Simulation through an artificial environment recreates a real situation to practice, learn, validate, test or develop an understanding of human systems or actions, with a high degree of interactivity and realism for participants[3, 4, 8, 12, 19, 20, 31, 32]. As a didactic technique, clinical simulation requires basic skills from teachers, namely the mastery of concepts, attitudes and procedures [22, 33], demanding rigorous and systematic planning yet flexible [23]. In order to achieve the expected outcomes, simulation design and development should consider criteria that facilitate the effectiveness of simulation-based experiences [22, 34], with especially relevant scenarios so that the simulation results are coherent and appropriate.
This study aimed to develop a standardized process of scenario writing aimed at realistic simulation to address the issue of the person with dependence in self-care activities and their family caregivers when preparing the return home after a critical event.
There is extended literature reporting the steps and methodologies to be used in the creation of scenarios [21, 23, 24, 35, 36]. However, the contexts where they are applied and the resources (low, medium or high-fidelity simulators) that clinical simulations use are so diverse, making it difficult to adapt and use scenarios that have already been validated in other settings.
The focus of attention in this study was the clinical scenario, considered by the teaching team to be the element where clinical simulation experiences could be enhanced. Some studies that used Computer-Based Scenarios for clinical teaching employed immersive simulation, virtual reality or mixed techniques [37–39], so they are substantially different from the type of simulation experience used in the present study and are not comparable. In the clinical simulation, the technique of dramatization through role-play was used. This strategy has been used in simulation activities, associated with satisfaction, self-confidence, knowledge, empathy, realism, decreased anxiety level, comfort, communication, motivation, reflection skills, critical thinking, and teamwork [1, 40].
Alongside the search for the best scientific evidence on the subject, the teachers of the curricular unit created a strategy (nominal group technique) to propose changes to the model in use and increase the fidelity of the scenarios used in the approach to the subject.
Thus, the creation of a standardized process of scenario writing through a virtual assistant was considered innovative and appropriate. The process involved analysing the most commonly used constructs in assessing people with self-care impairment and their caregivers and proposing a template with these concepts. For example, the ability/impairment in performing self-care activities was considered an element present in almost all scenarios. The self-care dependency evaluation form [30] is usually applied, in which 10 domains of basic self-care activities (feeding, walking, grooming, bathing, toileting, taking medication, transferring, turning, lifting and dressing) are assessed so these fields became part of the standardized scenario writing template. By creating a visual system in which we quickly perceive the data for assessing the person's ability to perform these self-care activities, we are reducing the amount of written information and creating a mechanism for the student to quickly perceive and retain this information during the simulation activity.
Visual stimuli are an important aspect of learning, as they arouse interest but may also help students to better retain content. The use of vector images in the scenarios facilitates the memorisation of key concepts that students should address in future real-life contexts and thus perform appropriate diagnostic activities and care planning.
When reviewing the scenarios created, the teachers discussed and agreed upon the Prebriefing and Debriefing methodologies. Thus, there was an agreement on the guidelines and information made available before the simulation (Prebriefing) so that the learning experience could be correctly prepared and experienced, following the correct use of materials and the ethical and deontological principles of the profession.
The model used in the Debriefing after the simulation activity was performed was also discussed and agreed upon. This moment is considered primordial to active learning, where the technical, affective, cognitive, and psychosocial skills and competencies experienced during the development of clinical simulation are developed [36]. The model adopted [36], which includes three stages: descriptive (how students saw themselves during the simulation), analytical (students analyse the simulated experience), and the application or transfer (aiming at the transfer to clinical practice), involving not only those who experienced the scenario but also the wider group. Thus, the adopted methodology ensured the content validity of the virtual scenario writing, which is a necessary characteristic for scenario fidelity [23].
The testing through the quasi-experimental study with students allowed a robust understanding of the typology of scenarios (traditional versus experimental), adding more gains to learning. The paired data analysis eliminates biases, ensuring greater validity of the results.
The virtual assistant for scenario creation can be seen as a resource that makes teaching work more productive by saving and allowing the reformulation and reusing of scenarios. Furthermore, the student only needs an electronic device to access the link to the scenario. Thus, this method of scenario creation proves to be sustainable and ecologically friendly. Technological applications and digital tools are under development in nursing education and are a resource that brings added value to the teaching-learning process [13, 19, 41]. The use of technologies as a reinforcement to traditional teaching methods is a valid strategy, capable of generating a change in students' attitudes, with a focus on learning [5, 19, 37–39]
Study limitations and implications for practice
This study had several limitations. First, its specificity and context were limited to a curricular unit of a Nursing higher degree education institution, hindering the generalizability of results. The testing of the scenario models was not blind, and students perceived which model was innovative, which may have influenced their assessment. However, we believe that the experience report may be motivating and guide other contexts and themes. In addition, the assessment of the opinion of students who played a more active role in clinical simulations was not fully controlled. Students who participated more actively were more likely to express a positive attitude towards learning; however, no evidence was found to corroborate this perception [19].