The synchronous group virtual simulation experience: Associate degree nursing students' perceptions

Abstract

The use of virtual simulations exponentially increased as nursing schools experienced an urgent need to integrate online educational technologies during the COVID-19 pandemic. This qualitative descriptive study was conducted to explore associate degree nursing students’ perceptions about the comprehensive Synchronous Group Virtual Simulation educational strategy. This strategy was developed based on the National League for Nursing Jeffries Simulation Theory (JST) and the Healthcare Simulation Standards of Best Practice^TM, including structured synchronous prebriefing and debriefing stages. Content analysis revealed 12 recurrent themes, from which 10 positive themes strongly correlated with concepts of the JST. Our findings support the effectiveness of a high-quality synchronous virtual simulation—guided by an empirically supported simulation theoretical framework and evidence-based simulation best practice standards—can be realistic, experiential, interactive, collaborative, learner-centered, and promote simulation participant outcomes.

Background

The use of virtual simulations exponentially increased in 2020 with the COVID-19 global public health crisis as nursing schools experienced an urgent need to implement online educational technologies. However, despite the rapid growth in the virtual simulations literature supporting positive student (participant) outcomes, there was limited evidence to guide virtual simulation best practices and curriculum integration. A systematic review conducted by Foronda et al. (2020) demonstrated that virtual simulations can improve nursing students learning outcomes, including “learning (knowledge), skills/performance, critical thinking, self-confidence, and provide learner satisfaction” (p. 51). However, this review identified a literature gap concerning best practices in the methods of administering virtual simulation as well as debriefing practices. Another systematic review conducted by Tolarba (2021) also found that virtual simulations have a positive impact on nursing student learning outcomes in the cognitive, skills, and affective domains of learning. This review also identified many variations in the use of virtual simulation technologies in nursing education, which limits the conclusions that can be made concerning the effectiveness of a particular virtual simulation technology or delivery method. These findings were evident during the 2020–2021 global lockdown as nurse educators rapidly transitioned from facilitating in-person human patient simulations (HPS) to online virtual simulations—experiencing a lack of consistency in virtual simulation delivery methods as well as virtual simulation prebriefing and debriefing practices (Badowski & Wells-Beede, 2022; Luctkar-Flude et al., 2021). Now, as nurse educators return to the “new normal,” which may include the permanent use of virtual simulations in the nursing curriculum, they must take the time to evaluate the effectiveness of virtual simulations experiences delivered during the COVID-19 pandemic and incorporate them following appropriate theoretical frameworks and evidence-based standards of best practice in simulation-based teaching and learning.

The National League for Nursing (NLN) Jeffries (2016) Simulation Theory provides a comprehensive view of the simulation experience, including its primary components, key elements, relationships, and outcomes. This theory has seven conceptual components: simulation context, background, design, simulation experience, facilitator and educational strategies, participant, and outcomes. During the simulation experience, there is a dynamic interaction between the facilitator and the participants. Facilitatory attributes such as skill, educational techniques, and preparation can influence the simulation experience. The facilitator implements educational strategies such as providing appropriate guidance and feedback during the prebriefing and debriefing stages, which enhance the simulation experience (Jeffries, 2016, 2021).

The International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice: Simulation^SM were announced initially in 2011 and revised in 2021 as the Healthcare Simulation Standards of Best Practice^TM. These standards provide guidelines to support the integration, use, and advancement of a simulation-based experience, including “virtual” and “online” learning (Watts et al., 2021). These standards provide detailed, evidence-based recommendations to guide the simulation design and all stages of the simulation experience, including the prebriefing and debriefing processes (Sittner et al., 2015; Watts et al., 2021). Prebriefing refers to not only briefing aspects but also the preparatory activities that occur before the simulation-based experience. Prebriefing activities are purposefully designed and may enhance learners’ success, the debriefing process, and the effectiveness of the simulation experience (McDermott et al., 2021). The debriefing process includes any activities of feedback or guided reflection in which participants have an opportunity to consider the consequences of their actions and assimilate knowledge, skills, attitudes, and behaviors. All simulation experiences are recommended to integrate a planned debriefing session, preceded by a structured prebriefing and guided by a skilled facilitator (Decker et al., 2021).

