Earticle

본 연구는 상부위장관 출혈 시뮬레이션 상황에서 간호대학생의 임상판단, 팀 의사소통 및 환자안전행동이 실제 수행 과정에서 어떻게 나타나는지를 탐색하기 위해 수행되었다. 연구는 Tanner의 임상판단모형을 적용한 탐색적 질적 사례연구로, 간호학과 4학년 학생 17명의 시뮬레이션 영상자료와 성찰일지를 지시적 질적 내용분석 방법으로 분석하였다. 연구결과, 간호대학생의 수행 경험은 ‘임상단서 인식과 해석의 연결’, ‘처치 중심 수행과 통합적 상황 조망의 제한’, ‘팀 의사소통의 구조화 부족과 폐쇄형 의사소통의 필요성’, ‘환자안전행동의 수행·누락과 재사정 요구’의 네 범주로 도출되었다. 학생들은 주요 임상단서를 비교적 신속하게 인식 하였으나 이를 통합적으로 해석하고 우선순위를 결정하는 데 어려움을 보였으며, ISBAR 보고의 필요성은 인식하고 있었으나 지시확인과 완료 보고를 포함한 폐쇄형 의사소통 수행은 미흡하였다. 또한 일부 환자안전행동은 수행되었으나 중재 후 재사정과 안전 확인은 부족한 것으로 나타났다. 본 연구는 임상판단, 팀 의사소통 및 환자안전행동 간의 연계 과정을 실제 수행 맥락에서 규명하였으며, 환자안전 중심 시뮬레이션 교육과 임상판단 역량 강화 프로그램 개발의 기초자료로 활용될 수 있을 것이다.

This study explores how nursing students’ clinical judgment, team communication, and patient safety behaviors were manifested during actual performance in an upper gastrointestinal bleeding simulation. An exploratory qualitative case study guided by Tanner’s Clinical Judgment Model was undertaken. Data were collected from simulation video recordings and reflective journals of 17 senior nursing students and analyzed using directed qualitative content analysis. Four categories emerged from the analysis: linking the recognition and interpretation of clinical cues, task-oriented performance and limited integrated situational awareness, insufficiently structured team communication and need for closed-loop communication, and performance and omission of patient safety behaviors and need for reassessment. Participants recognized major clinical cues relatively quickly; however, they experienced difficulties integrating information and prioritizing nursing interventions. Although they recognized the importance of ISBAR communication, their performance of closed-loop communication, including confirmation of instructions and reporting of task completion, was often inadequate. In addition, while some patient safety behaviors were appropriately performed, reassessment and safety verification following interventions were frequently lacking. The findings elucidate the interrelated processes of clinical judgment, team communication, and patient safety behaviors within the context of actual simulation performance. This study provides foundational evidence for development of patient safety–focused simulation education and programs aimed at strengthening clinical judgment competencies.

Purpose: The purpose of this study was to identify the effects simulation-based education combined team-based learning (SBE combined TBL) compared to simulation-based education (SBE) on undergraduate nursing students. Methods: A non-equivalent control group design with pre-and posttest measures was used. The participants in the study were 181 students. The SBE combined TBL group consisted of 84 senior students in 2013, and the SBE group consisted of 97 seniors in 2014. Collected data were analyzed using chi-square, independent t-test and ANCOVA with the statistical package SPSS 22.0 for Windows. Results: There was a significant improvement in communication skills, nursing performance confidence, team efficacy, and team performance scores in the SBE combined TBL group compared to the SBE group (t=2.45, p=.015; F=4.30, p=.040; t=3.06, p=.003; t=8.77, p<.001). However, there was no statistically significant difference in self-directed learning between the groups. Conclusion: SBE combined TBL compared to SBE is an effective teaching and learning method to enhance various positive educational outcomes for nursing students. Therefore, we suggest that future studies investigate the development of an integrated course in which team-based learning is applied to theoretical sessions and simulation-based training.

