Introduction

Learning in the Spanish health education system, established in 1977, focuses on acquiring necessary abilities and skills for the nursing care practice nurse, guaranteeing patient safety and quality of care.¹ With the introduction of new health teaching technologies based on competence areas in the European Higher Education Area since the year 2000, it became necessary to incorporate these advances to the nursing curriculum.⁽²⁾ Clinical simulation has emerged as a valuable educational tool in diverse fields, with the aim of improving the professional practice, minimizing errors, and promoting professionals towards excellence. Due to its use, it is possible to recreate scenarios that resemble real patient care situations where students face the challenge of applying their abilities, knowledge, and clinical attitudes, thus integrating theory and practice. This methodology usually consists of three main phases: predebriefing, simulation and debriefing.³ The debriefing, a crucial component of the experimental learning process that encompasses reflection, feedback, and future experimentation, allows students to develop and integrate knowledge acquired during direct experience.^4,5

Simulation scenarios are classified in different zones (from 0 to 4) in function of their complexity, starting with learning clinical abilities and technical procedures (zone 0 and 1) and advancing to teamwork training in crisis situations and human factors (zona 2 a 4).⁶ In 2014, the Degree in Nursing from the Faculty of Health Sciences at Manresa of Universitat de Vic- Universitat Central de Catalunya (UVic-UCC) incorporated the clinical simulation as key methodology to prevent errors, improve care practices, and guarantee patient safety. The clinical simulation sessions were aligned with specific themes of the study plan to educate nursing students about providing professional care, acquisition of legal and ethical standards, emphasizing on safety and quality.

To assess the effectiveness of the clinical simulation, two scales have been used internationally: the Debriefing Assessment for Simulation in Healthcare (DASH), developed by the Boston Center for Medical Simulation, centered on evaluating the debriefing process from the perspectives by students, evaluators, and instructors;⁷ and the Satisfaction with Simulated Clinical Experiences scale, validated in Spanish by Negrão et al.,⁸ and which measures satisfaction by nursing students with simulated clinical sessions in three dimensions: practice, realism, and cognitive.

Although these scales provide information about perceptions and student satisfaction, they do not evaluate specifically the transferability of the competences practiced in the clinical simulation to the real care practice. Previous studies⁹ indicate that simulations represent an advantage for health workers as they progress in reflective learning, clinical judgment, and decision making. Additionally, simulation scenarios represent a close, safe and non-punitive environment, where students can practice techniques in controlled, supervised manner, with the possibility of errors and unlimited repetition.¹⁰ Currently, studies exist¹¹ that assess student satisfaction in relation to their participation in the simulation. Another study¹² adds the debriefing evaluation, as previously discussed with the DASH, but no scale was found in the literature that measures knowledge transfer from clinical simulation to care practices, being a challenge to be achieved by the community of professors who teach or practice this simulation methodology. The aim of this research was to evaluate the perception of knowledge transfer from clinical simulations to the care practice in nursing students through effective debriefing.

Methods

With the purpose of contributing to understanding how an effective or good quality debriefing in clinical simulation facilitates knowledge transfer to the care practice and improves the formation of future nurses.

Population and sample. The entire study population included 428 nursing students registered in the Nursing Degree of the Faculty of Health Sciences at Manresa of Universitat de Vic- Universitat Central de Catalunya (UVic-UCC) with a final sample of 281 participants. The study sample was determined through convenience and included all the students who had participated in simulations and clinical practices during the academic year 2020-2021.

Type of study with observational, descriptive, and cross-sectional quantitative methodology.

Results

Throughout the four courses and for all the simulations, the mean global score obtained for the six elements of the DASH in Spanish was 6.61 over 7.00 [95% CI: 6.56-6.65] (Table 1).

