Satisfaction and Self-Confidence among Nursing Students with Simulation Learning During COVID-19

Abstract

Aim: This survey aimed to investigate nursing students’ satisfaction and self-confidence in simulation in education during the COVID-19 pandemic.

Design: A cross-sectional survey.

Methods: The survey was conducted at the faculty of nursing of a private university in Jordan. Students’ satisfaction and self-confidence levels in simulation learning were measured using the National League for Nursing (NLN) Student Satisfaction and Self-confidence in Learning Scales.

Results: A total of 138 undergraduate nursing students participated in the survey. Students’ satisfaction levels and self-confidence in simulation learning were lower (just above the midpoint of the scale) than scores reported in similar surveys. The lowest student ratings were reported as “the variety of learning activities that can be done using simulation” and “the self-confidence to develop the needed skills and knowledge to be used in real clinical settings”. The results also indicated that as students progress in the bachelor’s degree program, they develop higher levels of self-confidence in simulation learning.

Conclusions: Nursing students' experience of simulation learning was affected by the COVID-19 pandemic, showing the need for high-fidelity simulation. Education stakeholders are invited to invest in the resources of high-fidelity simulation to maximize its benefits and help in the recovery phase after the pandemic.

Introduction

With the complexity of healthcare systems and rapidly changing healthcare delivery environments, healthcare professionals need to acquire the needed knowledge and skills to meet emerging demands (Rogers, 2016). During educational preparation, being a “safe” practitioner, by meeting the minimum competencies at the entry-level to practice settings, was always set as the main goal (Mahasneh at al., 2020; Pongmarutai, 2010). Preparation for such outcomes starts early in educational programs by exposing students to different clinical situations with different levels of complexity (Campbell & Daley, 2017). Simulation was proposed to be among many solutions to better prepare nursing students, as it offers a controlled setting to practice clinical skills, with its related clinical decision making, in a safe environment (Bryant et al., 2020; Tubaishat & Tawalbeh, 2015). It holds no risk to students or patients in cases of any inaccurate clinical interventions (Campbell & Daley, 2017).

The concept of simulation was defined by Oxford Advanced Learner's Dictionary (2022) as “a situation in which a particular set of conditions is created artificially to study or experience something that could exist in reality”. However, in healthcare education, i.e., nursing, this definition may give a wide range of what can be named a “simulation” and how it can be conducted. Alinier (2007) described the different simulation modes based on educational needs and the available tools and technology (Alinier, 2007). Alinier then concluded six types of simulation in healthcare education. They are written simulations, three-dimensional models, screen-based simulators, standardized patients, intermediate fidelity patient simulators, and interactive patient simulators (Alinier, 2007). Then, with the advancement of simulation technology and the reported evidence of its supportive role in the different fields of healthcare education, including nursing, more attention was paid to investing in the latest and advanced High Fidelity Simulation (HFS) (Aljohani et al., 2019). HFS is defined as a “technology-based educational approach performed in a realistic and safe environment that uses an interactive patient simulator able to reproduce life-like clinical conditions allowing students to improve their technical and nontechnical skills” (Masotta, et al., 2020. pp. 120). Simulation “design” was described at the National League for Nursing (NLN) Jeffries’ simulation theory as one of the main factors that affect the process and the outcomes of using simulation in nursing education (Jeffries et al., 2015).

Using simulation in nursing education was found to have many benefits. It includes better nursing students’ self-confidence and satisfaction in the clinical areas (Bryant et al., 2020; Tawalbeh & Tubaishat, 2014), better clinical decision-making skills ( Bryant et al., 2020; Campbell & Daley, 2017), and a higher level of competence in acquiring cognitive knowledge and performing the needed clinical psychomotor skills (Bryant et al., 2020; Fawaz & Hamdan-Mansour, 2016). However, despite the presented evidence, it was observed by the research team in the current survey that nursing students’ satisfaction and self-confidence in simulation learning can be affected during COVID-19 pandemic restrictions. The observations were based on nursing students verbalizing their frustrations related to simulation learning methods during the COVID-19 pandemic. Thus, the current survey is being conducted to explain the observations in a scientific methodology.

The current survey aims to explore nursing students’ levels of satisfaction and self-confidence in simulation learning experiences during the COVID-19 pandemic. The objectives were proposed to measure the levels of satisfaction and self-confidence in simulation, to compare the levels based on different nursing students’ demographics and to evaluate the strength and direction of the relationship among satisfaction, self-confidence, and computer skills.

