The acquisition and effectiveness of “IDEAL” standards in discharge planning and education with simulation method

Abstract

Background

Basically, although all members of the health care team are responsible for the education of the patient and his/her family, discharge planning to provide self-care skills is the responsibility of the nurse. However, unfortunately, the satisfaction of patients with discharge education is not at the desired level. This study aims to examine the improvement of nursing students’ discharge education competencies through simulation method aligned with the IDEAL discharge planning model—Include, Discuss, Educate, Assess, and Listen—developed by the Agency for Healthcare Research and Quality (AHRQ).

Methods

A mixed-method design was used in the study. Nineteen second-year nursing students enrolled in surgical nursing courses during the 2023–2024 academic year participated in a five-session simulation, with each session lasting approximately one hour. General Self-Efficacy Scale and Simulation Design Scale were used to obtain quantitative data, and semi-structured individual in-depth interview form was used to obtain qualitative data. Mean, standard deviation, and paired t-test were used to evaluate quantitative data; descriptive content analysis was used to analyze qualitative data, and participants were selected through purposive sampling based on their involvement in all simulation activities.

Results

Quantitative results showed an increase in post-test scores across all discharge education sessions (General total pretest = 55.86 ± 6.59, posttest = 57.63 ± 6.70). The most significant improvement was observed in the “continuation effort and persistence” sub-dimension of the General Self-Efficacy Scale during the fourth session (p <.05). Among the Simulation Design Scale components, support sub-dimension received the lowest (X ± sd = 4.24 ± 0.56) and fidelity the highest (X ± sd = 4.58 ± 0.52) scores. Qualitative findings indicated that as simulation sessions progressed, students reported greater confidence and communication skills; however, challenges remained in applying some IDEAL components, particularly discussing patient goals and involving families in the process.

Conclusions

As a result, it was determined that the simulation intervention improved the discharge education skills of nursing students and increased their self-confidence. Incorporating the “IDEAL” framework can foster more patient-centered care by emphasizing the inclusion of patients and their families in the discharge planning process. By supporting patients’ understanding of post-discharge instructions, this approach can promote greater adherence to treatment plans and contribute to improved long-term health outcomes.

Introduction

Educational interventions during the discharge process have been shown to support patient recovery by improving self-care skills and confidence, reducing readmission rates, lowering healthcare costs, and enhancing care quality [1]. Conversely, inadequate education about disease management and medication use may contribute to avoidable hospital readmissions [2]. Post-discharge rehospitalization and its frequency is an important problem threatening patient safety [3].

While all members of the health care team are responsible for educating the patient and his/her family, discharge planning that will provide self-care skills is the responsibility of the nurse who provides uninterrupted care to patients. Therefore, it is an important responsibility of nurse educators to provide nursing students, who are future health professionals, with competence in individualized patient education, starting from early nursing education, so that they can more effectively evaluate the educational deficiencies of patients [2]. However, nursing students are less likely to encounter comprehensive content regarding discharge education during their education [3]. As stated in the study by Yürümezoğlu, the discharge planning ranks first among the nursing care that nursing students cannot meet in their clinical practice [4]. Although it is important for nurses to have the competence to effectively educate patients, nursing students are often limited to theory-based assignments and observing other healthcare professionals educating patients in clinical practice [2].

When the literature on the effective conduct of discharge is examined, it is seen that a comprehensive guide was prepared and implemented by the American Agency for Healthcare Research and Quality (AHRQ). This guide emphasizes the active involvement of patients and their families in the discharge process. The acronym “IDEAL” stands for five key components:

Include the patient and family as full partners in the discharge planning process,

Discuss essential areas to prevent post-discharge complications,

Educate the patient and family throughout the hospital stay using simple, clear language,

Assess the patient’s and family’s understanding of the care plan and reinforce teaching when needed, and.

Listen to and respect the goals, concerns, and preferences of the patient and family.

This structured approach promotes patient-centered discharge planning and aims to improve post-hospital outcomes [5].

As mentioned above, discharge planning and education activities are important skills that will ensure patient safety and cannot be imparted to students using only traditional teaching methods [6]. Therefore, educators are expected to support and facilitate the learning process of students and create cognitive environments that will enable them to manage their own learning processes for the acquisition of various skills such as responsibility, autonomy, initiative, accountability, and interpersonal relationships [6, 7]. The simulation method is an increasingly important and widespread method for students to acquire relevant skills, especially in the training of professionals receiving health education [8]. There are many reasons for using simulation in the education of professionals studying in the health field. These can be summarized as the ability to visualize the clinical environment in a real/realistic way, the ability of learners to develop the metacognitive competencies required for the complex health environment, and the ability to perform applications specific to a specific situation/skill [9].

Although effective discharge education is known to improve patient outcomes, studies indicate that nursing students often lack sufficient opportunities to practice discharge planning in clinical settings [4]. Furthermore, while the IDEAL discharge planning framework has been widely promoted for improving patient-centered transitions of care, its structured integration into nursing education through simulation remains limited. Existing literature largely focuses on theoretical knowledge or patient satisfaction, with relatively few studies exploring how simulation-based training using IDEAL principles can enhance students’ skills and confidence in discharge education. This study aims to address this gap by evaluating the impact of a simulation intervention guided by the IDEAL framework on the discharge education competencies of nursing students.

