Nurse Education Today 100 (2021) 104858

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Nurse Education Today

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Mixed-method study on the satisfaction of a high-fidelity simulation

program in a sample of nursing-degree students
María José Cabañero-Martínez a, Sofía García-Sanjuán a, *, Silvia Escribano a,
Manuel Fernández-Alcántara b, José Ramón Martínez-Riera c, Rocio Juliá-Sanchís a
a
Nursing Department, Health Sciences Faculty, University of Alicante, San Vicente del Raspeig, Alicante s/n-03690, P.O.B: 99, Spain
b
Health Psychology Department, Health Sciences Faculty, University of Alicante, San Vicente del Raspeig, Alicante s/n-03690, P.O.B: 99, Spain
c
Department of Community Intervention and History, Health Sciences Faculty, University of Alicante, San Vicente del Raspeig, Alicante s/n-03690, P.O.B: 99, Spain

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Training emotionally complex communication skills with standardized patients brings realism to
High-fidelity simulation simulation scenarios, and moreover, is associated with high levels of satisfaction among the students.
Nursing Objectives: (1) To measure the satisfaction of nursing students and factors related to their satisfaction and (2) to
Standardized patient
explore the effects perceived by nursing students after having a high-fidelity simulation training program using
Satisfaction
standardized patients.
Undergraduate
Design and participants: Mixed design. Pre-post quasi-experimental phase in which the Satisfaction Scale Ques­
tionnaire with High-Fidelity Clinical Simulation was administered in 156 students; a second, semi-structured
interview qualitative phase was completed by 11 students.
Results: Nursing students showed high satisfaction scores. The scores for utility and communication were
correlated with the students’ attitudes towards communication. In the second phase, two main themes and four
sub-themes emerged.
Conclusions: Teachers could implement high-fidelity simulation programs with standardized patients for training
emotionally complex communication skills to nursing students. These programs allow students to participate in
their own learning processes and help them to feel motivated and satisfied about the usefulness of their learning
experiences.

1. Introduction communication skills training (Willhaus, 2016) and are especially

important for training emotionally-complex situations (Oh et al., 2015)
Simulation in educational contexts refers to a situation that tries to which would otherwise be difficult to implement because of the lack of
represent real clinical practice through scenarios with different degrees effective alternative methodologies (Kim et al., 2016). Over the last
of fidelity. The use of simulated scenarios allows various clinical skills to decade, the use of standardized patients for training communication
be repeatedly trained in a safe environment (Alsaad et al., 2017; Yuan skills in nursing students has considerably increased, especially in the
et al., 2012) until an optimal learning level is reached and critical and areas of oncology, mental health, and palliative care (MacLean et al.,
reflective analysis skills are developed (Hegland et al., 2017; Raurell- 2017).
Torredà et al., 2020). Evaluating simulation programs using standardized patients pro­
High-fidelity environments involve the use of advanced technologies vides us with relevant information on their sustainability and viability
such as highly interactive mannequins (Sarabia-Cobo et al., 2016) which and allows us to look for opportunities for improvement (Kirkpatrick
provide realistic physiological responses (Cant and Cooper, 2010). and Kirkpatrick, 2006). Such evaluations can be undertaken at the
Standardized patients are individuals, students, or actors trained to following levels: level 1: ‘reaction’ (e.g., the satisfaction levels of the
represent patients in a realistic and consistent way (Cant and Cooper, participants); level 2: ‘learning’ (e.g., the knowledge and skills ac­
2010). Standardized patients bring realism to the scenarios presented in quired); level 3: ‘behavior’ (e.g., the application of acquired knowledge);

* Corresponding author.
E-mail addresses: [email protected] (M.J. Cabañero-Martínez), [email protected] (S. García-Sanjuán), [email protected] (S. Escribano),
[email protected] (M. Fernández-Alcántara), [email protected] (J.R. Martínez-Riera), [email protected] (R. Juliá-Sanchís).