Methods

This qualitative descriptive single site study was conducted in the United States at a Northeastern urban public community college. This research design allowed for discovering and understanding associate degree nursing (ADN) students’ perceptions after participating in the Synchronous Group Virtual Simulation (SG-VS) educational strategy, which included structured prebriefing and debriefing strategies. The overarching question was: What are the perceptions of ADN students about their experience participating in the SG-VS educational strategy?

Educational Strategy: The Synchronous Group Virtual Simulation (SG-VS)

This educational strategy was designed based upon the NLN Jeffries Simulation Theory, the Healthcare Simulation Standards of Best Practice^TM, and the NLN vSim® for Nursing Curriculum Integration Guide for Faculty. The NLN Jeffries Simulation Theory is a widely used theory that provides the constructs needed to conduct a high-quality virtual simulations experience. The Healthcare Simulation Standards of Best Practice^TM align with this theory, provide a roadmap for nurse educators (Jeffries, 2021), and should also be applied to virtual simulations, just as it would to the other simulation modalities. In consultation with the nursing department chair and course instructors, the SG-VS educational strategy (described in Table 1 ) was developed and facilitated by the primary investigator, who is an assistant professor of nursing, certified Clinical Nurse Leader, holds a post-master's certificate in nursing education, and is experienced in simulation-based teaching and virtual simulation technologies.

Table 1.

The Synchronous Group Virtual Simulation (SG-VS) Educational Strategy

Virtual Simulation Stages	Description
1) Students’ Preparatory Activities (Completed before the virtual simulation day)	Completion of assigned classroom materials and essential questions about the simulation topic before the virtual simulation day.
2) Synchronous Structured Prebriefing (45 Minutes)	Participation in the group prebriefing session, including the following: 1.Introduction of simulation facilitator and participants 2.Review of fiction contract and confidentiality 3.Review of simulation learning objectives 4.Review of essential questions included in the preparatory activities 5.Review of scenario overview 6.Review of provider's orders 7.Explanation of participants’ roles 8.Review of the vSim® for Nursing tutorial, including orientation to the virtual clinical environment 9.Completion of the vSim® for Nursing pre-test
3) Synchronous Group Virtual Simulation (35 min)	Group completion of the vSim® for Nursing scenario, which was controlled by the facilitator who shared the screen with all participants, followed their recommendations for nursing actions and paused the scenario as the participants brainstormed and agreed on nursing interventions. Completion of the vSim® for Nursing post-test.
4) Synchronous Structured Debriefing (45 Minutes)	Participation in the group debriefing session adopted from the Promoting Excellence and Reflective Learning in Simulation (PEARLS) debriefing framework (Cheng et al., 2016) including the following stages: 1.Reactions 2.Description 3.Analysis 4.Application and Summary
5) Virtual Simulation Evaluation	Completion of the Virtual Simulation Experience Questionnaire

As part of the course requirements, ADN students enrolled in Fundamentals of Nursing (first semester) and Medical-Surgical Nursing I (third semester) courses were expected to participate in the SG-VS experience in their assigned clinical sections (8–10 students). Students only had from “none” to “very little” prior experience with nursing virtual simulations. The SG-VS included students' participation in a 2-hour synchronous virtual simulation facilitated via the Zoom platform, which included a structured synchronous prebriefing, a group completion of one NLN/Laerdal vSim® Medical-Surgical Scenario, and a structured synchronous debriefing. The Promoting Excellence and Reflective Learning in Simulation (PEARLS) debriefing framework (Cheng et al., 2016) was used to guide the virtual simulation debriefing.

Data Collection

Due to the lack of validated measures to evaluate synchronous virtual simulation experiences, and the need to explore students’ perceptions about the SG-VS educational strategy, the researchers developed a qualitative Virtual Simulation Experience Questionnaire. This questionnaire consisted of the following open-ended questions:

• 1.How do you feel about the synchronous virtual simulation experience?
• 2.How did this experience help you meet the course's clinical objectives?
• 3.How do you feel about the prebriefing session?
• 4.How did the prebriefing session help you meet the simulation objectives?
• 5.How do you feel about the debriefing session?
• 6.How did the debriefing session help you meet the simulation objectives?
• 7.What did you like the most about this synchronous virtual simulation experience, including the prebriefing and debriefing sessions facilitated by your clinical instructor?
• 8.Please share any challenges or anything that you did not like about this virtual simulation experience
• 9.Are there any recommendations you would like to make to improve this experience?

