Content area
Aim
The aim of the study was to explore midwifery students’ experiences with simulation as pedagogic method when learning management of postpartum haemorrhage patients.
BackgroundMalawi is just starting to implement simulation-based education, even though it is recommended in midwifery education to enhance patient safety. Therefore, to ensure successful incorporation of simulation-based education into midwifery training programs, it is crucial to understand students’ experiences with the pedagogic method.
DesignThe study applied a descriptive-mixed-convergent design.
MethodOne-hundred and seven midwifery students participated in the study. Data were collected through questionnaires and three focus group discussions. Quantitative and qualitative data were analysed using descriptive statistics and content analysis respectively.
ResultsQuantitatively, students graded all the questions related to the simulation design elements, educational practices and students’ satisfaction and self-confidence in learning with mean scores above four on a 5-point Likert Scale. One theme and two sub-themes emerged from qualitative data analysis. Main theme: simulation mirrors demanded competence for professional practice; sub-themes: (1) a realistic and active learning method; and (2) a conducive environment for students’ learning.
ConclusionMidwifery students experienced simulation as a valued pedagogical approach to teaching and learning that mirrored postpartum management clinical skills necessary for them to practice as professionals in the resource-limited setting. More research is necessary to explore feasibility for simulation-based education in Malawi and whether students can apply the knowledge and skills acquired during simulation into clinical practice particularly within constrained environment.
Simulation-based education (SBE) has expanded significantly in midwifery programs in developed countries ( Tansley et al., 2016), but its adoption in low-income countries like Malawi remains limited. Most midwifery training institutions in Malawi continue to rely on traditional, teacher-centred methods, with SBE only recently introduced ( Mwalabu et al., 2023). Consequently, students often lack practical skills, particularly in managing critical conditions such as postpartum haemorrhage (PPH), the leading cause of maternal mortality in Malawi ( Najjuma et al., 2020).
SBE plays a vital role in preparing healthcare students for clinical practice by addressing cognitive, psychomotor, attitudinal competencies ( Iipinge et al., 2020). It enhances patient safety by allowing students to develop clinical skills in a risk-free, simulated environment ( Nestel et al., 2018) and is recommended by the World Health Organization as a method to improve patient outcomes ( World Health Organization, 2018). Studies from resource-limited settings show that students value SBE and feel more confident entering clinical environments ( Bø et al., 2022). However, challenges such as large class sizes, tight schedules and rigid curricula affect its implementation in sub-Saharan Africa ( Msosa et al., 2023; Tjoflåt et al., 2021).
In Malawi, the teaching of PPH management remains largely theoretical, leaving students underprepared for real-life clinical situations ( Kabondo et al., 2024). With a maternal mortality ratio of 345 deaths per 100,000 live births, 34 % due to PPH ( Ministry of Health, 2020; National Statistical Office, 2017), there is an urgent need to strengthen practical training. Despite this, little is known about how midwifery students in Malawi experience SBE in learning PPH management. This study therefore aims to explore students’ experiences with simulation as a pedagogic method in preparing them to manage PPH.
2 Methodology2.1 Study design
The study used descriptive convergent mixed-method design where quantitative and qualitative data were collected separately but concurrently. The mixed methods approach aimed to obtain a more complete understanding of the midwifery students’ experiences in using simulation as a pedagogic method ( Creswell and Clark, 2017).
2.2 Study participantsIn the quantitative study, 109 fourth-year students enrolled in the Bachelor of Science in Nursing and Midwifery integrated program were randomly selected and personally invited to participate through face-to-face communications. The researcher used a three-digit random number table to select participants. A list of fourth-year midwifery students enrolled in the Bachelor of Science in Nursing and Midwifery integrated program was obtained from the university registry, with students numbered from 001 to 150. Starting at a random point on the table, the researcher selected participants by moving horizontally through the numbers until 109 students were chosen. Two students declined and 107 agreed to participate in the study. During the time of study, midwifery students were studying the Midwifery Science 2 module, which included PPH.
In the qualitative study, those students who had participated in the quantitative data collection and had not travelled to different districts for their clinical practice, were requested to participate. The first 24 participants who reported were recruited for the focus group discussions (FGDs) ( Polit and Beck, 2017).