https://doi.org/10.1016/j.nedt.2021.104858
Received 18 November 2020; Received in revised form 12 February 2021; Accepted 25 February 2021
Available online 6 March 2021
0260-6917/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
M.J. Cabañero-Martínez et al. Nurse Education Today 100 (2021) 104858

and level 4: ‘outcome’ (e.g., student quality of life; Kirkpatrick & Kirk­ distributions remained unaltered throughout the intervention. A total of
patrick, 2006). This present work focused on student satisfaction as a 156 of all the eligible sample completed the post-intervention ques­
reaction metric (Fey and Jenkins, 2015) and also inquired into the tionnaire (loss rate = 24.27%).
perceived purposes and effects the program had on student learning in The second phase was qualitative and was carried out by telephone
relation to satisfaction. as a semi-structured interview. All the students who were contacted for
Several studies have showed had high satisfaction scores for simu­ the telephone interview (n = 11) voluntarily agreed to participate.
lation program on communication with standardized patients (Hsu
et al., 2015), in applied situations where these skills were a priority such 3.2. Intervention
as in oncology (Jang et al., 2019) or mental health (Goh et al., 2016)
contexts, or in programs focused on technical-skills training (Luctkar- The main objective of the simulation program was to train the stu­
Flude et al., 2012). However, Oh et al. (2015) in their meta-analysis dents in the use of effective healthcare communication skills in difficult
about the effects of simulation-based learning using standardized pa­ situations such as in the context of chronicity at different periods of
tients in nursing students, did not show a significant improvement in the patients’ lives and/or end-of-life care. The program was structured into
students’ perceived learning satisfaction, perhaps because of the high 8 sessions, each lasting 2.5 h. The first two sessions were preparation
heterogeneity of the group included in the review. Therefore, continued sessions prior to the simulated scenario training and were designed to
work with larger samples to investigate nursing students’ satisfaction introduce the students to the educational intervention and scenarios,
with these programs and to explore what they are most and least satis­ generate a known and safe environment for the groups by performing
fied with, is still required. Accordingly, Goh et al. (2016) concluded that group dynamics, and to organize the sub-groups. The high-fidelity
such studies should explore the perceived effects and positive benefits simulation with standardized patients was implemented in the 6
identified by students during their clinical placements, to allow re­ following sessions. We trained a total of 12 different scenarios, which
searchers to learn how simulation programs impact clinical practice in the following contents were trained: grief (n = 3), decision making and
these students. coping with difficult situations (n = 3), state of severe confusion in the
Indeed, nursing student satisfaction levels are considered an impor­ context of chronicity (n = 2), bad news (n = 1), pact of silence (n = 1),
tant factor that facilitate learning because they are related to greater pain management (n = 1), and end of life (n = 1). Therefore, every day
student participation (Lapkin et al., 2010), motivation (Walker et al., the groups trained two different cases.
2016), and can improve their performance and learning outcomes Each group (A–L) completed all the program scenarios (8 sessions
(Bremner et al., 2006; Mullan and Kothe, 2010). However, few studies and a total of 20 h). Therefore, each sub-group (n = 6) actively partic­
have analyzed the relationship between satisfaction and variables (such ipated in a total of 4 different simulation scenarios and observed the
as the topics they study or their methodology) as these relate to simu­ other simulations (20/24) for their group (A–L), actively participating in
lation programs. Thus, studies that have examined these variables show the debriefing. The session structure for each scenario was: pre-
that student satisfaction is related both to students’ knowledge of the debriefing, presentation of the case by the students, simulation, and a
theoretical aspects of the simulated case before engaging in it (Calamassi structured group debriefing during the simulation session, as suggested
et al., 2016), as well as their active participation during the experience elsewhere in the literature (Lee et al., 2020, Webster, 2014),
(Olaussen et al., 2020). Therefore, better knowledge of the factors A total of 8 teachers participated, and they had all received a 4-h
related to satisfaction, will help us to design effective scenario-based training program in the standardized training procedure that should
simulation programs (Olaussen et al., 2020) with standardized patients. be followed. Three qualified actors who were all experts in improvisa­
tion participated as the standardized patients. They received informa­
2. Aims tion and details about the appropriate interventions for each scenario so
that they could prepare beforehand.
The objectives of this study were to take a mixed method approach to
(1) measure the satisfaction of nursing students and factors related to 3.3. Instruments and other variables
their satisfaction and (2) to explore the effects perceived by nursing
students after having a high-fidelity simulation training program using We developed a questionnaire that included the following socio­
standardized patients. Thus, we asked the following research questions: demographic data: sex, age, and nationality (Spanish/other). In addi­
(1) What is the level of nursing student satisfaction after completing a tion, information related to prior training in communication skills was
high-fidelity simulation program using standardized patients? (2) What collected via two questions: “Have you received training in social/
variables that form a direct part of the program topic (communication communication skills during your nursing degree training?” and “Have
skills) are related to satisfaction? (3) What effects do nursing students you received training outside your nursing degree in social/communi­
perceive as being derived from the high-fidelity simulation program cation skills?”
using standardized patients? The students’ attitude towards communication was evaluated
through the Spanish version (Escribano et al., 2021) of the Attitudes
3. Methods Towards Medical Communication Scale (Langille et al., 2001), which had
an adequate internal consistency of 0.74 in the original version. The
3.1. Study design and participants Spanish adaptation contains 11 items which are measured on a Likert-
type response scale with 5 response options (strongly disagree = 1,
We carried out a mixed-methods study, implemented in two phases. strongly agree = 5). The total score ranged between 11 and 55 points
The first phase was quantitative (quasi-experimental design) and and higher scores indicated more positive attitudes towards communi­
implemented a high-fidelity simulation program with standardized pa­ cation. The scale showed an adequate internal consistency (α = 0.75)
tients. All eligible participants (n = 205), who were fourth-year students and excellent structural validity (CFI = 0.99; TLI = 0.99; RMSEA = 0.01
in the nursing undergraduate course during the academic period [95% CI = 0.00–0.05]), for the Spanish version.
2019–2020 at the University of XXXX, completed the simulation pro­ Communication skills were assessed using the Spanish Healthcare
gram between September and December 2019. The whole sample (N = Professionals Communication Skills Scale (HPC-SS; Leal-Costa et al.,
205) participated in the simulation program and were divided into 12 2016). This self-administered, 18-item instrument uses a Likert-type
laboratory practice groups (A–L) at random. Each group (comprising response scale with 6 response options (almost never = 1, to many
17–18 students) divided themselves up freely into a total of 6 sub- times = 6), and analyzes four dimensions: empathy, informative
groups, each with 2–3 members. Both the group and sub-group communication, respect, and social ability or assertiveness with an

