clinical experience and prior delegation education experience. These findings confirm that the two groups were comparable before the intervention ( Table 2).
3.2.2 Primary outcomes: preparedness to delegate, critical thinking disposition and role ambiguityThe results showed statistically significant improvements between the experimental and control groups in preparedness to delegate ( p < .001), critical thinking disposition ( p = .038) and role ambiguity ( p = .041; Table 3).
3.2.3 Secondary outcome: content analysis of debriefing journalsIn Module 1, participants demonstrated an understanding of delegation principles, nurses’ responsibilities and appropriate delegation of non-nursing tasks. In Module 2, they reflected on mastering supervision, feedback methods and two-way communication while considering hospital regulations and legal liabilities. In Module 3, participants discussed recognizing inappropriate delegation, understanding its causes and the importance of mutual trust and legal compliance in delegation. Representative quotes are provided in Table 4 to contextualize the identified themes and summarize the qualitative data.
4 DiscussionThe MSP-D was developed as a mobile web-based simulation program to enhance mobility, scalability and accessibility for nursing education This program uses mobile simulation as an innovative approach to address the unique challenges faced by Korean nurses in integrated nursing care wards, such as collaborating with nursing assistants and adapting to delegation practices. In this emerging context, ensuring optimal patient care depends on preparedness for delegation and reducing role ambiguity. The MSP-D equips nurses with the skills required to navigate these challenges and thrive in collaborative care environments.
In the expert evaluation, the MSP-D received high scores across various aspects, including a consistency of learning objectives score of 4.83, an appropriateness of content score of 4.69 and an appropriateness of terminology score of 4.83. These results highlight the program’s strong design quality and alignment with educational standards, further enhancing its credibility and usability.
In the learner evaluation, the MSP-D received a mean system convenience score of 4.83, indicating high satisfaction with the accessibility and usefulness of the mobile learning environment. According to Chen et al. (2020) and Hester et al. (2021), mobile learning improves the mobility and accessibility of learning resources, thereby effectively enhancing learners’ knowledge and satisfaction.
The experimental group that received MSP-D education showed a statistically significant improvement in preparedness to delegate compared with the control group. This finding demonstrates that the educational program systematically developed to address nurses' educational needs identified in previous studies ( Barrow and Sharma, 2023; Hughes et al., 2017; Yi et al., 2022) effectively clarified job roles, legal responsibilities and delegation communication. The program's effectiveness was evident despite approximately 50 % of participants having no delegation education experience prior to taking part in the study. Although Korean integrated nursing and caregiving services require nurses to undergo training before working in relevant wards, the training primarily focuses on practical aspects, such as patient acuity classification. However, our training covers principles of delegation and communication. This focus likely explains why many participants perceived they lacked prior delegation education. Under-delegation resulting from a lack of delegation competence leads to increased workloads for nurses and a decline in the quality of nursing care ( Park and Hwang, 2021), underscoring the necessity for delegation education in healthcare institutions and nursing colleges ( Barrow and Sharma, 2023; Kim and Kim, 2020). Consequently, healthcare institutions and nursing colleges face an imperative to further expand and enhance opportunities for delegation education because Korean nurses working in integrated care nursing services are still unfamiliar with delegation and working with nursing assistants on general wards.
Following the intervention, the critical thinking disposition scores of the experimental group were significantly higher than those of the control group. Despite the relatively short intervention period compared with other studies (3 weeks, 30-minute module sessions), participants' critical thinking significantly improved. However, Doğan and Şendir (2022) found no significant differences in critical thinking scores before and after a similar simulation education intervention, which differs from our results. The effectiveness of our simulation education may be attributed to the repetition of the three simulation scenarios related to delegation and the ability of learners to engage in repeated learning through mobile access. Shin et al. (2015) reported that critical thinking can be significantly improved by being exposed to a simulation scenario three times, supporting our findings. This improvement in critical thinking, essential for effective delegation, demonstrates the value of mobile simulation education.
After the intervention, the experimental group’s role ambiguity scores were significantly lower than those of the control group, indicating that the program effectively clarified principles and scope of delegation, inappropriate delegation practices and legal responsibilities. These findings align with Cengiz et al. (2021), who emphasized that understanding roles and responsibilities reduces role ambiguity and Wagner (2018), who highlighted the benefits of delegation communication education for nurses.
