Hybrid simulation approach enhances technical and non-technical skills in therapeutic pharmacology education

Abstract

Background

Safe medication administration is a critical competency for nursing students. Simulation-based learning, particularly hybrid simulation combined with role-playing, may enhance both technical and communication skills in clinical practice and reduce the gap with theoretical knowledge.

Methods

This quasi-experimental study assessed the impact of hybrid and role-playing simulation sessions on nursing students’ knowledge, skills, and patient communication in therapeutic pharmacology. Students participated in two sequential simulation sessions. Performance was evaluated across domains including correct patient identification, dosage calculation, medication preparation, hand hygiene, use of personal protective equipment, and patient communication.

Results

Significant improvements were observed across all domains, except for initial “right patient” verification. Hand hygiene compliance increased from 67.9% to 93.6%

(p < 0.001), use of personal protective equipment from 78.2% to 96.2% (p < 0.001), allergy verification from 44.3% to 91.8% (p < 0.001), and patient identification accuracy from 53.6% to 94.7% (p < 0.001). Correct dosage calculation and reconstitution rates improved dramatically from 1.3% to 93.6% (p < 0.001). Communication behaviors, including verification of patient identity and eliciting the reason for consultation, also showed substantial gains. Overall satisfaction with the simulation experience remained high throughout the study, all individual satisfaction items scoring between 4.56 and 4.69 out of 5.

Conclusion

Hybrid simulation combined with role-playing significantly enhances nursing students’ competencies in safe medication administration and patient communication. This educational approach provides a safe and immersive learning environment, bridging the gap between theoretical knowledge and clinical practice. The integration of structured simulation programs, experiential learning, and blended teaching methods can further consolidate medication safety skills and promote the development of competent, safety-conscious healthcare professionals.

Introduction

Medication administration is a fundamental nursing responsibility and one of the most error-prone processes in healthcare systems worldwide. Medication errors remain a leading cause of preventable adverse events, contributing significantly to patient morbidity, mortality, and increased healthcare costs [1, 2]. Because nurses are the final checkpoint in the medication-use process, their competence in pharmacology, dosage calculation, and administration safety are critical to ensuring patient protection.

To mitigate risks, nurses are required to implement structured safety barriers, including prescription verification and adherence to the “five rights” of medication administration right patient, right medication, right dose, right route, and right time. In several healthcare systems, these principles have been expanded to the “seven rights,” incorporating documentation accuracy and clinical justification [3]. However, compliance with these principles alone does not eliminate errors, particularly when communication failures and contextual factors intervene.

Increasing evidence highlights that medication safety depends not only on cognitive and procedural accuracy but also on non-technical skills such as clinical reasoning, situational awareness, teamwork, and interprofessional communication [4]. Standardized communication tools, including SBAR (Situation–Background–Assessment–Recommendation), have demonstrated effectiveness in improving clarity and reducing preventable errors [5]. Nevertheless, hierarchical organizational cultures in certain healthcare contexts may limit assertive nurse–physician communication, potentially compromising safe medication practices. This underscores the importance of integrating both technical and relational competencies early in nursing education.

Contemporary nursing education increasingly adopts simulation-based learning to enhance clinical competence in a safe environment. According to the Healthcare Simulation Standards of Best Practice [6], simulation promotes active learning, reflective practice, and skills transfer to real clinical settings. Systematic reviews have demonstrated that simulation improves medication calculation accuracy, pharmacological knowledge, and self-confidence among nursing students [7, 8]. Moreover, simulation has been associated with reduced learner anxiety and improved patient safety awareness.

