Ⅰ. INTRODUCTION

1. Background

Providing high-quality clinical practicums are an essential responsibility for nursing education and play a key role in preparing nursing students as future competent nurses (Kaihlanen et al., 2021). It is also critical that nursing students can receive education in a clinically reproducible environment that reflects the reality of practical nursing (Martínez- Galiano, Parra-Anguita, Delgado-Rodríguez, & González-Cabrera, 2021). The American Association of Colleges of Nursing declared that integrative nursing education should consider diverse patients, disease groups, community members, and healthcare provider teams with complex health problems to expect patient safety and effective health outcomes (American Association of Colleges of Nursing, 2022). However, such education is quite challenging for nurse educators to apply to nursing students in the existing traditional clinical practicum, also there is sometimes a gap between what nurse educators are expected to teach and what clinical care reality demands in the health sciences disciplines (Williamson et al., 2020).

It is becoming more and more difficult to provide quality clinical practicum experiences for nursing students in a limited clinical field. It is because of many reasons such as improper or unpredictable nature of clinical environment, the higher level of knowledge and agility of the patient, the practicum experience allowing mainly observation, the difficulty of securing appropriate clinical instructors, and moreover, recent pandemic situation of the COVID-19 in which face-to-face opportunity is suspended or restricted for the safety reason (Agu, Stewart, McFarlane-Stewart, & Rae, 2021). Therefore, there has been a growing demand for a new educational strategy to replace or supplement clinical practicum for nursing students. For a decade, nurse educators have adapted high-fidelity simulation education to suit of settings and populations reflecting clinical situations, which replaces parts of traditional clinical practicum, and still continue to seek evidence to support incorporating simulation practicum (Jackson, McTier, Brooks, & Wynne, 2022).

While most simulation research attempts have been made to nursing education targeted at a specific topic or a case of specific patient (Min, 2019), studies support the need for undergraduate nursing students to have increased experiences caring for multiple patients in diverse nursing care settings through implementing various subjects and learning contents to be ready to transition to nursing practice (Kirkman, Hall, Winston, & Pierce, 2018). According to several studies, integrated simulation or multi-patient simulation education improved nursing students’ critical thinking and clinical judgement (Shon & Moon, 2021) and perceptions of confidence and readiness to care (Oiler, Dharmasukrit, & Ackerman-Barger, 2018) with the environment similar to the actual complex and multifaceted health care system (Kirkman, Hall, Winston, & Pierce, 2018).

Critical thinking is vital for nursing practice, and it is imperative that nurse educators should educate nursing students to better establish their critical thinking ability in clinical learning programs (Boso, van der Merwe, & Gross, 2019). While facing with complex clinical situations, nurses should be able to apply critical thinking based on their existing knowledge and experience, in order to flexibly solve problems and make the best judgment for patients through appropriate analysis and reasoning (Cui, Li, Geng, Zhang, & Jin, 2018). In recent decades, nursing education has been struggling to find efficient and useful educational methods to cultivate critical thinking ability of nursing students (Cui et al., 2018), and it is widely accepted that critical thinking skills of nursing students can be improved by incorporating more innovative learning strategies utilizing such as high fidelity simulators and standardized patients into nursing education programs rather than sticking to classroom lectures and short and passive hands-on experiences in traditional clinical practicum (Doğan & Şendir, 2022).

Moreover, diverse attempts have been continuously made to improve the clinical competence of students by using various learning methods, including simulation-based teaching with high fidelity simulators, low fidelity simulators, standardized patients, or virtual simulators to train them as healthcare professionals (Herrera-Aliaga & Estrada, 2022). It is ideal for teaching reflective clinical skills and management of patients allowing nursing students to practice clinical skills and making patient care decisions in a safe environment resembling many healthcare topics and diverse clinical situations (Moran, Wunderlich, & Rubbelke, 2018). In a systematic review of 24 studies in the last 10 years, it is proved that overall simulation-based education did improve clinical competence better than the conventional nursing education (Asegid & Assefa, 2021). However, the authors of the systematic review reported significant heterogeneity among the studies (Asegid & Assefa, 2021), therefore it is required continuous efforts to develop more efficient simulation nursing education set-up along with evaluation of clinical competence with well-defined assessment method.

Especially, it is recommended that senior nursing students who are about to graduate should be provided with effective simulation education since more demands can be expected in their transitional period to new nurses in the upcoming future. Therefore, it is necessary to develop a simulation education program for senior nursing students, incorporating contents of comprehensive and diverse clinical topics and patient cases.

2. Purpose

The present study aimed to develop an integrated simulation practicum considering various clinical settings and cases of adult nursing, maternal nursing, child nursing, mental health nursing, community nursing, and nursing management for senior nursing students and explore the effects of the program.