Purpose: Nursing students' competence in virtual simulation-based learning is a key factor in its success. This study explored the validity and reliability of a virtual-simulation-based learning competency self-evaluation tool for nursing students. Methods: Data were collected from a web-based survey. First, 11 nursing professors participated in a focus group interview, and 7 simulation education experts participated in the preliminary item content validity. The participants in these two aspects were not the same. Then, a preliminary survey was conducted with 15 fourth-year nursing students in I City. Next, based on these three efforts, a final survey comprising 20 evaluation items was developed. This survey was administered to third- and fourth-year nursing students at four nursing colleges in Korean provinces (Seoul, Gyeonggi, Gangwon, and Gyeongsan-do); 222 complete questionnaires were used for the final analysis. Further, Kirkpatrick’s evaluation model was used for four steps each of tool development and verification processes of the associated psychometric aspects, for a total of eight steps. An exploratory factor analysis was performed on the collected survey data, and verify the tool's validity and reliability. Results: Four factors comprising 15 items explained 66.59% of the variance: learning preparation and start-up (4 items), nursing assessment (3 items), data interpretation (3 items), and problem solving (5 items). The Cronbach's α of the tool was 0.74, and that of the factors ranged from 0.72 to 0.80. Conclusions: The tool's validity and reliability were demonstrated using established methodologies. This tool can be useful for evaluating Korean nursing students' virtual simulation learning competence.

Purpose: Clinical reasoning, which is based on an understanding of the pathophysiological mechanismsof diseases, is a core nursing competency that involves analyzing patient-related data and providingappropriate nursing practices. Simulation-based education is effective in improving clinical reasoningcompetencies and communication skills. This study evaluated the effectiveness of virtual simulation-basedlearning in improving the communication skills and clinical reasoning competencies ofundergraduate nursing students. Methods: This study used a single-group pretest and posttest quasi-experimentaldesign to evaluate the effectiveness of virtual simulation-based learning. Data werecollected from June to September 2020. Thirty-seven nursing students in their third and fourth yearsof study who understood the purpose of this study were selected as participants. The collected datawere analyzed using SPSS Statistics 25.0 and Winsteps 3.68.2. Results: The communication skills (t =?12.80, p < .001) and clinical reasoning competency (t = ?4.67, p < .001) of the undergraduate nursingstudents who participated in the virtual simulation-based learning program improved significantlyafter participation. Additionally, a Rasch model analysis revealed that the overall clinical reasoningcompetency of undergraduate nursing students improved. Conclusion: Virtual simulation-based learningprograms for nursing students should be developed and implemented.

Purpose: Simulation-based education combined with mastery learning is more effective than simulation-based education alone. This study aimed to evaluate its effectiveness with regard to both technical and non-technical skills of simulation-based mastery learning (SBML) in blood transfusion training among undergraduate nursing students. Method: A nonequivalent control group pretest-posttest design was used. Fifty-one second-year students at a college of nursing in W city, South Korea, who had not started clinical practice were selected by convenience sampling and allocated to either the experimental or control group using the zigzag method. SBML program was consisted of a diagnostic test, repeated learning and formative assessments for non-passers. All outcome variables were measured before and after completion of the program. Results: The experimental group showed significantly increased performance scores of blood transfusion as compared to the control group (z=29.50, p<.001), with better outcomes in number of students achieving minimum passing score (χ2 =20.07, p<.001), self-confidence (F=17.68, p<.001), and communication skills (z=166.00, p=.003). Conclusion: This program was effective for undergraduate students to better improvement in performance, self-confidence, and communication skills, which can ensure greater safety in the transfusion. The results suggest that SBML ensures skill acquisition for clinical practice through improved performances in both technical and non-technical skills.

The aim of this study was to determine effects of team-based simulation learning on team efficacy, interpersonal understanding, and problem solving ability of nursing students with a non-equivalent control group pretest-posttest design. Subjects were senior nursing students enrolled in a simulation course. A total of 91 participants were divided into an experimental group (n = 44) and a control group (n = 47). The former consisted of teams of three to four students who experienced 15 sessions of team-based simulation learning for 8 weeks, while the latter received sessions of individual simulation learning. A survey regarding team efficacy, interpersonal understanding, and problem solving ability was conducted for the two groups before and after the treatment. Collected data were analyzed using SAS 9.2. The experimental group with team-based simulation learning exhibited a significant improvement in team efficacy after learning compared to the control group with individual simulation learning (t = 3.63, p ≤ 0.001). The level of interpersonal understanding also increased after learning for both experimental and control groups. The between-group variation was insignificant. The level of problem solving ability was increased to a greater extent for the experimental group than the control group, while the increase for the experimental group was statistically significant(t = 3.43, p ≤0.001). Team-based simulation learning was shown to be an effective learning method to enhance the team efficacy, interpersonal understanding, and problem solving ability of nursing students.