Despite these documented benefits, most studies have focused on single-modality simulation targeting technical or procedural components of clinical skills training (e.g., dose calculation, procedural tasks) rather than deliberately integrating multimodal strategies that combine both technical and non-technical elements of nursing practice [9]. While traditional simulation modes such as high-fidelity manikins and virtual scenarios have shown improvements in cognitive and psychomotor skills, evidence remains limited regarding their capacity to embed broader communicative and relational competencies alongside technical tasks in a unified pedagogical framework [9, 10]. To achieve optimal development of technical, behavioral, and relational skills, it is sometimes necessary to combine multiple active modalities across a simulation pathway, ranging from least to most immersive. Indeed, starting with role-playing defined as a simulation method in which the student alternates between the roles of caregiver and patient [11] (Lioce, p. 53) fosters, among other things, the development of new behavioral skills, critical thinking, and an understanding of the importance of professional demeanor within a safe environment. Following this initial method, it is necessary to move to a more immersive approach involving an actor playing the role of a patient. The simulated or standardized patient (SP) allows the learner to interact with an individual capable of providing real feedback, just as a patient would in a clinical setting. This simulation modality is highly powerful because it can be combined with simulation prosthetics, enabling the simultaneous performance of technical procedures. Although these approaches have been explored across a variety of clinical contexts, research specifically investigating their application to medication administration training remains limited [12]. Findings from hybrid simulation studies suggest that such integrated scenarios can support simultaneous practice of procedural skills and interpersonal communication, thus offering a more authentic representation of clinical complexity [9, 12]. Given that medication administration is a multifaceted clinical act requiring both technical precision and therapeutic communication, there remains a clear need to evaluate educational strategies capable of addressing these competencies concurrently in nursing curricula.

Therefore, this study aimed to examine the effectiveness of role-playing and hybrid simulations in enhancing nursing students' competencies in therapeutic pharmacology, with a particular focus on medication administration, dosage calculation, and patient communication. Additionally, the study sought to evaluate the students' satisfaction with this experiential learning approach.

Methods

Participants

The study was conducted with first-year undergraduate nursing students enrolled in the three-year Bachelor of Nursing programme at the International University of Rabat, Morocco. All first-year students (n = 85) were invited to participate in the study, and 78 students (91.76%) provided written informed consent. Participation was voluntary, and all students were informed about the study objectives before enrollment. The intervention was conducted in April 2025, during the second semester of the academic year,after students had completed all the theoretical teaching activities of the General and Therapeutic Pharmacology module. At the time of the intervention, the final module examination had not yet taken place. Although continuous assessments had been conducted throughout the module, their results were not used as an eligibility criterion, and all first-year students were invited to participate in the study. They had previously participated in a role-play simulation as part of another first-semester module, providing them with initial exposure to simulation-based learning. However, this was their first experience with hybrid simulation integrating role-play and simulated clinical practice. Tables 1, and 2.

Table 1.

Participants demographic characteristics (n =78)

n = sample, SD standard deviation, MAP medication administration process.

^*McNemar test.

Table 2.

Pre-post-MAP tests comparisons of the “Foor rights”

SD standard deviation

^aWilcon rank test.

^bStudent’s test

Instruments and measures

Four tools were used to collect data; 3 had been previously developed and published by other researchers: A) The knowledge Medical Administration Process (MAP) test [13]. The MAP test comprised 56 dichotomous (“True”/“False”) items covering the medical administration process. Questions were grouped into four categories based on the ten rights of medication administration described by Edwards and Axe [14]. right patient (9 items), right medication information (17 items), right medicine (18 items), and right medication administration (12 items). Each correct answer was awarded one point and incorrect answers received zero points, resulting in a total score ranging from 0 to 56. The stability and robustness of this test were evaluated using Cronbach's alpha. The analysis demonstrated good internal consistency, with a Cronbach's alpha coefficient of α = 0.84, indicating that the instrument showed satisfactory reliability. B) The Medication Administration Observation Tool (MAOT) was used [15] The MAOT initially comprised 20 observable actions. In this study, 16 actions were deemed applicable and analyzed using a binary scoring system: “complete” or “not complete”. C) For the learning experience, we was relied on National League for Nursing’s Student Satisfaction and Self-Confidence in Learning Scale [16]. D) The fourth tool was developed specifically for this study, It is an evaluation grid inspired by the SBAR (Situation–Background–Assessment–Recommendation) [5], adapted to evaluate patient-nurse communication. The SBAR framework was selected as the communication model because it provides a structured and standardized approach to information exchange, thereby reducing omissions, misunderstandings, and communication errors that may compromise patient safety. Although initially developed to improve communication among healthcare professionals, SBAR also supports structured interactions between healthcare providers and patients by encouraging clear, concise, and systematic communication. Within simulation-based education, its use helps nursing students organize clinical information, communicate their assessment logically, actively involve patients in the exchange of information, and formulate appropriate recommendations. By promoting accurate communication and shared understanding, SBAR is recognized as an effective strategy for enhancing communication safety and improving the quality of patient care. The grid contains 10 items, each scored on a three-point ordinal scale: 0 points for 'not done', 1 point for 'done incompletely', and 2 points for 'done completely. The internal consistency of the rubric, assessed using Cronbach's alpha, was good (Cronbach's α = 0.84). The corrected item–total correlations ranged from 0.43 to 0.72, and Cronbach's alpha if an item was deleted ranged from 0.81 to 0.85, indicating that all items contributed satisfactorily to the overall reliability of the instrument.

