Study design and participants
This study utilized a quasi-experimental, pre-test/post-test design to compare the learning outcomes of nursing students exposed to Simulated Clinical Immersion (SCI) against those in a traditional, lecture-based control group. This design was selected as a methodologically sound approach to assess the comparative effectiveness of teaching strategies where randomized controlled trial (RCT) allocation was deemed impractical due to logistical constraints within the academic curriculum. The target population comprised undergraduate nursing students. The final sample size was N = 128.
Sample size and power calculation
A formal power analysis was conducted a priori using (Specify the Software Used, e.g., G*Power) to determine the requisite sample size. Based on a moderate expected effect size (e.g., Cohen’s d = 0.50) observed in similar simulation-based education studies (Cite relevant prior studies here), with a statistical power (1−β) set at 0.80 and a significance level (α) of 0.05, the calculated minimum sample size was (Specify the required number, e.g., 102). The enrolled sample of N = 128 was therefore considered highly appropriate and sufficient to detect statistically significant differences between the groups.
Educational content and allocation
All participants received the same standardized didactic content on palliative care and end-of-life (EOL) principles for older adults prior to the intervention phase. This curriculum included: pain and symptom management, ethical and legal considerations in EOL care, and therapeutic communication with older patients and their families. This ensured equivalence in theoretical foundational knowledge across both groups.
Participants were assigned to either the intervention group (Simulated Clinical Immersion – SCI) or the control group (Traditional Lecture) via alternate allocation (Non-random assignment based on class section or enrollment order), aligning with the study’s quasi-experimental classification.
Measurement tools
Four instruments were administered as both pre-tests and post-tests to assess the core learning outcomes: knowledge, self-efficacy, and preparedness for EOL care. All instruments demonstrated high internal consistency in the current study.
Demographic data sheet
A researcher-developed demographic questionnaire was used to collect participants’ background information, including age, gender, prior exposure to palliative care, and previous experience with simulation-based learning. Content validity was confirmed through expert review by faculty specializing in palliative care education to ensure the clarity and relevance of the items.
EOL knowledge
The scale was adapted from Gellis et al. [11], to specifically target clinical knowledge in geriatric palliative care. While the original tool evaluated interprofessional team communication, the modified version focused exclusively on assessing knowledge related to EOL symptom management and ethical principles in older adults. The adapted questionnaire will be included in an appendix for transparency.
Clinical self-efficacy scale
This scale was adapted from two separate established tools to provide a comprehensive measure of students’ confidence in providing EOL care. The internal consistency of this adapted version in the current sample was confirmed by a high Cronbach’s α 0.91, supporting its reliability for this study’s context.
Simulation Effectiveness Tool (SET); The SET, developed by Elfrink et al. [12], assessed students’ perceptions of the simulation’s educational effectiveness. The tool includes 13 Likert-scale items addressing three key domains: learning outcomes, confidence building, and clinical relevance. The SET is a widely recognized and validated instrument for evaluating simulation-based learning. In this study, construct validity was maintained by ensuring item alignment with the goals of the SCI intervention. The tool yielded a Cronbach’s α of 0.89 during pilot testing, reflecting high internal consistency.
The pilot study used for initial testing of the instruments included a sample size of (N = 25) students. The internal consistency values (α) for all four instruments in the final N = 128 sample were consistently α > 0.80 confirming their excellent psychometric properties.
Ethical considerations
This study received approval from the Ethical committee of faculty of nursing at Zagazig University (Approval No. 130–2024), ensuring ethical compliance and protecting all participants’ rights. This approval, a testament to our unwavering commitment to upholding ethical standards, was crucial in the research process. Informed Consent: Participants were fully informed about the study and gave written consent before joining. It’s important to note that participation was entirely voluntary, and students had the right to withdraw at any time without any consequences, ensuring their security and control.
Intervention group: simulated clinical immersion (SCI)
The SCI experience was structured across three core phases (pre-briefing, simulation, and debriefing).
Simulation Scenario and Procedures. Each simulation session involved 8 students. 4 students acted as active participants (rotating roles such as primary nurse, communication lead, and assistant nurse), while 4 students served as active observers using a structured checklist and contributing to the debriefing phase. The scenario focused on a critically ill older adult presenting with an acute exacerbation of (Specify the clinical condition, e.g., advanced Chronic Obstructive Pulmonary Disease) requiring immediate symptom management and a goals-of-care discussion with the family. The session structure adhered to best practices in simulation reporting guidelines (Referencing Table 1 for healthcare simulation research).
Debriefing process
The debriefing session (approximately 30–40 minutes) immediately followed the simulation. It was led by faculty experts with specialized knowledge in geriatric care, EOL principles, and simulation-based learning. The process employed a structured debriefing model (Specify the model used, e.g., Plus-Delta or GAS) to facilitate student reflection and guided learning. Feedback was standardized across all sessions using a faculty checklist to ensure consistency in content, duration, and focus on the targeted competencies (e.g., pain assessment, ethical reasoning, therapeutic communication) regardless of the faculty member leading the session. The faculty instructors had an average of 7 years of experience in clinical nursing and 3 years of experience in simulation pedagogy.
Control group activities
The control group received only didactic, lecture-based instruction covering the identical learning objectives and theoretical content as the SCI group. The sessions included instructor-led presentations, assigned readings, and large group discussions but excluded any form of clinical simulation or high-fidelity experiential learning
Data analysis
Data were analyzed using SPSS version 26. Descriptive statistics summarized participant demographics, while independent and paired t-tests, along with chi-square tests, evaluated differences within and between groups. Effect sizes (Cohen’s d) quantified the practical significance of findings, interpreted using standard thresholds. Statistical significance was set at p < 0.05. The analysis revealed large effect sizes, underscoring the substantial impact of the simulation intervention on knowledge, self-efficacy, and perceived simulation effectiveness.