2.3 Study settingThe study was conducted at a university in Malawi that has been training nursing and midwifery students for forty-six years. The institution offers a range of midwifery education programs, including the University Certificate in Midwifery; Bachelor of Science in Midwifery (generic); Bachelor of Science in Midwifery (post-basic); Bachelor of Science in Nursing and Midwifery (generic); Master of Science in Midwifery; and Doctor of Philosophy in Midwifery. The Bachelor of Science in Nursing and Midwifery generic program admits approximately 150 students annually. Prior to clinical practice, students receive classroom instruction in midwifery theory.
Two weeks before the PPH simulation experience, the students were given a four-hour lecture on PPH. The next day a seven-hour skills practice session on PPH management clinical skills in the skills laboratory took place. The two lecturers who taught theory and were formally trained in SBE as facilitators, demonstrated the skills and students had to perform return demonstrations for each clinical skill. The two lecturers supervised the students when they performed the return demonstrations. The students were divided into six groups, with twenty-four students per group. The clinical skills included manual removal of retained placenta, compression of abdominal aorta, bimanual compression of uterus, balloon tamponade and non-pneumatic anti-shock garment.
2.4 Simulation experienceAfter the clinical skills training session, the students were told to review the PPH content again, but they were not given the simulation scenario. A day before the simulation session the students who were randomly chosen to take part in the study were divided into seven groups. Six of these groups had 15 students each and one group had 16 students.
The simulation experience followed briefing, the simulation and debriefing ( Decker et al., 2021). During the briefing, students were introduced to the simulation scenario and the learning objectives. The scenario involved a 30-year-old woman, para four, who had recently given birth. Following the third stage of labour, she experienced heavy vaginal bleeding. On assessment, no vaginal or perineal tears were found and her uterus was flabby.
In each group, five students assumed specific roles: midwife, assistant midwife, clinician, patient attendant and guardian. The remaining ten students in the simulation session were designated as observers, focusing on the learning objectives. A second-year student enrolled in the Bachelor of Science in Midwifery (post-basic) program at the institution portrayed the simulated patient, using a Mama Natalie simulator secured to the body to replicate PPH ( DeStephano et al., 2015). The scenario was played once for each group. Immediately after each simulation each lecturer trained in SBE as facilitators, facilitated one post-simulation debriefing at a time, which was conducted in the same room where simulation took place. The lecturers followed the six stages of Gibbs’s reflective cycle during the debriefing. These stages are 1)description, 2)feelings, 3)evaluation, 4)analysis, 5)conclusion and 6)action plan ( Gibbs, 1988). The debriefing sessions ranged from 28 minutes and 10 seconds to 48 minutes and 39 seconds.
2.5 Quantitative methods2.5.1 Instruments
Quantitative data were collected from midwifery students using self-reported questionnaires: (1)Simulation Design Scale, (2)Educational Practices Questionnaire and (3)Student Satisfaction and Self-Confidence in Learning Scale, which were developed as part of National League for Nursing 2003/Laerdal simulation research study ( NLN, 2021). The 20-item Simulation Design Scale assesses students' views of the significance of various simulation-related design aspects. The 20 items assess fidelity (2 items), support (4 items), problem-solving (5 items), objectives and information (5 items) and feedback (4 items). The first response scale looks at the simulation's feature aspects, while the second assesses how significant the features are to students.
The 16-item Educational Practices Questionnaire assess students' views about the value and efficacy of educational practices in simulation. The 16 items assessed collaboration (2 items), diverse learning methods (2 items), high expectations (2 items) and active learning (10 items). There are two 5-point Likert-type rating scales used in this questionnaire. The first scale uses 1 to indicate significant disagreement with the statement and 5 to indicate strong agreement with it to score the presence (agreement) of educational practice. The participants' assessment of the simulation exercise's significance is given on a second scale (1 being not significant and 5 being highly important).
Twelve items make up the Student Satisfaction and Self-Confidence in Learning Scale, which assesses self-confidence in learning (7 items) and satisfaction with current learning (5 items). A 5-point Likert-type rating scale is used as the response tool; 1 represents significant disagreement with the statement and 5 represents strong agreement.