This questionnaire was administered online via Survey Monkey immediately after completion of the debriefing. A generic online access link was shared with the students at the end of the virtual simulations experience via Zoom chat. The completion of this questionnaire was voluntary and anonymous. No student identifiers were collected.

Data Analysis

The responses were analyzed and coded using a content analysis approach, which is used to systematically explore large amounts of textual information to determine trends, patterns, and relationships of the words used (Vaismoradi et al., 2013). Content analysis is well suited for studies where every participant is asked and responds to the same questions (Waltz et al., 2017). This analysis was conducted by two study investigators who: 1) defined the units and categories of analysis, 2) developed a set of rules for coding, 3) individually read responses several times to familiarize themselves with the information; 4) individually categorized ideas and generated initial codes; 5) individually searched for, reviewed, and defined themes; and 6) compared and combined individual codes and themes into final ones by consensus agreement. To ensure trustworthiness: 1) data were meticulously transferred and organized using excel tables, 2) codes and themes were first independently developed by each investigator, 3) multiple meetings and debriefing sessions were conducted to compare and develop mutual codes and themes, and 4) investigators used an audit trail including detailed notes to explain the coding process and rationale for what codes were clustered together to form the basis of the themes.

Ethical Considerations

Exempt institutional review board (IRB) approval was received from the college where the study was conducted. The researchers completed the required modules for human subjects protection through the Collaborative Institutional Training Initiative (CITI) and obtained permission from the nursing department chair and course faculty to collect questionnaire data. Although participation in the SG-VS educational strategy was a course requirement, completion of the online questionnaire was optional. The SG-VS was not a graded assignment. Online questionnaire data were password protected and only accessed by the study investigators. To protect participants’ anonymity, questionnaires did not include any student names or demographic data. However, students’ aggregate demographic data were obtained from the program administrator for all participating courses.

Results

Of 125 students who participated in the SG-VS educational strategy, 86 completed the Virtual Simulation Experience Questionnaire (69% response rate). The students were predominantly female (84%). Students from the following racial/ethnic groups were represented: White (34%), Black (28%), Asian (20%), Hispanic (16%), and Multiracial (2%). Most students were between 25 and 44 years of age (79%); other students were under 25 years of age (12%) and between 45 and 54 years of age (9%).

Content analysis revealed 12 recurrent themes, from which ten positive themes were consistent with concepts of the NLN Jeffries Simulation Theory. Therefore, themes were categorized using these theoretical constructs. This section will highlight the most relevant supporting quotes. Additional supporting quotes are presented in Appendix A.

Simulation Experience

Realistic

Students expressed that the SG-VS experience was “realistic” and “felt as if [they] were in an actual clinical setting.” Additional key quotes included: “It put me back into the clinical setting, it got my heart pumping and adrenaline going,” and “Just like with a real patient in the hospital, we were able to begin with a physical assessment and walk through what we would do as soon as we set foot in a patient's room.”

Experiential

Students expressed that the SG-VS experience was “hands-on” and allowed them to apply the nursing process. Key quotes included: “Loved to be virtually hands-on with the patient” and “I learned a lot about assessment and implementation of procedures.”

Interactive

Students expressed that the SG-VS experience was “very interactive.” Key quotes include: “I liked the interaction with my peers and the [facilitator]” and “Loved the interactivity.”

Collaborative

Students acknowledged teamwork, collaboration, and communication. Key quotes include: “I specifically enjoyed working as a team,” “I liked doing it as a group because we can brainstorm and learn from each other,” and “It also assisted us with learning better communication and delegation within a clinical setting.”

Facilitator and Educational Strategies

Facilitator

Students acknowledged the importance of having a virtual simulations facilitator. Key quotes include: “I think doing it alone is not helpful, the guidance from [the facilitator] is vital”; “[The facilitator] truly helped keep us focused and productive”; and “I enjoyed [the facilitator] the most, the simulation experience was great because she made me feel comfortable participating and kept us all on track and focused.”

