The Effectiveness of High-Fidelity Simulation on Clinical Competence Among Nursing Students

Abstract

Introduction

Clinical competence is a pre-requisite for every student nurse to showcase their proficiency in providing quality nursing care. Effective clinical experience during the study period plays a pivotal role in developing clinical competence among nursing students. Hence, the purpose of the study was to find the effectiveness of high fidelity simulation (HFS) on clinical competence among nursing students.

Objectives

The objectives of the study were to determine the impact of HFS on level of clinical competence among nursing students, to find the association between selected demographic characteristics of nursing students with their level of clinical competence and also, to find the association between academic performances of nursing students with their level of competence.

Method

The current study employed a quasi-experimental study design. Sixty-five nursing students from second year Bachelor of Science in Nursing (BSN) program were selected using consecutive sampling technique. The data was collected using demographic data form, objective structured clinical examination (OSCE) grade performa, and academic score sheet. SPSS version 24 was used to analyze data.

Results

The study revealed a significant impact of HFS on clinical competence of nursing students. Majority (52.3%) of the nursing students obtained high level clinical competence following the HFS. The findings showed a significant association between gender and medium of instruction with the level of clinical competence of nursing students. Further, there was a significant correlation between academic performance and level of clinical competence of the nursing students.

Conclusion

HFS served as a useful pedagogical approach in fulfilling the clinical learning outcomes. It further facilitated readiness of nursing students in second year BSN in terms of developing competence and confidence for clinical placement at the hospital for the third year of their study. However, further research is required to determine if HFS can be used in developing clinical reasoning skills in nursing students.

Introduction

Due to the coronavirus disease 2019 (COVID-19) pandemic, restrictions were imposed for the clinical placement of nursing students at hospitals to safeguard the students and prevent its spread. Inevitably, the Ministry of Education (MOE) recommended the amendment of simulated training as an alternative to clinical placement for the first two years of Bachelor of Science in Nursing (BSN) program. Imparting quality clinical experience to nursing students within an attuned pedagogical learning was a momentous concern during the COVID-19 crisis. The core of nursing profession is grounded to practice. Practice promotes hands on experience to enhance attainment of technical skills in performing nursing care. Technical skills are further mastered by nursing students exclusively by interacting with patients during clinical placement. However due to the stipulated restriction on clinical placement of first and second year BSN students in hospital settings, suggestion was to implement high fidelity simulation (HFS) to achieve the clinical learning outcomes.

This flagged off the stage for setting and implementation of HFS at the institution. Although both first and second year clinical nursing curriculum were amended to the use of simulation strategy, the first year clinical training adopted low fidelity simulation (LFS) with emphasis on developing specific skill training as the students were undergoing foundations of nursing course in the academic year. The second year BSN curriculum involved adult health nursing I (AHN I) course and the syllabi comprised of learning outcomes related to nursing care of patients with disorders of cardiovascular system, respiratory system and gastrointestinal system. Hence, it was appropriate to introduce HFS to develop clinical competence among the second year nursing students to accomplish the clinical learning outcomes.

The nurse educators at the institution confronted the new challenge with enthusiasm. The nurse educators were trained to use the high fidelity simulators by the vendors of the mannequins. The training focused on the entire process of HFS. Following the training, the faculty was grouped based on their specialty to demonstrate the entire process of HFS.

Review of Literature

Simulation based training is a pedagogical approach that provides students with a safe opportunity to apply theoretical knowledge into practice. This technique is a replication of real life scenarios (Guerrero et al., 2022). Simulation provides clinical opportunities for nursing students to practice nursing care skills without fear of causing patient errors (Mohamed & Fashafsheh, 2019).