Of the 281 participants, 221 (representing 78.64%) had the opportunity during the practice period of experiencing the same cases as those worked on in the simulation; 83.20% were females and, by course, they were distributed thus: 45 students from the first, 84 from the second, 61 from the third, and 31 from the fourth. Regarding the transversal competence areas worked on during the simulations, the areas of patient safety, globally, 81.00% [78.77%-83.28%] of the students agreed that what was learnt during the simulation was transferred to the practice. The most transferred aspects were use of gloves with 99.52% [98.66%-100%] and introduction with name and professional category with 95.91% [93.30%-98.55%] for the four courses. Nevertheless, second-course students were the ones who least considered that this knowledge was transferred with 75.40% [71.88%-78.95%]; specifically, the least transferable aspects were: use of railings with bedridden patients with 54.82% [43.99%-65.53%], bringing the bell closer to a dependent patient with 69.00% [59.05-79.05], and verification of allergies with 40.53% [29.86%-51.09%]. Moreover, overall, the students reported that the simulations helped them to integrate strategies to improve this competence area with 78.50% [71.68%-85.27].

Additionally, the communication competence was the most transferred to the clinical practice with a mean of 95.40% [94.31%-96.46%] in all courses, with the first course having the highest rate with 97.30% [95.63%-99.04%] and the third course having a rather low rate with 94.10% [92.07%-96.13%]. The most-transferred item of communication was active listening, with 100% incidence and, on the contrary, the least-transferred item, although high at global rate, was effective communication among team members with 80.60% [66.43%-94.86%]; finally, the students stated that the simulations helped them to integrate strategies to improve this competence with 81.90% [76.78%-87.02%].

At the same time, teamwork, a competence of the third and fourth courses, obtained an overall transferability of 92.20% [89.57%-94.78%]; while the most-transferred aspect was respect for the members of the care team with 100%. It is fitting to note that the fourth-course students expressed 100% transferability in the integration of the care staff, communication among the care team, and recognition of teamwork in solving specific situations. Rather, in the third course the least valued items were communication and non-integration in the care team during the practice period, both with 96.70% [92.15%-100%]. Additionally, they stated that the simulations helped them to integrate strategies to improve this competence area by 60.70% [48.13%-73.18%].

Lastly, the leadership competence was only assessed in the fourth course, given that it is a competence area that is only worked on in said course, thereby, there was no comparison with previous courses. Said competence showed transference of 88.30% [82.89%-93.72%] of the knowledge learnt; the items with the highest scores were those related to the students' initiative to identify and solve situations and problems related with the staff or with the patients, with 100%, instead, the item with the lowest score was that related with not identifying the leader figure and not identifying orders with 87.13% [74.60%-99.60%]. Finally, the students reported that the simulations helped them to integrate recognition of the leader figure in 71.00% [54.04%-87.89%] and obtain the necessary knowledge to follow their orders in 67.77% [50.31%-85.17%]; for further information, see Table 2.

Reference is made to the second section of the survey "2^nd Post-Practicum Survey" of the specific competence areas worked on in the simulations. The first-course students manifested a transfer rate in basic communication skills of 83.70% [73.37%-94.07%], with the simulation related with active listening having the highest transference value of 86.00% [75.26%-96.84%] and the lowest related with direct communication with different types of patients with care purposes, uncooperative or collaborative or nervous and with their family environment of 81.40% [69.28%-93.51%]. The second course expressed a transfer rate in the management of the nursing consultation in nutritional education of 85.50% [76.47%-94.50%], as for the highest value of 98.50% [95.46%-100%] in validating the patient's understanding of their nutritional plan and the lowest value of 85.50% [76.47%-94.50%] in offering appropriate dietary recommendations.