Methods

Purpose of the study

The study aims to increase the competencies of nursing students regarding discharge in accordance with the IDEAL strategies determined by AHRQ in the planning and education of complex and continuous discharge through simulation application. In this context, the research questions and hypotheses are presented below:

What are the views of nursing students regarding their self-efficacy after the simulation application?

What is the level meeting AHRQ standards of nursing students?

H1

Self-efficacy scores of nursing students are higher after the simulation application.

H0

There is no difference in self-efficacy scores of nursing students after the simulation application.

Type of the study

The study was planned as a mixed method study. A convergent-parallel mixed-methods design was used, in which quantitative and qualitative data were collected simultaneously, analyzed separately, and then integrated to provide a comprehensive understanding of the research problem (Creswell, 2018).

Universe and sample

The study population consisted of second-year nursing students (N = 205) who were studying in the 2023–2024 Academic year and took wound care and Surgical Diseases Nursing courses on stoma. Second-year nursing students were included in this study because they had completed their fundamentals of nursing courses and were concurrently enrolled in surgical nursing and wound care courses, which contain theoretical and clinical content directly related to discharge planning simulations. Moreover, this academic year represents the first time students actively participate in clinical practice, making it a critical period in which they begin to integrate real patient experiences. For these reasons, second-year students constituted an appropriate sample for evaluating the development of discharge education competencies.

The sample size of the study was calculated using the G*Power 3.1.9.2 program, and the mean and standard deviation values ​​of the Self-Efficacy score in the study by Malekzadeh et al. were taken into account in the calculation of the effect size [10]. In the relevant article, the effect size was calculated as 1.44 using the pre-test and post-test mean and standard deviation values ​​of the experimental group. In this study, the minimum number of individuals to be included was calculated using G*Power 3.1.9.2, effect size: 1.44 α = 0.05, power: 0.99, and the minimum sample size was determined to be 10 participants. Considering that there would be a 20% data loss in the study, the study was conducted with more than this number of volunteer students (n = 24). However, the students who could not mark or completely fill out the pre-test and post-test forms due to internet problems on the 3D MedSim Learning Suite software, from which the pre- and post-application evaluations of the students were taken, were excluded from the scope of the study. As a result, the study was carried out with 19 students (Fig. 1). In order to align the intervention with the participants’ academic commitments, each simulation session was scheduled individually for the 19 s-year nursing students enrolled in the surgical nursing course during the 2023–2024 academic year. The five-session simulation, with each session lasting approximately one hour, was organized in a flexible manner—either as two sessions conducted in a single day (one in the morning and one in the afternoon), or as one session per day over five consecutive days. This individualized scheduling strategy ensured that all participants could engage fully with the simulation experience without conflicting with their existing educational responsibilities, while also maintaining the integrity of the intervention process. For the qualitative phase of the study, all 19 students who participated in the simulation sessions were invited to take part in individual, semi-structured interviews. The sample size for the qualitative component was determined based on the principle of data saturation, which was reached when no new themes or insights emerged during the final interviews.

Fig. 1.

Study model

In this study, simulation scenarios were structured based on the IDEAL discharge framework to align with its core components. Each simulation session was designed to reflect one or more IDEAL principles, guiding students in practicing patient-centered communication and discharge planning. During the simulations, students were expected to involve patients and their family members, discuss home-care risks, provide clear and accessible education, assess understanding, and respond to patient feedback. The implementation of these principles was supported by checklists and guided reflection during debriefing sessions to reinforce learning outcomes. The specific objectives that students were expected to achieve, along with the content areas covered in each discharge education simulation session, are detailed in Table 1.

Table 1.

IDEAL discharge education simulation session objectives

1st Session
To determine the person who provides/will provide care at home.
To use a whiteboard to provide discharge arrangements to the patient and his/her family.
To determine the goals of discharge education together with the patient and his/her family.
To explain to the patient and his/her family what will be done day by day within the scope of discharge education.
To plan meeting times with the patient and his/her families.
2nd Session	3rd Session
To inform the patient and his/her family about the patient’s general condition and to provide feedback
To discuss progress for the goals of the patient, his/her family, and clinician nurse
To explain treatments to the patient and his/her family
To provide the patient with the necessary information to properly care for the stoma and evaluate the peristomal skin	To provide information about the patient’s nutritional regimen
To involve the patient and his/her family in stoma care.
To plan meeting times with the patient and his/her family
4th Session	5th Session
To inform the patient and his/her family about the patient’s general condition and to provide feedback	To explain final treatment plan
To discuss progress for the goals of the patient, his/her family, and clinician nurse	To review the medication list with the patient and his/her family using the teach-back method
To explain treatments to the patient and his/her family	To schedule follow-up appointments
To provide information to the patient and his/her family about other situations that may be encountered	To assess home care needs
To plan meeting dates with the patient and his/her family	To provide written appointment dates to the patient and his/her family
	To provide written contact information of the personnel who will monitor after discharge

Data collection tools

General Self-Efficacy Scale

The original 23-item form of the General Self-Efficacy Scale was developed by Sherer et al. (1982). The scale is a 5-point Likert-type instrument, with responses ranging from “not at all true” to “exactly true.” Although the scale includes 23 items, only 17 are used in calculating the total score, while the remaining 6 items are excluded from scoring and 11 items are reverse scored. The scale has three sub-dimensions: initiation, perseverance, continuation effort and persistence. The total score of the scale can vary between 17–85 and an increase in the score indicates an increase in self-efficacy belief. The validity and reliability study of the scale was conducted by Yıldırım and İlhan, and the Cronbach Alpha coefficient was found to be 0.80 [11].

