Original Research Article

SAGE Open Nursing

Volume 9: 1–8
Effect of High-Fidelity Simulation on © The Author(s) 2023
Article reuse guidelines:
Self-Satisfaction and Self-Confidence sagepub.com/journals-permissions
DOI: 10.1177/23779608231194403
Among Nursing Students journals.sagepub.com/home/son

Dalia Toqan, MSN, PhD1, Ahmad Ayed, MSN, PhD1 ,

Inaam A. Khalaf, RN, MSN, PhD2 and Mohammad Alsadi, PhD3

Abstract
Introduction: Newly graduating nurses should be able to enter clinical practice as safe, accurate, competent, and compas-
sionate professionals in health care settings that necessitate them to be learners who can easily get familiar with a broad diver-
sity of clinical practice settings.
Purposes: The purpose of this study was to evaluate the effect of high-fidelity simulation experiences on self-satisfaction and
self-confidence among the pediatric nursing students.
Methods: A quasi-experimental design, post-test, was carried out through the recruitment of a convenience sample of 150
nursing students from Arab American University. The students were randomly assigned to the study (n = 75) or control (n =
75) groups. Data were collected using learner satisfaction and self-confidence scales.
Results: The results of the post-test revealed that there was a significant difference between both groups in self-satisfaction (t
(148) = 11.14, P < .001) and self-confidence (t (148) = 13.04, P < .001). The mean score of self-satisfaction for the study
group (22.45 ± 2.27) was higher than control group (16.80 ± 3.76). Also, the study group’ mean self-confidence score
(35.72 ± 3.49) was higher than the control group (27.28 ± 4.39).
Conclusion: High-fidelity simulation was confirmed to be an helpful tool to keep an effective and safe learning method for
pediatric nursing students, thus increasing their satisfaction and confidence.

Keywords
nursing, high fidelity simulation, students, self-satisfaction, self-confidence
Received 10 February 2023; Revised 20 April 2023; accepted 23 July 2023

Introduction situations (Hussein et al., 2017). Nursing educators face a

number of obstacles, including insufficient clinical environ-
Higher degrees of nursing expertise are required to respond ments (Dağ et al., 2019); a lack of clinical nursing staff
properly to complicated clinical contexts in the rapidly glob- (Harder, 2010; Jeffries, 2005; Sportsman et al., 2011); insuf-
alizing healthcare revolution (Kavanagh & Sharpnack, ficient chances to care for patients with acute life-threatening
2021). The difficulties need a reevaluation of nursing pro- conditions in hospital settings (Brannan et al., 2008); and
grams, particularly those involving instructional methodolo- patient safety, which may limit students’ involvement in
gies (Al Khasawneh et al., 2021). Recognizing the challenge delivering care (Sportsman et al., 2011). Such issues pose
for nursing instructors and suggesting a focus on creative challenges for nursing students to gain clinical experience
teaching techniques and student learning rather than students’
reporting. Depending on the way things have traditionally
been done, it may not be sufficient to qualify future nurses 1
Faculty of Nursing, Arab American University, Jenin, Palestine
for practice. (Ralph et al., 2014). Nursing students should 2
School of Nursing, The University of Jordan, Amman, Jordan
be prepared to enter clinical practice as accurate, safe, com- 3
Faculty of Nursing, Zarqa University, Zarqa, Jordan
passionate, and competent professionals in health care set- Corresponding Author:
tings that necessitate them to be learners who can quickly Ahmad Ayed, Faculty of Nursing, Arab American University, Jenin, Palestine.
become familiar with a broad range of clinical practice Email: [email protected]