본 연구의 목적은 SIM-PBL이 간호대학생의 정보활용능력, 자기주도적 학습능력, 학업적 효능감에 미치는 효과를 규명하기 위함이다. 대상자는 한국의 일개 대학교 간호학과 4학년 학생 81명이었다. SIM-PBL은 4주 동안, 주 1회(150분) 제공하였고, 교육 전후에 구조화된 설문지를 활용하여 정보활용능력, 자기주도적 학습능력, 학업적 효능감을 조사하였다. 교육 후에 정보활용능력의 하부영역 중 정보통합(p=.030), 정보표현(p=.003) 및 정보윤리(p=.016) 영역의 능력이 향상되었다. 그러나, 자기주도적 학습능력과 학업적 효능감은 교육 후에 변화가 없었다. SIM-PBL은 간호대학생의 정보활용능력을 향 상시키는데 효과적인 교수법임을 확인하였다. 앞으로, 신뢰성 높은 유용한 정보를 윤리적으로 활용할 수 있도록 돕는 SIM-PBL 교육방안이 필요하다.

The objective of this study was to determine the effects of simulation education with problem-based learning (SIM-PBL) on information literacy, self-directed learning ability, and academic self-efficacy of nursing students. The subjects were 81 fourth-year nursing students attending a university in Chungcheongnam-do, Korea. SIM-PBL was provided once per week (150 minutes each) for four weeks, and a structured questionnaire was used to survey information literacy, self-directed learning ability, and academic self-efficacy before and after educational training. After completing the four-week program, abilities in the sub-items of information literacy, such as information integration (p=.030), information expression (p=.003), and information ethics (p=.016) were improved. However, no differences in self-directed learning ability and academic self-efficacy were noted. Findings confirmed that SIM-PBL is an effective teaching method for improving the information literacy of nursing students. Therefore, it is necessary to come up with an SIM-PBL education plan for utilizing reliable and useful information ethically.

This paper discusses the performance of linear regression, regression tree, support vector regression, and ensemble learners in modelling airflow between two spaces based on accuracy and training time. To obtain training data, different scenarios from an existing computational fluid dynamics (CFD) model are simulated via transient analysis using Cradle scSTREAM. The raw dataset is transformed to having time step sizes of 2.5s, 5.0s, and 50.0s. Feature scaling is also employed on the each data set using both min-max scaling and z-score methods for a total of 9 datasets. Hyperparameters according to machine learning (ML) algorithms are varied such that 15 ML models across the four algorithms are developed. The results show that the regression trees perform the best over all other algorithms, with all models maintaining R2 values above 0.95 at the different datasets. On the other hand, as expected, all linear models demonstrated poor performance compared to nonlinear models. Data resolution affects model accuracy and training time, with accuracy declining slightly as time step size increased. It is also found that there is no significant effect of feature scaling. Lastly, ML models yield substantially cheaper simulation costs than CFD to simulate airflow.

Purpose: This study aimed to examine the mediating effect of teamwork on the relationship between immersion in simulations and clinical competency among nursing students. Method: A total of 173 nursing students who participated in simulation-based learning were included. Data were analyzed using descriptive statistics, t-test, ANOVA, Pearson’s correlation coefficients, and PROCESS Macro Model 4. Results: Clinical competency differed significantly according to satisfaction with clinical practice, previous semester’s GPA, major satisfaction, team relationships, level of preparation, and adequacy of pre-orientation. Mean scores were 4.27±0.51 for learning immersion in simulation, 4.53±0.49 for teamwork, and 4.47±0.49 for clinical competency. All the variables showed significant positive correlations. Learning immersion in simulation had both direct and indirect effects on clinical competency through teamwork. Bootstrapping confirms that teamwork partially mediats this relationship. Conclusion: Learning immersion in simulations was significantly associated with clinical competency and teamwork played a significant mediating role. Educational strategies should promote immersion and teamwork to improve clinical competency.