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internal consistency in each dimension of 0.77, 0.78, 0.74, and 0.65, Table 1
respectively. Characteristics of the interviewees.
Satisfaction with the simulation program was evaluated in Spanish ID Sex Age Communications skills Selection percentiles
with the High Fidelity Clinical Simulation Satisfaction Scale (ESSAF; (range: 69–107)
Alconero-Camarero et al., 2016) which comprises 41 items: 3 open E4 Female 20 73 P15 Communications skills
questions and 38 with a Likert-type response scale with 5 response op­ E1 Female 21 80 P15 Communications skills
tions (1 = totally disagree, 5 = totally agree). The ESSAF evaluates 8 E2 Female 21 83 P25 Communications skills
dimensions of satisfaction. In this study we used 3 of 8 the dimensions: E3 Female 30 84 P25 Communications skills
E5 Male 21 86 P25 Communications skills
utility (α = 0.92), communication (α = 0.92), and increased self- E7 Female 21 90 P50 Communications skills
confidence (α = 0.92). E9 Female 20 95 P75 Communications skills
The script for the semi-structured telephone interviews was based on E8 Female 21 96 P75 Communications skills
two axes (1) experience and satisfaction with the simulation program E6 Female 21 97 P75 Communications skills
E11 Female 20 99 P90 Communications skills
(How was your experience of the simulation program? and How did you
E10 Male 20 104 P90 Communications skills
feel when you participated in this type of program?); and (2) the
perceived effects of the simulation program (What did you gain from the
simulation program?, What factors do you think this training helped you telephone interview agreed to participate voluntarily.
to improve?, For you, what were the drawbacks of this type of training?,
and To what extent was this simulation program useful to you?). 3.6. Data analysis