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2 SAGE Open Nursing

that improves their knowledge and self-esteem (Sportsman cultural transformation in education should be monitored
et al., 2011). Therefore, promoting other non-conventional and evaluated in the short and long term. Besides, there
methods such as simulation-based education for undergradu- have been few studies conducted on HFS and its effect on
ate nurses allows nursing students to practice clinical skills Arab pediatric nursing students (Ayed et al., 2022;
within a safe learning environment (Doolen et al., 2016; Salameh et al., 2021). Therefore, the purpose of this study
Oanh et al., 2021). was to evaluate the effect of high-fidelity simulation experi-
ences on self-satisfaction and self-confidence among pediat-
ric nursing students.
Litreture Review
The benefits of simulation are characterized by allowing stu-
dents to learn and make mistakes that may be remedied Method
without compromising patient safety (Dearmon et al.,
2013; Rushton, 2015). Also, high-fidelity simulation (HFS) Study Design
increased satisfaction with theoretical-practical learning (Al A quasi-experimental post-test, two groups study was con-
Khasawneh et al., 2021; Lubbers & Rossman, 2017; Oanh ducted from March to June 2020.
et al., 2021; Weaver, 2015); increased the level of self-
confidence (Boling & Hardin-Pierce, 2016; Hwang & Kim,
2020; Oanh et al., 2021; Stayt et al., 2015); improved psy- Research Hypothesis
chomotor skills (Ahn & Kim, 2015; Vincent et al., 2015;
Zhen et al., 2021); improved decision-making (Ayed et al., The pediatric nursing students who engaged in HFS interven-
2021) and clinical judgment (Ayed et al., 2022; Cant & tion had more satisfaction and self-confidence than those
Cooper, 2017; Salameh et al., 2021). In addition, improve- who received traditional training.
ments have been obtained in learning (Shin et al., 2015),
the acquisition of competences, and self-efficacy (Cant &
Cooper, 2017). Thus, nursing students learn patient care, psy-
Sample and Setting
chomotor skills, problem solving, professional communica- Three hundred undergraduate nursing students registered in
tion, and critical thinking. They also promote their the pediatric nursing course at the third-year level from the
socializing and confidence in their professional roles (Pai, faculty of nursing at Arab American University. The study
2016). was conducted between March and May 2019. Most
Several studies revealed that self-satisfaction and confi- nursing school lecturers rely on traditional education,
dence improved after simulation. Tawalbeh and Tubaishat which is insufficient for teaching nursing students clinical
(2014) found more confidence in adopting Advanced skills. As a result, a simulation laboratory was constructed
Cardiovascular Life Support (ACLS) through simulation. in 2015 to increase clinical training and compensate for a
Lubbers and Rossman (2016) found that students who lack of training situations. The laboratory incorporates high-
received pediatric simulation training reported greater self- fidelity simulation; it has the look of a human-like simulator
confidence. Additionally, Sapyta and Eiger (2017) reported and can mimic a broad variety of anatomical features and
a significant statistical increase in confidence after taking physiological processes in humans. It can also replicate the
part in the simulation experience. Another study, done by physiological changes caused by some disorders as well as
Saied (2017), found that students were satisfied with the sim- a patient’s verbal responses. Students performed prepared
ulation experience and that their self-confidence levels scenarios to fulfill course goals (e.g., a head-to-toe examina-
improved following the simulation. However, randomized tion and practice on skills such as vital signs, blood tests,
controlled trials revealed no relationship between simulation intravenous insertion, Foley’s insertion, heart sound auscul-
experience and self-confidence in nursing students (Alinier tation, intubation, and so on).
et al., 2004, 2006; Blum et al., 2010; Brown & Chronister, Using G*Power version 3.0.10, a t test with a power of
2009). .80, an effect size of .5, and an alpha of .05, a sample size
Pediatric nursing students in Palestine have minimal pos- of 128 participants was needed. A sample (N = 150) was
sibilities for training because of restrictions such as not being recruited in order to overcome the attrition rate. The
allowed to perform particular procedures (i.e., insert cannu- current study enrolled the participants using convenience
las). As a result, students are frequently observers rather sampling. Selection was randomly allocated to either the
than participants in such nursing processes. Furthermore, study (n = 75) or control group (n = 75) to maintain the
there are several rare conditions that many nursing students homogeneity of the subjects. The researchers randomly
would be unfamiliar with before graduating. Simply put, sim- assigned the first student on the list to the study group and
ulation in nursing education among Arab students, mainly the second to the control group. The same procedure was fol-
pediatric nursing students, implies a paradigm shift and gen- lowed until the needed sample size was reached. The inclu-
erates a new teaching culture (Ayed et al., 2021). This sion criteria were: (a) being a nursing student; (b) attending
Toqan et al. 3

a pediatric clinical course; and (c) being willing to

participate.