Study design

This study utilized a repeated measures design to assess the effectiveness of two types of simulation interventions (role-playing simulation and hybrid simulation) on pharmacological knowledge and skills. The study was carried out in several phases, as shown in the diagram below (Fig. 1).

Fig. 1.

Study design flowchart

• aPre-test

  The initial phase of the study involved a diagnostic assessment utilizing the knowledge MAP test to evaluate baseline knowledge and comprehension in pharmacology [13].

• bRole-playing simulation

  After the pre-test, all students participated in a role-playing simulation session structured around the three essential phases of simulation: briefing, scenario execution, and debriefing [17]. During the briefing, students received an orientation to the simulation environment, equipment, and learning objectives, while psychological safety was established by emphasizing confidentiality, mutual respect, and the formative nature of the activity. The scenario's primary objective was to interpret a patient’s medical prescription while ensuring effective communication with the patient. During the scenario execution, we used an assessment grid specifically designed for this study, inspired by the SBAR grid [5]. The adopted grid focused exclusively on nurse-patient communication. Following each simulation session, students participated in a structured formative debriefing facilitated by experienced nursing faculty members trained in simulation-based education. The debriefing followed three sequential phases: reaction, analysis, and summary, encouraging participants to reflect on their performance, identify strengths and areas for improvement, and consolidate key learning points.

• cHybrid simulation

  Following the role-playing simulation, the students participated in a hybrid simulation. This simulation aimed to provide a more immersive experience by incorporating a mannequin for therapeutic administration alongside a standardized patient who interacted and responded to the nursing student’s questions. In the hybrid simulation, the standardized patient was a final-year undergraduate nursing student who received specific training before the intervention. A standardized script describing the patient's clinical history, symptoms, emotional behaviours, and expected responses was used to ensure consistency across all simulation sessions. The objectives of the scenario were to verify the patient’s medical record, administer the prescribed treatment, and accurately calculate the required dosage. During the scenario execution, the MAOT was utilized to assess the student’s performance [15].

• dRepetition of role-playing and hybrid simulation

  One week after the first simulation sessions, students participated in a second role-playing simulation followed by a second hybrid simulation. The second sessions were conducted using the same learning objectives, simulation scenarios, and assessment procedures as the first sessions, with the aim of reinforcing learning while evaluating knowledge retention and skill application over time. Repeating the simulation sessions enabled participants to consolidate their pharmacological knowledge and medication administration skills.

• ePost-test

  After completing all simulation sessions, the students underwent a post-test as a summative evaluation to assess the impact of these simulation experiences on their knowledge acquisition in therapeutic administration and dosage calculation. The same test used in the pre-test was administered to ensure consistency and allow for a direct comparison of results.

• fSatisfaction questionnaire

  Finally, participants completed though a survey the Student Satisfaction and Self-Confidence in Learning Scale developed by the National League for Nursing (NLN) to assess their perceptions of the simulation experience and overall learning outcomes [16]. The NLN is an internationally recognized organization dedicated to excellence in nursing education and has developed several validated instruments for evaluating simulation-based learning.