The questionnaires used in this study were evaluated for reliability using Cronbach’s alpha and are considered suitable for use in educational settings where simulation has been either newly introduced ( NLN, 2021). To our knowledge, this study represents the first application of these tools in midwifery training programs in Malawi.
2.5.2 Data collectionOn 25th May 2023, midwifery students responded to the self-reported questionnaire immediately after debriefing sessions of PPH simulation in a room adjacent to the simulation room. Students completed all the three self-reported questionnaires in English without difficulty.
2.5.3 Data analysisQuantitative and qualitative data were analyzed independently ( Creswell and Clark, 2017). Quantitative analyses were carried out using IBM SPSS Statistics version 29.0.1.0. Non-parametric statistics were conducted ( Creswell and Creswell, 2018) and presented as mean with standard deviation. Six questionnaires were excluded because less than 10 values were missing ( Creswell and Creswell, 2018).
2.6 Qualitative methods2.6.1 Instruments
Qualitative data were collected through a semi-structured interview guide designed to explore students’ experiences during the PPH simulation sessions, as well as their views on this teaching method. The key research question was as follows: “When you think about your PPH simulation experience which was done yesterday, can you share with us your experiences of the simulation?
2.6.2 Data collectionThe FGDs were conducted on the subsequent two days after the quantitative data collection. The first author and a trained research assistant conducted two FGDs on 26th May 2023 and the third FGD on 27th May 2023. Nine, eight and seven midwifery students were present in the first, second and third FGDs respectively. The groups were small enough for everyone to comfortably contribute, while still being large enough to allow for a variety of perspectives and experiences ( Fusch et al., 2022). After each FGD, the researcher started analysing the data. During the third FGD no new data were presented from the participants ( Creswell and Creswell, 2018). The research assistant was recruited from a reputable research institution, University of North Carolina project in Malawi who had previously worked on several research projects. Her main role during the FGDs was to facilitate and recorded the interviews using a voice recorder and the first author was taking interview notes. The FGDs lasted between one hour and sixteen minutes and one hour and thirty-seven minutes. Voice-recorded data were stored on a password-protected laptop and an external hard drive.
2.6.3 Data analysisData from audio recordings of FGDs were transcribed into eighty paged textual data. Data were analyzed using content analysis ( Graneheim et al., 2017). The first author read the interviews several times to obtain understanding of the data. The first author divided the text into meaning units that were condensed and further labelled into tentative codes. Then, the first, second and third author reviewed and discussed the meaning units, condensed meaning units and the tentative codes and it was agreed to revise the condensed meaning units and codes. An independently revision of condensed meaning units, codes was conducted by the first author. After reviewing and discussing the data in multiple sessions with the first, second and third author, the codes were finally sorted into one theme and two subthemes. Table 1 offers an example of the analysis related to the main theme.
2.6.4 Ethical considerationsThe study received ethical approval from College of Medicine Research Ethics Committee. Participants were fully informed, both verbally and in writing about the nature of the study, including issues of confidentiality, anonymity and the use of audio recording during data collection. They were advised that participation was entirely voluntary, and informed consent was obtained from each participant prior to their involvement. To maintain anonymity, participants were identified using numbers during self-administered interviews and FGDs. The right to withdraw from the study at any time without penalty was emphasized. All information was provided in English. At the conclusion of the interviews and FGDs, each student received $2.70 as a token of appreciation for their time and participation.
3 ResultsThe results describe first the demographic characteristics of the students who participated in the study and secondly how midwifery students in Malawi experienced simulation as a pedagogic method when learning PPH. The quantitative and qualitative findings are presented separately, further synthesised and integrated in the discussion.
3.1 Demographic characteristics of study participantsAs presented in Table 2 a total of 107 midwifery students participated in the study. Most participants were in the age group of 21–25 years (83 %) and females (86 %). Additionally, 24 students (19 females and 5 males), aged between 21 and 32 years, took part in the FGDs.
