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Effect of simulation-based teaching on nursing skill performance: a systematic review and meta-analysis

Open Access
|Sep 2021

Figures & Tables

Figure 1

Flow diagram showing the process of study identification and selection.
Flow diagram showing the process of study identification and selection.

Figure 2

Forest plot showing the effect size of individual studies.Note: CI, confidence interval.
Forest plot showing the effect size of individual studies.Note: CI, confidence interval.

Figure 3

Forest plot showing sensitivity analysis by one study remove method.
Forest plot showing sensitivity analysis by one study remove method.

Figure 4

Funnel plot showing publication bias among included studies.
Funnel plot showing publication bias among included studies.

Characteristics of included studies_

StudyInterventionsStudy type, duration, sample sizeScenarioOutcome measuresResultEffects
1Aqel & Ahmed 2014, Jordan,27 RCTTraining of participant over simulated case with cardiac arrest scenario and debriefing discussion.HFS, 25!90CPRDirect observation using Checklist: mock codes were conducted over manikin over floor and evaluation using AHA checklist.The results revealed the existence of a significant difference in the post-test CPR knowledge as well as the CPR skills in favor of participants in the intervention group.Improved
2Basak et al., 2016, Turkey,28, 29 Quasi, Single pre-post45 min paper-based drug dose calculation simulation and debriefing session for discussion.LFS, 45!82Actual physician prescriptionRating: Drug dose calculation was evaluated from 100 points immediately after training and 1 month later.The difference between the mean pre-test score and the mean post-test score was statistically significant (t = 8.767, df = 89, P = 0.001)Improved
3Basak et al., 2019, Turkey,30 RCT, equivalent control group20 min simulation with 40 min debriefing and self-evaluation for 10 min generally 80 min discussion about teaching skill over SPs.SP, 80!71Inhaler drug administrationDirect Observation using Check list: Teaching skill measured by checklist consisted of 15 procedural steps developed and tested by principal investigators.Total patient teaching skill score for control group was 26.73 ± 5.63 and 39.08 ± 5.49 for SP group which causes a statistically significant difference (P ≤ 0.01)Improved
4Bogossian et al. 2015, Australia,20 Quasi Single pre-postInteractive e simulation clinical scenario with video recording patient conditions, pop-up task, and respective response.VS, 24!367Cardiac, shock, and respiratoryVirtual skill performanceA paired t-test showed a significant improvement in performance between the first and last scenarios (t = −8.037, df = 366, CI 2.05–1.24; P = 0.00).Improved
5Bowling et al., 2015, USA,31 Quasi, equivalent control group50 min respiratory distress simulated cased training and participant required to react to simulated case.MFS, 50!73Respiratory distressOSCE with six station lasting 7 min and rater-based evaluationsThere was a significant difference for both groups in knowledge and skill performance (measured with a mini OSCE), but not between the groupsImproved
6Boyde M et al., 2018, Australia,24 Quasi, Single pre-postInnovative teaching of emergency management of patient using HF simulation with Jefferies simulation principles.HFS, Not mentioned, 50Emergency patientSelf-assessment: The self-efficacy in clinical performance scale was used to measure participant's assessment and handovepractice.The mean change in handover skill from 7.88 ± 1.76 to 8.79 ± 1.22 was statistically significant with t (41) = 3.41, P < 0.01Improved
7Chen et al., 2015, Canada,32 Quasi, equivalent control groupAuscultation skills training using low and HF training.HFS, 40!54Pneumothorax and a systolic murmur: Auscultation skillsOSCE using Check list: Participants required to correctly identify 20 different sounds on simulators.There was no evidence that the HFS group performed better than the LFS group in clinical skills or in auscultation sounds recognition on HFS.No change
8Durmaz et al., 2012, Turkey,33 RCTIntervention: Participants receive 4 h computer-based education simulation about pre-operative and post-operative patient management.VS, 4 h,82Pre-post caseOSCE for pre and post-operative management and deep breathing and coughing exercise: e.There was not a significant difference between the students’ post-education practical deep breathing and coughing exercise education skills (P = 0.867).Improved
9Ismailoglu et al., 2018, Turkey,25 Quasi, equivalent control groupIV training over virtual IV simulatorVS, Not clear, 62Encoded caseDirect observation Check list: Intravenous catheterization Skill list performance evaluation.Mean psychomotor skills score of the experimental group 45.18 (33.73 ± 4.22) was higher than that of the control group 20.44 (26.53 ± 4.45) with Z = 5.294, P = 0.000.Improved
10Jaberi et al., 2019, Iran,34 RCTAbdominal examination skill was tested after teaching student sing SP for 45 min.SP, 45!,87Physical examination of abdomenOSCE using checklist: Six station OSCE were used with one rater for each station were assigned to evaluate performance over SPs.The mean score in intervention group changed from 5.35 ± 1.77 to 15.39 ± 3.2, while it was changed 4.98 ± 2.17 to 14.43 ± 3.93 in control group. There was a significant difference between the mean pre-test and post-test scores in each group (P < 0.05).Improved
11Karabacak et al., 2019, Turkey,35 Quasi, Single pre-postA 12 h theory and laboratory-based training using SP on selected fundamental of nursing skills.SP, 12 h, 65Fundamental of nursing issuesSelf-assessment: Proficiency self-assessment Form for proper communication with the patient, establishing a safe patient unit, safe patient transfer and act on body mechanics.No significant difference has been found between pre-scenario (7.05 + 9.17) and post-scenario (5.89 + 2.02) scores about self-assessment of safe patient transfer (t = 1.01; P = 0.32).No change
12Keleekai et al., 2016, USA,36 RCT, equivalent control groupVirtual based 3 h training to improve/decrease IV reinsertionVS, 3 h, 58Peripheral IV securingDirect observation of virtual guided skill performance using Check list: Number of success and reinsertion of IV after demonstrating over IV arm model. Participants evaluated over 28-point check lists.The intervention was effective and resulted in several statistically significant improvements in knowledge, confidence, and skills both within and between study groups over time.Improved
