Community Health Nursing Students’ Perceptions of Self-Confidence,Satisfaction,and Learning Through Standardized Patient Simulations

Abstract

This study explores community health nursing students’ perceptions of standardized patient simulations in relation to self-confidence, satisfaction, and perceived learning effectiveness. Background: Standardized patients are commonly used in nursing education to provide realistic, practice-based learning experiences. They can support student engagement, skill development, and confidence, while also shaping students’ perceptions of their learning outcomes. A quasi-experimental study without a control group was conducted at the University of Tabuk simulation unit. Data were collected from 76 participants between October 1 and November 1, 2023, using the Educational Practice in Simulation Scale (EPSS), the Student Satisfaction in Learning Scale (SSL), and the Self-Confidence in Learning Scale (SCL). The study involved 3 weeks of simulation sessions, and statistical analyses included Cronbach’s α, t-tests, correlation analyses, and repeated measures ANOVAs. Additionally, qualitative data were gathered through open-ended questions. Quantitative findings from the EPSS reflected positive evaluations of active learning, collaboration, diverse learning methods, and high expectations. No significant gender differences were observed. SSL and SCL scores indicated generally high levels of satisfaction and self-confidence. The qualitative analysis emphasized the realism of the simulation, students’ proactive learning attitudes, and the value of teamwork and communication. Standardized patient simulations were positively perceived by students, particularly regarding self-confidence, satisfaction, and learning effectiveness. While the findings highlight the educational value of such simulations, further research using objective outcome measures and comparative designs is needed to strengthen causal inferences and explore broader applications.

Keywords

nurses pupil student community health care community health services

Introduction

Community health nursing is a fundamental component of comprehensive healthcare delivery in diverse communities. As healthcare systems evolve and become more complex, nursing education becomes pivotal. It equips students to navigate the multifaceted challenges of modern healthcare practices (Harmon et al., 2016). In pursuit of this goal, educators continuously explore innovative methods to enrich learning experiences and foster competency development among nursing students (Oermann & Shellenbarger, 2020). One such method gaining recognition is the integration of standardized patient interventions. These interventions involve simulated clinical interactions with trained actors portraying specific health conditions, behaviors, and emotions. This approach takes place in a controlled educational environment, providing students with opportunities to practice clinical skills, enhance communication, and sharpen critical thinking abilities. By engaging with standardized patients, nursing students bridge the gap between theory and practice, refining their capacities to assess, diagnose, and deliver patient-centered care (Goh et al., 2023).

The integration of standardized patient interventions yields several benefits. Firstly, it facilitates experiential learning, enabling students to apply theoretical knowledge to real-world scenarios. Through these interactions, students develop crucial skills in navigating complex patient encounters, fostering empathy, and adapting to diverse clinical contexts (Goh et al., 2023). Secondly, standardized patient encounters occur within a safe and supportive environment, where students can make mistakes, receive constructive feedback, and refine their skills without compromising patient safety (Sarikoc et al., 2017). Lastly, interacting with standardized patients enhances students' communication skills, including active listening, effective information conveyance, and collaboration within interdisciplinary teams (Oh et al., 2015). Implementing standardized patient programs presents challenges. Firstly, it requires significant resources such as trained actors, faculty supervision, and simulation facilities, making it resource- intensive (Johnson et al., 2020). Secondly, while standardized patients simulate clinical scenarios, they may not fully replicate the complexity of real patient encounters, raising concerns about authenticity. Lastly, evaluating student performance based on standardized patient interactions demands robust assessment tools and criteria to ensure assessment validity (Banks et al., 2019; Ghimire & Kachapati, 2020; Nestel et al., 2011). Despite the burgeoning interest in standardized patient interventions, limited research specifically delves into their impact on community health nursing students. Understanding the impact of standardized patient interventions on community health nursing students is crucial for advancing nursing education and preparing future nurses for diverse health care settings. Our study endeavors to address this gap by exploring community health nursing students’ perceptions of standardized patient simulations in relation to self-confidence, satisfaction, and perceived learning effectiveness. Through a comprehensive understanding of these dimensions, we aim to inform nursing education practices, enrich curricula, and better prepare students for their roles in community health settings.

Methods

Study Design

A quasi-experimental posttest design was employed.

Setting and Sample

This study included 76 fourth-year nursing students (31 males and 45 females) from the university of Tabuk. All students participated in the simulation-based training between October 1 and November 1, 2023. All participants were at the same academic level, had no prior experience in community health nursing, and were exposed to standardized patient simulations for the first time.