Content analysis of debriefing results from simulation education is crucial for developing an in-depth understanding of learners’ experiences. This analysis supports the effectiveness evaluation of the educational program by identifying learners' experiences, emotions and difficulties encountered during the simulation ( Paige et al., 2019). Content analysis of participants’ debriefing responses revealed that many aligned with the learning objectives, indicating successful learning and reflection. Specifically, analysing the debriefing content showed that learning and reflection were well executed, as several responses included content presented as the learning goal. These results demonstrate that the developed simulation program effectively conveyed the desired educational goals and enabled learners to understand and apply them well. Furthermore, the qualitative findings from the debriefing journals complement the quantitative results by providing deeper insights into the participants’ experiences. These findings support the quantitative results of improved preparedness to delegate, critical thinking and reduced role ambiguity. This alignment underscores how the integration of qualitative and quantitative data provides a more comprehensive understanding of the MSP-D’s impact, as qualitative reflections validate and enrich the numerical outcomes.
However, the findings of this study may differ in other settings, such as rural hospitals or facilities with distinct staffing models. Rural hospitals often face limited healthcare resources and reduced access to professional development programs, while hospitals without nursing assistants or with less clearly defined delegation roles may not experience the same benefits. Variations in patient needs, staff dynamics and institutional support could also influence the effectiveness of the program in these settings. Further research is needed to investigate these differences and adapt the MSP-D for diverse clinical environments. Additionally, the importance of evaluating the long-term effects of the program and the need for longitudinal studies should be acknowledged.
This study integrated Kolb’s ELT (1984) and Tanner’s CJM (2006) to develop the MSP-D, enabling learners to address various clinical situations through simulation ( Kolb, 1984; Tanner, 2006). By applying theoretical knowledge to real clinical situation through simulation. thereby enhancing their ability to effectively delegate tasks in complex scenarios, improving their delegation readiness and critical thinking skills and reducing role ambiguity. This study integrated Kolb’s ELT (1984) and Tanner’s CJM (2006) to develop the MSP-D, enabling learners to address various clinical situations through simulation. By applying theoretical knowledge to real scenarios, learners improved their ability to effectively delegate tasks, enhance critical thinking and reduce role ambiguity. These findings align with previous research highlighting the effectiveness of ELT and CJM in fostering clinical reasoning and decision-making in dynamic settings ( Davitadze et al., 2022; Jeong and Choi, 2017). Therefore, the MSP-D serves as a robust model for nursing education, emphasizing the need for educational programs grounded in sound theoretical frameworks.
4.1 LimitationsFirst, this study was conducted on the integrated nursing care wards of three general hospitals in a metropolitan area, which limits the generalisability of the results to hospitals with different structures or sizes. Second, although participants in the same hospitals were randomly assigned to either the experimental or control group and double-blind procedures were implemented to minimise diffusion effects, such effects are challenging to completely exclude. Thus, the results should be interpreted with caution. Third, this study relied on self-reported measures for preparedness to delegate, critical thinking disposition and role ambiguity, which may be subject to biases such as social desirability bias.
5 ConclusionThe MSP-D developed in this study was found to effectively augment nurses’ delegation capabilities and reduce role ambiguity while fostering critical-thinking skills. However, this study is subject to certain limitations, including potential diffusion effects and self-report bias. Therefore, while the findings provide evidence of an association between the intervention and the observed improvements, the potential influence of other factors cannot be completely ruled out. This outcome underscores that mobile education, characterised by its high accessibility and scalability that facilitates repeated exposures over brief periods, can suggest the potential to amplify the effectiveness of educational interventions. Mobile simulation education allows nurses to vicariously experience a range of scenarios that can be encountered in clinical environments, which may help bolster their practical response skills. Consequently, in settings where nurses and nursing assistants collaborate, it is prudent to administer delegation education based on authentic clinical scenarios, as demonstrated in this study, prior to facilitating cooperative work among nursing personnel. These proactive steps may not only help mitigate the heavy workloads and role ambiguity stemming from inappropriate delegation but also have the potential to enhance nursing care quality and patient safety. Nurses working with nursing assistants based on the relatively new nursing model could benefit from delegation training such as that provided through the MSP-D.
Ethical approvalDuring the program development stage, the study received an exemption from review by the Institutional Review Board of a university in 2021 (No. HYUIRB-202110–010). The study was later approved by the same board in 2022 for evaluating the program's effectiveness (No. HYUIRB-202204–022).
FundingThis research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF), funded by the Ministry of Education (No. 2019R1F1A1057717).