Methods

Sampling

A non-probability convenience sampling design was utilized in the current survey to recruit nursing students. The minimum needed sample size was calculated through the power analysis procedure described by Cohen (Cohen, 1992). Considering an α of 0.05, power of 0.8, medium effect size, and correlation testing as the highest needed statistical procedure, the minimum required sample was 85 nursing students. The number of potential participants was approximately 350 students, who were all invited to participate.

Instruments

The survey data collection tool included three parts: a brief introductory paragraph that consisted of a description of the survey objectives, purpose, and a consent statement to participate in the survey. Then, the second part consisted of questions about selected characteristics of participants, including age (in years), gender (male, female), academic year (1st, 2nd, 3rd, 4th ), enrolment type (admission from secondary school or LPN to RN programme), the use of simulation in clinical courses (yes/no), the use of simulation in theoretical courses (yes/no), and a Likert-type single-item self-rating scale of computer skills ranging from “1” as a “novice” in using computers and “7” which is “expert” in using computers.

The third section consisted of the widely used 13-item Student Satisfaction and Self-Confidence in Learning Scale developed by the National League for Nursing (NLN) in 2006, where 5 items are related to students’ satisfaction in simulation learning scale and 8 items are related to self-confidence in simulation learning scale. The psychometric properties of the scale were tested on comparable populations of nursing students and reported to be valid by running item analysis in subsamples concordant and discordant validity testing by Franklin, Burns, and Lee, (2014). Moreover, internal consistency was tested, and Cronbach’s alpha was 0.94 for the satisfaction subscale and 0.87 for the self-confidence scale (Franklin, et al., 2014). It was also confirmed by Unver and colleagues (2017) that the internal consistency was tested and reported a Cronbach’s alpha of 0.77–0.85, which is also above the acceptable level of 0.7 (Unver, et al., 2017).

The responses for each item of the scale range between “1 = Strongly disagree” and “5 = Strongly agree”. The mean score of all participants for each of the items was calculated. Additionally, the total mean score for the satisfaction and self-confidence subscales was also calculated with a possible range between 1 and 5. A higher mean score for the subscales indicates higher satisfaction and higher self-confidence with simulation-based education.

Data Collection Procedure

Data were collected online using MS Teams™ forms. The link to reach the form was made open to all nursing students through the university Teams™ groups at the faculty of nursing. It requires the students to use their access credentials to reach the form and complete it. The principal researcher contacts were made available to all students and faculty members if any inquiries were raised. At the same time, students’ responses were made anonymous even to the research team. Reminders were sent to students through the MS Teams™ groups. Upon reaching 138 responses, the form was made unavailable to students to respond to, and a “Thank you” notification was sent though MS Teams™ groups. The responses for each question on the form were made mandatory to submit; thus, no missing data were encountered. Additionally, to maintain ethical and voluntary participation, participants can withdraw from completing the form at any time.

Ethical Considerations

Ethical approval to conduct this survey was granted by the Institutional Review Board (IRB) at the faculty of nursing at Zarqa University under approval number [13/2021]. The survey ensured the voluntary participation of students and the right to withdraw at any time without any consequences. Electronic data were stored in a password-protected computer to maintain the privacy and confidentiality of the participants.

Results

p>After completing the data collection, responses were extracted as an MS Excel™ sheet and then entered into SPSS™ version 23.0 for data analysis. Descriptive statistics were conducted using frequencies, percentages, and calculations of scales’ means. Assumptions to run inferential statistics were also conducted and met. Then, a t-test was used to compare the mean scores of the two main dependent variables, satisfaction and self-confidence, between the two groups. ANOVA was used to compare the mean scores among three groups or more. Finally, Pearson’s product moment correlation was used to test the relationships between satisfaction, self-confidence, and computer skills (Bowers, 2019).

Sample Characteristics

One hundred thirty-eight bachelor’s degree students at the faculty of nursing at one private university in Jordan out of the 350 students invited to participate in the survey. The response rate was calculated to be 39.4%. The results show that students' mean age was 22 years (SD = 3.2), and more female students participated in the survey than males (n = 81, 58.7%). Students belonged to different academic levels, and second-year students were the largest participants in this survey (n = 51, 37%). Since two tracks are available for nursing students in Jordan to enroll in nursing programs, students in this survey mainly enrolled by the direct admission track after secondary school (78.3%, n = 108). Regarding computer skills, nursing students rated themselves to be at a “good” level (M = 5, SD = 1.3) in computer skills using a 1 to 7 self-rating scale (Table 1). 

