Speaking Up Against Hierarchy: A Simulation Geared Towards Nursing Students.

Background As simulation science continues to advance, the focus previously put on scenario creation and debriefing must now be applied to other components of the learning experience. There is a need to examine the effectiveness of pre-simulation activities and how they relate to the overall simulation experience and learning outcomes. However, few randomized controlled trials have been conducted comparing different approaches in the pre-simulation preparatory phase and the impact on learning outcomes. Methods A randomized controlled trial was conducted with undergraduate nursing students (n=83) who were randomized to a traditional paper case study (control group) or an interactive pre-simulation activity (intervention group). The use of the two-challenge rule and Satisfaction and Self Confidence in Learning (SSL) was evaluated. Results The proportion of students who utilized the two-challenge rule in the intervention group was significantly higher than the control group. Results from the two independent-samples Wilcoxon-Mann-Whitney test showed a significant difference in the median of the total score of the SSL W=2.5, p <0.001, satisfaction W=6.0, p <0.001, and self-confidence W=68.0, p <0.001 in learning between third-year nursing students in the control and intervention groups. Conclusion Our results showed significant differences in the use of the two-challenge rule by students who completed an interactive pre-simulation activity (intervention group) compared to those who completed the paper case study (control group). Additionally, students in the intervention group were more self-confident and satisfied with the entire simulation intervention than the control group. From a pedagogical perspective, this study also emphasizes the need to ground simulations in theory. Moreover, there is value in using progressive frameworks, i.e., revised Medical Research Council (2014) in simulation design and research to ensure high quality. More studies are required to examine the right dosage and type of pre-simulation activity and impact on learning outcomes.