CRediT authorship contribution statementHaena Lim: Writing – original draft, Software, Project administration, Methodology, Formal analysis, Data curation, Conceptualization. Yeojin Yi: Writing – review & editing, Validation, Supervision, Resources, Investigation, Funding acquisition, Conceptualization.
Declaration of Competing InterestThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
AcknowledgementsThe authors express their deep gratitude to Professor Ji-Young Yeo for her profound insights and invaluable advice on simulation education and debriefing, which significantly enriched the study. Appreciation is also extended to Sangmi Han and Danbi Oh for their valuable guidance on nursing delegation in the Integrated Nursing Care Services. Additionally, the authors thank all the nurses who participated in this study.
Appendix A Supporting informationSupplementary data associated with this article can be found in the online version at doi:10.1016/j.nepr.2025.104283.
Appendix A Supplementary materialSupplementary material
Supplementary material
| Learning title | Learning objectives | Learning content | I-CVI | Structure | Time | Components | |
| What should be considered when delegating nursing tasks? | -The principles of delegating nursing tasks can be enumerated.
-Depending on considerations of task, person, and environment, the delegation of nursing work can be judged. | Concept of
delegation | 1.00 | Pre-
learning | 10 min | Lecture with image, text and narration | |
| Principles of
delegation | 1.00 | Simulation | 10 min | Animated quiz with image, text, narration | |||
| Five rights of delegation | 0.83 | ||||||
| Debriefing | 10 min | Self-report | |||||
| Considerations for delegation | 1.00 | ||||||
| How should nurses delegate and supervise, evaluate, and give feedback? | -Able to issue appropriate delegation instructions and conduct two-way communication.
- Able to appropriately supervise the process and outcomes of delegated duties. -Able to receive reports of delegated tasks and evaluate them. | Delegation process | 1.00 | Pre-
learning | 10 min | Lecture with image, text and narration | |
| Simulation | 10 min | Animated quiz with image, text, narration | |||||
| How to delegate tasks | 1.00 | ||||||
| Debriefing | 10 min | Self-report | |||||
| What are the legal obligations of nurses and what are the barriers to delegation? | -Able to identify the legal obligations related to the delegation of duties of nurses.
-Can list obstacles to task delegation. -Able to describe types of faulty delegation. | Delegation and nurses’ legal liabilities | 1.00 | Pre-
learning | 10 min | Lecture with image, text and narration | |
| Barriers to delegation | 0.83 | Simulation | 10 min | Animated quiz with image, text, narration | |||
| Wrong types of delegation | 1.00 | Debriefing | 10 min | Self-report | |||
| S-CVI/AVE of learning content | 0.97 | ||||||
| Variables | All participants | Control group | Experimental group | χ
2 or | |
| (
| (
| (
| |||
| n(%) or M±SD | n(%) or M±SD | n(%) or M±SD | |||
| Age | 30.26 ± 6.20 | 29.25 ± 5.79 | 32.75 ± 8.40 | 0.62 | .429 |
| Gender | |||||
| Female | 88(91.6) | 44(91.7) | 43(95.6) | 0.58 | .678 |
| Male | 6(6.4) | 4(8.3) | 2(4.4) | ||
| Position | |||||
| Charge nurse | 27(28.7) | 13(27.1) | 19(42.2) | 2.36 | .134 |
| Staff nurse | 67(71.3) | 35(72.9) | 26(57.8) | ||
| Education | |||||
| Three-year graduate | 13(13.8) | 7(14.5) | 6(13.3) | 0.03 | .984 |
| Bachelor’s degree | 77(81.9) | 39(81.3) | 37(82.3) | ||
| ≥ Master's degree | 4(4.3) | 2(4.2) | 2(4.4) | ||
| Clinical career (years) | 6.28 ± 5.25 | 5.35 ± 5.53 | 7.25 ± 4.80 | −1.77 | .079 |
| < 3 | 16(33.3) | 12(26.7) | 2.34 | .335 | |
| 3–6.9 | 18(37.5) | 13(28.9) | |||
| ≥ 7 | 14(29.2) | 20(44.4) | |||
| Career at integrated nursing care
(years) | | | | | |
| < 3 | 31(64.6) | 26(57.8) | 0.45 | .501 | |
| ≥ 3 | 17(35.4) | 19(42.2) | |||
| Department | −0.26 | .791 | |||
| Internal medicine | 29(30.9) | 17(35.4) | 11(24.4) | 2.72 | .281 |
| General surgery | 28(29.8) | 11(22.9) | 17(37.8) | ||
| Others (Thoracic surgery,
Neurosurgery, Orthopaedic surgery) | 37(39.3) | 20(41.7) | 17(37.8) | ||
| Delegation education experience | 0.04 | .840 | |||