Simulation technique involves LFS and HFS (Grey, 2022). LFS supports the learning of specific procedure skills like temperature assessment technique, administration of intramuscular injection and so on. HFS is the use of full size, life-like computerized mannequins to demonstrate realistic clinical scenarios in a safe environment (Au et al., 2016). HFS can be used effectively by nurse educators to design clinical scenarios appropriate to accomplish the learning outcomes. The scenarios are framed to display the signs, symptoms of a particular disorder and interact with the learner. These scenarios are a replica of life-like clinical events created in the nursing skills laboratory (Black, 2018). Thus the assimilation of HFS into the curriculum bridges the gap between theory and practice.

During simulation, faculty can observe the students and control or make changes in the responses of the high fidelity mannequins from the control room without being observed by students. This enables the faculty to evaluate the students’ response in various situations. In addition, the faculty can recreate a scenario by critically utilizing the mannequins, manipulating the environment and by the effective use of audios (Hung et al., 2021). Thus, a diverse range of clinical scenarios can be created that are thought provoking to develop clinical competence in nursing students. The experience enables students to confidently face the real life clinical situations.

Clinical competence is the capability of students to demonstrate a task with the required outcomes (Mohamed & Fashafsheh, 2019). It's an amalgamation of knowledge, skill and attitude. Competence can be cultivated by methodically integrating subject knowledge into skills during the HFS. The essence of using the HFS is to accomplish the skills required effectively by nursing students in a safe and ethical environment. How do the students master these skills? Feedback is an important component in learning skills next to practice (Bastable, 2019). In this context, HFS has an advantage of integrating debriefing session immediately following the simulation. Teachers use debriefing sessions in HFS to deliberately reflect the events of simulation (Abulebda et al., 2022). Effective debriefing could contribute to a profound conceptualization of the events experienced during the simulation (Kido et al., 2021). This enables students to contemplate their performance and expertise enhanced due to their simulation experiences. HFS also permits for repeated practice which lays the stone for mastering the skill required (Grillo & Thomas, 2016).

Studies have shown that HFS has been an effective teaching strategy in improving knowledge of nursing students (Li et al., 2022). Students are better able to associate theory to practice following the experience in the simulation (Ayed & Khalaf, 2018). The effectiveness of the teaching strategy can be evaluated using appropriate assessment techniques. Keeping in mind the standards set by MOE for the credentialing and accreditation process, the curriculum at the institution is based on the competency framework and the assessment of the level of achievements as per Miller's pyramid.

This framework focuses on assessing clinical performance that embraces skill and aptitude. Miller's model identifies the clinical competence on four levels which includes knows, knows how, shows how and does. The lower two levels (knows and knows how) are related to the cognitive component and the upper two levels (shows how and does) are related to the skill attainment (Witheridge et al., 2019). Apparently, the observable performance indicator is set at the apex, which is a challenge for all those involved in testing clinical competence. Miller's model recommends use of simulated exercise to prepare the students to gain experience and familiarity on interacting in the actual clinical setting (Witheridge et al., 2019).

The course learning outcomes have a major role in triggering the students to achieve the relevant knowledge, skill and competence. The learning outcomes of the clinical curriculum in AHN I course were mapped with the Miller's model to assess nursing student's clinical performance. It was identified that the learning outcome in the clinical component for AHN I course was in par with Millers model. To mention with an example, one of the learning outcomes specified was, “Relate information from the etiological factors, pathophysiology, clinical manifestations, diagnostic tests and treatment modalities in the care of clients with selected medical and surgical problems.” This learning outcome required to gain knowledge (knows) through gathering facts and assimilating the concepts. The concepts identified were evaluated by the assessment methods like multiple choice questions, quizzes, team-based learning (TBL), written assignment, and problem-based learning (PBL). These assessment methods contribute to the internal grades for the students. This falls into the second level of Millers model, the “knows how.” The “shows how” was evaluated during the HFS sessions and any modifications or corrections were rectified in the debriefing session. To evaluate whether the performance is integrated to practice (does) objective structured clinical examination (OSCE) was conducted as part of clinical assessment.

Assessment serves as an essential part of evaluating the efficacy of any teaching strategy. The current study used OSCE to evaluate the clinical competence of the students following the HFS. OSCEs are accurate ways of assessing the clinical skills, as it is well framed so that it has less influence of being biased during evaluation which makes it an objective method of assessing the clinical skills (Tseng et al., 2021).