Ethical Consideration

This study was conducted in accordance with the ethical standards outlined in the Declaration of Helsinki and adhered to institutional guidelines. Ethical approval was obtained from the Institutional Review Board (IRB) of the University of Tabuk (Approval No. UT-329-172-2023). Prior to participation, all students were informed about the study's objectives, their right to withdraw at any time without academic penalty, and the voluntary nature of their participation. Informed consent was obtained electronically at the start of the survey, where participants indicated consent by selecting “Yes” before proceeding. No personal identifying information was collected, and all data was anonymized and securely stored. Only the primary researcher had access to the data. The study design minimized potential harm and posed minimal risk to participants. The anticipated educational benefits to participants and the contribution to nursing education research were considered to outweigh any potential risks.

Measurements/Instruments

The research instrument for this study involved the collection of data through the following measures: Educational Practice in Simulation Scale (EPSS): This scale comprises four subscales, including active learning (10 items), collaboration (two items), diverse ways of learning (two items), and high expectations (two items). Student Satisfaction in Learning Scale (SSL): This scale consists of five items. SCL (Self-Confidence in Learning): This scale comprises eight items. Each scale demonstrated high internal consistency, with Cronbach’s α values ranging from .81 to .96. These values confirm the reliability of the instruments used in this study. All these scales employ a five-point Likert-type scale ranging from “strongly disagree” to “strongly agree.” Additionally, data collection involved the inclusion of four open-ended questions in the survey: Q1. How did you feel throughout the simulation experience? Q2. Did you feel that you had the knowledge and skills to meet the objectives? Q3. Were you satisfied with your ability to work through simulation? Q4. What strengths did your group exhibit during the simulation?

These data collection instruments were utilized to gain comprehensive insights into the students' experiences, perceptions, and learning outcomes in the context of the simulation study.

Date Collection & Procedure

At the beginning of the semester, instructors convened with students in the college laboratory over 3 weeks, where lectures covered Family Assessment Models, Nursing Process, Home Visit Stages, Physiological Changes in the Elderly, Elderly Assessment Guide, and Family Assessment Guide. During these sessions, instructors outlined simulation training objectives, discussed expected fidelity levels, clarified the instructor's role, and articulated desired student outcomes. The training spanned 3 weeks, with sessions held each Tuesday and Thursday across five sections, each comprising 15 students and one instructor. Prior to the start of the semester, instructors underwent orientation and training facilitated by the research team.

Before each simulation session, instructors prepared standardized patients the day prior to simulate scenarios. The simulation itself consisted of three phases: Briefing Session: Instructors briefed students on the case objectives, dividing them into small groups of three students each. Scenario Running: Each group conducted assessments and interviews with standardized patients, utilizing equipment as needed within a 15-min timeframe. Other students observed via monitors in a separate room, noting strengths and areas for improvement. Debriefing Phase: Following each group's activities, a 20-min debriefing session commenced, addressing several key components: Group Discussion: Groups reflected on strengths and areas for improvement, fostering self-assessment and skill recognition. Emotional Sharing: Students openly discussed their emotions and challenges encountered during the simulation. Objective Evaluation: Groups assessed achievement of learning objectives to gauge progress. Skill Assessment: Students identified additional skills required for future scenarios and clinical practice. Peer Feedback: Observing students provided feedback on their peers' performance, enriching the learning experience and promoting collaboration. The Debriefing Phase was integral for self-assessment, emotional intelligence development, and peer-supported learning, ensuring students received constructive feedback and guidance essential for clinical readiness. Data collection occurred iimmediately post-debriefing from October 1 to November 1, 2023, facilitated through online questionnaires sent to students via email after each session concluded.

Statistical Analysis

The statistical analysis for this study was conducted using the IBM SPSS Statistics software (Version 27). The data set comprised responses from participants who completed various subscales designed to measure their satisfaction with simulation learning, self-confidence in their learning abilities, and the fidelity of the simulation to real-life scenarios. Descriptive statistics were first computed to provide an overview of the sample, including means and standard deviations for each subscale. Group differences based on gender were then examined using independent samples t-tests, which allowed for the assessment of statistically significant differences in the mean scores between male and female participants. Additionally, the internal consistency of the subscales was evaluated using Cronbach’s α to determine the reliability of the measures. A threshold of α > .70 was pre-established for acceptable reliability. Pearson correlation coefficients were calculated to explore the relationships between the different subscales, with a focus on identifying the strength and direction of associations between students' satisfaction, self-confidence, and perceived simulation fidelity. The significance level was set at p < .05 for all inferential statistics.