Purpose: The purpose of this study was to investigate the effectiveness of pre-briefing in simulation-based learning on nursing students’ satisfaction with simulation. Method: A quasi-experimental post-test study was applied with 174 senior nursing students at a private university in South Korea. The experimental group (n=88) underwent a pre-briefing program, whereas the control group (n=86) did not. During pre-briefing, students had time to study simulation scenarios, discuss nursing processes related to simulation scenarios, and experience a simulation environment before simulation practice. Satisfaction scores were measured using the Satisfaction with Simulation Experience scale(SSE). Results: The mean scores in satisfaction with simulation were higher in the experimental group than in the control group, and the difference was statistically significant (t=-4.23, p<.001). Conclusion: This study emphasizes that pre-briefing in simulation-based learning is important in increasing students’ satisfaction and should be included in the planning of simulation-based learning programs.

Purpose: This study was conducted to identify effects of debriefing based on the clinical judgment model for nursing students on their knowledge, skill performance, clinical judgment, self-confidence and learner satisfaction during simulation based end-of-life care (ELC) education. Methods: Simulation based ELC education was developed in six steps as follows: selection of learning subjects and objects, development of learning tools, a trial run of simulation-based education, students' skill training, and evaluators' training. Forty-eight senior nursing students (25 in the experimental group and 23 in the control group) participated in the simulation-based ELC education using a high-fidelity simulator. Debriefing based on the clinical judgment was compared with the usual debriefing. Results: ANCOVA showed that there were differences in knowledge (F=4.81, p=.034), skill performance (F=68.33, p<.001), clinical judgment (F=18.33, p<.001) and self-confidence (F=4.85, p=.033), but no difference in satisfaction (t=-0.38, p=.704) between the experimental and control groups. Conclusion: This study found that debriefing based on the clinical judgement model is effective for supporting nursing students for reflecting on clinical judgment and improving their diverse competencies in complex clinical settings such as ELC.

Purpose : The purpose of this study was to identify the attributes, antecedents, and consequences of the transition of simulation-based learning (SBL) in nursing schools. Methods : The study was conducted in accordance with Walker and Avant's conceptual analysis process. We searched MEDLINE, CINAHL, EMBASE, Google Scholar, and RISS (Korean Education and Research Information Service) databases, resulting in nine studies for an in-depth review. Results : The attributes of transition of SBL include (1) preparing for a professional role, (2) practicing in a real clinical setting, and (3) progressing toward expected competency. Antecedents of the concept include novice status, changing roles, clinical experience in controlled settings, and expected competency in the clinical setting. Conclusion : The transition of SBL includes the important feature of progression toward expected competency. Further research is needed to identify graduate nurses' experiences during this transition to establish a strategy for improving it and developing a measurement tool that reflects attributes of the concept.

Purpose: The purpose of this study was to examine the effects of simulation-based learning on the knowledge about and performance confidence in the nursing care of children with asthma. Methods: A one-group pre- and post- study design was used. A total of 70 nursing students participated in the study. In groups of five, the participants experienced simulation-based learning during their child health nursing practicum. The given scenario was about nursing care for children with asthma. The simulation learning was provided for 3 hours, and included a group discussion before the simulation and a debriefing. Results: After the simulation, knowledge about and performance confidence in the nursing care of children with asthma significantly increased. The nursing students reported a high level of satisfaction with the simulation-based learning. There was a significant positive correlation between knowledge and performance confidence. Conclusion: Simulation-based learning was effective for nursing students in the nursing care of children with asthma. Our results suggest utilizing this new way of learning to strengthen the clinical experience of child health nursing in nursing students.

이 연구는 간호학과 학부 과정에서 경험한 시뮬레이션 학습이 신규간호사의 문제해결과정과 임상수행능력에 미친 영향을 파악하기 위한 서술적 조사연구이다. 연구 대상자는 학부과정에서 시뮬레이션 학습 경험이 1회 이상 있으며 임상 경력 12개월 미만의 신규간호사 202명이다. 연구를 통해 학부에서 경험한 시뮬레이션 학습의 횟수와 신규간호사의 문제해결과정 및 임상수행능력에 미친 영향 간에는 유의미한 상관관계가 없었으며, 시뮬레이션 학습의 설계와 문제해결과정 및 임상수행능력에 미친 영향 간에는 유의미한 양의 상관관계가 있는 것으로 나타났다. 연구 대상자들이 경험한 시뮬레이션 학습의 설계를 군집분석으로 유형화하여 문제해결과정 및 임상수행능력에 미친 영향의 차이를 분석한 결과에서도 유의미한 차이를 나타냈다. 이 연구를 통해 학습의 효과를 향상하기 위해서 시뮬레이션 학습의 설계가 중요하다는 점을 확인하였으며, 효과적인 운영을 위한 기초 자료로 활용할 수 있을 것으로 기대한다. 추후 학부 과정의 시뮬레이션 학습이 간호사의 임상 능력에 미치는 영향에 대하여 보다 면밀한 평가가 이루어질 필요가 있다.