  The scale consisted of 13 items divided into two subscales on a five-point Likert scale and assesses two complementary dimensions: satisfaction with the learning experience (5 items) and self-confidence in learning (8 items). This instrument has been widely used in simulation-based education research and has demonstrated strong psychometric properties, including high internal consistency and construct validity across diverse nursing education settings. It was selected because it specifically measures learners' satisfaction with simulation-based education and their perceived self-confidence in achieving the intended learning outcomes, which were predefined secondary outcomes of the present study. Responses were measured using a Likert scale (1 = strongly disagree to 5 = strongly agree), where participants rated their level of agreement with each statement as "strongly disagree," "disagree," "undecided," "agree," or "strongly agree." Cronbach’s alpha has been reported as 0.94 for the satisfaction subscale and 0.87 for self-confidence subscale [18].

Data analysis

Statistical analyses were carried out using Jamovi software (version 2.3.18) [REF]. Categorical variables were presented as frequencies and percentages, with the McNemar and the Chi-squared tests comparing proportions between groups. Quantitative variables were expressed as mean and standard deviation or median and interquartile range. Then, they were compared using the Wilcoxon and Student’s tests. rank biserial correlation (r) was used to provide an effect size measure of the Role-Playing Simulation observed behaviors. A p-value less than 0.05 was considered statistically significant.

Ethical approval and consent to participate

This study was conducted among first-year nursing students at International University of Rabat, Morocco, as part of routine educational activities involving simulation-based learning aimed at improving medication administration competencies. Informed consent to participate was obtained from all participants prior to their inclusion in the study. Students were informed about the objectives of the study, and their participation was entirely voluntary.

According to the institutional policies of the International University of Rabat and national regulations governing educational evaluation activities, studies conducted within routine pedagogical practices that do not involve personal data collection do not require formal approval from an Institutional Review Board or ethics committee.

The study was conducted in accordance with the ethical principles of the Declaration of Helsinki.

Results

Demographic characteristics

Seventy-eight nursing students participated in this study. They were predominantly female (79.5%) with an average age of 19.5 ± 1.5 years old. Nearly half had prior knowledge (46.2%) and the majority (76.9%) had practiced MAP in the past.

Theoretical knowledge before and after the training

At baseline, all participants demonstrated a good level of knowledge regarding the MAP, as all average scores obtained were above the scale mean for each section. The improvement in scores was statistically significant (p < 0.001) with the exception of the “right patient” section (p = 0.972) after the training.

Observed behaviors with SBAR grid

The results (Table 3) show significant improvements across all observed behaviors from T1 to T2. The mean scores increased for all items. Higher improvements were noted in areas such as asking for the patient's name (0.87 to 1.8), determining the reason for consultation (0.87 to 1.56), and answering patient questions (0.67 to 1.56). The p-values for all comparisons are less than 0.001 (except for item 4, which is 0.008), indicating statistically significant changes. The negative rank biserial correlation values suggest a strong, inverse relationship between ranks at T1 and T2, meaning participants ranked lower initially but showed improved ranks in T2.

Table 3.

Comparison of role-play observation results: before (T1) and after (T2) hybrid simulation

Table 4 presents a comparative observation of key medication administration practices between two hybrid simulation sessions. The first session is considered Simulation 1 and the second Simulation 2 (Sim 1 and Sim 2). There were significant improvements in most actions from Sim 1 to Sim 2. For example, hand hygiene compliance rose from 67.9% to 93.6%, and the use of Personal Protective Equipment (PPE) increased from 78.2% to 96.2% (both p < 0.001). Notably, essential safety measures, such as checking allergies and verifying patient ID using two forms, improved significantly (from 10.3% to 74.4% and from 7.7% to 84.6%, respectively). Medication calculation and reconstitution also showed marked improvement, with correct calculation rates rising from 1.3% to 93.6%.

Table 4.