Development of the Simulation Standardized Patient Scenarios

The development of standardized patient simulation scenarios comprises three essential phases:

Goal Setting: This phase is rooted in the alignment of course learning outcomes with the overarching goals of the nursing curriculum and program learning outcomes. Scenario Development: The creation of scenarios is based on the specific course content, ensuring that they accurately reflect the educational objectives. Scenario Review and Piloting: These scenarios are critically assessed and refined by experts in the field of community health nursing within the faculty. These experts, comprising associate professors and assistant professors, play a pivotal role in the enhancement and validation of the scenarios. The three scenarios that have been accurately constructed are as follows: Management of Hypertension and Diabetes in the older adult with the aims of to evaluate the students' ability to provide comprehensive care for older adult suffering from hypertension and diabetes, focusing on their assessment, intervention, and management. Home Assessment of a COVID-19 Patient with aims of assessing the students' proficiency in conducting a thorough home assessment of a COVID-19 patient, emphasizing safety protocols, patient support, and effective communication during a pandemic. Family Assessment with aims of appraising the students' competence in conducting a holistic family assessment, considering the family as a unit of care, addressing their needs, and promoting overall well-being. These scenarios, carefully designed and refined, form an integral part of the nursing curriculum, enabling students to acquire valuable practical skills and knowledge in the field of community health nursing.

Results

Students’ Perceptions of the Effectiveness of Learning

The Educational Program Satisfaction Scale (EPSS) was utilized to assess students' evaluations of their learning experiences in three scenarios related to Medication Management for Hypertension and Diabetes, Home Assessment of COVID-19 patients, and family assessment. The scale demonstrated strong reliability across its domains, with Cronbach’s α values ranging from .81 to .96. In the Medication Management for Hypertension and Diabetes scenario, students rated their experience positively on a five-point Likert scale, with mean scores of 4.12 for active learning, 4.26 for collaboration, 3.99 for diverse learning methods, and 4.21 for high expectations (Table 1). Independent samples t-tests showed no significant gender differences in perceptions (p > .05) across all domains (Table 3). Correlation analysis revealed strong positive relationships between various educational domains. High expectations showed significant correlations with active learning (r = .87, p < .01), collaboration (r = .80, p < .01), and diverse learning (r = .83, p < .01; Table 4).

Table 1.

Student’s Perceptions of Effectiveness of Learning (n = 76).

	Hypertension & diabetes	Home assessment	Family assessment
Subscale/Items	Mean ± SD	Mean ± SD	Mean ± SD
Active learning	4.12 ± 0.05	4.22 ± 0.76	4.06 ± 0.39
1. I had the opportunity during the simulation activity to discuss the ideas and concepts taught in the course with the teacher and other students.	4.13 ± 1.08	4.29 ± 0.95	4.30 ± 0.89
2. I actively participated in the debriefing session after the simulation	4.06 ± 0.91	4.33 ± 0.37	4.20 ± 0.95
3. I had the opportunity to put more thought into my comments during the debriefing session.	4.05 ± 0.96	4.24 ± 0.83	4.20 ± 0.94
4. There were enough opportunities in the simulation to find out if I clearly understand the material.	4.06 ± 0.91	4.22 ± 0.85	4.22 ± 0.88
5. I learned from the comments made by the teacher before, during, or after the stimulation.	4.20 ± 0.94	4.20 ± 0.90	3.01 ± 1.51
6. I received cues during the simulation in a timely manner.	4.16 ± 0.89	4.05 ± 0.97	4.20 ± 0.84
7. I had the chance to discuss the simulation objectives with my teacher	4.13 ± 0.94	4.20 ± 0.92	4.13 ± 0.94
8. I had the opportunity to discuss ideas and concepts taught in the simulation with my instructor.	4.22 ± 0.88	4.22 ± 0.85	4.12 ± 0.99
9. The instructor was able to respond to the individual needs of learners during the simulation.	4.15 ± 0.91	4.30 ± 0.91	4.20 ± 0.96
10. Using simulation activities made my learning time more productive.	4.13 ± 0.91	4.16 ± 0.81	4.16 ± 1.00
Collaboration	4.26 ± 0.01	4.21 ± 0.07	4.19 ± 0.03
11. I had the chance to work with my peers during the simulation.	4.28 ± 0.82	4.20 ± 0.88	4.17 ± 0.94
12. During the simulation, my peers and I had to work on the clinical situation together.	4.25 ± 0.90	4.22 ± 0.75	4.21 ± 0.83
Diverse ways of learning	3.99 ± 0.09	4.15 ± 0.09	4.10 ± 0.01
13. The simulation offered a variety of ways in which to learn the material.	3.90 ± 1.02	4.14 ± 0.94	4.09 ± 1.06
14. The simulation offered a variety way of assessing my learning.	4.08 ± 0.88	4.17 ± 0.99	4.11 ± 0.98
High expectations	4.21 ± 0.02	4.21 ± 0.08	4.17 ± 0.04
15. The objectives for the simulation experience were clear and easy to understand.	4.19 ± 0.82	4.22 ± 0.84	4.14 ± 0.89
16. My instructor communicated the goals and expectations to accomplish during the simulation.	4.24 ± 0.99	4.21 ± 0.94	4.20 ± 0.88
Total	4.14 ± 0.10	4.19 ± 0.02	4.13 ± 0.06