The Intervention
The simulated scenario followed the Best-Practices INACSL
Standards: Simulations SM (INACSL, 2016a):

• Pre-briefing: The students were provided with informa-

tion to establish a psychologically-safe context and to
consolidate the learning process (Rudolph et al., 2014)
two weeks before the simulation scenario. The students
were given a brief instructional paper regarding the simu-
lation scenario, which enabled them to prepare and
develop an evidence-based strategy. This report com-
prised the clinical history and health status of the child
with bacterial meningitis who needed hospital admission.
• Briefing (5 minutes): The simulated scenario was summa- Figure 1. Sampling and flow of subjects through the study.
rized by presenting a brief description of the clinical
case’s background.
• Simulated scenario (30 minutes): The simulation scenario The researchers provided students who showed a desire to
included a 4-year-old child complaining of bacterial men- participate in the study with information related to the study.
ingitis; the scenario was developed by Campbell and The researchers supplied students who showed a desire to
Daley (2013). Taking vital signs, attaching a heart participate in the study with information related to the
monitor, supplying oxygen as recommended by patient study. The participants obtained printed information concern-
symptoms, measuring oxygen saturation, analyzing ing the time of the study. The researchers assigned the stu-
breath sounds, monitoring the results of laboratory and dents randomly to the study or control group.
diagnostic tests, measuring arterial blood gases (ABGs), The study was carried out in two phases to overcome the
and offering medications were all aspects of the interven- contamination between the groups.
tions. In the simulation room, active cameras and micro- Phase I: The researcher provided the control group with a
phones were employed during the clinical simulation 3-hour lecture about bacterial meningitis and traditional clin-
session. The students went over the scenario for the ical practice in a hospital setting for 2 weeks. After the com-
expert role again and again until they were comfortable pletion of the clinical practice, the control group filled out the
with the demonstration. questionnaire. Phase II: The study group went through a
• Debriefing (30 minutes): Once the simulated scenario was 3-hour session of traditional teaching that included a
completed, it was analyzed and discussed (INACSL, PowerPoint presentation regarding bacterial meningitis, clin-
2016b). Following the recommendations proposed by ical training, and a simulation scenario session. The research
Phrampus and O’Donnell (2013), we used the gather, group is divided into nineteen teams of four students each
analyze, and summarize (GAS) debriefing tool to structure (primary nurse, secondary nurse, physician, and family).
this phase. As a result, the nursing students went over and After the completion of the simulation session, the study
analyzed the best evidence-based practices related to the group filled out the questionnaire (Figure 1).
clinical case, as well as commented on and studied in
depth the best actions, errors, and needed improvements
highlighted throughout the clinical simulation session. The Instruments/Tools
During the debriefing phase, nursing instructors who
had been trained on the clinical simulation approach The tools were:
offered feedback to nursing students on their performance.
• The socio-demographic characteristics questionnaire was
developed by the researcher. It was composed of “age,
gender, general point average (GPA), previous experience
Data Collection Procedure in the healthcare setting, and if there was an experience
The researchers invited the students to participate in the outside of nursing courses in children’s care with bacterial
study. Additionally, an announcement about the study was meningitis.”
posted on the students’ board in coordination with the • Learner Satisfaction and Self-Confidence in Learning
nursing faculty administrator. (LSSCL) scale: The LSSCL is a 13-item, 5-point Likert
4 SAGE Open Nursing