Ⅱ. METHODS

1. Study design and participants

The present study was a quasi-experimental design that employed control group pretestposttest design. All senior students (n = 67) among 280 nursing students from a university in Korea included in this study between March and June 2020. Inclusion criteria were as follows: completed the fundamentals of nursing and medical-surgical nursing course, had no previous experience with simulation practicum, and provided written consent to participate in the study voluntarily. The participants were conveniently assigned to the experimental group (n = 31) and the control group (n = 36), considering the capacity of each place to perform the practicum. There were no dropouts in this study (Figure 1).

We calculated the sample size adequacy using G*Power 3.1 software (https://www.psychologie.hhu.de) and arrived at a required total sample size of 34 (17 for each group) according to an α level of 0.05, a conventional medium effect size of 0.25, and a power of β = 0.80 for the F-test. Assuming this, the number of participants for this study was considered appropriate.

2. Intervention

In order to develop the draft of an integrated simulation practicum, we collected professional opinions from 7 nursing professors with various majors (adult nursing, maternal nursing, child nursing, psychiatric nursing, community nursing, and nursing management) along with a literature review. The draft included 7 scenarios covered different topics; (1) therapeutic communication on crisis of suicide attempt in patient with depression, (2) cardiac patient with chest pain, (3) patient with traumatic brain injury in a motorcycle accident, (4) smoking cessation counseling in public health center, (5) oxytocin- induced labor case in obstetrics nursing, (6) child with febrile seizure, and (7) safety management for patient at high risk of fall. Also, it included a detailed design with selected subjects and patient cases, the adequate number of students in each group, and information on each patient case (diagnosis, signs and symptoms, laboratory test results, electronic medical records, prescription, medication list, and progress notes), simulation time distribution, space composition, and so on. In addition, we included the goal of the scenario, instructional plan, step-bystep template for operation and debriefing, detailed prompt, and toolkit for each simulation scenario. The draft of the practicum was professionally reviewed and verified by 7 clinical nursing experts, revised according to the experts’ recommendations, and completed as a final version of an integrated simulation practicum.

The theoretical framework for performing the intervention in this study was Jeffries’s Simulation Model (Jeffries, 2005), which suggests essential elements of simulation design to effectively achieve students’ learning outcomes. According to the model, our simulation design included learning objectives, fidelity, task complexity, instructor suggestion, and debriefing. Also, the instructors performed the intervention as a guide on simulation education, evaluated using specific scenarios, and supported learners throughout the practicum, and the learning experience was actively shared with the learner through debriefing after the practicum.

As for the experimental group, a total of 31 students were divided into 4 groups, and each group consisted of 7-8 students. The simulation practicum was conducted in each group sequentially for 3 weeks designated as 2 practicum credits (60 hours) by the instructors of 7 nursing professors and 2 trained teaching assistants. The practicum took place in 3 simulation rooms and a debriefing room of the nursing simulation center at a university. In each simulation room, the environment was prepared to simulate a real context, providing more realism. Among the scenarios, two of them dedicated to high-fidelity adult simulators, one for high-fidelity baby simulator, one for high-fidelity maternity simulator, and three for standardized patients. At the first day, it started with a preassessment and an orientation about the integrated simulation practicum and the environment, followed by 7 simulation practicum sessions (each for 8 hours) sequentially, and a post assessment was conducted on the last day of the simulation practicum. The operation sequence of 7 simulation practicum sessions was carried out according to the order mentioned as the above development for convenience.

The control group, a total of 36 students, were divided into 4 groups (9 students for each group) and participated in traditional clinical practicum for 3 weeks at one of the various nursing care settings (i.e., medical/ surgical wards, emergency room, operating room, or public health center), which had been previously conducted at the nursing school of a university. For ethical considerations, students in the control group were considered to experience the same integrated simulation practicum as the experimental group in the next semester (between September and December 2020).

3. Measurements

We collected the participants’ demographic characteristics, critical thinking disposition, clinical competence, and practicum satisfaction with a structured self-reported questionnaire. Data collection for critical thinking disposition and clinical competence was conducted before and after the practicum for both the experimental and the control groups, and practicum satisfaction was assessed only after the practicum for both groups. The preassessment was conducted at the first day before the practicum, and the postassessment was conducted on the last day after the practicum. The assessment of outcomes for both groups was conducted by a research assistant who was not involved in grading.

1) Critical thinking disposition

Critical thinking disposition was measured using the Critical Thinking Disposition Scale developed by Kwon et al. (2006). It consists of 35 questions on a 5-point Likert scale with 1 to 5; producing total score range between 35 and 175. The higher the total score, the higher the level of critical thinking disposition. Cronbach’s α was .89 in a previous study (Kwon et al., 2006) and .89 in the present study.