Simulation Design Scale

The scale developed by Jeffries and Rizzolo (2006) was adapted into Turkish by Ünver et al. [12]. The scale consists of 20 items and 5 sub-dimensions (“Goals and Information”, “Support”, “Problem Solving”, “Feedback/Guided Reflection”, and “Degree of Fidelity (Realism)”). The sub-dimension “Goals and Information” consists of 5 items, the sub-dimension “Support” consists of 4 items, the sub-dimension “Problem Solving” consists of 5 items, the sub-dimension “Feedback/Guided Reflection” consists of 4 items, and the sub-dimension “Degree of Fidelity (Realism)” consists of 2 items. The scale is evaluated in 2 parts. In the first part, it is evaluated whether the best simulation design elements are applied in the simulation application. In the second part, the importance of simulation design elements for students is evaluated. The first part is evaluated as “strongly disagree with the statement”, “disagree with the statement”, “undecided”, “agree with the statement”, “strongly agree with the statement”, and “not applicable”. The second part is evaluated as “not important”, “partially important”, “undecided”, “important”, “very important”. The total Cronbach Alpha value of the scale is 0.90.

Individual in-depth interview form

The form, created in line with the literature, consists of 10 questions. The form questions students’ observations of the discharge education they observed in the healthcare environment, their evaluations of their individual practices regarding discharge education, their thoughts about the IDEAL strategy, and their feelings about the simulation application.

Ethical considerations

Permission to use the scales used in the study was received via e-mail from the researchers who conducted the Turkish validity and reliability studies. In order to conduct the study, permission (2023/368350) was obtained from the Scientific Research and Publication Ethics Committee of the institution where the study was conducted. Additionally, AHRQ was contacted via e-mail and permission was obtained for the forms to be used in the evaluation of IDEAL standards. The volunteers participating in the study were informed about the purpose of the study and how it would be conducted, and verbal and written consent was obtained from the participants. During the interviews with the students, they were addressed with the user numbers they were defined with on 3DMedSim. To ensure participant anonymity during the qualitative data collection process, each student was identified using a unique user number assigned through the 3DMedSim platform. These user numbers were utilized in the transcripts of individual interviews to maintain confidentiality and prevent the disclosure of personal information. At no point were real names or identifying details linked to the data. The confidentiality of all data was strictly maintained; audio recordings and transcripts were stored securely on password-protected devices accessible only to the research team.

Data collection process and analysis

To collect quantitative data, a single group pre-test-post-test design was used, while individual in-depth interviews were conducted for qualitative data. The Descriptive Characteristics Form was used to determine the descriptive characteristics of the students. The “General Self-Efficacy Scale” was applied to the students as a pre-test and post-test, and the “Simulation Design Scale”, the validity and reliability of which was carried out by Ünver et al., was applied to evaluate the simulation after the simulation application.

The prepared pre-test and post-test tools and the Simulation Design Form were uploaded to the 3D Medsim application, and the students were asked to make the necessary markings on this application via their mobile phones before and after the simulation intervention (Fig. 2). 3DMedSim is a computer-based platform used to enhance clinical skill development through interactive, immersive scenarios. It allows learners to practice various medical procedures in a risk-free environment that closely replicates real-life clinical settings. After downloading the 3DMedSim application, students who had completed the preparation and pre-test phases were required to complete the tasks assigned to them in order to proceed to the post-test phase. Upon completing these tasks, they accessed the training content by clicking the “Training” button within the app. Subsequently, they conducted their scenario-based simulations, which were recorded within the application. After completing the simulations, students were able to independently carry out the post-test phase via their personal smartphones. However, these video recordings were not subjected to formal data analysis and were not coded or evaluated based on predefined behavioral criteria. Instead, the recordings were used solely for the purpose of supporting participants’ self-assessment during and following the individual interviews (Fig. 3). Participants were encouraged to reflect on their own performance by reviewing the simulation videos, which served as a tool for facilitating critical thinking and personal insight rather than as a source of empirical data.

Fig. 2.

MedSim application screen

Fig. 3.

Images from students’ scenario sessions recorded via 3DMedSim

Before coming to each scenario session, the students completed the pre-test section and what to read/watch specific to that day’s scenario via the 3DMedSim application. The applications were recorded on video using the audio and visual system in the simulation laboratory where the simulation was carried out. After each scenario session, the students completed the post-test section and the Simulation Design Scale through the same application. Later, the students were taken to a debriefing session and their opinions and thoughts were taken on how they carried out the necessary steps specific to the AHRQ Discharge Form. After the simulation sessions were completed, the data were extracted from the software and statistical analyses were performed. The interviews in the debriefing sessions were transcribed and coded with voicedocs. Qualitative data were analyzed using descriptive content analysis by one of the researchers. The interviews were conducted by the same researcher, a professor with expertise in nursing education and qualitative research methods. The interviewer is highly experienced in conducting semi-structured interviews and is well-versed in employing active listening techniques and strategies aimed at promoting participant comfort, openness, and trust throughout the interview process. Mean, standard deviation, and paired t-test were used to evaluate quantitative data, while descriptive analysis was used to evaluate qualitative data.