Implementation of this strategic approach in nursing education not only safeguards the patient safety, but also improves technical skills in students, which enhances provision of quality nursing care for patients during clinical placement at the hospital setting. Thus, the purpose of the study was to find the effectiveness of HFS on clinical competence among nursing students.

Objective of the study were:

1. To determine the impact of HFS on level of clinical competence among nursing students.

2. To find the association between selected demographic characteristics of nursing students with their level of clinical competence.

3. To find the association between academic performance of nursing students with their level of competence.

Methods

Design and Sampling

A quasi-experimental post-test only time series design was used to assess the effectiveness of HFS on clinical competence among nursing students. The sample was selected using consecutive sampling technique. The study was conducted among second year BSN students at the college as they were the first batch to undergo HFS learning as a part of clinical curricular requirement. The estimated sample size was 63, which was determined using Cochran's equation, however, all the 65 nursing students of second year BSN who fulfilled inclusion criteria were included in the study.

Inclusion/Exclusion Criteria

The criteria for inclusion into the study was nursing students in the second year BSN program who underwent HFS as a part of the clinical training and willing to participate in the study. The exclusion criteria was to eliminate students who were absent for any one of the three OSCE's.

Data Collection Instruments

Data was collected using demographic data form, OSCE grade performa, and academic score sheet.

The demographic data form included data related to age, gender, high school education (government institution/private institution), medium of instruction at high school, current program as their choice and prior simulation experiences.

The OSCE grade performa was used to collect marks scored by students in each of the OSCEs.

The OSCE was evaluated using checklists that were tailored by the course coordinator. “The Lippincott manual for nursing procedures” was the reference textbook used to construct the checklist. Content validity of the OSCE was determined by first drawing the layout of the blue print. Following, the matrix was mapped to the evaluation of test content with the course learning outcome and the program learning outcomes. Further two experts from adult health nursing specialty who were members of the vetting committee validated the checklist used to evaluate the OSCE. The reliability was established by evaluating the nursing students’ performance using these checklists. The checklists were detailed in terms of structured marks distribution to avoid bias and maintain consistency in marking process by the observers when evaluating the students.

Three OSCE's were conducted during the academic year with a gap of 3 months between each of them. Each OSCE had five stations and following the OSCE, the course coordinator uploaded the sum total of marks obtained in all the stations by each student in the university management system (UMS) under the minicex. The investigators approached the exam office of the university to obtain the scores of OSCE 1, 2, 3 and the grade point average (GPA) for AHN I course.

Subsequent to compiling of OSCE scores on the OSCE grade performa, the level of clinical competence was analyzed by calculating the average of the three OSCE scores and were grouped as follows:

1. low competence: 14–26.

2. medium competence: 27–37.

3. high competence: 38–50.

The Academic Score Sheet was used to collect the marks of students in the AHN I theory exam.

Data Collection Technique

Prior to the commencement of the academic year, the nursing faculty had hands on training on the technical component of using the high fidelity simulator mannequins. The sessions dealt with preparation of scenario appropriate to fulfil the learning outcomes.

As per the curricular requirement, the syllabi of AHN I (clinical) for second year BSN included a set of procedures to be incorporated into the HFS. The scenario was prepared in a manner so that the procedures taught in the practical class could be incorporated into HFS.

Table 1 shows the procedures and the format used to evaluate the completion of the skill. After the students demonstrated the procedures competently, the faculty who observed the procedure was required to give an approval on skill attainment by signing against the procedure for each individual student. It was mandatory that the signature would be given only if the students demonstrated the procedure accurately and skillfully (clinical practicum manual, 2020).

Table 1.

Checklist on Skill Attainment.