Prebriefing

Students expressed their satisfaction with the prebriefing and acknowledged that it was helpful, set the tone, and promoted confidence. Key quotes include: “helpful,” “The prebriefing prepared me,” “The prebriefing helped me organize the steps I would take to deliver nursing care,” “The prebriefing helped me to develop confidence,” and “The prebriefing made us understand things better and, as a result, be more confident during the simulation.”

Debriefing

Students expressed that the debriefing was “great,” “excellent,” “wonderful,” “very good,” and acknowledged that it helped them express feelings and emotions, identify performance gaps, and get valuable feedback. Key quotes include: “Debriefing was a good way to decompress and talk about some of our emotions and feelings after going through the scenario”; “It was nice to discuss our feelings, our success, and what could've been done better”; and “The debriefing helps us understand our mistakes and how we can prevent future mistakes.”

Participant Outcomes

Reaction (Satisfaction and Confidence)

Students expressed satisfaction with the SG-VS experience and acknowledged that it positively affected their confidence. Key quotes include: “Great experience,” “Excellent experience,” “Really enjoyed it,” “Great! I learned a lot, and it increased my confidence in preparing for actual hospital practice.”

Learning (Changes in Knowledge, Skills, and Attitudes)

Students expressed that the SG-VS promoted learning and understanding of the nursing process, critical thinking, and clinical judgment. Key quotes include: “It helped me understand,” “This experience made me think critically while maintaining patient care and following protocols,” “It allowed us to put into practice nursing interventions and assessment while utilizing critical thinking skills,” “It wasn't just about getting the work done but understanding our decisions and what is best for the patient,” and “It allowed us to feel invested in the patient and understand the consequences of making decisions in a clinical setting.”

Behavior (Transfer of Learning to Clinical Practice)

Students acknowledged that the SG-VS experience helped them connect with real clinical experiences and apply nursing knowledge, skills, and attitudes (KSAs). Key quotes include: “We were able to connect the case scenario with clinical site situations,” “This experience will stick with me so I would be able to know what to do in similar situations in the future,” “This experience allowed me to apply the knowledge I received through lectures and readings to a real-life situation,” and “[…] just as how the hospital provides a sense of teamwork, you are also able to get that feeling from the group simulation.”

More Virtual Simulations in Smaller Groups

Despite the small number of negative responses, two critical themes arose: 1) more virtual simulations and 2) smaller virtual simulations groups. Participants recommended “virtual simulations experiences to be a part of every clinical semester” and “to incorporate more virtual simulations in the nursing program.” In addition, several students recommended conducting virtual simulations in “smaller groups.”

Discussion

Our findings are consistent with concepts of the NLN Jeffries Simulation Theory and support that a well-structured synchronous virtual simulation that integrates the Healthcare Simulation Standards of Best Practice^TM can be realistic, experiential, interactive, collaborative, and learner-centered. Participants' interactions occurring during a SG-VS may improve realism, psychological fidelity, students' connectedness, and virtual simulations performance. In addition, preparatory activities and prebriefing (McDermott et al., 2021) as well as debriefing on demand or post-scenario (Decker et al., 2021) facilitated by a competent instructor (Persico et al., 2021), may promote participants' satisfaction, confidence, learning of KSAs, critical thinking, clinical judgment, and future clinical behaviors. A well-structured prebriefing and debriefing also have the potential to improve students’ self-efficacy and future clinical performance (Penalo & Ozkara San, 2021)

One of the main strengths of this study was the comprehensive SG-VS educational strategy, which was conducted synchronously online, allowing for the simulation participants and the facilitator to have real-time interactions and discussions. Addressing a gap in the virtual simulations literature (Badowski & Wells-Beede, 2022; Luctkar-Flude et al., 2021), the SG-VS included structured prebriefing and debriefing strategies (Table 1), which were positively perceived by the students. Prebriefing promotes participants’ psychological safety and the achievement of simulation objectives. A structured prebriefing must be purposefully planned to promote student learning outcomes by clarifying simulation expectations, introducing learners to simulation objectives, and fostering a safe and collaborative learning environment (Decker et al., 2021; Jeffries, 2021; Leigh & Steuben, 2018; McDermott, 2016; McDermott et al., 2021; Persico et al., 2021). Although prebriefing does not get as much attention as other simulation elements (such as debriefing) in the simulation literature, it is a vital component of the virtual simulation experience that sets the stage for other simulation elements, including facilitation, scenario performance, and debriefing.