Results

Findings regarding discharge education sessions

It was observed that the post-test scores increased compared to the pre-test scores in each discharge education session. 4. It was determined that the post-test score in the 4th session continuation effort and persistence sub-dimension increased significantly, and the general scale post-test score was significantly higher (Table 2).

Table 2.

General self-efficacy scores before and after discharge education sessions (n = 19)

		X	sd	t	p
1st Session	Initiation Pre-test/Post-test	4.18/4.28	0.45/0.38	-1.078	0.295
	Perseverance Pre-test/Post-test	4.67/3.72	0.73/0.73	− 0.289	0.776
	Continuation effort and Persistence Pre-test/Post-test	2.91/3.12	0.80/0.79	-1.433	0.169
2nd Session	Initiation Pre-test/Post-test	4.29/4.35	0.37/0.42	− 0.771	0.450
	Perseverance Pre-test/Post-test	3.46/3.64	0.80/0.75	-1.808	0.087
	Continuation effort and Persistence Pre-test/Post-test	3.04/3.23	0.87/0.79	-1.934	0.069
3rd Session	Initiation Pre-test/Post-test	4.29/4.30	0.49/0.54	− 0.198	0.845
	Perseverance Pre-test/Post-test	3.78/3.68	0.73/0.75	0.811	0.428
	Continuation effort and Persistence Pre-test/Post-test	3.21/3.39	0.87/0.78	-1.111	0.281
4th Session	Initiation Pre-test/Post-test	4.33/4.42	0.42/0.39	-1.481	0.156
	Perseverance Pre-test/Post-test	3.81/3.85	0.74/72	− 0.490	0.630
	Continuation effort and Persistence Pre-test/Post-test	3.12/3.56	0.86/0.75	-3.249	0.004
5th Session	Initiation Pre-test/Post-test	4.32/4.52	0.51/0.42	-1.521	0.146
	Perseverance Pre-test/Post-test	3.94/3.98	0.72/0.75	− 0.697	0.494
	Continuation effort and Persistence Pre-test/Post-test	3.51/3.60	0.83/0.82	− 0.583	0.567
General Total	Pre-test/Post-test	55.86/57.63	6.59/6.70	-2.940	0.009

After every 5 scenario applications in which 19 students participated, the simulation was evaluated by applying the Simulation Design Scale. Accordingly, the Support sub-dimension has the lowest mean, while the degree of fidelity sub-dimension has the highest mean (Table 3).

Table 3.

Findings regarding simulation design (n: 24)

	n*	Min.	Max.	X ± sd
Goals and Information	118	3.00	5.00	4.34 ± 0.57
Support	118	3.25	5.00	4.24 ± 0.56
Problem Solving	118	2.60	5.00	4.35 ± 0.56
Feedback/Guided Reflection	118	2.00	5.00	4.48 ± 0.53
Degree of Fidelity	118	3.00	5.00	4.58 ± 0.52

*All volunteer students were included, and it includes data from 5 simulation applications obtained from each student

Comments on discharge education sessions

Comments on discharge simulation sessions are presented under the headings for five sessions prepared within the scope of IDEAL standards.

Comments on the 1st session

In the interviews conducted with the students, in the 1st session, the majority of the students stated that they experienced stress and felt inadequate when they first met the patient. Some students stated that they felt inadequate before starting the application but felt more confident during the process.

At first, I was anxious, I thought I might forget something and not be able to do it, or I listened to them a little more carefully while I was giving information. … I was actually excited in terms of self-confidence, but I was not confident, I did not think that I could do. (No: 700).

the patient also had an expectation from me, I felt like I couldn’t meet it. … Patients don’t expect much from us, but here, when they saw me as a nurse and expected something, I think I realized the seriousness of the situation at that moment, not a little bit, it was like I caught it right that moment (No: 822).

In terms of performing the expected behaviors in the 1st session within the framework of the IDEAL discharge standards and form, the majority of the students stated that they included the family member in the process, did not provide information about the whiteboard because they were not used to it/had not seen it, only determined the educational need rather than determining educational goals together with the patient and his/her family, and could not adequately perform all the steps of the 1st session of the IDEAL discharge steps.

We had steps like explaining the whiteboard, including the patient and his/her family in the process.…I think I did all of them, but I forgot whether I could explain the whiteboard or what I provided to the patient … I did every step, but I don’t know if I did it right. (No: 700).

About the illness I could not talk much about the hospital process, the patient’s and his/her family’s goals after the illness. … I showed him/her the goals and what he/she had to do. … The goals were not very clear, that is another shortcoming of mine…. (No: 760).

They stated that if they were to re-enact the scenario, they would like to change things such as feeling more confident, communicating more with the patient, and making plans together.

The patient’s fears It would be better to spend the first day like talking more actively about what the patient’s fears.…. I think I should have paid a little more attention to the adequacy of knowledge. Because I educate the patient I need to be at a sufficient level about the subject that the patient will be educated on so that I do not give the patient wrong information.…. When the patient told me that he/she had fears, I could have asked him/her what his/her fears were and made a certain question and answer. It would be more logical to ask him/her what he/she was curious about or what he/she wanted to learn from me, what his/her expectations were from me when I provided education, and it would be more logical to plan for what he/she wants from me.….(No: 746).

When they were asked about the most important learning they gained from the scenario, they stated that the patient’s concerns should be handled carefully, good communication was required, and action should be taken in a planned manner.