Note. Bold values indicate the total mean scores for each subscale.

In the home assessment scenario, the scale’s reliability was again confirmed, with Cronbach’s α values ranging from .87 to .96. Students rated the simulation highly, with mean scores of 4.22 for active learning, 4.21 for collaboration, 4.15 for diverse learning methods, and 4.21 for high expectations (Table 1). The t-test results indicated no significant gender differences, except for high expectations, where female students rated the experience significantly higher (M = 4.37) than male students (M = 3.98), with a p-value of .048 (Table 3). Correlation analysis indicated strong correlations with high expectations and active learning (r = .79, p < .01), collaboration (r = .75, p < .01), and diverse learning (r = .76, p < .01) (Table 4).

In the family assessment scenario, Cronbach’s α values ranged from .85 to .91, demonstrating the scale’s reliability. Students’ evaluations reflected strong engagement, with mean scores of 4.06 for active learning, 4.19 for collaboration, 4.10 for diverse learning methods, and 4.17 for high expectations (Table 1). The t-test results indicated no significant gender differences across all domains (Table 3). Pearson correlation analysis showed significant positive correlations, with high expectations and active learning (r = .89, p < .01), collaboration (r = .88, p < .01), and diverse learning (r = .79, p < .01) maintaining significant associations (Table 4).

Students’ Satisfaction, Self-Confidence in Learning, and Fidelity

For the Week 1 scenario on medication management for hypertension and diabetes, high Cronbach’s α (.91 for satisfaction, .94 for self-confidence, and .93 for fidelity) indicated scale reliability. Students expressed robust satisfaction (M = 4.05), significant self-confidence (M = 4.09), and high-fidelity perceptions (M = 4.04) underscoring their positive evaluation of the simulation's educational value (Table 2). Gender comparison via t-tests showed no significant differences in satisfaction, self-confidence, or fidelity between male and female students (Table 3). Additionally, satisfaction was strongly correlated with self-confidence (r = .87, p < .01) and fidelity (r = .88, p < .01), while self-confidence and fidelity also demonstrated a strong relationship (r = .82, p < .01; Table 4). In week 2's home assessment of COVID-19 patient scenario, Cronbach’s α remained high (.93 for satisfaction, .96 for self-confidence, and .90 for fidelity). Students rated satisfaction (M = 4.17), self-confidence (M = 4.22), and fidelity (M = 4.14) highly, indicating strong approval and realism perception of the simulation (Table 2). Gender-based t-tests revealed no significant differences in perceptions between males and females across satisfaction, self-confidence, or fidelity (Table 3). Moreover, satisfaction and self-confidence were highly correlated (r = .90, p < .01), along with satisfaction and fidelity (r = .82, p < .01), and self-confidence and fidelity (r = .80, p < .01; Table 4).

Table 2.

Students’ Satisfaction, Self-Confidence in Learning, and Fidelity (n = 76).