The SG-VS debriefing followed the PEARLS debriefing framework (Cheng et al., 2016), which includes phases of reaction, description, analysis, and summary. The PEARLS “blended approach to debriefing encourages educators to purposefully merge various debriefing strategies to tailor discussion to learner needs and learning context” (Cheng et al., 2016, p. 1). The PEARLS debriefing script is a valuable tool for debriefers because it does not only provide specific phases of debriefing, but also representative phrases are provided to guide possible wording choices, which can be easily adopted to a virtual simulation debriefing. Based on study findings, the virtual simulations literature (Goldsworthy & Verkuyl, 2021; Gordon, 2017; Gordon & McGonigle, 2018), and considerable experience implementing the PEARLS debriefing in nursing simulations, the authors believe that this is an effective framework to facilitate a synchronous virtual simulation debriefing.

Additional emerging themes were "smaller virtual simulations groups” and "more virtual simulations." We recommend further studies examining appropriate virtual simulations group size and the effect of the integration of virtual simulations in the undergraduate nursing curriculum (e.g., virtual simulations as an in-person clinical or HPS preparatory activity). Additional research priorities include studies evaluating the effect of different prebriefing and debriefing frameworks such as the PEARLS in virtual simulations, Debriefing for Meaningful Learning, and Debriefing with Good Judgment. In addition, an exploration of the effect of different virtual simulations prebriefing and debriefing delivery methods including face-to-face, synchronous, asynchronous, or self-debrief is needed.

The use of virtual simulations exponentially increased in prelicensure nursing education during the COVID-19 global pandemic. As a result, virtual simulation technologies became more easily accessible and many nursing programs integrated them to their curriculum. If properly designed and enhanced with evidence based education strategies, such as prebriefing and debriefing, virtual simulation technologies can be an important complementary clinical education tool for nursing schools that have limited access to high fidelity simulation laboratories; do not have sufficient educators able to deliver in-person simulation activities; aim to provide on-demand resources to prepare students for in-person clinical or simulation experiences; and are required to deliver on-line clinical experiences due to cancelations of in-person clinical activities due to public health concerns. However, nurse educators must consider this with caution and strive to collect outcome data to inform future decisions concerning the use of virtual simulations to replace a percentage of traditional in-person clinicals.

Lastly, preparing students for the Next Generation NCLEX® (NGN) examination is a priority and challenge for ADN program educators. High-quality virtual simulations have the potential to help students prepare for the expected behaviors that they need to know, perform, and become comfortable with for this examination, which is expected to be more interactive than the current NCLEX examination. Most importantly, virtual simulations that include evidence-based structured prebriefing and debriefing strategies can be an important tool in promoting students’ clinical judgement and clinical decision-making, which are vital skills for entry-level nurses and will be tested in the NGN examination (NCSBN, 2019).

Limitations

This study had several limitations. First, the use of a convenience sample of ADN students at an urban public community college. Since the participants in this study were all from the same college, the experiences of students in other regions or programs may not be reflected in the findings of this study. Another limitation was experienced in the prebriefing and debriefing processes. Although the structured virtual simulations prebriefing and debriefing were facilitated by the same instructor (researcher), following a specific set of guidelines, participants in different groups may have thought and reacted differently regarding student-facilitator questions and comments; therefore, the prebriefing and debriefing sessions were not identical between groups. In addition, variables outside the researcher's control—including technological barriers, lack of commitment to participate in synchronous activities, stressors associated with the COVID-19 pandemic, and external distractors—may have impacted students’ engagement in the SG-VS educational strategy. Lastly, this study included a researcher-developed online questionnaire, which included questions that were written in a way that may have not provoked neutral or open answers. Also, the primary investigator (simulation facilitator) is a full-time faculty person at the college where the study was conducted, which may have caused students to be less expressive of the negative aspects of the SG-VS educational strategy. In addition, online questionnaires are one-way conversations, since the researcher can't ask clarifying questions or probe for more information.  Therefore, the authors recommend replicating this study using more rigorous qualitative methodology using interviews or focus groups. Despite these limitations, qualitative responses were substantial and represented important elements of the NLN Jeffries Simulation Theory and Healthcare Simulation Standards of Best Practice^TM.