S. no.	Skills	Date	Signature of faculty
1	Writing a care plan
2	Setting up IV infusion and regulating flow rate IV cannula site care Cannula removal Changing IV set and solution Administration of IV medication (IV push/IV piggy bag) Intravenous insertion Blood specimen collection
3	Pre-operative care Post-operative care Sterile dressing and wound packing Wound irrigation Suture removal Care of hemovac drain
4	Gastric lavage Gastrostomy and jejunostomy feeding Colostomy/illeostomy care Ostomy irrigation
5	Cardio-pulmonary resuscitation Obtaining ECG tracing Application/maintenance of compression devices
6	Postural drainage and chest physiotherapy Suctioning Oral and nasal Tracheostomy suctioning Tracheostomy tube care Pleural chest tube care Bag and mask resuscitation
7	Finger stick glucose test
8	Care of suprapubic catheter Bladder irrigation Intermittent (closed) Continuous

The students of second year BSN were divided into two groups. The first group was assigned the time from 8:30 AM to 12:30 PM and the second group from 1:00 PM to 5:00 PM with each group getting 4 hours training using HFS for 2 days per week. Multiple stations each with two faculty observers were set in the clinical skills laboratory to accommodate the nursing students and the students were put through with the process of HFS. Prior to engaging in the HFS, the procedures listed under the list of skill attainment were demonstrated by the course faculty in the practical session and each student was given a chance to return demonstrate the procedure. This ensured that the students developed the required skills to perform individual nursing procedures as a pre- requisite for HFS. The following steps were involved in the process of HFS:

• Step 1: Didactic lecture on the procedure.

• Step 2: Prebriefing session.

• Step 3: Running the scenario.

• Step 4: Debriefing involving the feedback on the performance and suggestion for opportunities to improve.

• Step 5: Evaluation by conducting OSCE.

The course faculty prepared six clinical scenarios to accomplish the course outcomes in the second year BSN for the academic year. Respectively two clinical scenarios each focused on the nursing management of patients with cardiovascular disorders, respiratory disorders and gastrointestinal disorders involving surgical management.

On the day of the simulation, the students received a prebriefing for 5 minutes. The prebriefing involved orientation, expected learning outcomes and the ground rules for the HFS. Two faculty each were assigned in facilitating the scenario in each stations. One of the faculty stayed in the control room running the scenario, managing the response by providing the voice for the simulator and manipulating the response of the simulator based on the students action. The other faculty stayed in the simulation room to assist the students if needed. The whole simulation was video recorded.

Following the HFS, a debriefing session was carried out by running the scenario and self-reflection by the students. At the end of the HFS by all groups, a faculty led group discussion was carried out. In some instances, individual debriefing was also carried out based on the student request or if any student's performance was not satisfactory.

Ethical Consideration

Permission to conduct the study was obtained from the research ethical committee, following which, the Dean of the college was approached to obtain permission to collect data.

The list of students in the second year BSN was collected from the class coordinator and based on the feasible time the students were gathered in a classroom and explained the purpose of the study and the technique to complete the demographic data form. The students were also informed of their rights to withdraw from the study at any time. Confidentiality was maintained by providing an individual code and a written consent was obtained from the participants for their willingness to be a part of the study.

Statistical Analysis

The data was organized and analyzed based on the objectives using SPSS version 24. The statistical tests used were descriptive statistics, repeated measures ANOVA, Chi square and Pearson correlation coefficient. The level of significance was set at 0.05.

Results

Demographic Characteristics

The distribution of study participants along the demographic characteristics are presented in Table 2.

Table 2.

Demographic Characteristics of Nursing Students (N = 65).