3.2 Quantitative resultsThe descriptive statistics from self-reported questionnaires are presented in Tables 3–5. The results showed mean scores of above four on the 1–5 Likert scales, with standard deviations of one and below in all the questions. The mean ratings design scale questionnaire ranged from four and above, refer to Table 3. The students felt that the simulation design elements were well presented throughout the simulation session with 1 meaning “strongly disagreeing with the statement and 5 meaning “strongly agreeing with the statement” on a 5-point Likert scale. Regarding the importance of simulation design, the students’ mean scores were above four with 1 meaning “not important and 5 meaning “very important” on a 5-point Likert scale. This section had a standard deviation of less than one on all questions.
Table 4 shows educational practices where students agreed that they experienced active learning, collaboration with peers, diverse ways of learning and high expectations during the simulation sessions. Regarding the importance of educational practices, students reported mean scores of four and above at 1–5 Likert scale with standard deviation of less than one.
Table 5 relates to students’ satisfaction and self-confidence in learning. The students were satisfied and had achieved self-confidence in learning during simulation sessions with mean scores of more than four and standard deviation of one and below.
Reliability was measured by Cronbach's alpha and the values were between 0.797 and 0.912 ( Table 6).
3.3 Qualitative findingsThe qualitative analysis resulted in identification of one main theme: simulation mirrors demanded competence for professional practice. This consisted of two further sub-themes: (1) realistic and active learning method; and (2) a conducive environment for students’ learning. The main theme “simulation mirrors demanded competence for professional practice” reflects students' experience with simulation as a valued teaching method. The midwifery students experienced that simulation help them to understand the acquired competencies for providing professional practice. Each sub-theme is presented with quotations from the FGDs to illustrate meaning of the text.
3.3.1 Realistic and active method of learningThis sub-theme relates to the midwifery students’ experiences on realism related to the PPH simulated case scenario and various ways students had to engage in their learning. Students compared simulation with lecture and skills practice and described simulation as real-life experience in a hospital setting which prepared and gave them confidence, they need for professional practice. Two students said: With the simulation, it’s like we are in the real hospital setting. (FGD 2, Student 7). With the simulation, I have confidence because if someone can tell me there is PPH, I know what I will do and I will not run away. (FGD 1, Student 7).
The PPH simulation scenario represented realistic elements such as the guardian, multidisciplinary healthcare team and the simulated patient, for the students. The students compared the manikins which were used for skills practice and the simulated patient who could respond and express emotional stress, as very realistic and something that students do not experience during lecture and skills practice: for me, it was the way the patient was conducting herself. (Others agree in the background)…we could see what we needed to do from the way the patient was conducting herself. (FGD 1, Student 5).
More significantly, simulation helped students to experience and understand some abstract concepts effectively. The students said realism was also experienced to understand notions that are difficult to comprehend during lecture and practicing with manikins in skills laboratory. These included physical presentation of patient; teamwork; and psychological support to patient and guardian. One student stated: During lecture, we were just taught to ‘provide psychological support.’ During simulation however, the psychological support is being provided. In class, we talk about reassuring the patient, but the skill of reassuring the patient is not taught. (FGD 1, Student 2).
The real-life experience enhanced students' satisfaction, confidence and psychological readiness for clinical practice as expressed by one of the students: I was satisfied because it (meaning simulation) gave me a true picture of what I will meet in the ward…(FGD 3, Student 5).
The students were engaged and participated actively by reviewing the subject of PPH before simulation sessions; during simulation scenario and debriefing session, an experience different from lecture and skills practice. By reading reviewing literature related to PPH raised students’ confidence level to actively participate during simulation session. During simulation scenario students had an opportunity to practice care on simulated patient with PPH. Thus, allowing students to gain necessary experience and improve their competence: People (midwifery students) prepared because they wanted to know something about postpartum hemorrhage before coming into the room (simulation room)…It helped us to read on things which we could not have read if not for simulation (FGD 1, Student 1).
Another student said: In class, it’s like we are imagining that this is what is going to happen. But, during the simulation, we were able to estimate or measure the blood lost. During simulation, we had a chance to perform the interventions. (FGD 2, Student 7).
This sub-theme shows that students compared simulation to classroom teaching and skills practice, where students described simulation as real-life practice. Students mentioned the simulated patient, better understanding of the abstract concepts during simulated scenario and patient with emotional aspects of a human being as real and different from classroom teaching and skills practice. Students actively participated before and during simulation and during debriefing sessions which they reported as important for their learning.