Conclusion

Among the various types of programs that educate prelicensure nursing students, ADN programs prepare the largest number of undergraduate students within a short curriculum timeframe. Therefore, ADN programs may benefit from the use of high-quality virtual simulations to promote students’ readiness for clinical or HPS experiences, the NGN licensure examination, and future clinical practice. As nurse educators continue to integrate virtual simulations in the ADN curriculum, it is imperative to design, implement, and evaluate high-quality virtual simulations experiences that include theoretical frameworks and the Healthcare Simulation Standards of Best Practice^TM.

Declaration of Competing Interest

The authors declare no conflict of interest.

Appendix A

Synchronous Group Virtual Simulation Experience:

Recurrent Themes and Examples of Students’ Supporting Quotes

Concepts of the NLN Jeffries Simulation Theory	Recurrent Themes	Examples of Students’ Supporting Quotes
Simulation Experience (Synchronous Group Virtual Simulation)	Realistic	“Realistic” (n=12) “It is the closest I've felt to actually being in a clinical setting.” “I felt as if I was in an actual clinical setting.” “It put me back into the clinical setting. It got my heart pumping and adrenaline going.” “Just like with a real patient in the hospital, we were able to begin with a physical assessment and walk through what we would do as soon as we set foot in a patient's room.” “It felt as close to having a real patient […] during a time when we aren't able to be in the hospital as students.” “[…] during this time where we can't go on clinical rotations; it provided a somewhat real-life experience.” “It pretty much seems like we are providing care for a real patient.” “This experience makes us feel like we are in the hospital taking care of a real patient.”  “It puts you in a near real-life situation. You feel as though you are in a patient's room.
	Experiential 1. “Hands-on” 2. Application of the nursing process.	“Hands-on.” (n=9) “Loved to be virtually hands-on with the patient.” “This type of hands-on exposure really helps me learn.” “Given the current distance learning, this was the most hands-on training we have gotten.” “I learned a lot about assessment and implementation of procedures.” “[…], we were able to begin with a physical assessment and walk through what we would do as soon as we set foot in a patient's room.” “It goes through the nursing process effectively.” “Going through the nursing process, especially during this time of remote learning.”
	Interactive 3. Very interactive experience	“Very interactive.” (n=7) “I liked the interaction with my peers and the [facilitator].” “Interesting, stimulating, interactive.” “Loved the interactivity.”
	Collaborative 4. Teamwork and collaboration 5. Communication	“I specifically enjoyed working as a team during this online group virtual simulation.” “This was a great opportunity to work as a team […].” “I really liked the teamwork.” “[…] doing it as a group—because we can brainstorm and learn from each other.” “We learn a lot from each other's points of views and experiences.” “We were able to evaluate ourselves as a team.” “We (classmates) worked together as a group; learning from each other as a result. “It also assisted us with learning better communication and delegation within a clinical setting.” “[This experience] assisted us with learning better communication and delegation within a clinical setting.”
Facilitator and Educational Strategies	Facilitator 6. Promotes a Dynamic Interaction 7. Promotes an Environment of Trust and psychological safety Note: This theme supports the following Healthcare Simulation Standards of Best PracticeTM: Facilitation	"I think doing it alone is not helpful. The guidance from [the facilitator] is vital.” “[The facilitator's] skills on prebriefing and debriefing make everyone actively participate […]” “[The facilitator's] was kind and instructive, prodding without being harsh or condescending, and truly helped keep us focused and productive.” “I enjoyed [the facilitator] the most. The simulation experience was great because she made me feel comfortable participating and kept us all on track and focused. “I loved how detail-oriented our [facilitator] was. She explained everything thoroughly and was great in leading and guiding us through the entire session.” “The [facilitator] did not make it uncomfortable for students when a question was answered wrong. Rather, she provided a chance to correct the mistake through her non-judgmental guidance. “[The facilitator] made it so enjoyable and made us feel at ease.’