… well I would like to approach him/her calmly and in order, depending on what he/she wants from me, he/she is experiencing hospital anxiety. I would continue by explaining it over and over. If I do not explain it completely, if I move on to the education, the patient will not understand anything anyway, the patient is already anxious. I would like to continue by reducing the anxiety of the patient. Then, when I reduced it, we could determine a goal together, and I could explain the discharge education steps based on the goal we determined with the patient. First of all, I think I need to continue a strong communication with my patient.(No: 802).

Comments on the 2nd session

In the interviews conducted with the students, the majority of the students stated that they felt more comfortable in the 2nd session compared to the previous session, while some students stated that they forgot some topics due to excitement and felt less competent as a result.

This time I was a little more relaxed. After all, it was more of a practical application rather than providing information, I mean theoretical information … (No: 672).

What else did I feel, for example, I was a little anxious while demonstrating the application, I had to show the things I forgot … After that, I thought I had reduced the patient’s. … I felt a lack of confidence professionally….at this stage, of course I am not very good.(No: 776).

In terms of implementing the expected behaviors in the 2nd session within the framework of the IDEAL discharge standards and form, the students stated that they included the patient’s family in the process, but they did not discuss the progress in line with the goals of the patient, his/her family, and clinician nurse, and they did not determine the educational goal together.

on the second day, there was feedback to the patient’s family about the condition.…. I asked the patient about the complaints, he said there was nothing wrong with him.…I could have asked the patient about this and the questions in my mind about how to proceed further, but I did not ask any additional questions. I think I was giving the patient a skill while giving it to him and the patient’s treatments were explained to him. I mean I could have asked about the medications for morning, noon, and evening, I asked if you had taken your medication. The patient takes this medication, but for which illness am I taking it? … I think I included the patient and his relatives a little bit (No: 822).

The students stated that if they were to re-enact the scenario, the subjects they would want to change are using materials appropriately, informing the patient more by acting calmer, doing activities that will provide more information before the application.

I could have been calmer. I was a little excited. Other than that, I was fine. I felt better.(No: 760).

I think I would want to come in after watching a video and better introduce the devices to the patient so that he could do it later is there anything else I would want to change after discharge? I could have done it in a more comprehensive way or written down in a brochure what the patient should and should not do. (No: 822).

When the students were asked about the most important learning they gained from the scenario, they stated that the patient should be approached with more confidence, that it is important to include the patient and his/her family in the process more, that the education should be carried out in a planned manner and that stress should be controlled during this process, and that they need more information about nursing practices.

… involving the patient while explaining the applications, actually having him take part in a task while we are doing it can actually make the patient gain self-confidence. … As I said for myself, I realized that I will never understand the situation that the patient is going through unless I experience it. In other words, being in that situation is a different psychology, in other words, it is very difficult. It is also difficult to guide the patient. (No: 675)

I think no education is something that can be done just at random. It really needs to be planned and be person-oriented … The patient should be approached like this should be done in this way and the necessary care should be taken.(No: 678).

I think I get a little more stressed, I mean I forget to do the things I think about when I get inside.…. So if I am stressed, I forget to do the things I always want to do.…. I realized that I need to be more relaxed. Because I will always encounter situations like this and it will be a part of life. (No: 730)

Comments on the 3rd session

In the interviews conducted with the students, some students stated that they felt better with experience and could convey information more easily in the 3rd session, while some students stated that they could not achieve the performance they wanted due to lack of knowledge.

Well for a few questions, I felt like I could not answer them properly, I was prepared, but I guess I was not prepared enough….(No: 742).

You know, it is something I do not have much knowledge about. If I knew better and memorized it better, I could give much better information … (No: 788).

..I realized that since I came prepared, I could give information to the patient more easily. For example, I can say that there is such a difference between one day and three days. At first, I came running away like that, I stood taller because I knew what I would tell or rather what I would give to the patient, such self-confidence…(No: 708).

In terms of implementing the expected behaviors in the 3rd session within the framework of the IDEAL discharge standards and form, the students stated that they informed the patient and his/her family in general, but they could not complete the stage of discussing the progress in line with the goals of the patient, his/her family, and clinician nurse.

…I do not know how we can discuss the progress of it while giving information, I cannot understand. I could observe the progress in the first session, I observed it myself, but I did not give any feedback..(No: 651).

…On other days today, just how was the patient’s progress. The first day, he was very stressed, I mean he was extremely stressed, he was asking how he was going to live. He was always in a very pessimistic mood as if it was the end of everything how I was going to continue, but when I went today, he was better. He is a little more used to it. I mentioned that he had trouble changing his bag when I went yesterday. But when I asked him today, he said that he changed it today without any trouble because he changed it before when I was not there.,….(No: 836) The students stated that if they were to re-enact the scenario, the subjects they would want to change are better planning and being more knowledgeable about the process, using educational materials, and providing more information for the patient’s life at home.

I would have had a list as concrete evidence, which would have made it easier to communicate with the patient. If I had asked questions about what they paid attention to during their hospital stay, whether they were uncomfortable eating or not, or whether they were sleeping, it would have been easier, I think. … preparation is very important, the level of knowledge affects it, because the previous experience and the new experience that will be added should be proportional to each other, so that it can be continued.….there are brochures in hospitals for stoma care, I could have read them better or I could have gone to them and said, I have a patient like this, if I had gotten information from a more expert person, I could have conveyed it more easily and more confidently. If I had read it myself and read such information from books, articles, proven theses, it would have been more useful for me.….(No: 746).