During the motivational interview, the students reported a transference of 80.00% [70.01%-89.99%], with the highest value in the application of the patient’s emotional containment, as well as in techniques of emotional support and active listening with 98.50% [95.59%-100%] and the lowest value of 80.00% [70.01%-89.99%] in providing reinforcement and motivation for adherence to treatment. With respect to nursing care in cardiology care, there was a transfer rate of 69.33% [57.96%-80.73%], with the highest value of 93.30% [79.03%-100%] related with performing an electrocardiogram, and the lowest, of 68.20% [47.04%-89.32%] in the application of postoperative knowledge in pacemaker surgical interventions. Finally, in home nursing care they reported a transfer rate of 83.10% [73.71%-92.44%], with the highest value, of 91.10% [83.37%-98.78%] in relation with the nursing diagnosis, and the lowest value in relation with the registry of patient care and needs, with 82.50% [72.90%-92.18%]. The third course expressed a transfer rate of 66.70% [50.49%-82.84%] in nursing care with hematological alterations, regarding extraction of blood samples, checking the blood groups, and performing blood transfusions. In immediate life support of 66.70% [28.23%-100%] conducting the ABCDE nursing assessment and in pediatric nursing care of 69.40% [56.01%-82.76%], with recommendations for breastfeeding, vaccination schedule, and administration of usual medication. The fourth course manifested a transfer rate in nursing care of chronic complex patients in primary care of 82.60% [65.85%-99.37%] with the performance of the nursing assessment and application of tests or functional scales. Regarding adult advanced life support of 80.00% [60.79%-99.21%] and pediatric life support of 100%, tracking algorithms, monitoring and identifying cardiac rhythms and administering medication during cardiorespiratory arrest. Finally, for the advanced practice nurse it was 75.00% [46.26%-100%] with the implementation of recommendations and follow-up guidelines.

Lastly, globally, students who were able to carry out simulation cases and apply them in care practices, reported that the simulations helped 76.66% [63.89%-89.59%]: with this being higher in the fourth course (85.90%) and lower in the third course (67.60%); they were also able to transfer knowledge from said simulations to their role as professional nurses in 81.70% [72.08%-91.90%]: being higher in the fourth course (95.60%) and lower in the third course (77.00%) (Table 3).

Discussion

The findings herein regarding the effectiveness of the debriefing in the clinical simulation, according to the results obtained from the DASH, indicate a positive perception by the students. These results suggest that the instructors have the capacity to create a suitable environment for reflexive learning through organized sessions that promote profound discussions about the student’s performance. Previous research in nursing programs have yielded results similar to the present project with 6.61 [6.56-6.65], ranging between 6 and 6.50; highlighting the need to improve the introduction at the beginning of the simulation activities (element 1), as well as the instructor’s ability to maintain a participative learning environment (element 2).^14-19 Other studies focused on the formation of health professionals have also obtained similar assessments as the present study, suggesting that the debriefing was effective and of high quality²⁰. The importance is underscored of maintaining a safe environment and promoting professional integrity during the simulation, recognizing its profound impact on health students.²¹ Additionally, the crucial relevance of the experience and training of professors in clinical simulation to guarantee student satisfaction is highlighted.

With respect to knowledge transfer to the clinical practice, most students state that knowledge acquired during the clinical simulations applies effectively in the care practice. The data reveal that 81.00% of the students consider that what they learnt during the simulations on patient safety was transferred to the practice, with gloves and adequate introduction with name and professional category obtaining transferability rates close to 100%. Furthermore, it is highlighted that 95.40% of the students experienced high transference of communication skills, with active listening being a 100% universally transferred element. In teamwork, it is observed that 92.20% of the students experienced effective transference of abilities, highlighting respect for staff members as a 100% universally transferred aspect.

These findings coincide with prior scientific evidence²² that support the effectiveness of the clinical simulations in the transference of skills to the clinical practice. Previous research ^(23,24 have demonstrated that clinical simulations offer a safe and controlled environment where students can practice and consolidate clinical skills before facing real situations with patients. In this sense, simulations not only serve as effective teaching tools, but also contribute significantly to the development of competencies crucial for quality care in real clinical settings.

Although different programs exist ^(25,26 in nursing based on simulation, this study provides the novelty of determining the differences in the perception of knowledge transfer and competence areas among the courses of the university nursing degree. For example, the data show that students from the first course have a high transferability rate in basic communication skills, such as active listening and empathy, which suggests effective Integration of these skills as of early training stages. This finding may be supported with prior studies²⁷ that highlight the importance of developing effective communication skills during the first years of nursing formation to establish a solid base for the clinical practice. In turn, the perception of lower transferability in aspects of patient safety by the students from the second course is also supported in the literature. Previous research²⁸ have identified deficiencies in knowledge and the application of patient safety protocols among nursing students during intermediate stages of their training. This suggests the need for specific educational interventions, like the Integration of simulation scenarios focused on patient safety, to address these critical areas of the clinical practice and improve the perception of transferability of knowledge in this group of students.