Demographic characteristics		Frequency	Percentage (%)
Age (years)	18–21	42	64.6
	22–25	22	33.8
	26–29	0	0
	30–33	1	1.5
Gender	Female	53	81.5
	Male	12	18.5
High school education	Government	42	64.6
	Private	23	35.4
Medium of instruction at high school	Arabic	54	83.1
	English	11	16.9
Current program: as your choice	Yes	64	98.5
	No	1	1.5
Prior simulation experience	Yes	14	21.5
	No	51	78.5

The data was collected from 65 nursing students. Table 2 shows that among the study participants, majority (64.6%) were between 18 and 21 years of age. Gender wise distribution showed that majority (81.5%) were females. About 64.6% nursing students had their high school education in government schools. The medium of instruction at high school of majority (83.1%) of the nursing students was Arabic and 98.5% of them joined the current program by their own choice. Further, majority (78.5%) of the nursing students did not have any prior simulation experience.

Level of Clinical Competence in Nursing Students

The level of clinical competence was analyzed and is presented in Table 3.

Table 3.

Level of Clinical Competence (N = 65).

Competence level	Frequency	Percentage (%)	Mean	Std. deviation	Min	Max
High competence	34	52.3	2.517	.533	1.00	3.00
Medium competence	30	46.2
Low competence	1	1.5

Table 3 demonstrates that among the 65 nursing students, majority (52.3%) showed high competence following the HFS.

To compare the participants’ performance in the three OSCEs, repeated measure analysis of variance was performed and the result is as shown in Table 4.

Table 4.

Mauchly's Test of Sphericity (N = 65).

Within subject effect	Mauchly's W	Approximate Chi-square	df	Sig	Epsilon
					Greenhouse–Geisser	Huynh–Feldt	Lower-bound
Clinical competence	.983	1.072	2	.585	.983	1.000	.500

Table 4 displays the analysis done using Mauchly's test of sphericity. The results showed that sphericity is not violated as x²(2) = 1.072, p < 0.585.

Table 5 summarizes the results of multiple comparisons between each pair of OSCE's assessed. Further analysis using repeated measures ANOVA with test on within subjects also shows a significant difference in the mean scores of the three OSCE's assessed [F(1.967, 125.877) = 62.402, P < .05].

Table 5.

Test Within Subjects Effects Regarding Clinical Competence (N = 65).

Source of variation	Sum of squares	Df	Mean squares	F	Sig.
Clinical competence
Sphericity assumed	3320.399	2	1660.200	62.402	.000
Greenhouse–Geisser	3320.399	1.967	1688.198	62.402	.000*
Huynh–Feldt	3320.399	2.000	1660.200	62.402	.000
Lower-bound	3320.399	1.000	3320.399	62.402	.000
Error (clinical competence)
Sphericity assumed	3405.425	128	26.605
Greenhouse–Geisser	3405.425	125.877	27.054
Huynh–Feldt	3405.425	128.00	26.605
Lower-bound	3405.425	64.000	52.210

* Significant p < .05.

Further analysis using pairwise comparison is shown in Table 6.

Table 6.

Pairwise Comparison (N = 65).

OSCE	Mean difference	Std. error	Sig.
OSCE 1–OSCE 2	−2470	.847	.015
OSCE 1–OSCE 3	−9.723	.916	.000
OSCE 2–OSCE 1	2.470	.847	.015
OSCE 2–OSCE 3	−7.253	.948	.000
OSCE 3–OSCE 1	9.723	.916	.000
OSCE 3–OSCE 2	7.253	.948	.000

Adjustment for multiple comparisons: Bonferroni.

* The mean difference is significant at .05 level.

From Table 6 it is evident that the subsequent Post hoc test conducted to determine which pairs of means were significantly different using pairwise multiple comparisons with Bonferroni correction shows significant differences between the mean of six pairs of OSCE's assessed at P < .05 level of significance. The analysis reveals that the OSCE scores significantly increased from OSCE 1 - OSCE 2 and from OSCE 2 - OSCE 3.

Hence, the results of ANOVA indicate a significance on the effect of HFS on clinical competence.

Association Between Selected Demographic Characteristics of Nursing Students With Their Level of Clinical Competence

Table 7 highlights the association between demographic characteristics of study participant and clinical competence. Significant association was observed between the demographic characteristics (gender, medium of instruction at high school) with level of clinical competence.

Table 7.