[Insert Table 1 here]

Based on the distributions of the reported scores, the results showed that most of the students (93.5%, n = 129) believed that simulation training at the clinical training laboratories was preferred over online remote training using videos and online simulation modules. Despite the percentage drops in learning the needed theoretical knowledge using simulation training (65%, n = 90), it is still the preferred teaching method compared to the online remote module (35%, n = 48) (Table 1).

Levels Of Satisfaction And Self-confidence

Table 2shows that the students' total satisfaction with simulation learning was just above the midpoint of the scale (M = 3.1, SD = 1.3). The students reported the highest rating for “enjoying” how the instructors taught them using the simulation in both methods and reported the lowest rating for the variety of learning materials and activities used through simulation in general for both methods. 

Table 2: Satisfaction and self-confidence in simulation learning 

[Insert Table 2 here]

Regarding the students’ total self-confidence in simulation learning, Table 2 demonstrates that it was also above the midpoint of the scale (M = 3.0, SD = 1.2). The highest rating was for the statement that students rely on the instructors to tell them what they need to learn of any simulation activity during class time, while the lowest student rating was for their confidence in developing the needed knowledge and skills to perform the necessary tasks in real clinical settings.

Students’ Characteristics And Simulation Learning

The results showed no statistically significant difference between male and female students regarding satisfaction in simulation (t = 0.27, df = 111.9, p = 0.74) or self-confidence in simulation (t = 0.48 df = 109.5, p = 0.64). Regarding the type of admission, the results demonstrated that there is no significant difference between students who are new admissions to the program and LPN to RN students in their levels of satisfaction with simulation learning (t=-1.5, df = 136, p = 0.13) or their levels of self-confidence in simulation learning (t=-1.59, df = 136, p = 0.12). Similarly, the academic level showed no statistically significant difference among the different year levels in their satisfaction with simulation learning (F = 2.1, df = 3, p = 0.1). However, there was a statistically significant difference among the students at the different year levels in their levels of self-confidence in simulation learning (F = 9.5, df = 3, p < 0.001). Post hoc analysis shows that the higher the year level, the higher the level of self-confidence is reported, where 4th -year students have the highest self-confidence mean (3.4 (SD = 0.97)) (Table 3). 

Table 3: Demographics and simulation learning

[Insert Table 3 here]

Despite the significant correlation between computer skills and satisfaction using simulation learning (r = 0.28, p < 0.001) and with self-confidence in simulation learning (r = 0.21, p < 0.05), it was reported as a weak positive correlation in Table 4. A strong positive correlation was reported between satisfaction and self-confidence in using simulation in learning (r = 0.71, P < 0.001). In other words, as students' self-confidence in using simulation in learning increases, their satisfaction with using it will increase as well, and vice versa.

[Insert Table 4 here]

Discussion

In the era of the COVID-19 pandemic and the resulting restrictions on higher education, nursing students and educators were obligated not to access clinical settings. Thus, the alternative was to conduct the different theoretical and clinical classes using simulation at the clinical laboratories at the university campus or remotely using online simulation modules. In the current survey, students’ levels of satisfaction and self-confidence in simulation learning were both just above the midpoint of the scales’ possible scores (3.1 and 3.0, respectively), which is lower than the results reported by Aldhafeeri and Alosaimi (2020); Omer (2016), Fawaz and Hamdan-Mansour (2016), and Salameh (2017). The research team observations about the frequent students’ frustration of using simulation can be one of the reasons to explain the lower scores of students’ satisfaction and self-confidence in the enforced simulation-based learning during the COVID-19 pandemic.

In the current survey, the lowest rating was also given to “the limitation in the variety of learning activities that can be done through simulation”. This can be referred to as the simulation type that is being used in the current survey. While a combined mixture of different levels of simulation was used for students in the current survey, Fawaz and Hamdan-Mansour, (2016) and Aldhafeeri and Alosaimi (2020) focused on the importance of integrating and focusing only on high-fidelity simulation in nursing education. High-fidelity simulation (HFS) was proven in the literature to have better educational outcomes in terms of preparing student nurses before reaching clinical settings (Aldhafeeri & Alosaimi, 2020). However, that is not easily feasible for all nursing students at universities to have it utilized at all clinical courses for such an extended period of time, as it requires an extensive presence of resources, including expensive equipment, enough simulation labs and training over extended periods of time (Aldhafeeri, & Alosaimi, 2020; Fawaz, & Hamdan-Mansour, 2016).