	HTN & DM	Home assessment	Family assessment
Subscale/Items	Mean ± SD	Mean ± SD	Mean ± SD
Satisfaction with current learning	4.05 ± 0.07	4.17 ± 0.08	4.23 ± 0.06
1. The teaching methods used in this simulation were helpful and effective.	4.08 ± 1.01	4.14 ± 0.86	4.16 ± 0.93
2. The simulation provided me with a variety of learning materials and activities to promote my learning the community health nursing curriculum.	4.00 ± 1.04	4.05 ± 0.95	4.17 ± 0.94
3. I enjoyed how my instructor taught the simulation.	4.14 ± 0.91	4.26 ± 0.87	4.26 ± 0.83
4. The teaching materials used in this simulation were motivating and helped me to learn.	3.96 ± 1.06	4.18 ± 0.93	4.25 ± 0.88
5. The way my instructor(s) taught the simulation was suitable to the way I learn.	4.11 ± 0.95	4.25 ± 0.85	4.32 ± 0.77
Self-confidence in learning	4.09 ± 0.04	4.22 ± 0.06	4.23 ± 0.07
6. I am confident that I am mastering the content of the simulation activity that my instructors presented to me.	4.19 ± 0.81	4.24 ± 0.87	4.25 ± 0.86
7. I am confident that this simulation covered critical content necessary for the mastery of medical surgical curriculum.	4.05 ± 0.94	4.13 ± 0.86	4.22 ± 0.84
8. I am confident that I am developing the skills and obtaining the required knowledge from this simulation to perform necessary tasks in a clinical setting.	4.05 ± 0.89	4.17 ± 0.88	4.22 ± 0.84
9. My instructors used helpful resources to teach the simulation.	4.16 ± 0.96	4.30 ± 0.89	4.32 ± 0.82
10. It is my responsibility as the student to learn what I need to know from this simulation activity.	4.09 ± 0.93	4.18 ± 0.90	4.32 ± 0.84
11. I know how to get help when I do not understand the concepts covered in the simulation.	4.13 ± 0.96	4.29 ± 0.84	4.09 ± 0.95
12. I know how to use simulation activities to learn critical aspects of these skills.	4.10 ± 0.80	4.25 ± 0.96	4.21 ± 0.92
13. It is the instructor’s responsibility to tell me what I need to learn of the simulation activity content during class time.	4.09 ± 1.02	4.24 ± 0.93	4.25 ± 0.83
Fidelity	4.04 ± 0.02	4.14 ± 0.06	4.26 ± 0.05
14. The scenario resembled a real-life situation.	4.06 ± 1.04	4.21 ± 0.92	4.21 ± 0.88
15. Real life factors, situations, and variables were built into the simulation scenario.	4.06 ± 1.02	4.13 ± 0.95	4.30 ± 0.89
16. The encounter with standardized patient was realistic.	4.01 ± 0.97	4.09 ± 1.09	4.29 ± 0.89
Total	4.06 ± 0.02	4.17 ± 0.04	4.24 ± 0.01

Note. Bold values indicate the total mean scores for each subscale.

Table 3.

Comparison of Students' Perceptions of Learning Effectiveness, Satisfaction, Self-Confidence, and Fidelity by Gender (n = 76).

Subscale	Gender	N	Hypertension & DM	Home assessment	Family assessment
Students perception of effectiveness of learning			Mean ± SD	Mean ± SD	Mean ± SD
Active learning total	Men Women	31 45	4.03 ± 0.88 4.18 ± 0.67	4.08 ± 0.99 4.36 ± 0.53	3.95 ± 0.88 4.10 ± 0.58
	t p		−0.809.421	−1.418.161	−0.788.433
Collaboration total	MenWomen	3145	4.13 ± 0.864.33 ± 0.78	4.04 ± 0.964.32 ± 0.61	4.04 ± 1.024.25 ± 0.75
	t p		−1.031.306	−1.203	−0.869.387
Diverse way of learning total	MenWomen	3145	3.94 ± 0.904.00 ± 0.86	4.06 ± 1.074.22 ± 0.80	4.04 ± 1.084.12 ± 0.94
	t p		0.299.765	−0.729.467	−0.374.709
High expectation total	MenWomen	3145	4.13 ± 0.924.25 ± 0.75	3.98 ± 1.114.37 ± 0.58	4.08 ± 0.964.20 ± 0.77
	t p		−0.612.542	−1.994.048	−0.668.506
Student satisfaction, self-confidence in learning and fidelity
Satisfaction total	MenWomen	3145	4.11 ± 0.874.02 ± 0.84	4.02 ± 0.934.02 ± 0.65	4.19 ± 0.904.24 ± 0.71
	t p		0.348.730	−0.349.728	−0.618.537
Self-confidence total	MenWomen	3145	4.12 ± 0.904.09 ± 0.68	4.04 ± 1.024.02 ± 0.53	4.15 ± 0.964.26 ± 0.67
	tp		0.966.336	−0.486.629	−1.587.117
Fidelity total	MenWomen	3145	4.10 ± 0.894.01 ± 0.98	4.08 ± 1.034.02 ± 0.81	4.17 ± 0.194.30 ± 0.11
	t p		0.372.711	−0.372.711	−1.422.159

Table 4.

Correlation Analysis of Educational Variables Over 3 weeks with Responses to Open Ended Questions (n = 76).