| Yes | 46(48.9) | 23(47.9) | 23(51.1) | ||
| No | 48(51.1) | 25(52.1) | 22(48.9) | ||
| Simulation experience in a university | |||||
| Yes | 59(62.8) | 31(64.6) | 27(60.0) | 0.21 | .674 |
| No | 35(37.2) | 17(35.4) | 18(40.0) | ||
| Simulation experience in a hospital | |||||
| Yes | 56(59.6) | 33(68.7) | 22(48.9) | 3.79 | .060 |
| No | 38(40.4) | 15(31.3) | 23(51.1) | ||
| Preparedness to delegate | 58.28 ± 6.21 | 59.41 ± 5.92 | 57.07 ± 6.34 | 1.85 | .068 |
| Critical thinking | 98.02 ± 10.38 | 97.79 ± 10.24 | 98.78 ± 11.12 | −0.22 | .827 |
| Role ambiguity | 22.82 ± 3.01 | 22,75 ± 3.25 | 22.91 ± 2.75 | −2.57 | .797 |
| Variables | Group | Pre-test | Post-test | Paired
| | Mean Difference | 95 % CI | Effect Size (Cohen's d) | | | |
| M±SD | M±SD | M±SD | |||||||||
| | Cont. (
| 59.41 ± 5.92 | 58.77 ± 6.89 | 2.16 | .396 | −0.65 ± 5.22 | −3.28 ∼ 2.00 | 0.89 | −5.59 | <.001 | |
| Exp. (
| 57.07 ± 6.34 | 64.37 ± 5.56 | −5.95 | < .001 | 7.31 ± 8.24 | 4.77 ∼ 9.83 | |||||
| | Cont. (
| 97.79 ± 10.25 | 97.33 ± 10.15 | 2.47 | .650 | −0.45 ± 6.94 | −4.65 ∼ 3.73 | 0.49 | .−2.11 | .038 | |
| Exp. (
| 98.27 ± 10.64 | 102.62 ± 11.25 | −2.07 | .044 | 4.35 ± 14.11 | −0.30 ∼ 9.00 | |||||
| | Cont. (
| 22.75 ± 3.25 | 22.41 ± 2.67 | 1.06 | .366 | −0.33 ± 2.52 | −1.56 ∼ 0.88 | 0.43 | 2.07 | .041 | |
| Exp. (
| 22.91 ± 2.75 | 21.44 ± 1.75 | 3.58 | .001 | −1.46 ± 2.75 | −2.45 ∼ −0.49 |
| Module | CJM | Questions | Code | | Category | Key Quotation |
| 1 | Noticing | What information was helpful for delegation? | Check the scope of delegated tasks | 4(7.8) | Nursing delegation according to the delegation principles | "While I had delegated tasks before, I wasn’t fully aware of the exact criteria. The lecture taught me about the 5 Rights of delegation and the importance of considering key factors during delegation." |
| Five rights of delegation | 12(23.5) | |||||
| Considerations of delegation | 15(29.4) | |||||
| Nurses’ legal liability related to delegation | 20(39.2) | |||||
| Is there any difference from what you expected compared to considerations of delegation? | Nurses’ legal liability related to delegation | 11(61.1) | Understanding task delegation and nurses’ responsibilities. | |||
| Delegating non-nursing tasks | 2(11.1) | |||||
| Necessity of delegation | 3(16.7) | |||||
| Concept of delegation | 2(11.1) | |||||
| Interpreting | Why did you decide to delegate, and what was the rationale? | Improving the efficiency and quality of nursing | 12(24.0) | Appropriate delegation of non-nursing tasks and improvement of the quality of nursing | "I decided to delegate tasks like meal assistance to nursing assistants, ensuring patient safety by first assessing their capabilities and confirming accurate task performance." | |
| Delegating non-nursing tasks | 4(8.0) | |||||
| Considerations of delegation | 34(68.0) | |||||
| Responding | Do you think you have appropriately delegated under the delegation principle? | Recognising the need for effective nursing delegation | 42(80.8) | Need for effective nursing delegation | "Reflecting on my delegation practices, I realized they were pretty appropriate, but I aim to improve by making more accurate and situationally aware decisions in the future." | |
| Lack of supervision and evaluation. | 10(19.2) | |||||
| Reflecting | What would you do differently if you encountered a similar situation in a clinical setting? | Delegation instructions using two-way communication | 8(13.6) | Nursing delegation according to the delegation principles | "After assessing the patient's condition, I will confidently delegate tasks by following the 5 Rights of Delegation and key considerations." | |
| Delegation decisions under considerations of delegation | 24(40.8) | |||||
| Supervise delegated tasks and strengthen feedback | 17(28.8) | |||||
| Check hospital regulation of delegation | 2(3.4) | |||||
| Consider the delegatee’s work abilities | 8(13.6) | |||||
| 2 | Noticing | What information was needed to direct the delegation and provide feedback? | Check the scope of delegated tasks | 19(35.2) | Delegation instructions with two-way communication and must be reported the results. | "While I understood the importance of clear communication, the simulation cases helped me realize the significance of two-way communication in delegation." |