scale developed by the National League for Nursing experience in healthcare settings or outside of nursing
(Jeffries, 2005). The instrument is divided up into two courses related to children’s care with bacterial meningitis
subscales, each of which is intended to assess student (137 [91.3%]).
learning satisfaction (five items) and learning self- The analysis also revealed that more than half of the 42
confidence (eight items). Scores on the satisfaction sub- (56.0%) participants in the study group were female. The
scale can range from 5 to 25, and on the self-confidence sample’s mean age was 21.7 ± 1.27. The students’ ages
subscale from 8 to 40, with higher scores representing ranged from 20 to 26 years old. The mean GPA was 2.8 ±
more satisfaction. It was translated into Arabic in accor- 0.43. The students’ GPA ranged from 2.03 to 3.94. Most stu-
dance with World Health Organization (WHO) guide- dents 57 (76.0%) had no previous experience in healthcare
lines. Cronbach’s alpha coefficients for the LSSCL scale settings or outside of nursing courses in caring for children
(self-satisfaction = .92 and self-confidence = .89) were with bacterial meningitis 68 (90.7%). Concerning the
determined to be satisfactory in this study. This scale is control group, there were 45 (60.0%) female students and
widely used in simulation-based learning (Adamson 30 (40.0%) male students. The mean age was 21.5 ± 1.03
et al., 2013; Franklin et al., 2014; Kardong-Edgren years. The average GPA was 2.63 ± 0.51. The students’
et al., 2010; Reierson et al., 2020). GPA ranged from 1.00 to 3.97. About two-thirds of the stu-
dents 53 (70.7%) hadn’t worked in a healthcare setting. The
majority of the students, 69 (92.0%), had no previous expe-
Ethical Considerations rience outside of nursing courses in caring for children
Ethical approval was obtained from Arab American with bacterial meningitis, as seen in Table 1.
University. The researchers approached potential study par-
ticipants among the students and described the study’s Research Questions Results. An independent t test was per-
purpose. Participants who agreed to participate in the study formed to assess the differences between the means of self-
and fulfilled the inclusion criteria were given a thorough satisfaction of the experimental and control groups (t =
description of the research. They were also notified that 11.14, df = 148, P < .001). The mean score of self-
their participation was completely voluntary and that they satisfaction for the study group (22.45 ± 2.27) was higher
could opt out of the research at any time without penalty. than the control group (16.80 ± 3.76). This result indicates
They were also told that the risks of participating were no that high-fidelity simulation improves self-satisfaction
more than those of any other simulation and that student con- among nursing students. Also, an independent t-test was
fidentiality was preserved. Following that, we requested that used to assess the differences between the means of self-
they sign an informed consent form. The researchers, on the confidence of the experimental and control groups (t =
other hand, were familiar with both groups. The names of the 13.04, df = 148, P < .001). The experimental group mean
participants were saved on the computer but were not backed self-confidence score (35.72 ± 3.49) was higher than the
up. For ethical reasons, we used a waitlist control group control group’s (27.28 ± 4.39). This result indicates that
approach, in which, when we finished the study, we high-fidelity simulation enhances self-confidence among
exposed the control group to the same experiences as the nursing students, as seen in Table 2.
study group.
Discussion
Data Analysis The purpose of the current study was to evaluate the influ-
Descriptive and inferential statistics were used. Data were ence of high-fidelity simulation experiences on self-
analyzed using SPSS 23.0 software The homogeneity of satisfaction and self-confidence among pediatric nursing stu-
the two groups in terms of demographic variables was deter- dents. Based on the findings of the current study, there was a
mined using the Chi-squared test. An independent test was statistically significant difference between the intervention
used to compare the differences between the two groups. and control groups in terms of satisfaction and confidence
after engaging in HFS. The satisfaction and confidence
scores of the study group were higher than the control
Results group. These findings support the effectiveness of the
current study intervention (HFS) as a teaching method in
Socio-Demographic Characteristics of the Participants improving the levels of satisfaction and confidence among
Sample Characteristics. One hundred and fifty participants students attending the pediatric course. These results are in
met the eligibility criteria. The sample consisted of 87 line with the results of other studies, where the authors
(58.0%) females and 63 (42.0%) males. The students’ ages found that levels of satisfaction with the learning process
ranged from 20 to 26 years old. The mean age was 21.6 ± improved with the use of high-fidelity simulation (Curl
1.16 years. The students’ GPA ranged from 1 to 3.97. The et al., 2016; Labrague et al., 2019; Negrão-Baptista et al.,
majority of the students, 110 (73.3%), had no previous 2014). Also, these results of this study were supported by
Toqan et al. 5

Table 1. Comparison of the Sample Characteristics Between the Two Groups According to Background Characteristics (N = 150).

