A comparison of the effects of teaching through simulation and the traditional method on nursing students' self-efficacy skills and clinical performance: a quasi-experimental study

Simulation is a version of some actual instruments or working conditions designed to illustrate some behavioral dimensions of a physical or abstract system via the behavior of another system. The main goal of simulation in healthcare is to prepare students to face clinical situations, increase patients' safety, reduce errors, and improve nurses' clinical judgments. Thus, students can get a command of the skills that are less likely to be acquired in real-world situations [1]. Nurses need constant learning to update their knowledge and skills [2]. In other words, medical knowledge is increasingly being expanded. Thus, teaching nursing should become a dynamic form of teaching and move towards innovation, advancement, and implementation of modern teaching and educational methods [3]. Nowadays, IT-based instruments have significantly permeated all areas of medical sciences, particularly education [4]. Continuous education by applying technologies can bring essential advantages such as enhancing knowledge and effectiveness, improving performance quality, and increasing nurses' skills and professional qualifications [1].

Moreover, the method can bring about flexibility, easy access, and an opportunity to play valuable roles in nursing education at any time [5]. Simulation-based nursing education is a pedagogical approach that is increasingly gaining popularity. Simulation as a teaching method includes activities that mock an actual clinical environment and has been designed to illustrate processes, decision-making, and critical thinking via techniques such as role-play or instruments like educational films and models, scenarios, and case studies [6, 7]. The use of simulation in nursing education seems justifiable due to the lack of sufficient feedback in clinical environments, patients' inactivity during the examination process, the lack of access to a sufficient number of patients, the ever-changing composition of patients in real-world conditions, the lack of available clinical situations, and the significant number of students in clinical environments [8]. Simulation can improve students' knowledge, skills, and performance in nursing education. Students attain higher levels of critical thinking by practicing and acquiring new professional skills without interfering with patients' safety and health [9]. Implementing the method can also enhance nurses' learning and provide helpful feedback so they can become skillful nurses. The simulation scenarios empower nursing students in applying the educational, perceptual, and psychological experiences of learning and help students to acquire the skills necessary for thinking, evaluating, problem-solving, decision making, and analyzing the data [10]. Transferring the information concerning classrooms and clinical environments to the simulated environment in a different way and portraying the characteristics of clinical situations and people's actual lives are some features of simulation-based education [11]. The method can increase the tendency to group work and expand the spirit of cooperation and collective influence among the students. Simulated environments can provide places for the students to expand their capabilities in terms of the specialized skills of their professions without imposing any threat to the patients' lives [12].

Nursing students play a key role in continuously taking care and improving patients' health and making the healthcare system more efficient in the future. Thus, enhancing the quality of the healthcare system is a major concern, and nurses' performance is an important and significant factor that influences healthcare quality [13]. On the other hand, efficient nurses need skills like problem-solving and capabilities such as making decisions for clinical situations. Therefore, clinical performance is important in the nursing education system [14]. Thus, the main goal of internship courses during a nursing education program should be the development of self-efficacy and providing the highest level of education. Bandura's Self-Efficacy Theory is an instrument that can be applied to assess the degree of certainty in the students' clinical skills performance [15]. According to Bandura's theory, people with sufficient self-efficacy are more likely to adapt to the requirements of a particular situation; on the other hand, people with low self-efficacy face serious problems while performing certain activities. Clinical experience and sufficient education are two major factors that form clinical certainty. Students with higher self-efficacy are efficient and self-regulating while facing future challenges [16]. The modern world requires self-regulating learners. The construct of self-efficacy is crucial in educational environments since Bandura's theory explains that such places fertile lands for growing and forming self-efficacy [17]. The findings of many studies indicate that self-efficacy is quite effective in acquiring knowledge, growing and improving skills, and implementing knowledge and scientific/professional skills [18]. Due to the breakout of the COVID-19 pandemic and the importance of simulation in educating nursing students, the current study was conducted to investigate the effects of simulation-based education and the traditional method on the nursing students' self-efficacy and clinical performance in Kermanshah University of Medical Sciences in 2021.

The collected data were analyzed using descriptive (mean and SD) and inferential statistical techniques (independent-samples and paired-samples t-test and the COVARIANCE analysis) by SPSS 23.