3.4. Ethical considerations SPSS software (version 25) was used for all the statistical analyses
(IBM Corp., Armonk, NY). We performed a descriptive analysis of the
This study received approval from the University Bioethics Com­ response frequency for each categorical item and calculated the mean
mittee (UA-2018-10-24) and was carried out in accordance with the and standard deviation (M ± SD) for the continuous variables. The
criteria established by the Declaration of Helsinki and the European normality of data was assessed using the Kolmogorov–Smirnov test with
Union’s Good Clinical Practice Standards. Participation in the study was Lilliefors correction. Mann–Whitney U tests were used to compare
voluntary and therefore the students were informed that they could gender and mean satisfaction scores. Spearman tests (rho) were used to
withdraw from the study at any time, despite their obligation to com­ evaluate correlations between satisfaction, age, attitudes towards
plete the simulation program as part of their required nursing degree communication, and perceived communication skills.
assignments for the corresponding subjects they had enrolled in. The qualitative analysis was performed following the six-stage the­
Participation or non-participation in this work did not influence the matic analysis framework by Braun and Clarke (2006) by performing a
students’ degree program grades for these subjects in any way. triangulation process with the different data sets. The research team
comprised three doctoral nurses with previous experience in conducting
3.5. Data collection qualitative research. The results were analyzed by the whole team and a
final consensus was reached on the most relevant data interpretations
In the first preparation session (phase 1) we administered an elec­ according to the data collected in the first part of the study. No computer
tronic questionnaire via Google Forms using the university’s institu­ software was used in our qualitative analyses.
tional internal platform to collect the sociodemographic variables and
data about the students’ perceived skills and attitudes towards 4. Results
communication using the evaluation scales described above. After
implementation of the program, the same electronic questionnaire was 4.1. Phase 1
administered again to measure the students’ satisfaction with the
simulation program. To encourage participation, we followed a stan­ Of the 156 students who completed both the pre-and post-training
dardized methodology in which we sent three reminders containing the questionnaires, 84% were female (n = 131). Their mean age was 22.85
questionnaire link, leaving one week between each email. The first wave years (SD = 5.29; range = 20–48 years), and 96.80% (n = 151) were
was sent on the last day of the simulation program, and data were Spanish. Most of the students had received specific training in commu­
collected up to one month after its completion. In addition to the cor­ nication skills during their undergraduate nursing training (96.20%; n =
responding instrument items, both questionnaires included detailed in­ 150), and 18.60% (n = 29) had also had this type of training outside of
formation about the study, stated the voluntary nature of participation their degree course training. The students began the simulation program
in the research, described the data treatment (which was solely for with high positive attitudes towards communication (M = 52.62; SD =
research purposes and was handled as a group, with complete confi­ 2.51) and a high perception of having adequate communication skills
dentiality), and requested the students’ express informed consent to (M = 89.41; SD = 2.52).
their participation. The scores for all the ESSAF dimensions were high (Table 2). The
The qualitative data (phase 2) was collected from February to March mean utility score was 58.69 (SD = 7.20; range = 24–65); 14.03 for
2020 when the students were completing their clinical practices. A communication (SD = 1.99; range = 3–15; and for the increase in self-
theoretical sampling was carried out based on the percentiles of the confidence, it was 12.98 (SD = 2.33; range = 3–15). All the responses
students in terms of their perceived communication skills, obtained from exceeded 4 out of 5 points, and 95.5% of the students (n = 149) said the
the HPC-SS scale scores (Leal-Costa et al., 2016). Five of the selected simulation “had improved their communication with patients”. The
students had communication skills variable percentiles under 50 and 6 items with the lowest satisfaction rates corresponded to the self-
had percentiles over 50 (Table 1). Because of movement and social confidence dimension, specifically, “The simulation promotes self-con­
contact restrictions related to the COVID-19 pandemic, one of the re­ fidence” and “This practical increased my confidence” items, which had
searchers contacted the selected students by telephone, explained the response rates of 78.2% and 79.5%, respectively.
purpose of the study and arranged a date to conduct the interviews The Table 3 shows the relationships between the degree of satisfac­
through a digital platform. With the students’ prior consent, these in­ tion with socio-demographic variables (gender and age) and other fac­
terviews were recorded in a digital audio format to allow their verbatim tors related to the training program. After verifying the assumption that
transcription and subsequent analysis. Each interview lasted approxi­ the data was non-normal, our analyses showed no relationship between
mately 20 min. All the students (n = 11) who were contacted for a the ESSAF and socio-demographic variables. There were significant