| Delegate according to considerations of delegation | 9(16.7) | |||||
| The ability of the delegatee to perform the tasks | 10(18.5) | |||||
| Supervise and provide feedback on the performance of delegated tasks | 16((29.6) | |||||
| Interpreting | What was the rationale for the delegation instructions and feedback? | Hospital regulation of delegation | 10(19.6) | The hospital's regulations and legal liabilities must be considered when delegating tasks. | "Through delegation education, I was able to address gaps in my legal knowledge." | |
| Confirmation of legal obligations related to delegation | 5(9.8) | |||||
| Delegate according to the principles and considerations | 25(49.0) | |||||
| Result of patient assessment | 11(21.6) | |||||
| Responding | Do you think your delegation instructions and feedback were good enough, and on what basis? | Performing delegation and feedback according to the delegation principles | 19(37.2) | Clear delegation instructions are required, including reporting methods. | "I learned that clear instructions and feedback are crucial for effective task delegation." | |
| Insufficient supervision and feedback | 12(7.8) | |||||
| Lack of knowledge about delegation | 4(31.4) | |||||
| Lack of two-way communication | 16((29.6) | |||||
| Reflecting | What parts of delegation directives and feedback did well? | Written delegation instructions | 10(18.5) | Using written delegation instructions with two-way communication and strengthening supervision of delegated tasks. | "I must ensure that delegated tasks are properly supervised and avoid neglecting oversight." | |
| Two-way communication | 22(40.7) | |||||
| Delegation according to the principles of delegation | 6(11.1) | |||||
| Strengthen supervision and feedback on delegated tasks | 12(22.2) | |||||
| 3 | Noticing | What was the wrong delegation situation in the scenario? | The delegatee determines the delegation | 19(36.5) | Understanding inappropriate delegation | "The decision to delegate lies with the nurse." |
| Delegate oral administration to delegatee | 21(40.4) | |||||
| Lack of mutual trust with delegatee | 12(23.1) | |||||
| Interpreting | What was the basis for thinking that the nursing delegation of simulation cases was inappropriate? | Must be delegated in compliance with medical law | 15(25.9) | Understanding the reasons for inappropriate delegation | "Even for simple tasks, those requiring the nurse's judgment based on the patient's condition cannot be delegated." | |
| The nurse decides whether to delegate | 19(32.8) | |||||
| Delegating tasks requiring professional nursing knowledge and judgment is not allowed | 24(41.3) | |||||
| Responding | What did you think when you saw the legal liabilities of nurses and wrong types of delegation? | Education needed to improve delegation capacity | 16(28.1) | Identifying the need for legal groundwork | "I clearly understood under-delegation and over-delegation, which has helped improve my delegation practices." | |
| Need to improve work efficiency through appropriate delegation | 6(10.5) | |||||
| We need to understand the wrong delegation | 4(7.0) | |||||
| Accurate communication is important | 6(14.0) | |||||
| Must be delegated on legal evidence | 15(26.3) | |||||
| Nursing delegation impacts patient outcomes | 8(14.0) | |||||
| Reflecting | How can tasks be delegated effectively? | Need to prepare a specific legal basis for nursing delegation | 24(49.0) | Grasping the necessity of mutual trust and legal compliance in delegation | "Effective delegation, guided by considerations, legal standards, and hospital policies, is essential for delivering high- quality patient care." | |
| Nurses’ legal liabilities in nursing delegation | 7(14.3) | |||||
| Need for more precise legal standards for nurse's task delegation | 3(6.1) | |||||
| Establish a relationship of mutual trust with the mandated person | 9(18.4) | |||||
| Participate in training to enhance delegation capacity | 6(12.2) |
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