13Lee et al., 2019, Taiwan, China,37 Quasi, equivalent control groupIntegrating simulation-based teaching over advanced acute care adult scenario on shock, resuscitations for 90 min.HFS, 90!52Shock and resuscitationsDirect observation at clinical sites using Check list: Evaluated based on predesigned check list for clinical evaluation at actual practical setting.No significant difference in clinical performance was observed among groups.No change
14Liaw et al., 2015 Singapore,38 RCT, equivalent control groupThe interactive web-based programmer 3 h training on patient identification, early recognition, vital sign monitoring, and management.VS, 3 h, 67Deteriorating patientsDirect observations using Check list: The simulation performance tool was adapted and modified from the original RAPIDS tool and used to assess specific and global rating scale. l. Two independent raters evaluated recorded video of performance.There was a significant change in Assessing and managing clinical deterioration in experimental group pre-test 18.17 (3.55), post-test 25.83 (4.79), and Reporting clinical deterioration pre-test 10.09 (2.31) post-test 12.83 (2.41).Improved
15Lubbers et al., 2016, USA,39 Quasi, Single pre-post1 h simulation, pre-post–simulation discussion.HFS, 3 h and 30!58Not mentionedSelf-assessment of Knowledge, confidence and performance.The Skill score, revealed significant increases from pre-test 2.25 to post-test 4.13, t = 21.21, P < 0.001).Improved
16Meyer et al., 2011, USA,23 Quasi, equivalent control groupReplacing 2 weeks (25%) of clinical work or rotation with simulation-based teaching in skill lab.VS, 24 h, 120VariousDirect observation using rating scale Clinical faculty assessment of student performance in clinical work and compared with control group who spent 100% in clinical rotations.Faculty rated students with patient simulation experience higher than those who had not yet attended simulation mean 1.74 (0.75), P = 0.02).Improved
17Morton et al., 2019, USA,26 Quasi, Single pre-postTraining using HFS portraying a patient with cardiac arrest.HFS, Not mentioned, 37CPRDirect observation using Check list: Mock Code Evaluation Tool basically developed based on AHA (2015) guideline for basic life supports.There is no statistically significant difference in performance obtained following simulation-based training.No change
18Sarmasogle et al. 2016, Turkey,40 Quasi, equivalent control groupSP-based training of Arterial blood pressure and Subcutaneous injection, feedback, and discussion with SP.SP, 4 h, 77Hypertension and acute painDirect observation using Check list: Performance assessment using check list for arterial blood pressure measurements and subcutaneous injection by two raters.The mean performance score for the measurement of arterial blood pressure was 76 ± 7.6 for the control group and 83 ± 3.1 for the experimental group (P < 0.001). However, no significant difference was found between the groups’ performance scores on subcutaneous injection administration.Improved
19Stayt LC, et al., 2015, UK,41 RCT2 h clinical skill teaching; systematic ABCDE assessment and management process on medium fidelity patient simulator (ALS Simulator, made by Laerdal Medical) using a clinical scenario of an acutely unwell patient who is exhibiting signs of clinical deterioration.SP, 2 h, 98Deteriorating patientOSCE using check list. The OSCE comprised of a check list of 24 objective performance criteria that evaluated participants’ performance of assessing and managing a deteriorating patient using a patient simulator.The results indicate that students who received simulation training performed a systematic ABCDE assessment and managed the deteriorating patient more effectively than those who received a didactic teaching approach.Improved
20Sumner et al., 2012, USA,42 Quasi, Single pre-postParticipants received the intervention by attending a 4-hour basic arrhythmia program on the second day of nursing orientation.MFS, 4 h, 138Arrhythmia casesSelf-assessment: post simulation self-report of caring and resource utilization in caring of patient with arrythmias patients.Following simulation there was transfer of knowledge to clinical practice.Improved
21Toubasi S et al., 2015, Jordan,21 Quasi, Single pre-postStep by step simulation and debriefing of cardiac arrest scenario using AHA guidelines.MFS, 8 h, 30Cardiac arrestDirect observation using Check list: Validated skill scenario testing tool which was developed by the AHA to assess performance according to the AHA 2010 guidelines.There is a significant mean difference of 2.9 in overall skill performance and BLS score after simulation (t = 7.4, df = 29, P < 0.01).Improved
22Unver et al., 2013, Turkey,43 Quasi, Single pre-post4 h training using SPSP, 4 h, 85Medical administrationOSCE: OCEF were used.There was a significant difference (30.26) in pre-test (24.02 ± 16.06) to post-test (54.28 ± 14.54) skill performance measurements (P < 0.01; t = 14.35).Improved
23Vidal VL et al, 2013, Turkey,44 Quasi, equivalent control groupComputer-based training with demonstration, return demonstration and verbal feedback regarding performance of phlebotomy.VS, 3 h, 73PhlebotomyDirect observations using Check list: the skill checklist used by the mentors consisted of 21 items addressing the necessary steps for the completion of a phlebotomy procedure and 3 items related to overall performance.There is significant among the group in mean skill performance score in pain factor (P = 0.006), hematoma formation (P = 0.000), and number of reinsertions (P = 0.000).Improved
24Woda et al., 2019, USA,22 Quasi, Single pre-postA 20 min training using HFS and debriefing about care of patient with type I DM.HFS, 20!233Type one DMDirect observation of using Check list: Performance evaluated using 10 item evaluation rubrics by research assistance on major areas of DM care.Simulation did have a significant positive effect on performance change scores (P < 0.001; r = 0.28). The mean pre-test score on performance items was 0.73 (SD = 0.14), and the mean post-test score on performance items was 0.76 (SD = 0.12)Improved