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Table 2 Table 3
Descriptive data for the degree of satisfaction with the high-fidelity simulated Relation between the degree of satisfaction, sociodemographic variables and
experience (n = 156). others related to the training program (n = 156).
M (SD) Somewhat ESSAF dimensions
agree/
Utility Communication Increased self-confidence
Totally agree
n (%) Socio-demographics variables
Age a − 0.35 − 0.03 − 0.01
Utility dimension (range: 13–65) 58.69 –
Gender b 1338.50 1600.50 1.549.50
(7.20)
Male (M/SD) 57.60 (6.09) 14.36 (1.08) 12.96 (2.13)
The simulation is useful for assessing the clinical 4.54 143 (91.7)
Female (M/SD) 58.89 (7.39) 13.97 (2.11) 12.98 (2.34)
situation of patients (0.67)
Other variables
The simulation has improved my ability to provide 4.58 143 (91.7)
Attitude a 0.24** 0.16* 0.11
care (0.71)
HPC-SS a 0.18* 0.13 0.05
The simulation helps you improve your 4.49 140 (89.8)
communication skills and ability to work with the (0.77) Note: M = Average; SD = Standard deviation; ESSAF = Satisfaction Scale
team Questionnaire with High-Fidelity Clinical Simulation (Alconero-Camarero et al.,
The simulation allowed us to effectively plan patient 4.29 133 (85.3)
2016); Attitude = Spanish version of the Health Communication Attitude Scale
care (0.87)
(manuscript in process); HPC-SS = Healthcare Professionals Communication
I have improved my technical skills 4.38 134 (85.9)
(0.87) Skills Scale (Leal-Costa et al., 2016).
a
I have strengthened my critical thinking and decision- 4.65 147 (94.3) Rho de Spearman statistic.
b
making skills (0.61) Mann-Whitney U statistic.
*
The simulation helped me assess the patient’s 4.51 142 (91) p < 0.05.
condition (0.68) **
p < 0.01.
This experience has helped me prioritize care 4.53 142 (91)
(0.68)
I have improved my communication with the team 4.38 135 (86.6)
Table 4
(0.82)
I have improved my communication with patient 4.44 138 (87.4)
Extracted topics and sub-themes.
families (0.77) Themes Sub-themes
I have improved my communication with patients 4.62 149 (95.5)
(0.60) 1.1 Empowerment in learning
1. Immersion in new teaching
Interacting with simulated experiences has improved 4.53 141 (90.4) 1.2 Emotional management in the context of
methodologies
my clinical competence (0.69) the new methodology
I have learned from the mistakes I made during the 4.74 147 (94.2) 2.1 Self-confidence and self-security
2. Usefulness of the simulated
simulations (0.63) 2.2 Impact on a personal and professional
experience program
Communication dimension (range: 3–15) 14.03 – level
(1.9)
The teacher was in charge of giving constructive 4.63 143 (91.7)
feedback (0.75) educational methodology that represented an evident change with
The analysis at the end of the session (debriefing) 4.72 146 (93.6) respect to the methodologies they had encountered in their training up
helped me to reflect on the experience (0.68) until that point. Although they recognized the value of the theoretical
The analysis at the end of the session (debriefing) 4.68 145 (93)
content, putting their knowledge into practice had allowed them to train
helped me to correct my own errors (0.70)
Increased self-confidence dimension (range: 3–15) 12.98 – their skills at another level.
(2.33)
The simulations promote self-confidence 4.26 122 (78.2)
(0.94) 5.1. Empowerment in learning
This type of practical has increased my confidence 4.23 124 (79.5)
(0.92)
General satisfaction of the sessions 4.49 144 (92.3) The interviewees recognized a change in their student roles and the
(0.72) advantages of actively participating in the learning process. This
methodology forced them to investigate and mobilize new and different
strategies by themselves, relying on collaborative teamwork and indi­
correlations between the students’ attitudes towards communication
vidual introspection to be able to progress through the simulation pro­
before the simulation training and the utility and communication di­
gram. Likewise, they recognized debriefing as a key part of the learning
mensions of the ESSAF. The students’ perceived communication skills
process.
before the simulation program were associated with the utility dimen­
sion of the ESSAF, but we found no correlations with the communication “I found it to be an effective way to learn, not only in the moment of doing
and self-confidence dimensions of the ESSAF (Table 3). the simulation ourselves, but also seeing [the simulations of] others” (E9);
“The debriefing forced you to be active because then you had to
comment” (E10);“You didn’t go to this practical [with] the same
4.2. Phase 2
[feeling] as other [ones]. You went to this one with more enthusiasm, you
were much more motivated […]. While you saw the simulations [of
Eleven students, who had participated both in the simulation pro­
others], you also thought about how you would do it” (E2).
gram and the first part of the study and who also met the theoretical
sampling criteria participated in the second study phase (Table 1). Their
mean age was 21.45 years (SD = 2.74; range = 20–31 years) and 81.1%
were women (n = 9). As shown in Table 4 and as described below, two 5.2. Emotional management when using the new methodology
main themes and four sub-themes emerged during the students’
discourses. Inexperience led the students to experience stage fright, shame, un­
certainty, anxiety, nerves, etc., which were all emotions that they had to
5. Theme 1: immersion in new teaching methodologies identify and manage as part of their learning process. Despite having
completed more than 1500 h of practical clinical experience, they had
The students identified the simulation program as a novel never had to take the lead in a care-giving process or resolution of a case.

