Nurse Education Today 36 (2016) 419–421

Contents lists available at ScienceDirect

Nurse Education Today

journal homepage: www.elsevier.com/nedt

Can nursing students' confidence levels increase with repeated

simulation activities?☆,☆☆
Cynthia L. Cummings ⁎, Linda K. Connelly
University of North Florida, United States

a r t i c l e i n f o s u m m a r y

Article history: In 2014, nursing faculty conducted a study with undergraduate nursing students on their satisfaction, confidence,
Accepted 3 November 2015 and educational practice levels, as it related to simulation activities throughout the curriculum. The study was a
voluntary survey conducted on junior and senior year nursing students. It consisted of 30 items based on the Stu-
Keywords: dent Satisfaction and Self-Confidence in Learning and the Educational Practices Questionnaire (Jeffries, 2012).
Simulation
Mean averages were obtained for each of the 30 items from both groups and were compared using T scores for
Clinical Education
Confidence
unpaired means. The results showed that 8 of the items had a 95% confidence level and when combined the
Active learning items were significant for p b.001. The items identified were those related to self-confidence and active learning.
Nursing students Based on these findings, it can be assumed that repeated simulation experiences can lead to an increase in stu-
Competence dent confidence and active learning.
Scenarios © 2015 Elsevier Ltd. All rights reserved.

Three years ago, the adult health faculty at our university decided to
increase undergraduate nursing students' exposure to simulation activ-
ities. Two faculty members began a concerted effort to incorporate sim-
ulation into junior and senior year curriculums. This was done by
including two group and individual simulation experiences in adult
health I, adult health II and their capstone course, professional nursing
integration. We received permission from administration to utilize
these experiences as part of their clinical time. We exchanged 8 h of ob-
servation clinical for 8 h of simulated laboratory time. Once we decided
on the number of simulations, we began looking at different systems
and chose an online product that included pre- and post-quizzes, de-
tailed patient information and a documentation system. We selected
scenarios to coincide with what was being taught in class and we sched-
uled students in groups of three to four for these sessions. The final se-
nior experience involved an individual scenario and was graded using a
rubric (Cummings, 2014). The seniors also attended a group role play
scenario involving delegation and interdisciplinary graduate students.
At the completion of these simulation experiences, the students
were asked to voluntarily complete a survey. The survey was made up
of 3 tools, the Student Satisfaction with Leaning Scale, Self-Confidence
in Learning and the Educational Practices Questionnaire (Jeffries,
2012). The survey consisted of 30 items with answers scored on a Likert
☆ I would like to acknowledge the support of the University of North Florida.
☆☆ I received no funding for this research.
⁎ Corresponding author at: University of North Florida Brooks College of Health 1 UNF
Drive Jacksonville, Fl 32224, United States.
E-mail address: Cynthia.cummings@unf.edu (C.L. Cummings).
scale from 1–5, with 5 being the highest. The Student Satisfaction with
Learning Scale consisted of 5 items with a reliability of r = 0.94. The
Self-Confidence in Learning Using Simulation scale consisted of 8
items with a reliability of r = 0.87 and the Educational Practices in
Simulation Scale was made up of 16 items with a reliability identified
as r = 0.86 and 0.91 (Jeffries and Rizzolol, 2006). Approval for the sur-
vey was obtained through the National League for Nursing.
The study was approved by the Institutional Review Board (IRB)
from the University of North Florida. The survey was voluntary and
the students elected to participate if they desired. After one year, we
compared the mean averages for each item. Fifty-four students
responded, with 34 from the third semester or junior students and 20
from the fifth semester or senior students. The means varied between
3.6 and 5, with a large number between 4 and 5. The mean averages
for each item were compared between junior and senior year students
using T scores for unpaired means. What we found was that 8 questions
had a confidence level of 95% (Fig. 1). When the 8 questions were com-
bined the significance was p b.001 (Fig. 2). The questions found signif-
icant were:
1. I am confident that I am mastering the content of the simulation ac-
tivity. (self-confidence)
2. I am confident that this simulation covered critical content necessary
for the mastery of medical-surgical content. (self-confidence)
3. I am confident that I am developing the skills and obtaining the re-
quired knowledge from this simulation to perform necessary tasks
in a clinical setting. (self-confidence)