2) Clinical competence

Clinical competence was measured using the Korean Nurses’ Core Competency Scale developed by Lee, Kim, and An (2017). It consists of 70 items rated on a 5-point Likert scale with 1 to 5; producing total score range between 70 and 350. The higher the score, the higher the clinical competence. Cronbach’s α was .97 in a previous study (Lee et al., 2017) and .97 in the present study.

3) Practicum satisfaction

Practicum satisfaction was measured using a tool developed by Wotton, Davis, Button, and Kelton (2010) and translated into Korean and revised by Lee, Park, and Noh (2013). It consists of 8 questions on a 7-point Likert scale with 1 to 7; producing total score range between 8 and 56. The higher the total score, the higher the level of practicum satisfaction. Cronbach’s α was .95 in a previous study (Lee et al., 2013) and .79 in the present study.

4. Statistical analyses

Data were analyzed using SPSS version 23.0 (IBM Corporation, Armonk, NY, USA). The demographic characteristics of the participants were analyzed using frequencies, means, and standard deviations. Baseline homogeneity of demographic variables, as well as critical thinking disposition, clinical competence, and practicum satisfaction, between the experimental and control groups were analyzed using independent t-test and Fisher’s exact test. Differences in critical thinking disposition, clinical competence, and practicum satisfaction between the groups before and after the intervention were analyzed using analysis of covariance (ANCOVA).

5. Ethical consideration

This study was approved by the Institutional Review Board of Ajou University (IRB no. AJOUIRB-MDB-2020-086). All participants provided written informed consent and were assured that their information would remain confidential. Participant agreement forms were obtained after the research assistant explained the purpose of the study and the confidentiality of the data. Anonymity was guaranteed by the suppressed encoding of each participant’s name.

Ⅲ. RESULTS

1. Participants’ demographic characteristics

Baseline demographic characteristics are presented in Table 1. The mean ages of the experimental and control groups were 22.29 and 22.14, respectively. The majority of the participants were women (87.1% for the experimental group and 83.3% for the control group), had grade point averages between 3.5 and 4.0 (41.9% for the experimental group and 41.7% for the control group), and reported their satisfaction with major as high (61.3% for the experimental group and 52.8% for the control group). There were no significant differences in demographic characteristics between the two groups (Table 1).

Baseline outcome variables are presented in Table 1. The mean scores of the critical thinking disposition in the experimental and control groups were 118.10 and 120.11 (out of 175), respectively. And the mean scores of the clinical competence in the experimental and control groups were 237.71 and 242.11 (out of 350), respectively. There were no significant differences in critical thinking disposition and clinical competency between the two groups (Table 1).

2. Effects of the integrated simulation practicum

The effects of the integrated simulation practicum on the senior nursing students’ critical thinking disposition, clinical competence, and practicum satisfaction are shown in Table 2 and Table 3.

Evaluation of the participants’ outcomes after the intervention indicated significant improvements in critical thinking disposition (p = .017) and clinical competence (p < .001), compared to the baseline in both groups. The mean score of the critical thinking disposition in the experimental group increased from 118.10 to 124.23, and that in the control group increased from 120.11 to 125.86. The mean score of the clinical competence in the experimental group increased from 237.71 to 268.81, and that in the control group increased from 242.11 to 266.22 (Table 2). However, there were no differences between the groups in the degree of improvements of critical thinking disposition and clinical competence.

Regarding practicum satisfaction, there was a significant difference in the mean score between the two groups after the intervention (mean of the experimental group = 48.37; mean of the control group = 44.64; p = .003) (Table 3).

Ⅳ. DISCUSSION

The present study developed an integrated simulation practicum based on the Jeffries Nursing Education Simulation Framework (Jeffries, 2005) for senior nursing students and evaluated the effects of the practicum using a quasi-experimental design. Both the experimental and control groups showed an improvement in critical thinking disposition and clinical competence without betweengroup differences. In addition, it demonstrated significantly better positive effects on the participants’ satisfaction with the practicum in the experimental group, compared to the control group.

Jeffries Nursing Education Simulation Framework (Jeffries, 2005), which was used to guide this study, is a comprehensive framework endorsed by the National League for Nursing and becoming a popular teaching pedagogy to provide theoretical direction for nurse educators to plan, conduct, and evaluate the simulation activities (Al Khasawneh, Arulappan, Natarajan, Raman, & Isac, 2021). Based on this theoretical framework, we could develop an integrated simulation practicum and conduct the intervention and evaluate students by considering specific components presented in the framework (i.e., active learning, diverse learning, feedback, student/ faculty interaction, collaboration, time on task, prebriefing and debriefing, etc.) (Jeffries, 2005). Developing simulations using this framework will provide engaging and pedagogically sound simulation experiences for both nurse educators and the students in future studies.