3.3.2 Conducive environment for students’ learningThe midwifery students experienced a supportive setting during PPH simulation and they reported that this was good for development of their clinical skills. The students had no feelings of being judged or criticised during simulation sessions when their mistakes were identified as reflected in the following quotes: After noting that you have missed a point, they did not criticize. (FGD 1, Student 2). We were laughing and that means we grasped the things (meaning the skills) as though we were all peers. When the feedback is harsh, it makes you tense (FGD 1, Student 7).
The peer learning during simulation and receiving feedback from their student fellows during debriefing, also provided students with a safe learning environment: They also gave us an opportunity to correct ourselves. When it is the lecturer correcting you, you think they are only doing that because they are lecturers. But, when it is your friend, you tell yourself that if my friend is pointing this out, it means this is really a mistake. (FGD 1, Student 3).
Another student commended availability of some resources as supportive for their learning which students might not find in real hospital situation: During simulation, we were supported as students in such a way that, we had resources that we needed in order to do the simulation. (FGD 2, Student 4).
Good lecturers and student relationship, getting feedback from fellow students during debriefing and availability of some resources during simulation scenario, created a psychologically safe environment for students’ learning during simulation session.
4 DiscussionThe aim of this study was to explore midwifery students’ experiences with simulation as pedagogic method when learning management of patients with PPH. In this section, quantitative and qualitative findings are merged and compared with get a comprehensive understanding of the students’experiences with simulation. The discussion is structured under the headings: simulation mirrors demanded competence for professional practice; realistic and active learning method; and conducive environment for students’ learning.
4.1 Simulation mirrors demanded competence for professional practiceThe merged findings from quantitative and qualitative data show that students experienced simulation as a teaching and learning method that enhanced their learning, satisfaction and competence. Both quantitative and qualitative findings highlight the effectiveness of simulation-based learning for midwifery students. Quantitative data showed high levels of satisfaction and self-confidence among students, with mean scores exceeding 4.0 on a 5-point Likert scale. The qualitative findings also revealed that students valued simulation as a meaningful pedagogical approach that closely reflected real-world midwifery practice. The students perceived simulation sessions as offering deeper skill acquisition, particularly in managing PPH compared with traditional classroom teaching and skills lab practice. These findings are in line with a previous study conducted in low-income countries ( Bø et al., 2022). It is interesting to note that even when 15 or 16 midwifery students simulated the PPH scenario in a small and compacted room due to resource constraints, students nonetheless applauded simulation, which might strengthen their competence about PPH management.
Literature reveals several contextual barriers that prevent SBE from being implemented. These include workloads and absence of infrastructure and equipment ( Ferguson et al., 2020), which equally affect most Malawi healthcare training institutions ( Mbakaya et al., 2020). It is therefore imperative to meticulously contemplate these constraints and integrate SBE into the national midwifery curriculum to implement SBE, which may help to reduce maternal deaths in Malawi where PPH is the leading cause and skilled midwives are an essential requirement ( Agea et al., 2019; National Statistical Office, 2019).
4.2 Realistic and active learning methodStudents reported high levels of active learning and peer collaboration during simulation, mean scores of more than 4.0, which was echoed in qualitative responses describing the sessions as realistic and reflective of real-life clinical experiences. The realistic elements described were the presence of guardian, multidisciplinary healthcare team and simulated patient. The simulation differed significantly from classroom teaching and skill practice on manikins in another crucial way since students experienced that the simulated patient responded to their actions and expressed emotions, which they acknowledged as being vital for their learning. The simulated patient's emotions and responses triggered students to feel simulation as authentic, which gives students opportunity to integrate theory to practice ( Alharbi, 2020). This is one of the key aspects in creating meaningful learning experience ( Lovink et al., 2024). Students felt as though they were caring for a real patient in a real hospital, which prompted them to manage the simulated patient according to needs. According to Lovink et al., (2021), responses which come from the simulated patient during simulation are called implicit feedback-in-action. Such responses are important related to the students learning as the students consider their interventions based on the simulated patient's responsiveness ( Lovink et al., 2021). This means that it is not only feedback during debriefing that is valuable for the students’ learning, but also the reactions of the simulated patient during simulation ( Lovink et al., 2024). Therefore, as simulation is new in Malawi, the aspect of trained simulated patient is vital and worthy to be considered.