http://dx.doi.org/10.1016/j.nedt.2015.11.004
0260-6917/© 2015 Elsevier Ltd. All rights reserved.
420 C.L. Cummings, L.K. Connelly / Nurse Education Today 36 (2016) 419–421
Fig. 1. Mean results for 8 Items.
4. I know how to use simulation activities to learn critical aspects of
these skills. (self-confidence)
5. I actively participated in the debriefing session after the simulation.
(active learning)
6. I had the opportunity to put more thought into my comments during
the debriefing session. (active learning)
7. There were enough opportunities in the simulation to find out if I
clearly understand the material. (active learning)
8. Using simulation activities made my learning time more productive.
(active learning)
Fig. 2. Combined T score for all 8 items had a p b.001.
These survey questions concerned confidence and active learning.
Based on the student responses, it appears that the student identified
an improved belief in mastery of the content and confidence in their
knowledge base for the required skills and critical content related to
adult health nursing. The simulation experiences all dealt with adult
health content, ranging from postoperative care to emergency situa-
tions. The students may encounter a patient having chest pain, an asth-
ma attack, polypharmacy issues or diabetic education. Each scenario
addressed a specific adult health situation and the student was given
objectives to meet. The simulations required critical thinking and active
learning in a real world environment. They may be acting alone or in a
group and must decide on a course of action and then reflect on their
performance.
The curriculum was adapted, so that in the junior year, the student
was exposed to 4 simulation activities that dealt with adult health I
and adult health II content. For adult health I, it could be a diabetic pa-
tient, a patient experiencing stroke symptoms or a postoperative client.
The students were in a group of 3 to 4 students and were required to
read about the scenario prior and to complete a pre-quiz on the topic.
Following the simulation, the students were debriefed on their experi-
ence and then were asked to document on a specified electronic health
record for that patient and to complete a post-quiz. For adult health II
simulations, the students also were in groups of 3 to 4, but the content
dealt with higher level acuity patients. The situations could be a patient
who had sepsis, a gun-shot victim, a patient experiencing a myocardial
infarction, a patient with an asthma attack, or a patient in respiratory
failure. The activities of preparation and documentation were the
same as in adult health I.
Senior year, the students participated in group simulations with the
obstetrics and pediatrics courses and then returned to their final cap-
stone course, professional nursing integration. In this course, each stu-
dent attended a group simulation experience, in which they were
randomly assigned the role of oncoming or off-going nurse, patient
care technician or patient/family member. The students, who selected
the role of patient or family, followed a set script in which they called
for various needs throughout the morning. The student nurses were re-
quired to delegate and prioritize the care to these patients. The final
simulation activity consisted of an individual performance on a random-
ly selected scenario. The senior student received report on their patient
and then entered the room as the nurse for the day. They were required
 C.L. Cummings, L.K. Connelly / Nurse Education Today 36 (2016) 419–421
to perform an assessment, call the physician for orders, follow through
with the orders and then reevaluate the patient condition and make
any changes. Following their performance, they debriefed the situation
and were required to document fully on an electronic record system.
The patient scenarios selected for this individual performance were
very similar to ones they had been exposed to during junior year. The
scenarios were posted at the beginning of the semester, so that students
could review them if they so desired. The simulation survey was posted
through an online system and the students were asked to voluntarily
participate at the completion of each semester. The results were anony-
mous and there was no connection to individuals through this system.
In addition to confidence levels, another critical area identified as