The result of the study revealed that statistically significant improvement of critical thinking disposition from before to after the practicum for both experimental and control groups. Comparing with previous studies, Alamrani, Alammar, Alqahtani, and Salem (2018) compared the effects of simulation- based and traditional teaching methods for 30 senior nursing students in the subject of electrocardiogram interpretation (for 3-4 hours). The result presented that both teaching methods had approximately equal benefit to the improvement of critical thinking ability of the nursing students (Alamrani et al, 2018). Also, Kelleci, Yilmaz, and Aldemir (2018) enrolled 60 nursing students and randomized them to high-fidelity simulation training with 13 scenarios for 40 hours (on perineal care, oral drug administration, and respiratory applications) and traditional education groups. The result presented that the simulation method was found not to be inferior in improving the critical thinking ability of students compared to the traditional education method (Kelleci et al., 2018). Critical thinking is the key component for nurses in problem solving and making major decisions independently and quickly in critical situations. Critical thinking requires cognitive skills and willingness to think about different and diverse issues, and by referring these skills, nursing students can apply previously acquired knowledge properly into the complex clinical situations (Ali-Abadi, Babamohamadi, & Nobahar, 2020). Therefore, critical thinking disposition can impact on the expected clinical role expression of nursing students, and it should be well-trained during the undergraduate nursing education by being exposed to a variety of clinical situations and experiencing them. We assumed that the integrated simulation practicum, which provided various clinical situations and patient cases, improved the students’ critical thinking disposition as effectively as the traditional clinical practicum experiences in the real-world.

The result of the current study indicated that statistically significant improvement of clinical competence from before to after the practicum for both experimental and control groups. Comparing with previous studies, Lee et al. (2019) enrolled 100 senior nursing students either in a simulation practicum with 4 scenarios of acute care adult course in intensive care unit (ICU)-like laboratory (for 36 hours) or in a traditional clinical practicum in the hospital ICU, and the result presented that significant improvements in clinical performance were found in both groups without differences between the groups. Also, Raman et al. (2019) included 74 nursing students of a maternity nursing course in a traditional clinical training group or in a high-fidelity simulation (for 34 hours) combined with traditional clinical training, and the result revealed no significant differences in the clinical competency between the two groups (i.e., simulation combined with traditional clinical training group did not perform worse than the peers who exposed in 100% traditional clinical training group). These results are considered to be similar to the result that our developed simulation practicum is not inferior to the traditional practicum with the resemble patients from the clinical setting. We tried to deliver a simulation environment as diverse and real-world clinical practices to help students build their clinical competencies through multitude of different scenarios. We assumed that the students’ clinical com petencies were empowered by learning experiences through different scenarios in a comfortable and safe simulation environment. Psychologically safe and comfortable environment allows for nursing students to learn from their mistakes and foster the clinical ability to avert defensive behaviors (Turner & Harder, 2018). Also, nursing students can be engaged and reflected on their performance in a non-threatening and controlled environment with no risk of harm to both patients and students with less anxiety (Rashwan, El Sheshtawy, Abdelhalim, Eweida, & Khamis, 2021). However, the simulation technology still has often many limitations to provide an exactly lifelike practicum experience when it comes to some clinical situations (Alinier & Oriot, 2022). Therefore, it is necessary to continue to build for evidence to provide more efficient and useful practicum strategy for nursing students through an appropriate combination of simulation and traditional clinical practicum in future studies.

The results of the current study suggest that the integrated simulation practicum and traditional clinical practicum provide significant but approximately equal benefit to critical thinking ability and clinical competence of senior nursing students. In addition, the integrated simulation as well-developed and implemented educational program with the collaboration of diverse academic and clinical experts can be effectively promote senior nursing students with more positive satisfaction with the education.

This study has several limitations. First, it applied a quasi-experimental design with a small sample size. Thus, significant differences could affect the variables between the experimental and control groups, and caution is required in the interpretation. Second, the sample was selected from a nursing school in a university, South Korea using convenience sampling, therefore it has poor generalizability. Third, the intervention period of 3 weeks was relatively short for expecting the outcome changes among the participants. Future studies that include a larger number of participants and an extended period of intervention and follow- up are needed.

Ⅴ. CONCLUSIONS

This study sought to use an integrated simulation practicum with diverse clinical scenarios of various settings for senior students. Given the results of higher student satisfaction along with the increase in critical thinking disposition and clinical competence at the similar level as the traditional clinical practicum, the innovative use of simulation in this context is well suited to senior nursing students on the verge to become nurses in various clinical and community nursing care settings. It can be utilized as an effective approach to facilitate successful transitional practicum for senior nursing students in a controlled environment with no risk of harm to both patients and students. We suggest further studies with more diverse scenarios on simulation practicum and the latest educational technology that increase active interaction and the sense of reality to fulfill the learner’s needs and satisfaction.