Maybe I could talk more about the process at home, the quality of life other than nutrition, etc. … (No: 760).

When the students were asked about the most important learning they gained from the scenario, they stated that communication is as important as knowledge and skills, that educational materials will make positive contributions to patient education, and that an empathic approach to patients and their relatives is important.

if they worry on their own without my effort, education can be more useful. I remembered my mother and father. Their will to pay attention to themselves and my warning them are not the same, the former is more important. I realized this. (No: 700).

where there is an excess of information, written materials can be much more effective. Brochures or visual materials can be very different.…. Yes, what did I learn in this scenario? I can be boring. Believe me, I am a student too. I cannot listen after a forty-minute lesson, too. I get tired. It is very illogical to sit in front of the patient and explain for half an hour.(No: 796).

Skill, I keep going back to the same things, but skill, yes, skill is very important. I realized that too, but besides skill, talking to the patient is also very important. (No: 822).

Comments on the 4th session

In the interviews conducted with the students, it was observed that most of the students felt better and started to gain confidence in the 4th session. However, some students expressed that they had confidence issues due to lack of knowledge and concern about making incorrect transfers about the medications included in the scenario presented in this session.

Being individually responsible in the environment filled me with pride. This time I am doing something. Normally, in internships, we ask and ask, they say let our master come, we cannot do anything before he/she comes, there’s no one here, you are the one who implements the decision. You are the one who will go and call him, let him come, it made me feel proud. (No: 812).

… the medication issue was a little difficult, yes, but when they all came together, it was hard for me. I had a hard time keeping them all in mind. I mean how many times a day, I wonder what it was used for? What were its side effects? When they came one after another, it was a little harder to keep them in mind, I mean I felt bad, I felt inadequate. (No: 864).

In terms of implementing the expected behaviors in the 4th session within the framework of the IDEAL discharge standards and form, the students stated that they provided information to the patient and his/her family, but that they conducted the discussion of progress in the form of questions and answers in line with the goals of the patient, his/her family, and clinician nurses, included the patient and his/her family in the process better, and reduced the educational content by testing the patient’s previous knowledge.

…. First, I asked him about his knowledge, so as not to go into detail … I think I did not bombard him with questions too much. I think I answered the questions that came to his mind..(No: 678).

the progress for the patient and family goals was discussed: When I asked the patient, is there anything? He said there was nothing he wanted to say or was on his mind. He only had question marks in his mind about physical activities. We discussed a little bit about that. In other words, we talked to each other. I examined at his wound and there was no problem. I gave him information about it too, but I guess I did not say anything, I do not know exactly … (No: 702) The students stated that if they were to re-enact the scenario, the subjects they would want to change are learning more about the medications presented in the scenario and that using educational materials is important.

You know, I could have gone a little prepared about the medications. Because the brochure I prepared was a little complicated, I kept getting confused about where to look and what to explain, but I think I could have gone in with a more organized brochure and given the patient answers in this way. (No: 672).

I can give the patient a brochure. In this brochure, our medicines are written like this. You have to use this like this, you have to use this like this. … I can give it to him and his wife.…. (No: 748).

When the students were asked about the most important learning they gained from the scenario, they stated that the patient should be observed well and evaluated in a holistic manner, the preparation process should be good when providing education about medications, and that one should be knowledgeable and confident when working with patients.

… experience, other than that, what is important is communication with the patient and the patient’s human profile is different. On the first day, at least when you enter, on the first day of discharge education, I think the most important thing is to observe yourself very well. … Some patients do not talk at all because they are anxious, some may react much more harshly, some cry and we cannot communicate at all. It may be to create such human profiles and adjust the following education days and processes accordingly. (No: 651)

After this scenario, being determined, confident and knowledgeable can really change many things. Knowledge and self-confidence, affect, affect. I realized that they affect our profession a lot. I think about improving myself as much as I can. (No: 678).

Normally, we need to focus on the patient, not the disease, but we generally pay attention to the disease and its complications, so we will look at it holistically. (No: 802).

Comments on the 5th session

In the interviews conducted with the students, most of the students stated that they felt more comfortable and happier in the 5th session. On the other hand, they expressed their concerns that they were still unable to provide adequate guidance to the patient.

The patient asked me what to do if there was a problem. I could direct the patient, who could he reach? He asked me how he could reach me if there was a problem. I could tell the patient. (No: 675).

I felt calm, relaxed.…after this short experience I really believed I could do it. (No: 766).

In terms of implementing the expected behaviors in the 5th session within the framework of the IDEAL discharge standards and form, the students stated that they provided information to the patient and his/her family, but that they only partially discussed the progress in line with the goals of the patient, his/her family, and clinician nurse, and that they could have included the patient and his/her family in the process more.

The progress towards clinician goals was discussed with the patient: So we did not discuss directly. We actually discussed the education session a little bit. Like how it has been so far but we did not discuss the general situation.(No: 798).

…I did not include the patient’s family, the progress towards clinician goals was discussed with the patient: I asked the patient questions about yesterday, did he have any concerns? I asked if he had any concerns or anything on his mind about yesterday, but this could have been done for his relatives as well. I did not include relatives.….(No: 812).

The students stated that if they were to re-enact the scenario, the subjects they would want to change are the need for holistic evaluation of the patient and greater involvement of the patient’s family in the process, the importance of using stoma-related evaluations and educational materials.