This study was a descriptive research investigating the impact of simulation-based learning on the problem solving process and clinical competence of new nurses. The 202 participants were new nurses who have provided nursing care for less than 12 months have experienced simulation-based learning more than once in their undergraduate courses. This study found that the number of times participants have experienced the simulation-based learning had no correlation with their problem solving process and clinical competence, but simulation design features correlated with their problem solving process and clinical competence. The results of clustering analysis that examined differences in the effects on problem solving process and clinical competence by classifying simulation design features by clustering also showed significant differences. This study has confirmed the importance of simulation design to simulation-based learning in nursing education. We hope that the findings of the study will be used for effective operation of simulation-based learning. In the future, objective assessment methods will be required to evaluate the effects of simulation-based learning provided in undergraduate courses on nurses' clinical competence.

Purpose: This study aimed to examine the effects of simulation-based learning on the critical thinking disposition, communication confidence, and performance confidence in nursing care for children with fever. Methods: A one-group pre- and post-test design was used. A total of 59 nursing students participated. Results: The results of this study showed that the effectiveness of simulation-based learning showed statistically significant improvement in critical thinking disposition, communication confidence and performance confidence. Conclusion: The findings indicate that simulation-based learning in the nursing care of children with fever may be an effective teaching-learning method for nursing students.

This study aimed to develop a simulation-based scenario for pediatric nursing based on Kawasaki disease and to evaluate its impact on nursing students' knowledge, critical thinking disposition, self-efficacy, stress levels, and clinical performance. Methods: The scenario template was developed using the ADDIE model based on the National League for Nursing/Jeffries Simulation Framework. A quasi-experimental, single-group pretest-posttest was used. The study was conducted between March 3 and April 18, 2025, with 64 fourth-year nursing students. Self-report questionnaires were used to assess knowledge, critical thinking disposition, and selfefficacy. Stress was measured using physiological indicators, and clinical performance after the simulation was independently evaluated by both the instructor and researcher. Results: The scenario template required approximately six hours, and the simulation scenario operated for 20 minutes. Evaluation of the simulation`s effectiveness showed significant improvements in knowledge of Kawasaki disease (t=-6.96, p<.001), critical thinking disposition (t=-4.08, p<.001). The average clinical performance score was 64.81±6.61 out of a total of 86 points. Conclusion: The simulation-based learning method using the developed Kawasaki pediatric nursing scenario template was shown to be effective in enhancing clinical performance among nursing students. It may serve as a valuable educational tool for pediatric nursing education and future simulation-based training programs.

본 연구는 문제중심학습 연계 시뮬레이션 기반 교육을 개발하고 적용하여 간호학생의 학습동기, 학습전략과 학업성취도에 미치는 효과를 검증하고자 시도하였다. 연구대상자는 간호학과 4학년 학생 69명으로 2015년 9월부터 10월까지 문제중심학습 연계 시뮬레이션 기반 교육을 개발, 적용하고 학습동기, 학습전략, 학업성취도를 설문조사하였다. 연구결과, 문제중심학습 연계 시뮬레이션 기반 교육 후 통제 동기(외재 동기)는 감소하고, 자율성 동기(확인된 동기, 내재 동기)는 증가하였으며, 자원관리전략 활용 정도가 향상되었다. 학업성취도(학업성과, 교육만족도) 모두 확인된 동기와 학습전략(인지전략, 메타인지전략, 자원관리전략)과 정상관관계가 있었다. 결론적으로 문제중심학습 연계 시뮬레이션 기반 교육은 간호대학생의 자율성 동기를 증진하고 자원관리전략의 활용 정도를 향상시키는데 효과적인 교육전략으로 볼 수 있다. 문제중심학습 연계 시뮬레이션 기반 교육을 다양한 간호 상황에서 적용하여 학습 관련 변인에 영향을 미치는 요인과 매개변수를 파악하는 연구가 필요하다.