These data reinforce the importance of understanding the areas of greater and lesser knowledge transfer in the nursing formation.²² According to the results presented, the areas with greater transference include the use of gloves, introduction with name and professional category, active listening, and respect toward the members of the healthcare staff. In contrast, the areas with lesser knowledge transfer include, among others, the use of railings with bedridden patients, bringing the bell closer to a dependent patient, and verification of allergies in students from the second course. It was found that communication and integration in the healthcare staff during the practices, and identification of the leader figure and the leader’s orders had lower transferability rates in students from the third and fourth courses, respectively.

Hence, adapting the clinical simulations to the specific needs of each cohort of students and competence area is justified not only due to the differences observed in the perception of transferability, but also by prior evidence²² that supports the importance of addressing these specific areas of professional development during the nursing formation. These personalized strategies have the potential of both improving student confidence and competence, and can have a positive impact on the quality of patient care in real clinical settings.²¹

The study acknowledges certain limitations, such as the use of convenience sampling and dependence on the subjective perception of students. Future research should incorporate mixed methods to obtain fuller comprehension of how the debriefing in the clinical simulation impacts upon the care practice. In addition, strategies can be explored to improve knowledge transfer in areas where lower transferability rates are observed.

For decades, nursing literature has indicated the existence of a gap ⁽²⁹ between academic theory and practical application, with limited evidence of significant progress to reduce this disparity and this research emphasizes the simulation’s potential as an educational strategy to approach this gap, given that the results show that this educational methodology is effective to increase the students’ perception in their transition to clinical care practice. This project offers results that confirm the scientific evidence ^30-32 that simulation of the clinical practice has transference of the learning by the nursing students, contributing to their knowledge, abilities, confidence, and judgement. Nonetheless, the study agrees with other studies^24,29 on the need to continue exploring this setting and the need is identified for more longitudinal research to further delve into the long-term learning results from simulation.

The debriefing, as a reflection and analysis process after the clinical simulation experiences, is universally recognized as an essential component to clarify and consolidate the knowledge acquired during these practices. The results of the DASH-based "1^st Post Clinical Simulation Survey" provide evidence that the professors who facilitated the clinical simulation exhibited the necessary behavior to conduct an effective debriefing with our nursing students. Moreover, the "2^nd Post-Practicum Survey" revealed that the students perceive that the clinical simulation allows them to transfer knowledge from transversal competence areas to the care practice, enhancing their capacity in patient safety, therapeutic communication, teamwork, and leadership. In this sense, the research offers a significant contribution to the field of nursing education upon identifying specific areas of greater and lesser knowledge transfer among students from different courses and competence areas. The findings establish that, although there is a solid integration of basic communication skills, such as active listening and empathy, from the initial stages of training, deficiencies persist in critical clinical practice areas, like patient safety and leadership in healthcare teams.

These results support continuing and strengthening learning based on clinical simulation for nursing students, given that this methodology provides an effective platform to apply essential concepts and abilities, thus, improving the quality of patient care and attention. Furthermore, these findings suggest that the simulations in the classroom help nursing students to close the gap between acquiring knowledge and applying them to patient care.

In conclusion, this study provides conclusive evidence about the effectiveness of debriefing in clinical simulation to facilitate knowledge transfer to the care practice among nursing students. The results emphasize the importance of a structured and reflexive debriefing to enhance clinical competence and improve patient care in future nursing professionals. Likewise, these back the need to adapt clinical simulations to the particularities of each student group and competence area. This adaptation is sustained not only on the discrepancies identified in the perception of transferability, but on previous evidence that underscores the relevance of addressing specific areas of professional development during the nursing formation. These tailored strategies can increase student confidence and competence, generating a positive impact on the quality of patient care in real clinical settings.

To end, future research is considered necessary to address variations between educational programs and competence areas, as well as to continue optimizing the design and application of clinical simulations in nursing formation to guarantee its effectiveness and relevance within the context of the practice professional. These types of research could delve into identifying the best practices in debriefing and in the adaptation of simulations to the specific needs of each student cohort, which could contribute significantly to continuous improvement of formation in nursing and, lastly, to the offer of high-quality care to patients.