Chi-squared
Variable
Intervention Control group Test
Total n (%) group n (%) n (%) statistic P-Value

Gender Male 63 (42.0) 33 (44.0) 30 (40.0) 0.246 .62

Female 87 (58.0) 42 (56.0) 45 (60.0)
Age 20–22 years 130 (86.7) 63 (84.0) 67 (89.3) 2.345 .310
23–25 years 18 (12.0) 10 (13.3) 8 (10.7)
>25 years 2 (1.3) 2 (2.7) 0 (0.0)
Previous experience in HC setting Yes 40 (26.7) 18 (24.0) 22 (29.3) 0.545 .46
No 110 (73.3) 57 (76.0) 53 (70.7)
GPA 1–1.99 3 (2.0) 0 (0.00) 3 (4.0) 3.984 0.136
2.2.99 107 (71.3) 52 (69.3) 55 (73.3)
3–4 40 (26.7) 23 (30.7) 17 (22.7)
Previous simulation experience Yes 117 (78.0) 62 (82.7) 55 (73.3) 1.904 .168
No 33 (22.0) 13 (17.3) 20 (26.7)
Experience outside nursing courses in direct patient Yes 13 (8.7) 7 (9.3) 6 (8.0) 0.084 .77
care of children with bacterial meningitis? No 137 (91.3) 68 (90.7) 69 (92)
Nursing courses you have had in which clinical One 1 (0.7) 0 (0.0) 1 (1.3) 4.982 .17
experiences were included Two 7 (4.7) 5 (6.7) 2 (2.7)
Three 14 (9.3) 4 (5.3) 10 (13.3)
Four 128 (85.3) 66 (88.0) 62 (82.7)
P-Value significant at the .05 level.

Table 2. Differences Between Self-Satisfaction and Self-Confidence on the self-confidence of nursing students (n = 54). The
at Post-Test for Both Groups (N = 150). study showed significant increase in self-satisfaction and
confidence post the experience.
Variable M SD t-Test P-Value
According to the findings, students who participated in the
Self-satisfaction Intervention 22.45 2.27 11.14 <.001 pediatric simulation course expressed more self-confidence
Control 16.80 3.76 after the course than before. Also, the same results of high con-
Self-confidence Intervention 35.72 3.49 13.04 <.001 fidence after simulation were reported in the Sapyta and Eiger
Control 27.28 4.39 (2017) study, which indicated that there was a statistically sig-
P-Value significant at the .05 level. nificant raise in confidence scores following participation in the
simulation session. Furthermore, a quasi-experimental study
carried out by Saied (2017) examined the effect of using sim-
Bambini et al. (2009) who indicated that simulation experi- ulation scenarios on the pediatric nursing students’ knowledge,
ence is beneficial in constructing a learning environment self-efficacy, satisfaction, and confidence (N = 158). The
that contributes to confidence. Prescott and Garside (2009) results indicated that the students were satisfied with the simu-
also assessed simulation experiences among nursing students lation experience, and their self-confidence scores were higher
(N = 45). The findings revealed that there is universal agree- after the simulation session. Another study that supports these
ment that simulation is a beneficial learning approach that results was conducted by Omer (2016) to explore the percep-
fosters confidence. Approximately 49% of respondents tions of 117 nursing students’ satisfaction and self-confidence
agree, with 49% strongly agreeing, that their confidence after clinical simulation experiences using a survey method.
has improved following the simulation. Although many stu- Following the clinical simulation experience, participants
dents stated that simulation was stressful during the initial reported a high degree of satisfaction and self-confidence in
interview, they stated that as they obtained more experience their skills to perform an effective intervention, conduct
in the simulated environment, they became substantially health assessments, detect patient deterioration events, and
more confident and competent in their skill level. Tawalbeh engage as an effective team member.
and Tubaishat (2014) compared the confidence of nursing Lack of self-confidence in nursing students may limit their
students in the simulation experience of advanced cardiac ability to master new skills (Lundberg, 2008). As a result,
life support (ACLS). Simulation improved nursing students’ self-confidence is an essential topic for research. Nursing
confidence about ACLS. Another quasi-experimental study faculty members and students must understand the notion
conducted by Lubbers and Rossman (2016) assessed the of self-confidence in order for antecedents such as knowl-
effects of the pediatric community simulation experience edge, support, and preparation to be encouraged in
6 SAGE Open Nursing