Some abstract concepts such as teamwork and psychological support to the patient and guardian were better understood by students through simulation. These concepts are taught during lectures with the assumption that students comprehend exactly what the lecturer is trying to convey. However, this study revealed an understanding that some students find it difficult to comprehend certain healthcare concepts. Simulation could be a useful technique to help students understand key concepts ( Shaw and Switky, 2018). This was reflected from one of the students: “.In class, we talk about reassuring the patient, but the skill of reassuring the patient is not taught. So, during simulation all that is covered…” (FGD 1, Student 2). In midwifery education, simulation is a method that can possible close the knowledge gap between theory and clinical practice ( Newton and Krebs, 2020).
4.3 Conducive environment for students’ learningThe other main finding concerned positive interactions between lecturers and students and peer learning and feedback during debriefing. Students’ experiences created a psychologically safe environment, conducive for students’ learning. This finding was identified in students’ qualitative responses, but also evident in their responses to the quantitative questions. Working in collaboration with peers and getting constructive feedback from lecturers and fellow students were highly rated by students. Psychological safety is viewed as fundamental element that makes learning positive as it drives learners to maximize their potential and to be creative ( Lateef, 2020). During the debriefing sessions students had the ability to recognize their own mistakes for improvement and commended corrections from their peers as perceived positively than lecturers’ comments. Most significantly, midwifery students were positive to apply what they learned from their mistakes into clinical practice in the event that they encounter PPH patients ( Kolbe et al., 2020). The study demonstrates students' improved level of knowledge, competence and their readiness in caring for patients with PPH. Kruk et al., (2018) documented the importance of transforming health workforce by strengthening pre-service education, as one of the universal actions for improving quality of care in the healthcare system. However, further research is required because this study does not show how the students would use their PPH knowledge and clinical skills in the clinical settings.
5 Study limitationsThe questionnaire was developed based on SBE in developed countries. In addition, the sample size for the FGDs (24 participants) is relatively small. Another limitation is the impact of the researcher's and data collector's roles in data collection, as they were lecturers at the study location. However, multiple data sources were used to cross-verify the findings such that the quantitative findings also support the qualitative data, enhancing the findings' validity. Furthermore, this research was limited to one midwifery program in Malawi, therefore its findings cannot be generalizable. The study focussed on students’ experiences of simulation only and not lecturer’s experiences which would have equally enriched the study findings. Further research with many participants and multiple settings is required to determine the effectiveness of simulation.
6 ConclusionThe present study reveals how midwifery students’ experiences with SBE as pedagogic method when learning management of PPH. Overall, the students expressed SBE as a valued pedagogical approach to teaching and learning that mirror necessary clinical skills for them to practice as professionals. The findings describe that the students experience simulation as an active method of teaching which contributed significantly to their learning and skill development. The positive interaction between the students and lecturers during the simulation sessions, the peer learning and constructive feedback from fellow students, made a foundation for psychologically safe environment for students’ learning. While midwifery students recognize simulation as an essential teaching tool that would improve their PPH management clinical skills, further research is required since this study does not demonstrate how students would apply their PPH knowledge and clinical skills in the clinical setting.
Ethics approval and consent to participateThe study was approved by the College of Medicine Research Ethics Committee certificate number COMREC REF. Number P.02/22/3587. The management of the training institution in Malawi gave its approval for the study, thus no additional authorization was required. All participants signed a letter of consent to participate in the study.
Funding sourcesThe study was supported by NORHED II project - Implementation of simulation-based education in Malawi and Tanzania funded by Norwegian Agency for Development Cooperation (NORAD). The role of the funders was to provide funds for the study.
CRediT authorship contribution statementKabondo Charity: Writing – original draft, Supervision, Project administration, Methodology, Formal analysis, Data curation, Conceptualization. Kafulafula Ursula: Writing – review & editing, Supervision, Methodology, Conceptualization. Kumbani Lily: Writing – review & editing, Supervision, Methodology, Conceptualization. Furskog-Risa Eva Christina: Writing – review & editing, Supervision, Methodology, Formal analysis, Conceptualization. Tjoflåt Ingrid: Writing – review & editing, Supervision, Methodology, Formal analysis, 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.