Comparison of medication administration actions between first and second hybrid simulations

n = sample, ID identification, PO per Os/by mouth, PPE personal protective equipment, VS vital signs

Student satisfaction and self-confidence in learning through hybrid simulation

Table 5 presents mean scores for student satisfaction and self-confidence in learning through hybrid simulation. Results indicate high satisfaction, with the overall satisfaction score reaching 23.06 ± 1.645, and all individual satisfaction items scoring between 4.56 and 4.69 out of 5, each showing high statistical significance (p < 0.001). Students particularly appreciated the suitability of the simulation to their learning style (4.69 ± 0.465).

Table 5.

Student satisfaction and self-confidence in learning scale mean scores

The self-confidence scores were also strong, with an overall mean of 36.68 ± 2.183. All items scored above 4.5, reflecting students’ confidence in mastering MAP and utilizing resources effectively. This suggests that the hybrid simulation significantly boosted both satisfaction and self-confidence in medication administration training.

Global satisfaction

The satisfaction regarding the course remained high, though the distribution shifted slightly from 39.7% to 28.2% feeling it “Highly satisfying” and from 53.8% to 69.2% feeling it “Quite satisfying". The small category (6.5%) who felt the course was “Less satisfying” dropped to 2.6% after the training. These changes were not significant (p = 0.076).

All the participants self-assessed their pharmacotherapy skills positively (Excellent, Good, Satisfying) with no significant change between pre- and post-training (0.515).

Discussion

The present study demonstrates that hybrid simulations combined with role-playing substantially enhance nursing students’ competencies in therapeutic pharmacology, particularly in safe medication administration, dosage calculation, and patient communication.. Most assessment domains showed significant improvements following the intervention, except for “right patient” verification, suggesting that active learning strategies effectively reinforce critical steps in the medication administration process [19].

Student communication skills also improved markedly. The ability to verify patient identity, elicit the reason for consultation, and respond appropriately to patient questions showed significant gains, consistent with the literature emphasizing communication as a final safeguard against medication errors [20]. Mastery of technical skills is a prerequisite for developing relational competencies, as patient interaction may introduce attentional interruptions that could increase error risk [21]. The substantial gains observed in this study likely stem from the sequence of complementary learning modalities employed, consistent with Kolb’s experiential learning cycle [22]. Indeed, sequencing simulations where learning points from one session are integrated into the next while increasing the focus on professional realism (transitioning from role-play to using simulated patients) is a key factor for success. Encouraging patient engagement—such as verifying medications, asking about dosage, or clarifying procedural steps—further reduces the likelihood of errors while fostering trust and patient-centered care [23]. Indeed, as shown by Miller [24] who, despite finding no between-group differences, noted that the use of an assistive tool enhances practice safety, the results indicate that such tools make practices safer Other studies reinforce the importance of communicating well with the patient, which constitutes the ultimate barrier to the risk of error, especially among novice nursing students [25].

Regarding Table 3, it's important to note that the role-play observation grid assesses students' ability essential information for effective interprofessional communication using the SBAR (Situation, Background, Assessment, Recommendation) tool. The grid evaluates various aspects of patient interaction, from basic identification to more complex tasks like determining medical history and providing therapeutic education. These skills are fundamental in preparing students to communicate effectively with other healthcare professionals using the structured SBAR approach. By improving these skills through hybrid simulation, as evidenced by the significant improvements from T1 to T2, students are better equipped to contribute to clear, concise, and comprehensive interprofessional communication in clinical settings.

Comparative analyses between the two hybrid simulation sessions revealed significant improvements in safety–critical practices. Hand hygiene compliance increased from 67,9% à 93,6% (p < 0.001), use of personal protective equipment rose from 78.2% to 96.2% (p < 0.001), allergy verification improved from 44.3% to 91.8% (p < 0.001), and patient identification accuracy increased from 53.6% to 94.7% (p < 0.001). Correct dosage calculation and reconstitution rates showed a dramatic improvement from 1.3% to 93.6% (p < 0.001), highlighting the effectiveness of simulation-based interventions in bridging the theory–practice gap [13].