Variables	Week 1	Week 2	Week 3
High expectations & active learning	r = 0.87p < 0.01	r = 0.79p < 0.01	r = 0.89p < 0.01
High expectations & collaboration	r = 0.80p < 0.01	r = 0.75p < 0.01	r = 0.88p < 0.01
High expectations & diverse learning	r = 0.83p < 0.01	r = 0.76p < 0.01	r = 0.79p < 0.01
Satisfaction & self-confidence	r = 0.87p < 0.01	r = 0.90p < 0.01	r = 0.90p < 0.01
Satisfaction & fidelity	r = 0.88p < 0.01	r = 0.82p < 0.01	r = 0.89p < 0.01
Self-confidence & fidelity	r = 0.82p < 0.01	r = 0.80p < 0.01	r = 0.83p < 0.01

In week 3’s family assessment scenario also demonstrated high internal consistency (.93 for satisfaction, .96 for self-confidence, and .95 for fidelity). Students reported strong satisfaction (M = 4.23), high self-confidence (M = 4.23), and positive fidelity perceptions (M = 4.26), reflecting their unanimous approval of the simulation’s educational effectiveness (Table 2). Gender comparison through t-tests showed no significant differences in satisfaction, self-confidence, or fidelity (Table 3). Correlation analyses across all scenarios revealed strong positive relationships between satisfaction, self-confidence, and fidelity. Satisfaction was highly correlated with self-confidence (r = .90, p < .01) and fidelity (r = .89, p < .01), and self-confidence and fidelity also showed a strong correlation (r = .83, p < .01; Table 4).

Open-Ended Questions Results

During Week 1's Medication Management for Hypertension and Diabetes scenario student responses highlighted a predominantly positive reception. Many students appreciated the simulation's realism and practical relevance, noting its effectiveness in mirroring authentic healthcare scenarios. Emotional engagement was evident, with expressions of enjoyment and satisfaction. Moreover, students reported increased confidence in their clinical skills and professional readiness, with several suggesting strategies for personal improvement and pedagogical adjustments to enhance future simulations (Table 5). During Week 2's Home Assessment of COVID-19 patient scenario, student feedback similarly praised the simulation's realism and educational value. They expressed confidence gained from engaging with a standardized patient in a lifelike setting, underscoring the simulation's effectiveness in preparing them for real-world challenges. Students were satisfied with their performance and readiness to handle similar situations, emphasizing the role of teamwork and effective communication in their success (Table 5).

Table 5.

Responses to Open Ended Questions (N = 76).

Category	Description	HTN & DMN	Home assessmentN	Family assessmentN
Learning experience	Good experience, enjoyed it	35	33	25
	Felt confident	12	9	6
	Enjoyed, found satisfied and efficient	9	7	8
Experienced emotions	Exciting	15	11	6
Experienced emotions	Feels good/ loved it	39	34	10
Learning process	It was comprehensive	2	2	2
Learning process	Well managed and realistic	6	3	1

Week 3's family assessment scenario, where student responses again reflected positive experiences. They described the simulation as enriching and exciting, contributing to their confidence and satisfaction with their performance. Collaborative efforts were highlighted as pivotal in conducting thorough patient assessments and delivering effective health education (Table 5).

Comparison of Scores Across 3 weeks

Repeated measures ANOVA analyzed active learning scores (Q1 to Q10 of Table 1) across 3 weeks for 76 participants. Mean scores were consistent (Week 1: M+ SD = 4.12 ± 0.76; Week 2: M+ SD = 4.22 ± 0.76; Week 3: M+ SD = 4.06 ± 0.69). No significant changes over time were found (Pillai's trace = 0.02, F (2, 74) = 0.92, p = .405, partial eta squared = 0.02). Mauchly's test confirmed sphericity (χ² (2) = 0.93, p = .628). Both within-subjects effects and contrasts showed no significant trends. Collaboration scores (Q11 and Q12 of Table 1) remained stable (Week1: M+ SD = 4.25 ± 0.83; Week 2: M+ SD = 4.21 ± 0.78; Week 3: M+ SD = 4.19 ± 0.84). No significant changes were detected (F (2, 150) = 0.11, p = .897, partial eta squared = 0.00). Sphericity was confirmed (χ² (2) = 0.71, p = .703), and contrasts showed no significant trends (Table 6).

Table 6.

Comparison of Students Perception of Effectiveness of Learning Scores and Student Satisfaction, Self-Confidence in Learning/Fidelity Across 3 Weeks (Repeated Measure ANOVA Results).