AcknowledgementsWe wish to thank the midwifery students at the training institution in Malawi for their valuable participation and interest in the study.
Consent for publicationThe paper has been approved for publication by all the authors
| Meaning units from FGDs | Condensed meaning units | Codes | Sub theme | Theme |
| The patient made it seem like it was a real situation. She really made us feel like we were in a real hospital and the patient was really having PPH. It helped us a lot because we were acting as if we were in a real hospital. (FGD 2 student 5) | The standardized patient’s realistic representation made the simulation feel like an actual hospital scenario, prompting students to act accordingly. | | Realistic and active learning method | Simulation mirrors demanded competence for professional practice |
| The environment, it was really a conducive environment for learning because when you talk of a mannequin, sometimes you don’t even know where to start from. In this scenario however, the patient was screaming to say ‘nurse, I am bleeding’ and you knew to call for help and the flow was good. (FGD 1, Student 1) | The learning environment felt realistic and engaging. Unlike with mannequins, the simulated patient gave verbal cues that guided actions, making the scenario flow naturally and feel satisfying. | | A conducive environment for students’ learning |
| Characteristics | Number
(n = 107) | Percentage
(%) |
| Age (years) | ||
| 21–25 | 83 | 77.6 |
| 26–30 | 17 | 15.9 |
| 31–35 | 7 | 6.5 |
| Gender | ||
| Male | 21 | 19.6 |
| Female | 86 | 80.4 |
| Agreement | Agreement | Importance | Importance | |
| Item | Mean | Standard Deviation | Mean | Standard Deviation |
| Objectives and Information | ||||
| There was enough information provided at the beginning of the simulation to provide direction and encouragement. | 4.7 | 0.5 | 4.7 | 0.4 |
| I clearly understood the purpose and objectives of the simulation. | 4.7 | 0.5 | 4.6 | 0.5 |
| The simulation provided enough information in a clear matter for me to problem-solve the situation. | 4.6 | 0.5 | 4.6 | 0.6 |
| There was enough information provided to me during the simulation. | 4.6 | 0.5 | 4.6 | 0.5 |
| The cues were appropriate and geared to promote my understanding. | 4.5 | 0.6 | 4.5 | 0.7 |
| Support | ||||
| Support was offered in a timely manner. | 4.4 | 0.7 | 4.5 | 0.6 |
| My need for help was recognised. | 4.5 | 0.6 | 4.4 | 0.8 |
| I felt supported by the teacher's assistance during the simulation | 4.5 | 0.6 | 4.7 | 0.5 |
| I was supported in the learning process. | 4.7 | 0.5 | 4.7 | 0.5 |
| Problem-Solving | ||||
| Independent problem-solving was facilitated. | 4.1 | 0.7 | 4.2 | 0.8 |
| I was encouraged to explore all possibilities of the
simulation. | 4.4 | 0.7 | 4.4 | 0.7 |
| The simulation was designed for my specific level
of knowledge and skills. | 4.7 | 0.6 | 4.7 | 0.5 |
| The simulation allowed me the opportunity to prioritise nursing assessments and care. | 4.7 | 0.5 | 4.7 | 0.5 |
| The simulation provided me an opportunity to goal
set for my patient. | 4.6 | 0.6 | 4.7 | 0.5 |
| Feedback/Guided Reflection | ||||
| Feedback provided was constructive. | 4.7 | 0.5 | 4.7 | 0.5 |
| Feedback was provided in a timely manner. | 4.6 | 0.6 | 4.7 | 0.5 |
| The simulation allowed me to analyse my own behaviour and actions. | 4.6 | 0.7 | 4.6 | 0.7 |
| There was an opportunity after simulation to obtain guidance/feedback from the teacher in order to build knowledge to another level. | 4.9 | 0.4 | 4.8 | 0.4 |
| Fidelity (Realism) | ||||
| The scenario resembled a real-life situation. | 4.9 | 0.4 | 4.8 | 0.4 |
| Real-life factors, situations and variables were built
into the simulation scenario. | 4.8 | 0.5 | 4.8 | 0.5 |