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“At first, I didn’t know what to say or do, but then I [started] controlling et al. (2017) concluded, in their integrative review of the evidence for
it” (E1); “It helped me feel less ashamed” (E5); “We had the pressure the use of simulated patient programs and their relationship with
[that the practical] was assessable, and I was afraid of [disadvantaging] developing therapeutic communication skills among undergraduate and
my class-mates if I did it wrong, but little by little, I managed [the process] graduate nurses, that there was a bias towards quantitative research and
and enjoyed and learned from the simulation” (E9). the use of questionable tools and small sample sizes. Thus, they sug­
gested that mixed-method studies with larger samples, valid tools, and
rigorous qualitative protocols would be required to guarantee adequate
6. Theme 2: usefulness of the simulation program triangulation of research results. Our students reported high satisfaction
scores for the simulation program, similar to those in other programs
The interviewees highlighted the usefulness of the program to that trained communication skills with standardized patients (Donovan
implement the knowledge they had acquired through their theoretical and Mullen, 2019; Goh et al., 2016; Hsu et al., 2015; Jang et al., 2019;
classes in a real and dynamic way. This allowed them to improve their Johnson et al., 2020).
use of different communication resources in interviews with patients. Almost all the students were satisfied with the usefulness of the
“Communication techniques are learned from the beginning but putting simulation program, stating that “they had improved their communi­
them into practice was decisive [in helping me] to feel prepared” (E4); “it cation with patients” or “had learned from mistakes they had made
helped me to know what I should say and especially, how to handle si­ during the simulations”. These feelings were also supported by most of
lences.” (E1). the students in the second-phase interviews. The latter students were in
clinical placements, thus giving us the opportunity to learn how the
At the time of the interview, the students were completing the last simulation program had impacted them in a real context (Goh et al.,
300 h of their practical clinical experience. This allowed them to assess 2016). These students highlighted the usefulness of integrating theory
to what extent they could use the resources they had acquired during the into practice in realistic ways (Goh et al., 2016), as well as their
simulation program to solve problems in real situations. Most of the perceived ability to transfer the new communication skills they had
interviewees had already experienced situations like those in the acquired from simulated experiential situations in similar real-life con­
simulations. texts (Carson and Harder, 2016). Indeed, Thomas and Mraz (2017)
explored the transfer of experiences from simulations into the student-
“In the psychiatry practical I remembered these simulations and applied
to-professional transition process and showed how the simulation and
what I had learned” (E5); “In the pain unit, we had a lot of telephone
debriefing processes improved the ability of new graduates to make
contact and I was able to put into practice various techniques that I had
clinical decisions, solve problems, and use clinical reasoning in complex
learned in the simulation, especially when dealing with family members”
patient care situations. These results show how students perceive stan­
(E7).
dardized patient simulation as an effective methodology to train
communication skills in nursing students, thereby preparing them for
6.1. Self-confidence and self-security future clinical practice (Øgård-Repål et al., 2018); this was one of the
reasons why the students expressed high satisfaction towards such
The interviewees claimed that they had felt safer when faced with learning strategies.
real situations because they had already trained and practiced them in a In line with other studies (Alconero-Camarero et al., 2019; Swenty
safe environment. In addition, previous experience increased their self- and Eggleston, 2011), the high level of student satisfaction with the
confidence because they felt that they had clear tools to control the communication dimension (which was related to the debriefing process)
situations, which therefore increased their self-security when facing real also stood out. The debriefing was recognized as an important part of the
situations. simulation program because it allowed the students to learn from their
mistakes, reflect upon their experiences, and improve their performance
“I feel more confident talking to patients and know what to say and what and self-perceived competence (Dufrene and Young, 2014). According
to be careful with [now]” (E6); “when we’re faced with a real situation, to our results, active participation increased the students’ motivation to
we need to draw from experience and because we’re new, having the learn, which agrees with the findings of the meta-analysis by Oh et al.
opportunity to practice helps us a lot” (E4). (2015), which also highlighted how student motivation positively
influenced the knowledge and the acquisition of clinical skills. So, we
can conclude that students positively recognize active methodologies
6.2. Impact at the personal and professional levels such as simulation, which encourage their participation and personal
reflection upon their learning. However, as suggested in a recent sys­
The interviewees said that the simulation program had had a very tematic review and meta-analysis (Lee et al., 2020), careful attention
positive impact on them at a personal level to allow them to get to know must be paid to the debriefing methods used so that they adequately
each other more, help them reflect upon their weaknesses and points for impact learning outcomes. In this sense, implementing structured
improvement, and to progress in terms of emotional competence. At a reflection processes, as we did in this current work, is key.
professional level it had increased their experience and therefore, helped Regarding the self-confidence dimension, although the participants
them to acquire basic professional skills they could use in clinical reported high satisfaction levels, a smaller portion (with respect to the
practice, as reflected in the following examples: other dimensions) agreed that the simulation program promoted self-
confidence and that their self-confidence had increased. As some stu­
“When I saw myself in the recordings and remembered what my col­
dents indicated in their interviews, this could be because some of the
leagues told me, I reconsidered what things I had to work on... I’m more
emotions they had faced in the simulation program, such as fear, shame,
fluent [now] and control my nerves better” (E10).
or uncertainty (Fraser and McLaughlin, 2019) made them feel insecure
or less confident in their ability to address situations, despite them un­
7. Discussion dertaking the program in a respectful student-centered environment that
provided constructive feedback (Kang and Min, 2019). However, the
Using a mixed methodology, this current work allowed us to measure students also indicated that they had subsequently felt safer when faced
satisfaction levels and explore, in depth, the factors that affect the with real-life situations because they considered that their training had
satisfaction of nursing students completing a high-fidelity simulation provided them with more personal resources and better emotional
program with standardized patients as a teaching resource. MacLean management abilities to cope with these situations. In this line, Schlegel