… I wonder if I could have asked about his feelings a little more … I think emotions are very important. I mean, I think it is important what a person feels.(No: 651).

But I was not very happy with it, I explained it this way so that there would be material about colostomy, but he might not have understood it … I mean, the patient can understand it more easily visually. … so I made it easier to have visual material in his hand. (No: 675).

I would wait for the spouse. I would probably want the partner to be involved. Other than that, I could do a general repetition.…. I could explain it briefly and repeat it, it would help him to understand it better…. (No: 700).

… The most important thing for me is to trust yourself first, then you can give trust to the patient, and I say again. Look at it holistically. (No: 802).

When the students were asked about the most important learning they gained from the scenario, they stated that patient education should be carried out in a planned manner in line with the needs of the patient, that it is important to inform about the path/methods to be followed in accessing health services after discharge, that confident communication should be maintained, and that it is important to provide educational materials. Additionally, some students stated that they needed to complete their lack of preliminary preparation and theoretical knowledge.

… In order to ensure permanence, documents should be prepared according to the patient’s needs and requirements, perhaps they should be prepared and reviewed side by side. … (No: 845).

I realized that I was inadequate in theoretical subjects. My theories. … I already knew that it was low, but I never imagined that it was this low. So I needed to study it a little more.…. (No: 672).

Discussion

In this study conducted to develop discharge education skills of nursing students within the framework of IDEAL standards, it was observed that the post-test scores increased compared to the pre-test scores in each discharge education session. Additionally, it was determined that the post-test score in the 4th session continuation effort-persistence sub-dimension increased significantly, and the general scale post-test scores were significantly higher. In the literature, it is frequently emphasized that there are deficiencies in the knowledge of nursing students, especially in their ability to transfer and apply the theoretical learning and information they acquire in the classroom to clinical practice and the learning environment [2]. In the study conducted by Maclean et al. on students discharging standardized patients, it was determined that the students experienced a high level of self-awareness, confidence, and sense of accomplishment, and that this process helped to better understand the importance of verbal and non-verbal communication skills [13]. Weiss et al. determined that discharge education skills of nursing students increased with simulation [14]. In the study conducted by Smith et al. in which simulated discharge education was conducted through interprofessional collaboration, it was determined that the students’ critical thinking skills and awareness of listening to the patient’s voice in the shared decision-making process increased, their ability to prioritize their own list of the patient’s disabilities improved, and their confidence level regarding discharge planning increased [15]. That’s why, it is thought that simulation helps students increase their self-confidence in acquiring discharge education skills.

In this study, the significant difference in the continuation effort-persistence sub-dimension in the 4th session of discharge education was considered an important finding. In the 4th session, the students were expected to provide information about how the patient used medications. As revealed in the qualitative interviews, the students had a lack of knowledge about medications. Additionally, the students’ skills regarding which issues should be emphasized when providing information about medications were not at the desired level. As is known, although medications provide benefits to many patients, their use can also bear significant risks. It is estimated that 20% of adult patients experience an adverse medication event after hospital discharge. While not all medication errors result in adverse patient impacts, they can reduce efficacy and undermine patient trust in the healthcare system. Effective transitions from hospital to community are as important as the care a patient receives as an inpatient, and many organizations recognized the importance of targeting medication use in transitions of care to improve medication safety. Although improving medication safety is an important issue when individuals are discharged from the hospital, problems can still occur [16]. Medication education is directly related to the “Educate (E)” component of the IDEAL discharge planning framework. This component emphasizes providing clear, accurate, and comprehensible information to patients and their families regarding the discharge process, the patient’s condition, and the steps to be taken after discharge. During the simulation sessions, students practiced delivering patient-centered education on medication regimens, usage instructions, and possible side effects, reflecting the practical application of this component. In this context, students’ recognition of the responsibility associated with medication education and their increased effort in this area were reflected in a significant improvement in the “continuation effort and persistence” sub-dimension. The higher scores observed in this sub-dimension compared to others may be attributed to the students’ increased self-awareness regarding the importance of medication education.

After every 5 scenario applications in which students participated, the simulation was evaluated by applying the Simulation Design Scale. Accordingly, the support sub-dimension had the lowest, while the degree of fidelity sub-dimension had the highest mean. In a study, Uzelli Yılmaz and Sarı determined that the support sub-dimension had the lowest mean, and the feedback/guided reflection sub-dimension had the highest mean in simulation design [17]. In Önder’s study to determine the effect of pressure injury on classification and diagnosis skills, it was determined that the application carried out in the laboratory was significantly lower in the support sub-dimension compared to the on-site simulation application [18]. The result obtained in this study may be attributed to the fact that the nursing students included in the sample were not familiar with such an application before and expected more support from the educator due to the anxiety they experienced during the application.