	Prebriefing 8. Helpful 9. Sets the tone 10. Promotes confidence Note: This theme supports the following Healthcare Simulation Standards of Best PracticeTM: Prebriefing: Preparation and Briefing (McDermott et al., 2021).	“[The prebriefing] was helpful […]” (n=52) “[The prebriefing] prepared me […]” (n=12) “The prebriefing conference helped me organize the steps I would take to deliver nursing care.” “[In the prebriefing] the objectives were laid out very clearly, which enabled me to understand exactly what was expected of me […].” “I think was a great way to get you thinking and refresh your knowledge before the simulation started.” “I think [the prebriefing] was a good way to get our mindset ready. We started working as a team as soon as the prebriefing started.” “I like [the prebriefing] a lot. It was a nice warm-up to the simulation; it got our head thinking in the right direction.” “The [prebriefing] helped me to develop confidence.” “[The prebriefing] made us understand things better and, as a result, more confidence during the simulation.”
	Debriefing 11. Promotes expression of feeling and emotions 12. Helps identify performance gaps and achievements 13. Valuable Feedback 14. Promotes student satisfaction Note: This theme supports the Healthcare Simulation Standards of Best PracticeTM: Debriefing (Decker et al., 2021).	The debriefing was: “great” (n=8); “excellent” (n=5); “wonderful” (n=3); “very good” (n=5). “Debriefing is very beneficial as it allows the participants to share their thoughts and feelings regarding the stimulation.” “A safe place to reflect on our interventions.” “[Debriefing] was a good way to decompress and talk about some of our emotions and feelings after going thru the scenario. “It was nice to discuss our feelings, our success, and what could've been done better.” “The debriefing was great; it allowed us to see what we succeeded in and what we need to work on. It was great to voice our strengths and weaknesses.” “The debriefing gave me insight into my weakness and showed me how to improve.” “[The debriefing] helps us understand our mistakes and how we can prevent future mistakes.” “It was well needed to discuss what I may have forgotten, what I could have done better, and what I did right.” “I think it was a good way to recap everything that was done and talk about what was good and any mistakes made.” “[The Debriefing] was valuable in terms of feedback, what went well, and what needs additional work. “It allowed us to ask questions or get further feedback on areas we need to focus […].”
Outcomes: Participant	Reaction 15. Satisfaction 16. Self-Confidence	“Great experience.” (n=24) “Excellent experience.” (n=12) “Really enjoyed it.” (n=10) “Wonderful” (n=3) “Amazing” (n=3) “I was pleasantly surprised by how much I enjoyed it. It was orderly and informative.” “Great! I learned a lot, and it increased my confidence in preparing for actual hospital practice.” “[This experience] was very stimulating to our minds. It brought to the forefront the concepts and knowledge we need to expand on, i.e., time management and confidence in using the knowledge we already know […].”
	Learning 17. Understanding of nursing care concepts 18. Knowledge, skills, attitudes 19. Critical thinking 20. Clinical decision making	“[This experience] helped me understand [nursing care concepts].” (n=36) “This type of "hands-on exposure" really helps me learn.” “[This experience] refreshes my knowledge on the symptoms and help me connect the points, think about nursing interventions, and the care plan.” “I had a reflection on everything we've talked about in class by applying critical thinking in nursing.” “This experience made me think critically while maintaining patient care and following protocols.” “This [experience] allowed us to put into practice nursing interventions and assessment while utilizing critical thinking skills.” “I really enjoyed the simulation itself and feeling like we had to think on our feet quickly.” “[This experience] was useful to think, decide, and learn about the right assessments and interventions.” “It wasn't just about getting the work done but understanding our decisions and what is best for the patient […]” “[This experience] allowed us to feel invested in the patient and understand the consequences of making decisions in a clinical setting.”
	Behavior 21. Cognitive connection with real clinical experiences 22. Application of nursing knowledge, skills, and attitudes	“This experience will stick with me so I would be able to know what to do in similar situations in the future.” “We were able to connect the case scenario with clinical site situations.” “In these uncertain times, group virtual simulations provided an opportunity for me to continue with the clinical portion of the class and merged all that I have learned in the lecture portion.” “[This experience] gives us the chance to apply what we have learned from the book into a real situation […].” “This experience allowed me to apply the knowledge I received through lectures and readings to a real-life situation.” “It helped me meet the objectives by allowing me to be more hands-on with the scenario that was provided (even though virtual) you are able to see the patient and apply nursing care.” “[…] just as how the hospital provides a sense of teamwork, you are also able to get that feeling from the group simulation.”