	Pillai’s Trace			Wilk’s Lambda			Hotelling's Trace			Roy's Largest Root
Variables	Value	\|F\|	Sig	Value	\|F\|	Sig	Value	\|F\|	Sig	Value	\|F\|	Sig
Active learning total	0.024	0.916	0.405	0.976	0.916	0.405	0.025	0.916	0.405	0.025	0.916	0.405
Collaboration total	0.003	0.111	0.895	0.997	0.111	0.895	0.003	0.111	0.895	0.003	0.111	0.895
Diverse way of learning total	0.028	1.057	0.353	0.972	1.057	0.353	0.029	1.057	0.353	0.029	1.057	0.353
High expectation total	0.002	0.064	0.938	0.998	0.064	0.938	0.002	0.064	0.938	0.002	0.064	0.938
Satisfaction total	0.023	0.887	0.416	0.977	0.887	0.416	0.024	0.887	0.416	0.024	0.977	0.416
Self-confidence total	0.024	0.894	0.413	0.976	0.894	0.413	0.024	0.894	0.413	0.024	0.894	0.413
Fidelity total	0.047	1.810	0.171	0.953	1.810	0.171	0.049	1.810	0.171	0.049	1.810	0.171

Scores for “Diverse Ways of Learning” (Q13 and Q14 of Table 1) were consistent (Week 1: M = 3.97; Week 2: M = 4.16; Week 3: M = 4.10). No significant changes over time were found (Pillai's Trace = .028, F (2, 74) = 1.057, p = .353). Sphericity was met, and contrasts showed no significant trends (Table 6).

High expectations scores (Q15 and Q16 of table 1) did not vary significantly (Week 1: M = 4.20; Week 2: M = 4.22; Week 3: M = 4.17). The ANOVA results were non-significant related to (F (2, 74) = 0.070, p = .933, partial eta squared = .001), and sphericity was met. These results suggest that students’ high perceptions remained stable, potentially due to a ceiling effect, where students had already reached a high level of perceived benefit at the start of the intervention (Table 6).

Satisfaction scores were consistent across the 3 weeks, with no significant differences observed (Pillai’s trace = .023, F (2, 74) = 0.887, p = .416). Self-confidence also remained stable over time (Pillai’s trace = .024, F (2, 74) = 0.894, p = .413), indicating that participants maintained a steady level of confidence throughout the intervention. Fidelity scores showed slightly more variation (Pillai’s trace = .047, F (2, 74) = 1.810, p = .171), though these differences were not statistically significant (Table 6).

Discussion

This study aimed to explore community health nursing students’ perceptions of standardized patient simulations in relation to self-confidence, satisfaction, and perceived learning effectiveness. In terms of active learning, the mean scores remained relatively consistent across the three scenarios, ranging from 4.06 to 4.22. This consistency suggests that students perceived each scenario as equally effective in promoting active engagement and participation in learning activities. Despite minor fluctuations in mean scores, the lack of significant differences over time indicates that students' perceptions of active learning were stable across the 3 weeks. Similarly, collaboration scores also showed little variation across the scenarios, with mean scores ranging from 4.19 to 4.26. This consistency suggests that students consistently perceived teamwork and cooperative learning experiences as valuable across different simulation scenarios. The non-significant changes in collaboration scores over time further support the notion that students' perceptions of collaboration remained stable throughout the study period. For diverse ways of learning, the mean scores also remained relatively stable across the three scenarios, ranging from 3.97 to 4.16. This indicates that students perceived each scenario as effective in providing diverse learning methods, allowing them to engage with the material in various ways. The lack of significant differences in mean scores over time suggests that students' perceptions of diverse learning methods were consistent throughout the study period. Regarding high expectations, mean scores were consistent across the scenarios, ranging from 4.17 to 4.22. This suggests that students consistently perceived each scenario as meeting their educational expectations and standards.

Furthermore, self-confidence in learning and fidelity scores across the three scenarios also yielded consistent findings. Mean scores for satisfaction, self-confidence, and fidelity remained stable across the scenarios, indicating that students' perceptions of these aspects of the simulation experience were consistent over time. Overall, the consistency and stability of mean scores across the three scenarios suggest that students' perceptions of simulation-based learning remained relatively constant throughout the study period. This consistency underscores the perceived effectiveness of simulation-based learning in promoting active engagement, collaboration, diverse learning methods, meeting high expectations, satisfaction, self-confidence, and fidelity among nursing students (Bailey & Emory, 2022). The utilization of simulation-based learning, particularly with standardized patients, has demonstrated a positive influences on students' self-confidence, satisfaction and perceived learning, ultimately supporting the acquisition of both knowledge and clinical skills (Johnson et al., 2020; Kim-Godwin et al., 2013; Oh et al., 2015; Sarikoc et al., 2017).