improving, is the active learning environment. The students noted
that their participation in debriefing improved, as well as their opportu-
nity for comments, understanding of content, and productivity. As they
went through the simulations over time, they became more open and
reflective with their comments and questions. The same faculty mem-
bers debriefed the students throughout and the students were aware
of the type of questions and reflections that maybe discussed during
this time. They did not view the debriefing sessions as a negative area,
but more as a safe environment in which to express their opinions.
Therefore, it can be assumed that repeated simulation activities can
increase student confidence levels. Yet, can we translate confidence into
competence? In Bandura (1997), p. 393 work on self-efficacy, he refers
to self-confidence as an individual's belief in themselves and their abil-
ity to succeed. Self-efficacy is a person's belief that he or she can succeed
at a specific task or range of task. The more confidence the student has,
the greater the chance that they will partake in a task and succeed.
Benner et al. (2008) often speaks on critical reflection with clinical ex-
periences and the need for nurses to reflect on performance and deter-
mine best practice. The greater the opportunity for an active learning
experience, the greater the ability the student has to assimilate this in-
formation. Vygotsky (1978) proposed that learning cannot be separated
from the real world. Students must experience accommodation and as-
similation of ideas in an active learning environment. The instructor acts
as a support, providing a scaffold by which the student can build on
knowledge. The student's metacognition is either changed by accom-
modating this information into previous knowledge or assimilating
this as new knowledge. For meaningful change to occur, the student
must be an active participant in a real world scenario. This is where sim-
ulation activities can provide student engagement that leads to en-
hanced knowledge and a framework for future experiences.
So, why is this important? It is very difficult to measure clinical com-
petence. We attempt to do this with walk through exams and clinical
evaluation. However, all clinical experiences are different and involve
a variety of variables. If we can control for these variables and expose
students to structured situations, then we can provide them a method
by which they can incorporate these scenarios into their clinical experi-
ences. Most of the simulated experiences deal with emergent or high
stress situations. These often are the very situations in which students
do not have exposure because of the critical nature within the hospital
setting. Tosterud et al. (2013) noted that it is vital for students to receive
training on assessment, prioritization and actions under conditions in
which patient safety is not a threat.
Critical thinking ability is one of the most basic competencies of
nursing and is crucial to performance (Chang et al., 2011; Fero et al.,
2010; Garrett et al., 2010). The greater the exposure to critical situa-
tions, the increased ability the nurse has for clinical reasoning (Billings
and Halstead, 2009). Tseng et al. (2006) discussed the need to focus
on problem-based learning to enhance motivation, critical thinking
ability and problem-solving abilities. Rodgers (2007) stated that learner
feelings of self-confidence tend to be improved when simulation based.
Using high-fidelity simulation as a tool to develop practical communica-
tion and collaboration skills has been proven to increase the student's
satisfaction and self-confidence (Thidemann and Soderhamn, 2013).
Park et al. (2014) stated that the likelihood of students gaining
421
competence and critical thinking skills for practice is limited, while
Goodstone et al. (2013) revealed that simulation over time can improve
critical thinking scores. In a study by Kaddoura (2010) ten new nursing
graduates reported that clinical simulation improved their confidence
and decision making abilities. Bambini et al. (2009) noted that simula-
tion introduces novice students to the process of being able to perceive
aspects of patient care and promote confidence and self-efficacy.
This study provides some insight into the benefit of simulation for