Association Between Demographic Characteristics and Clinical Competence (N = 65).

Demographic characteristics		Chi-squared value	Df	P value
Age (years)	18–21	3.18	4	.528
	22–25
	30–33
Gender	Female	7.85	2	.02*
	Male
High school education	Government institution	1.8	2	.371
	Private institution
Medium of instruction at high school	English	9.88	2	.007*
	Arabic
Current program of choice	Yes	31.99	1	.996
	No
Prior simulation	Yes	.350	2	.840
	No

* Significant at p < .05.

Correlation Between Academic Performances of Nursing Students With Their Level of Clinical Competence

Pearson correlation coefficient was computed to assess the relationship between the variables and is presented in Table 8.

Table 8.

Correlation Between Academic Performance and Clinical Competence.

	Theory GPA	Competence
Theory GPA	.
Competence	.512**	.

** Correlation is significant at .000 level.

Table 8 presents that the variables academic performance and competence are found to be strongly correlated r(65) = .512, P = .000, hence representing that theory and competence and are interrelated.

Discussion

This was the first time the institution used HFS and the findings of the study recognized that the pedagogical approach stimulated a sense of confidence in the nursing students to face the subsequent years of clinical placement.

Based on objectives of the study, analysis of the data showed that majority of study participants obtained high clinical competence levels following the HFS. This is consistent with the study conducted by Knapp (2023) who identified that HFS training improved participant's knowledge and trauma patient care. Hambach et al. (2023) in their study identified that following HFS, there was an improvement observed in the clinical competence and clinical judgment skills which are the two main obligatory skills in nursing. The researchers reported that simulation had an impact on developing clinical judgment and competence and therefore should be inculcated in the BSN curriculum from the beginning. Debriefing sessions in the HFS enabled students to evaluate their performance and take corrective actions reflecting on development of clinical competence necessary for clinical placement (Guerrero et al., 2022). The researchers concluded that the simulation offered a safe environment for practice and identified gaps in learning. This enabled them to recognize appropriate actions to change behaviors for improved clinical performance.

Fino and Case (2022) reported that the simulation on end-of-life experiences prepared the students with coping abilities to face end-of-life care. With the use of HFS the researchers were able to create similar end of life scenarios in the laboratory that stimulated the use of coping strategies among students in the clinical setting when providing end of life care. The study by Gandossi et al. (2023) highlighted that nursing students experienced moral distress when facing end of life care. HFS could be combined with the regular classes to overcome the challenge prior to clinical placement. These findings provide evidence on the fact that HFS can be used in nursing education to equip nursing students with the attributes of emotional intelligence to cope with challenges faced during the clinical placement.

Ozdemir and Kaya (2022) also stated in their study that HFS improved catheterization skill among nursing students and recommended HFS to improve and maintain nursing skills. These studies have shown that HFS is an effective teaching strategy to improve competence in nursing care procedures as per the curricular requirement. The systematic review conducted by Labrague et al. (2019) also supports the findings. The reason for this could be that the high fidelity pedagogical approach creates a real life scenario on a wider range to evoke the sense of realism necessary to prepare the students to encounter in the clinical setting.

The studies also provide evidences directing towards need for equipping nursing students with the necessary knowledge and skills prior to exposure to clinical areas. Considering the limitations of clinical practice in the current study, HFS education is a promising alternative in clinical education to improve competence so as to face the clinical area in the subsequent years with confidence.

The study findings showed significant association between the demographic variables—female gender and English as medium of instruction at high school with level of clinical competence. Study conducted by Nair and Lee (2020) also reported significant relation between medium of instruction at high school and academic performance. The researchers rationalized by stating that the finding is associated with the fact of being involved in the language prior to the undergraduate program could have paved a path to master the language and there by triggered the improvement in academic success, as the medium of instruction in the BSN program at the college of nursing where the study was conducted was also English. In the present study, majority (96.5%) of the study participants were females. Further in the study by Nair and Lee (2020) majority of the study participants were females. The researchers associated this finding to the fact that nursing in general is reflected as a profession dominated by females.