On the one hand side of the current survey, the results showed no difference in the levels of satisfaction and self-confidence in simulation between students admitted after secondary school and LPN to RN students; on the other hand, the higher the year level of the students, the higher their self-confidence in simulation learning, which is congruent with the results reached by Salameh (2017). This can be explained by the duration of exposure to real clinical settings during the program courses prior to the COVID-19 pandemic. The higher the year level, the higher the duration that the student spent at real clinical settings during the bachelor’s degree program. Then, when high reliance on simulation came in, a possible explanation could be that higher experience students could be more capable of connecting what they learned in simulation to a real-life situation they faced before COVID-19. Previous exposure to clinical settings at the LPN level did not make a difference in the levels of satisfaction of self-confidence, which may be related to the different competencies needed between the two levels of practice.

Another dimension was shown in the current survey results, where nursing students linked their computer skills with the level of beneficial outcomes that can be achieved by learning through simulation. Students perceived that the higher their computer skills were, the better educational outcomes could be achieved. This perception can be explained by the reliance on multiple electronic devices through the simulation training, which could create a level of anxiety that needs to be dealt with. Shearer (2016) reported this issue in a systematic review about anxiety in using simulation and discussed the theme of “unknown”, which describes the student experience in dealing with unknown devices and settings that may lead to an increased anxiety level of the student. A thoughtful preparation, orientation to the setting, and clear instructions about the scenario are among the steps to reduce the level of students’ anxiety in using simulation and thus maximize its benefits.

Conclusion And Recommendations

This survey is synchronized with previous research efforts to analyze the impacts of the COVID-19 pandemic. It highlights one dimension of pandemic inflictions on nursing education: the use of simulation technology. Simulations were presented in the literature to be effective and promising ahead of the pandemic. With the enforced use of simulation in nursing education, more frustration can be brought to students’ educational experience, which may negatively affect the satisfaction and self-confidence in learning the needed clinical and theoretical knowledge using simulation technology, especially if it is not the high fidelity level. Possible explanations of the resulting modest levels of Satisfaction and Self-confidence with simulation can be referred to the global frustration of the pandemic and its inflictions on all aspects of life, enforcing the simulation on students and not giving them the “additional leisure” of simulation, not using the high fidelity simulation level at all the times at all courses. More investigation is suggested to elaborate more on such arguments.

Health care researchers are also invited to investigate the effects of the COVID-19 pandemic on simulation learning and training in multiple healthcare disciplines and other industrial, applied, and social disciplines. The current survey results may also open the door to conducting qualitative studies to explore the lived experiences of students and instructors as well as using simulation technology during the COVID-19 pandemic. In addition to looking into the best approach of integrating simulation in nursing education, whether to make it obligatory for certain specified courses, all nursing education courses and what percentage of the courses time compared to classical educational approaches.

Limitations

Despite the strengths presented in conducting the current survey, limitations were also faced. The survey was conducted using a non-probability convenience sampling design at one university in Jordan; this inflicts caution regarding the generalizability of the results. Moreover, using a descriptive methodology may limit the full exposure of nursing students’ lived experience with simulation-based learning during COVID-19.

Declarations

Ethics approval and consent to participate

The study was granted ethical approval to conduct the study by the Institutional Review Board (IRB) at the faculty of nursing at Zarqa University under approval number 13/2021. Informed consent was obtained from all participants. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Not applicable.

Availability of data and materials

The authors confirm that the data supporting the findings of this study are available within the article.

Competing interests

The authors have no conflicts of interest to declare that they are relevant to the content of this article.

Funding

This research is funded by the Deanship of Research at Zarqa University/Jordan (Grant Reference Number: ZU7264).

 Authors’ contributions

MA, IO, and HK: Conceptualization; Data curation; and Formal analysis. MA, IO, HK: Funding acquisition; Investigation; Methodology; and Project administration.

MA, IO, HK, AT, AJN: Writing - original draft; Writing - review & editing.

 Acknowledgments

The publication of this article was funded by Qatar National Library.

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