active learning and also confidence levels. While the study was limited
to our population and the scenarios to which the students were ex-
posed, the results are similar to many others previously discussed. In ad-
dition, the method of incorporating simulation activities into the
curriculum follows an educational pattern for social cognitivism. It
would benefit the faculty to continue to survey student satisfaction
and confidence levels and attempt to understand which activities may
show greater student confidence and learning. In general, the students
expressed satisfaction with most activities, with mean scores between
4 and 5 on the items. Simulation therefore, provides an opportunity to
structure knowledge and to supply crucial content, as well as critical
thinking experiences. The more students are presented with critical
thinking situations, whether in simulated activities or other instruction-
al methods, the greater their ability to refine and build on their perfor-
mance strategies. As an educator, it is our responsibility to incorporate
these methods and guide our students in their role development. Ulti-
mately, any process which can increase a student's confidence through
active learning situations will be a benefit in producing better prepared
nurses.
References
Bambini, D., Washburn, J., Perkins, R., 2009. Outcomes of clinical simulation for novice
nursing students: communication, confidence and clinical judgment. Nurs. Educ.
Res. 30 (2), 79–82.
Bandura, A., 1997. Social Foundations of Thought and Action: a Social Cognitive Theory.
Preston Hall, Englewood, NJ.
Benner, P., Hughes, R.G., Sutphen, M., 2008. Clinical reasoning, decision making and ac-
tion: thinking critically and clinically. In: Hughes, R.G. (Ed.), Patient Safety and Qual-
ity, an Evidence Based Handbook for Nurses. Agency for Healthcare Research and
Quality, Rockville, MD.
Billings, D., Halstead, J., 2009. Teaching in Nursing, Guide for Nursing Faculty. 3rd ed.
Elsevier, St. Louis, MO.
Chang, M.J., Chang, Y.J., Kuo, S.H., Yang, Y.H., Choiu, F.H., 2011. Relationship between crit-
ical thinking ability and nursing competence in clinical nursing. J. Clin. Nurs. 20,
3224–3232.
Cummings, C.L., 2014. Evaluating clinical simulation. Nurs. Forum 50, 2,109–2,115.
Fero, L.J., O'Donnell, J.M., Zullo, T.G., Dabbs, A.D., Kitutu, J, Samosky, J.T., Hoffman, L.A.,
2010. Critical thinking skills in nursing students: comparison of simulation-based
performance with metrics. J. Adv. Nurs. 2182–2193.
Garrett, B., MacPhee, M., Jackson, C., 2010. High fidelity patient simulation: consideration
for effective learning. Nurs. Educ. Perspect. 31 (5), 309–313.
Goodstone, L., Goodstone, M., Cino, K., Glaser, C., Kupperman, K., Dember-Neal, T., 2013.
Effect of simulation on the development of critical thinking in associate degree nurs-
ing students. Nurs. Educ. Res. 34 (3), 159–162.
Jeffries, P.R., 2012. Simulation in Nursing Education From Conceptualization to Evaluation.
2nd ed. NLN Publications, NY.
Jeffries, P.R., Rizzolol, M.A., 2006. High Fidelity Simulation: Factors Correlated With Nurs-
ing Student Satisfaction. NLN Publications.
Kaddoura, M.A., 2010. New graduate nurses' perceptions of the effects of clinical simula-
tion on their critical thinking, learning and confidence. J. Contin. Educ. Nurs. 41 (11),
506–516.
Park, M.Y., McMillan, M.A., Conway, J.F., Cleary, S.R., Murphy, R., Giffiths, S.R., 2014. Prac-
tice based simulation model: a curriculum innovation to enhance critical thinking
skills of nursing students. Aust. J. Adv. Nurs. 30 (3), 41–51.
Rodgers, D.L., 2007. High-fidelity patient simulation: a descriptive white paper report Re-
trieved May 16, 2015 http://sim-strategies.com./downloads/Simulation%20White%
20Paper2.pdf.
Thidemann, I.J., Soderhamn, O., 2013. High-fidelity simulation among bachelor students
in simulation groups and use of different roles. Nurse Educ. Today 33, 1599–1604.
Tosterud, R., Hedelin, B., Hall-Lord, M.L., 2013. Nursing students perception of the high
and low fidelity simulation used as a leaning method. Nurs. Educ. Pract. 13, 262–270.
Tseng, H.C., Jian, S.Y., Hsu, Y.Y., Chin, C.C., Chou, F.H., 2006. Effectiveness of applying prob-
lem based learning to a nursing course on “symposiums regarding clinical cases”.
J. Health Sci. 8, 121–131.
Vygotsky, L., 1978. Mind in Society. Harvard University Press, Cambridge, MA.