In the interviews conducted with students after the simulation sessions, it was observed that although different opinions emerged based on the scenarios in various sessions, students gradually developed greater self-confidence with increased practice. However, they struggled particularly with discussing progress in line with the goals of the patient, their family, and the clinical nurse, and with actively involving the patient and their family in the discharge planning process. These are critical areas, as evidence shows that active involvement of patients and caregivers in all stages of discharge planning leads to better outcomes [19]. Providing appropriate discharge education is crucial to facilitate patients’ participation in their own self-care management. Moreover, well-planned discharge education reduces the likelihood of noncompliance to treatment and care and helps in the early detection of clinical symptoms. These patients often do not have another support system at home to help them take their medications, attend follow-up appointments, and follow the diary [20, 21]. That’s why, providing effective discharge education to patients is vital. However, discharge education is often not sufficient to meet patient expectations. In their study on the quality of discharge education, Nurhayati et al. obtained patient opinions, and it was determined that the patients experienced moderate satisfaction [22]. Encouraging patients to stay motivated and involving people who will support care in the process can help determine whether certain services, such as home health or rehabilitation services, should be considered [19]. On the other hand, in their study on whether and how caregivers’ participation in discharge processes and their experiences with discharge planning and education affect patient outcomes after hospitalization, Topham et al. determined that although caregivers reported that instructions were clear at the time of discharge, there were gaps in their knowledge about how to care for the patient after they went home. On the other hand, in their study on participation of caregivers in discharge processes, whether and how their experiences with discharge planning and education affect patient outcomes after hospitalization, it was determined that although caregivers reported that the instructions were clear at the time of discharge, there were gaps in their knowledge about how to care for the patient after they went home. The participants indicated that post-discharge knowledge gaps included difficulties with key areas such as mobility, medications, drainage care, and sleep [23]. As can be seen, it is possible to say that discharge education continues after hospital education. It is thought that increasing the educational activities emphasizing the importance of caregivers in effectively managing the process in nursing education programs will help students achieve this competence. Furthermore, these improvements can help bridge the gap between hospital-based teaching and real-life post-discharge needs.

The issues that the students most wanted to change in discharge simulation practices were determined as better communication with the patient and his/her family, planned behavior, obtaining more information, preparing educational materials, and benefiting more from them during the process. In their systematic review of discharge education, Newnham et al. found that most research focuses on the use of printed materials and person-based discharge communication methods, including verbal instructions (face-to-face or via telephone interviews) [24]. There are studies examining the use of information technology (IT) such as computer-generated and video-based discharge communication applications. This result indicates that traditional educational tools are still used/preferred in patient education and that students prefer this method in simulation applications because they see such applications in their environment.

In addition to the issues mentioned above and intended to be changed, controlling individual stress and evaluating the patient in a holistic manner are the most important messages obtained from simulation applications. Individualized patient discharge plans help reduce hospital length of stay and rehospitalization rates by improving patients’ quality of life scores and patient satisfaction [19, 25]. However, one of the most common problems encountered in the discharge process is that a holistic evaluation, including the patients’ readiness for discharge, the assessment of their learning needs, and their ability to care for comorbidities, cannot be performed [26]. On the other hand, it is a pleasing finding that the students realized the importance of holistic evaluation in the simulation intervention regarding discharge education.

Limitations of the study

Due to internet problems experienced during the application, the quantitative data of three students were excluded from the evaluation. Although minor internet issues led to the exclusion of three participants, they did not significantly affect the study results. Additionally, discharge practices were planned during the academic year at suitable times for some students, causing them to undergo more than one scenario practice in a row. The limited time between sessions may have negatively affected the students’ ability to internalize the experience gained in the consecutive sessions. The qualitative data of the study is limited to the experiences of the students who participated in the study. Furthermore, the exclusion of some participants from the quantitative analysis due to technical issues may have reduced the representativeness of the sample, and the small number of participants may limit the generalizability of the study’s findings. The absence of patient perspectives is another limitation, as it restricted the evaluation to student experiences only. Additionally, the findings may not be fully generalizable to other nursing programs due to the single-institution sample.

Conclusion

In this study conducted to develop the discharge education skills of nursing students within the framework of IDEAL standards, it was determined that the post-test scores increased in each discharge education session, and in terms of simulation design, the support sub-dimension had the lowest and the degree of fidelity sub-dimension had the highest mean. The most problematic area in terms of implementing the IDEAL discharge education steps was the discussion of progress in line with the goals of the patient, his/her family, and clinician nurse and the active involvement of the patient and his/her family in the process. However, as students participated in more sessions, their self-confidence improved, and they began to recognize the importance of holistic patient assessment and individualized education. These findings align with the primary objective of the study: to enhance nursing students’ competence in discharge planning using a structured, evidence-based approach. The use of simulation guided by the IDEAL framework proved effective in reinforcing communication, planning, and patient education skills. Future research should investigate the long-term retention of these skills in clinical practice, compare simulation-based methods with other educational strategies, and examine the impact of such training on patient satisfaction and engagement in discharge experiences.

Author contributions

The conception and design of the study: AK Acquisition of data: AK, AD, SK, NI, AA, FE Analysis and interpretion of data: AK, AD, SK, NI, AA, FE Revising the article for important intellectual content: AK, AD, SK, NI, AA, FE Final approval of the version to be submitted: AK, AD, SK, NI, AA, FE Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: AK, AD, SK, NI, AA, FE.

Funding

This study was supported by Düzce University BAP (Scientific Research Project) - Project No: 2021.16.01.1271 Scientific Research Project.)

Data availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to the privacy of participants.

Declarations

Ethics approval and consent to participate

The study was conducted following Declaration of Helsinki. In order to conduct the study, permission (2023/368350) was obtained from the Scientific Research and Publication Ethics Committee of the institution where the study was conducted. The volunteers participating in the study were informed about the purpose of the study and how it would be conducted, and verbal and written consent was obtained from the participants. Informed consent was obtained from all participants for the use of visual and audio recordings captured during the simulation sessions. The images included in this article were used with permission and in accordance with ethical guidelines.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.