simulation sessions and clinical placements (Perry, 2011). Alinier, G., Hunt, B., Gordon, R., & Harwood, C. (2006).
The building of self-confidence must be acknowledged as a Effectiveness of intermediate-fidelity simulation training technol-
core component for undergraduate program development ogy in undergraduate nursing education. Journal of Advanced
and implementation (Chesser- Smyth & Long, 2013). Nursing, 54(3), 359–369. https://doi.org/10.1111/j.1365-2648.
2006.03810.x
Alinier, G., Hunt, W. B., & Gordon, R. (2004). Determining the
Strength and Limitations of the Study value of simulation in nurse education: Study design and
initial results. Nurse Education in Practice, 4(3), 200–207.
Although the study generated significant results and added https://doi.org/10.1016/S1471-5953(03)00066-0
Arab nursing students to the body of literature, it contains a Al Khasawneh, E., Arulappan, J., Natarajan, J. R., Raman, S., & Isac,
number of limitations that must be addressed. The first limi- C. (2021). Efficacy of simulation using NLN/Jeffries Nursing
tation was the convenience sample; this study only included Education Simulation Framework on satisfaction and self-
bachelor’s degree nursing students from one private univer- confidence of undergraduate nursing students in a Middle-Eastern
sity. The second limitation was the short study duration, country. SAGE Open Nursing, 7, 23779608211011316. https://
doi.org/10.1177/23779608211011316
and the study may have been limited by the use of only
Ayed, A., Khalaf, I. A., Fashafsheh, I., Saleh, A., Bawadi, H.,
one simulated scenario.
Abuidhail, J., Thultheen, I., & Joudallah, H. (2022). Effect of
high-fidelity simulation on clinical judgment among nursing stu-
dents. INQUIRY: The Journal of Health Care Organization,
Implications for Practice Provision, and Financing, 59, 00469580221081997. https://
Nursing schools can promote high-fidelity simulation doi.org/10.1177/00469580221081997
through nursing courses. Qualitative research is recom- Ayed, A., Malak, M. Z., Alamer, R. M., Batran, A., Salameh, B., &
mended for future studies to explore the students’ experi- Fashafsheh, I. (2021). Effect of high fidelity simulation on clin-
ences towards HFS. ical decision-making among nursing students. Interactive
Learning Environments, 31(4), 2185–2193. https://doi.org/10.
1080/10494820.2021.1875004
Conclusion Bambini, D., Washburn, J., & Perkins, R. (2009). Outcomes of clin-
ical simulation for novice nursing students: Communication,
High-fidelity simulation helps provide pediatric nursing stu- confidence, clinical judgment. Nursing Education Perspectives,
dents with a safe and relevant learning environment, enhanc- 30(2), 79–82.
ing their satisfaction and confidence. Furthermore, the study Blum, C. A., Borglund, S., & Parcells, D. (2010). High-fidelity
confirmed the use of high-fidelity simulation in combination nursing simulation: Impact on student self-confidence and clini-
with clinical training in educating pediatric nursing students, cal competence. International Journal of Nursing Education
with the integration intended to bridge the knowledge- Scholarship, 7(1), 1–14. https://doi.org/10.2202/1548-923X.
2035
nursing practice gap.
Boling, B., & Hardin-Pierce, M. (2016). The effect of high-fidelity sim-
ulation on knowledge and confidence in critical care training: An
Declaration of Conflicting Interests integrative review. Nurse Education in Practice, 16(1), 287–293.
The authors declared no potential conflicts of interest with respect to https://doi.org/10.1016/j.nepr.2015.10.004
the research, authorship, and/or publication of this article. Brannan, J. D., White, A., & Bezanson, J. L. (2008). Simulator
effects on cognitive skills and confidence levels. Journal of
Nursing Education, 47(11), 495–500. https://doi.org/10.3928/
Funding
01484834-20081101-01
The authors received no financial support for the research, author- Brown, D., & Chronister, C. (2009). The effect of simulation learn-
ship, and/or publication of this article. ing on critical thinking and self-confidence when incorporated
into an electrocardiogram nursing course. Clinical Simulation
ORCID iD in Nursing, 5(1), e45–e52. https://doi.org/10.1016/j.ecns.2008.
Ahmad Ayed https://orcid.org/0000-0003-2164-8183 11.001
Campbell, S., & Daley, K. (2013). Simulation scenarios for nursing
educators. 2nd ed. Springer Publishing Company LLC.
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