The results also highlighted a positive correlation between theory and clinical competence among the study participants. The results are consistent with the findings of Kim and Kim (2021), who reported that students with high academic achievement also showed higher clinical competence. Guerrero et al. (2022) reported that during simulation students made use of their previous learning to practice which further improved their knowledge and skills to gain expertise in clinical practice. The findings can be associated with the fact that clinical competence in nursing practice encompasses students to knowing, performing and mastering the clinical skills. It is evident that adequate knowledge is a guiding tool to improve clinical competence. The findings of the current study was consistent with the achievement of the learning outcomes related with ADH I course in the second year of the BSN program.

Further, the demonstration of high level of competence following the HFS is consistent with Miller's model where clinical competence (does) is on the highest level and knowledge (knows) at the lower level. From this we can ascertain that, to develop competence the nursing students need to possess knowledge which is at the lower level of the pyramid of Miller's model shown as knows, followed by knows how, shows how and does. Hence the correlation between academic performance and clinical competence is not by coincidence, but by the appropriate use of HFS as teaching strategy.

Strengths and Limitations of the Study

The current study demonstrates that HFS offers an appropriate teaching strategy on developing clinical competence among the nursing students. The intelligent management of debriefing and feedback sessions can improve clinical competence and achieve the learning outcome. These sessions analyze the clinical capabilities and pave an essential means in identifying gaps to improve the teaching strategy. The study findings identified that the clinical learning with HFS has a significant contribution to achieve the learning outcomes for the second year AHN I clinical requirement. HFS is thus a dynamic pedagogical strategy and findings of the study has revealed that it is valuable teaching strategy in integrating theoretical knowledge to practice thus promoting the development of knowledge, technical and interpersonal skills needed in nursing clinical practice. This technique has improved the mindset for improving critical thinking necessary for becoming competent professionals.

However, concerning the generalization of the results of the study, the limitations need a mention. Small sample size and involvement of only one class for analysis was a major limitation of the study. The sampling technique used was consecutive sampling, it limits generalization to larger group. Involvement of various levels of the program or comparison between HFS between various institutions of nursing will have a greater impact on identifying the effectiveness of HFS.

Implication to Practice

The current study has a major contribution to nursing education. The clinical placement of students can be strengthened appropriately through preparation of the students by the intelligent use of HFS teaching strategies. Introduction of HFS into the curriculum paves an opportunity for students to practice in a safe environment without the fear of committing errors. The teaching strategy is appropriate for development of psychomotor and analytic skills spelled out in the course outcome. Not only is the HFS confined to a particular area or topic, but the pedagogy can be effectively used by nurse educators to recreate clinical scenarios along a range of options based on the curricular requirement in the nursing laboratory that may not be possible in the clinical setting.

Nurse researchers can confirm the appropriateness of HFS in nursing education by building up on the current research using a control group. Further, studies should explore the role of HFS on the student's development of critical thinking, emotional intelligence and development of appropriate tools to evaluate the student response.

Conclusion

The study findings demonstrated that HFS enhanced the nursing students’ clinical competence and is an appropriate pedagogical approach to train the students to face the real life clinical situation. Following the training using HFS, students improved their scores in the subsequent OSCE showing a true measure of development of essential nursing skills. HFS simulation also promoted the students to incorporate knowledge gained in theory classes to practice. This strategy is a very useful pedagogical approach in the novice period to imbibe confidence in nursing students to face the real clinical scenario. Based on the findings of the study HFS strategy should be used in all core courses of nursing to prepare students to confidently face the real clinical scenario. Further research studies in the use of HFS should include a control group to confirm the advantages of HFS to prepare the students to face the clinical placement in the hospital.

Abbreviations

HFS

High Fidelity Simulation

BSN

Bachelor of Science in Nursing

GPA

Grade Point Average

OSCE

Objective Structured Clinical Examination

COVID-19

Corona Virus Disease 2019