| Agreement | Agreement | Importance | Importance | |
| Item | Mean | Standard Deviation | Mean | Standard Deviation |
| Active learning | ||||
| I had the opportunity during the simulation activity
to discuss the ideas and concepts taught in the course with the teacher and other students. | 4.7 | 0.6 | 4.7 | 0.5 |
| I actively participated in the debriefing session after
the simulation. | 4.7 | 0.5 | 4.7 | 0.5 |
| I had the opportunity to put more thought into my
comments during the debriefing session. | 4.5 | 0.6 | 4.6 | 0.5 |
| There were enough opportunities in the simulation to find out if I clearly understand the material. | 4.4 | 0.7 | 4.4 | 0.7 |
| I learned from the comments made by the teacher
before, during, or after the simulation. | 4.7 | 0.5 | 4.7 | 0.5 |
| I received cues during the simulation in a timely
manner. | 4.4 | 0.8 | 4.5 | 0.7 |
| I had the chance to discuss the simulation objectives with my teacher. | 4.6 | 0.7 | 4.8 | 0.5 |
| I had the opportunity to discuss ideas and concepts
taught in the simulation with my instructor. | 4.6 | 0.6 | 4.6 | 0.6 |
| The instructor was able to respond to individual
needs of learners during simulation. | 4.4 | 0.8 | 4.5 | 0.6 |
| Using simulation activities made my learning time
more productive. | 4.8 | 0.5 | 4.7 | 0.5 |
| Collaboration | ||||
| I had the chance to work with my peers during
simulation. | 4.8 | 0.5 | 4.7 | 0.5 |
| During simulation, my peers and I had to work on
the clinical situation together. | 4.8 | 0.5 | 4.7 | 0.6 |
| Diverse Ways of Learning | ||||
| The simulation offered a variety of ways in which to
learn the material. | 4.5 | 0.7 | 4.6 | 0.6 |
| This simulation offered variety ways of assessing my
learning. | 4.6 | 0.6 | 4.6 | 0.6 |
| High Expectations | ||||
| The objectives for simulation experience were
clear and easy to understand. | 4.7 | 0.5 | 4.7 | 0.6 |
| Agreement | Agreement | |
| Item | Mean | Standard Deviation |
| Satisfaction with Current Learning | ||
| The teaching methods used in this simulation were
helpful and effective. | 4.7 | 0.7 |
| The simulation provided me with a variety of learning materials and activities to promote my learning the medical-surgical curriculum. | 4.6 | 0.6 |
| I enjoyed how my instructor taught the simulation. | 4.6 | 0.6 |
| The teaching materials used in this simulation were
motivating and helped me to learn. | 4.7 | 0.6 |
| The way my instructor(s) taught the simulation was
suitable to the way I learn. | 4.7 | 0.6 |
| Self-confidence in Learning | ||
| I am confident that I am mastering the content of
simulation activity that my instructors presented to me. | 4.5 | 0.6 |
| I am confident that this simulation covered critical
content necessary for the mastery of medical-surgical curriculum. | 4.5 | 0.6 |
| I am confident that I am developing the skills and
obtaining the required knowledge from this simulation to perform necessary tasks in a clinical setting. | 4.5 | 0.6 |
| My instructors used helpful resources to teach the
simulation. | 4.6 | 0.6 |
| It is my responsibility as the student to learn what I
need to know from this simulation activity. | 4.6 | 0.7 |
| I know how to get help when I do not understand the
concepts covered in the simulation. | 4.4 | 0.7 |
| I know how to use simulation activities to learn
critical aspects of these skills. | 4.5 | 0.7 |
| It is the instructor's responsibility to tell me what I
need to learn of simulation activity content during class time. | 4.2 | 1.0 |
| Questionnaires | Cronbach's alpha values |
| Design scale, agreement | 0.797 |
| Design scale, importance | 0.855 |
| Educational practices, agreement | 0.854 |
| Educational practices, importance | 0.871 |
| Student satisfaction and confidence in learning | 0.912 |
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