Summary of effect size for subgroup analysis_

Comparison and GroupsNumbers of studiesEffect size (d) SMD, CI, P valueI2, %Z value
All studies Groups241.01 (CI [0.62, 1.41], P < 0.01)93.95.13
  Single group101.02 (CI [0.52, 1.50), P < 0.01)954.46
  Double groups141.00 (CI [0.56, 1.44], P < 0.01)92.94.48
Simulator types
  HF71.23 (CI [0.55, 1.93], P < 0.01)94.83.5
  Medium fidelity30.89 (CI [−0.14, 1.93], P = 0.09)86.51.69
  LF31.27 (CI [0.24, 2.29], P = 0.0202.4
  SP51.03 (CI [0.23, 1.84], P = 0.01)962.5
  VSs60.69 (CI [−0.04, 1.4], P = 0.06)95.41.85
Types of participants
  Clinical staffs31.08 (CI [0.43, 1.74], P < 0.01)85.83.25
  Nursing students80.98 (CI [0.61, 1.37], P < 0.01)955.11
Regions (country)
  America81.22 (CI [0.62, 1.82], P < 0.01)94.64.02
  Europe100.76 (CI [0.24, 1.29], P = 0.004)95.32.85
  Middle East61.17 (CI [0.48, 1.86], P = 0.001)88.743.34
Design
  Quasi170.96 (CI [0.57, 1.34], P < 0.01)94.784.86
  RCT71.14 (CI [0.54, 1.75], P < 0.01)91.13.7
Types of scenarios
  Acute121.07 (CI [0.73, 1.41], P < 0.01)88.16.18
  Cold120.92 (CI [0.35, 1.49], P < 0.02)95.163.16
DOI: https://doi.org/10.2478/fon-2021-0021 | Journal eISSN: 2544-8994 | Journal ISSN: 2097-5368
Language: English
Page range: 193 - 208
Submitted on: Jun 14, 2020
Accepted on: Jul 17, 2020
Published on: Sep 21, 2021
Published by: Shanxi Medical Periodical Press
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year

© 2021 Agezegn Asegid, Nega Assefa, published by Shanxi Medical Periodical Press
This work is licensed under the Creative Commons Attribution 4.0 License.