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et al. (2012) found that providing more opportunities for students to outcomes with health outcomes (level 4).
practice their communication skills in high-risk conversations improved
their self-confidence and reduced their anxiety levels in real-world CRediT authorship contribution statement
clinical settings. Thus, this increased student perception of self-
confidence and self-security was one of the main reasons why commu­ All authors should have made substantial contributions to all of the
nication skills training through a simulation program with standardized following: (1) the conception and design of the study and acquisition of
patients should be started from the earliest stages of health profession data, and analysis and interpretation of data, (2) drafting the article or
curricula (Donovan and Mullen, 2019; Labrague et al., 2018; Sarikoc revising it critically for important intellectual content, (3) final approval
et al., 2017). of the version to be submitted.
Finally, our results showed that students with more positive attitudes
towards communication and who perceived themselves as having better Author statement
communication skills before starting the training, were also more
satisfied with the utility of the simulation program. In this sense, Ishi­ This manuscript has not been published, nor is under consideration
kawa et al. (2014) suggested that positive attitudes may influence the by any other journal.
process of the learning. Therefore, we believe that it would be important
to implement previous training in communication skills before simula­ Funding sources
tion programs, thereby increasing their overall satisfaction levels. This
previous approach to the content, focused on increasing skills and atti­ This research was funded by I3CE-Networking Programme for
tudinal competencies, will later allow students to get more out of the research in university teaching, Institute of Education Sciences of the
simulation training programs, especially in terms of usefulness of its University of Alicante. Editions 2018-19 (ID: XARXES-I3CE-2019-4344)
usefulness. and 2019-20 (XARXES-I3CE-2019-4755).

7.1. Limitations
Declaration of competing interest
First, we used a convenience sample and only studied a single-
university cohort. Studies in other centers with samples of nursing stu­ None.
dents that are representative at the national level must be carried out for
these results to be generalizable. Second, this current work did not References
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