These results—combining various approaches with a tool that facilitates the standardization of interactions—suggest a way to streamline and secure practices. Naturally, further studies are needed to reinforce this approach by directly evaluating student behavior during clinical placements. Instructional design models such as 4C/ID [26] along with problem-based and experiential learning approaches [27, 28], and blended teaching methods combining lectures, hands-on training, and role-playing [29], further strengthen students’ competencies and awareness of medication safety. The integration of technology-assisted learning modules [30] and the application of transformational leadership principles in nursing education [31] can additionally motivate students to consistently adopt safe practices. Collectively, these strategies contribute to the development of competent, confident, and safety-conscious healthcare professionals.

The discrepancy between students' self-reported prior knowledge of medication administration and their previous clinical exposure may reflect the complementary nature of theoretical instruction and clinical practice in nursing education. Although some students had already observed or performed medication administration during their first clinical placement, this early practical experience may not have been sufficient for them to perceive themselves as knowledgeable or competent in the absence of formal theoretical instruction. This finding highlights the importance of integrating theoretical learning with supervised clinical practice and simulation-based education to promote both competence and self-confidence in medication administration.

Finally, it is interesting to note that simulation sessions held early in the training program allow students to become aware of their skill levels and gaps in theoretical knowledge—as evidenced by the pharmacotherapy results, which showed no increase. In the learning process, the student moves from a state of unconscious incompetence to an awareness of these gaps.

Limitations

This study has several limitations that should be acknowledged. First, it was conducted in a single nursing school, which may limit the external validity and generalizability of the findings to other nursing education programs with different educational contexts, curricula, or student populations. Replication in multicenter studies would help determine the transferability of these results.

Second, the quasi-experimental pre–post design without a parallel control group does not allow the complete exclusion of potential testing effects or other uncontrolled factors that may have contributed to the observed improvements. Although the pre–post approach was appropriate for evaluating the educational intervention in a real-world setting, future controlled studies are warranted to strengthen causal inference.

Furthermore, in pre- and post-assessments involving a time interval between periods, isolating the effect of the simulation is challenging due to potential contamination bias arising from students reviewing the material between sessions. Consequently, the findings should be interpreted with caution.

Finally, knowledge and performance were assessed only one week after the intervention. Consequently, this study does not provide information on the long-term retention of technical and non-technical skills or on their transfer to clinical practice. Further longitudinal research is needed to evaluate the sustainability of these learning outcomes over time.

Conclusion

This study suggests that hybrid simulation combined with role-playing is a promising educational approach for enhancing nursing students' medication administration competencies, including both technical and non-technical skills. Beyond improving learning outcomes, this teaching strategy may help students identify gaps in their theoretical knowledge and clinical performance while supporting reflective practice. It may also serve as a valuable tool for formative assessment before or after clinical placements. Further multicenter studies with larger samples are needed to confirm these findings and examine their transfer to clinical practice and their impact on patient safety.

Authors’ contributions

OC: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Data curation, Writing – original draft, Writing—review & editing, Visualization, Project administration. FZM: Conceptualization, Methodology, Validation, Resources, Writing—review & editing. GD: Conceptualization, Methodology, Validation, Formal analysis, Data curation, Writing – original draft, Writing—review & editing. NK: Conceptualization, Methodology, Validation, Writing—review & editing, Supervision. HE: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Resources, Writing- review & editing, Supervision. All authors have read and approved the final manuscript.

Funding

There was no funding for this study.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted among first-year nursing students at International University of Rabat, Morocco, as part of routine educational activities involving simulation-based learning aimed at improving medication administration competencies. The study focused on the assessment of students’ technical and non-technical skills during simulation sessions.

The study did not involve patients, human tissue, or the collection of personal or sensitive data. Informed consent to participate was obtained from all participants prior to their inclusion in the study. Students were informed about the objectives of the study, and their participation was entirely voluntary. They were also assured that the collected data would remain anonymous and would be used solely for research purposes.

According to the institutional policies of the International University of Rabat and national regulations governing educational evaluation activities, studies conducted within routine pedagogical practices that do not involve personal data collection do not require formal approval from an Institutional Review Board or ethics committee.

Therefore, formal ethics committee approval was deemed unnecessary for this study. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.