This study was conducted in order to develop an education program based on simulation with problem-based learning, to apply it to nursing students, and to examine its effects on the students' learning motivation, learning strategy, and academic achievement. The subjects of this study were 69 seniors majoring in nursing. Education based on simulation with problem-based learning was applied to the students from September to October in 2015, and then a questionnaire survey was conducted on their learning motivation, learning strategy, and academic achievement. According to the results of this study, the education based on simulation with problem-based learning reduced the nursing students' other-directed motivation (external motivation), increased their self-regulation motivation (identified motivation, intrinsic motivation), and improved their use of resource management strategies. In addition, academic achievement (academic performance, and educational satisfaction) was in a positive correlation with identified motivation and learning strategies (cognitive strategy, meta cognitive strategy, and resource management strategy). In conclusion, education based on simulation with problem-based learning was found to be an effective education strategy for enhancing nursing students' autonomous motivation and improving their use of resource management strategies. Thus, it is necessary to promote the application of simulation with problem-based learning in various care situations and to study factors and parameters influencing learning related variables.

본 논문은 지적장애학생을 대상으로 몰입형 가상현실 기반 모의학습 프로그램이 편의점 이용에 필요한 의사 소통 능력과 학습태도에 미치는 효과를 파악하는데 목적이 있었다. 이를 위해, 지적장애 고등학생 23명을 연구 대상으로 선정하여, 실험집단에 11명과 통제집단에 12명을 배치하였다. 실험집단에는 HMD 기반의 몰입형 가상현실 기법을 활용한 편의점 모의학습 프로그램을 적용하였고, 통제집단에는 전통적인 중재 프로그램을 적용하였다. 프로그램은 해당 학교의 여름방학 동안 주 5회씩 4주간 실시되었으며, 1회 중재 시간은 40분이었다. 프로그램의 효과를 파악하기 위하여 사전-사후 평가를 실시하였고, 독립표본 t검증을 통해 분석하였다. 연구 결과, 실험집단이 통제집단 보다 의사소통 능력이 향상되었고, 학습태도 또한 더 긍정적으로 나타났다. 이는 지적장애학생의 언어 및 의사소통 교육에 있어 몰입형 가상현실을 활용한 모의학습이 유용한 교수-학습 방법으로 활용될 수 있음을 시사한다.

The purpose of this study was to identify the effects of an immersive virtual reality-based simulation learning program(IVR-SLP) on the communication competence and learning attitude of students with intellectual disabilities. To do this, 23 participants with intellectual disabilities were selected from 2 special schools. 11 students were placed in an experimental group and 12 students in a control group. An IVR-SLP, focusing on possible situations in a convenience store, was implemented within the experimental group and a traditional intervention program was implemented within the control group. The programs were conducted 5 times per week for 4 weeks and each session lasted approximately 40 minutes. Evaluations were carried out by using a pre- and post- test, and the results of the evaluation were analyzed using the independent t-test. The results of this study indicated that the communication competence of the experimental group showed greater improvement than that of the control group. In addition, the learning attitude of the experimental group became more positive than that of the control group. This implies that the immersive virtual reality-based simulation learning program can be a very effective tool for teaching language and communication skills to students with intellectual disabilities.

Purpose: Improving students’ self-confidence is an important strategy in simulation learning. This study aimed to identify the factors influencing students’ self-confidence in simulation learning based on the Jeffries Simulation Framework. Method: A cross-sectional survey was conducted with 140 senior nursing students’ at a university, and data were collected through self-reported questionnaires. Data on students’ self-confidence were collected for student/ facilitator factors (satisfaction on major, overall grade average, and facilitator satisfaction), educational practice factors (active learning, collaboration, diverse ways of learning and educational goals), and simulation design characteristics factors (objectives/information, support, problem solving, feedback, and fidelity). Data were analyzed using an independent t-test, one-way ANOVA, Pearson’s correlation, and hierarchical multiple regression analysis. Results: The regression model had an adjusted R2 of .61, indicating that education goal, active learning, facilitator satisfaction, and fidelity were significant predictors of students’ self-confidence in simulation learning. Conclusion: To increase students' self-confidence with simulation learning strategies, it is necessary to design lessons that include educational goals, active learning, improved student satisfaction with the facilitator and fidelity based on the Jeffries Simulation Framework.