The findings indicated that the nursing students' mean scores in terms of self-efficacy skills increased after the intervention (142.13) compared to their pre-test scores (87.57). In addition, simulation-based education was influential on the students' self-efficacy skills. Besides, the students' mean clinical performance scores increased after the intervention (4.57) compared to their pre-test scores (2.16); thus, it was shown that the simulation-based technique influenced the nursing students' clinical performance. In justifying the obtained results, it can be argued that implementing the simulation-based technique in medicine makes it possible for the students to face rare occasions and intervene in them. It improves group work and the related skills in the would-be doctors and increases the group members' self-confidence [19]. The current study's findings were in line with Sajjadi et al., Kargar et al., and Rahmani et al., [11, 18, 20]. Sajjadi et al. showed that the participants educated with an online simulation-based technique received higher scores in terms of satisfaction after the intervention and 10 days later reported better scores in terms of their performance compared to the speech-based group. Moreover, it was shown that 10 days after the intervention, the time taken to execute a certain scenario in the online simulation-based group was significantly lower than the speech-based group [11]. Moreover, Kargar et al. conducted a study titled "a study on the effects of simulation on nurses' performance in neonatal resuscitation in Behbahani Hospital" ad showed that the level of knowledge in the control and experimental groups increased by 9 and 10 scores, respectively; thus, the difference between the two groups was not significant. In addition, no difference was observed between the two groups regarding the pre-test performance. However, a significant difference was observed one month after the educational program, and the participants in the experimental group performed significantly better than their counterparts in the control group. The findings indicated that simulating and simultaneously filming for educational purposes is more effective on learning [18]. Heydarzadeh et al. conducted a study titled "the effects of computerized simulation and implementing models on the nursing students' perception of self-efficacy during cardiopulmonary resuscitation". The mean scores and the SD of the students' self-efficacy perceptions before and after the intervention in both groups were significantly different (23.5 in the model-based group and 15.4 in the computerized simulation group). The study's findings showed that either of the above techniques increased self-efficacy perceptions concerning cardiopulmonary resuscitation; thus, educational institutions can implement either technique for educating their students depending on their particular situations and facilities and train nurses with higher qualifications to provide service for their patients [21]. Implementing modern educational techniques such as simulators and educational films can effectively increase students' cognitive, communicative, and practical skills [22], which was in line with the findings of the current study. A study by Khalaila indicated that implementing the simulation-based technique increased the mean scores of nurses' self-efficacy after an intervention program [23]. Liaw et al. implemented the simulation-based technique in control and experimental groups. The experimental group (including 15 people) started a 6-h simulation program providing 4 clinical scenarios concerning pneumonia, shocks, hyperglycemia, and septic shock to manage a critical patient, and a question and answer session was held at the end. Moreover, a performance assessment was performed using a videotape and a panel of assessors who were unaware of the study's objectives. Comparing the pre-test mean scores did not indicate any significant differences between the two groups, but a significant difference was observed in the post-test performance of the experimental group [24]. The study by Rodrigues et al. indicated that implementing simulation-based educational software is a useful strategy to assist nurses and develop their professional skills and training [25]. The study by Fidalgo et al. on pharmacy students showed that implementing films, moving pictures, designs, and texts in integrated content can significantly enhance the students' conceptual understanding and learning [26]. Moreover, the study by Lis et al. on a group of medical students indicated that implementing educational films in the experimental group was useful in improving the students' self-efficacy and clinical skills [27]. The findings were found to be in line with the findings of the current study. Thus, people's understanding of their duties and the management of critical conditions, their belief in being able to show a successful performance, and presenting accurate solutions to attain desirable consequences are clear representations of self-efficacy. If they are well-represented in nurses, their clinical performance and the quality of their healthcare activities will be enhanced. Lee et al. conducted a study on nurses and indicated that simulation-based education has significant effects on the nurses' qualifications and clinical performance  [28], which was in line with the findings of the current study. Furthermore, the findings of Hsin-Hsin Lin showed that the simulation-based approach significantly impacts nursing students' self-efficacy and performance qualifications [29], which was also in line with the findings obtained in the current study. Yon Hee Seo et al. showed that simulation-based education significantly impacts Korean nursing students' clinical argument, problem-solving processes, self-efficacy, and clinical qualification [30], which was in line with the current study's findings. Moreover, the findings of Salwa et al. indicated that the simulation-based approach significantly impacts nursing students' communicative skills, self-efficacy, and clinical qualification [31].

Bandura (1997) has stated that people with high self-efficacy beliefs show more resistance when dealing with problems; According to Bandura, self-efficacy encourages motivation and cognitive resources of a person and is a factor for exercising control over a specific event. According to Bandura, a person's emotions, thinking, and behavior in any situation depend on his sense of ability [32]. In situations where a person is confident about his/her abilities, his behavior, cognition, and emotions are entirely different from situations where a person feels incompetent and insecure or lacks competence.

Simulation as a method of education consists of all activities that mock a real-world clinical environment and has been designed to illustrate processes, decision-making, and critical thinking by role-playing and instruments like educational films and models. Simulation-based education makes it possible to transmit the knowledge and skills required for the healthcare activities performed by a nurse, and it can enhance students' evaluation of their capabilities.