The study's gender analysis reveals negligible differences in students’ perceptions of educational effectiveness. Although slight variations were observed in satisfaction and high expectations, independent samples t-tests did not show statistically significant differences, indicating that gender does not substantially influence students' views on simulation-based learning. Additionally, Students consistently expressed positive sentiments about the simulation experiences across all scenarios. They frequently emphasized the realistic and practical nature of the scenarios, indicating that the simulations closely resembled real-life situations they might encounter in their future nursing practice (Alinier et al., 2023). Emotional reactions were prevalent, with students expressing enjoyment, satisfaction, and a sense of accomplishment. Moreover, many students noted a significant increase in confidence because of the simulations. They expressed confidence in their performance and their readiness to handle similar situations, suggesting that the simulations contributed to their perceived self-assurance and preparedness for real-world nursing scenarios (Ghimire & Kachapati, 2020).

The educational utility of the simulations was also emphasized, with students recognizing them as effective learning and development tools. They appreciated the opportunities the simulations provided for hands-on learning, critical thinking, and problem-solving in a controlled environment. Additionally, students frequently highlighted the importance of teamwork and effective communication during simulations. They acknowledged the value of collaborative efforts in managing patient assessments and interventions, emphasizing the role of teamwork in delivering effective patient care. Utilizing standardized patients notably enhanced students' perceived satisfaction and confidence levels prior to their clinical rotations (Johnson et al., 2020).

Qualitative responses from students conveyed a positive perception of standardized patients as an effective method for bridging the gap between theoretical knowledge and practical application. Furthermore, a significant finding of the study is the strong positive correlations observed between students' satisfaction with the simulation experience, their self-confidence in learning, and their perception of fidelity to real-life scenarios. Suggesting that a satisfying simulation experience is associated with higher self-confidence and perception of realism (Chamberlain, 2017). These findings underscore the importance of creating immersive and engaging simulation experiences that not only support perceived learning outcomes but also boost students' confidence in their clinical skills and decision-making abilities (Ghimire & Kachapati, 2020). Simulation using standardized patients effectively improves students perceived skills, satisfaction, and self-confidence compared to low-fidelity mannequins among nursing students (Andrea & Kotowski, 2017; Basak et al., 2019).

However, this study has several limitations that should be considered when interpreting the findings. First, the small and homogeneous sample size, as well as the single institution setting, limit the generalizability and long-term applicability of the findings. Future studies should expand the sample size by including multiple universities and using random sampling for better representativeness. Second, the short duration of the study restricted the ability to assess long-term retention or the sustainability of perceived learning outcomes. Third, the reliance on self-reported data introduces the potential for response bias. While efforts were made to ensure anonymity and voluntary participation to reduce social desirability effects, the subjective nature of self-assessments remains a limitation. Moreover, the absence of objective clinical performance measures such as OSCE scores or direct observation precludes definitive conclusions about actual skill acquisition. Future research should incorporate these objective assessments to triangulate findings. Fourth, the study did not collect data on individual differences such as prior clinical experience, academic background, or personality traits, which could influence students’ responses to simulation. Including these variables in future research would offer a more nuanced understanding of simulation effectiveness across diverse learner profiles. Fifth, the study lacked statistical controls for potential confounding variables, such as past academic experience, individual characteristics, or variations among instructors. Future studies are recommended to apply multivariate approaches to account for these factors and strengthen internal validity. Finally, the consistently high ratings observed across all simulation scenarios suggest a potential ceiling effect, where students may have reached a saturation point in perceived benefits early in the intervention. Future studies may consider longer simulation periods, varied scenario complexity, or mixed simulation modalities to sustain engagement and capture evolving student perceptions over time.

Conclusion

The study findings reveal consistent and stable perceptions among community health nursing students across various domains, including active learning, collaboration, diverse ways of learning, high expectations, satisfaction, self-confidence, and fidelity, across three simulation scenarios. Students consistently reported high levels of engagement, collaboration, satisfaction, and confidence throughout the study. Gender differences in perceptions of educational efficacy were minimal, suggesting the inclusivity of simulation-based learning. The positive correlations observed between satisfaction, self-confidence, and fidelity indicate an association with immersive and engaging simulation experiences in nursing education.

Footnotes

Acknowledgements

Authors would like to extend their sincere gratitude to the fourth-year nursing students for their invaluable contributions to this study. Your active participation and commitment were essential to its success.

ORCID iDs

Khulud Ahmad Rezq

Maaidah M. Algamdi

Ethical Consideration

Author Contributions

Khulud Ahmad Rezq: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Writing – original draft, Writing – review & editing. Maadiah Algamdi: Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Validation, Writing – original draft, Writing – review & editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

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