Simulation-Based Mastery Learning to Facilitate Transition to Nursing Practice : Nurse Educator

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Simulation-Based Mastery Learning to Facilitate Transition to Nursing Practice

Tan, Kimberly-Ann Zi Ying BSc (Nursing) (Hons); Seah, Betsy PhD; Wong, Lai Fun MEd; Lee, Cindy Ching Siang MEd; Goh, Hongli Sam PhD; Liaw, Sok Ying PhD

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doi: 10.1097/NNE.0000000000001224


Nursing graduates are expected to be work-ready, demonstrate clinical competence, and practice safe care independently at their workplace upon completion of their undergraduate education.1 The transition from student to the first few months of a nursing career is a critical yet highly stressful period for professional adjustment.2 In addition to the new graduate transition programs provided at clinical workplaces, academic nursing institutions play a critical role in transitioning final-year nursing students to practice.3

The integration of immersive simulation-based learning in the nursing curriculum is an approach to expose nursing students to realistic clinical scenarios and provide practical opportunities to gain key experiential knowledge and prepare them for real health care settings.4 It is an instrumental learning tool used alongside clinical practice to present various complex clinical situations.5 A ward-based simulation program reflecting the complexity of actual clinical practice allows nursing students to practice a wide range of clinical skills, including collaboration, decision making, and work delegation. This program was found to prepare and facilitate final-year nursing students for their clinical practicum in transitioning to graduate nurse practice.6,7 However, apart from simulation learning, the program did not focus on ensuring simulation performance standards, which required the learners to reach a predetermined level of simulation performance before transitioning to clinical practice.

The incorporation of mastery learning model into simulation, known as simulation-based mastery learning (SBML), has gained popularity to ensure that all final-year trainees achieve a defined proficiency level within a stipulated period.8 SBML is aligned with competency-based education as it features deliberate practice, formative assessment, progressions, and feedback to help all individual learners achieve mastery of learning outcomes within a stipulated time frame.9 The SBML model proves particularly useful for transitioning undergraduate students or newly graduated nurses to prepare them for workplace practice.1,10 The model prescribed critical elements for enhancing existing simulation-based education, improving clinical skills, and achieving positive downstream effects on clinical practice among medical graduates.11 However, most studies that examined SBML focused on one particular skill rather than the impact of SBML at a program level and failed to consider multiple competencies required to manage a real-life scenario.12 In addition, its effectiveness remains underevaluated in nursing education.13 As performance is context-related, Willi et al12 recommended understanding the transfer process from simulation to actual practice before conducting outcome studies. Thus, a qualitative approach was employed in this study to understand this process by evaluating nursing students' perspectives on the impact of SBML on their transition to clinical practice.


Simulation-Based Mastery Learning Program

The SBML program was carefully implemented prior to students taking a 10-week clinical practicum. The program was conducted for about 150 final-year nursing students over a period of 3 weeks, with each student undergoing about 18 hours of simulation as presented in the Figure. A set of features identified by McGaghie et al14 for mastery learning was applied in developing and implementing the SBML program. These processes included the following: (1) establishing the learning outcomes; (2) conducting the simulation-based educational strategies with deliberate practice and feedback; (3) setting a minimum pass score using a competency-based assessment tool; (4) conducting baseline and formative clinical assessment using team-based objective structured clinical examination (OSCE); (5) determining the advancement to the next educational unit; and (6) determining the engagement of additional practice to reach mastery standard.

Eighteen-hour simulation-based mastery learning program. OSCE indicates objective structured clinical examination.

Simulation-Based Educational Strategies

The goal of the SBML program was to facilitate students' transition to clinical practice as a registered nurse. As shown in the Supplemental Digital Content Table (available at:, the learning outcomes included meeting the core competencies on patient care, communication, clinical procedure, safe practice, clinical reasoning, and professionalism. These were developed on the basis of the Singapore Nursing Board's core competencies of registered nurse competencies and the need assessment from employer surveys of nursing graduates' clinical performance. A variety of simulation-based educational strategies, including high-fidelity simulation, procedural simulation, and computer-based screen simulation, were employed to achieve the learning outcomes.

Simulated patients (SPs) and high-technological patient manikins were used in the high-fidelity simulation to reproduce a realistic clinical environment. Multiple case scenarios that reflected the care continuum for 2 patients were used in the simulation learning to engage the students on common nursing tasks of a qualified registered nurse (refer to Supplemental Digital Content, Table, available at: Using an experiential-based learning approach, the students participated in the 8-hour high-fidelity simulation over 2 days in small groups of 10 to 12 conducted in the simulation laboratory. The students switched roles as observers or role players to care for the 2 ward patients. Each scenario lasted between 15 and 20 minutes and was followed by a debriefing session.

Prior to high-fidelity simulation, the students were given an opportunity to engage in procedural simulation through self-directed learning (SDL) activity in the simulation laboratory to practice their psychomotor skills with feedback from the facilitators. They were also given access to computer-based simulation created by the school to develop their clinical reasoning skills for assessing and managing patients with clinical deterioration using the Airway, Breathing, Circulation, Disability, and Expose/Examine (ABCDE) systematic approach and for reporting on the deteriorating patient using Identify, Situation, Background, Assessment, and Recommendation (ISBAR) mnemonics. The procedural and computer-based simulation modalities prepared the students to proceed to a more complex set of skills and behaviors to care for a group of patients in the high-fidelity simulation.

Team-Based Objective Structured Clinical Examination

The team-based OSCE was conducted for both formative and summative assessments. The formative assessment served as a baseline assessment for students to determine the level of difficulty and receive feedback on their initial performance. The summative assessment was conducted at the completion of the simulation-based learning to determine the achievement of the learning outcomes. The assessment determined the student's progression to undertake the transition-to-practice clinical practicum based on meeting the minimum passing standard. Students who did not meet the minimum passing standard were provided additional practice and were reassessed for their competency. A competency-based assessment tool that was previously developed on the basis of 6 domains of core competencies of a registered nurse was adapted to set the minimum passing score. Each domain was rated using a 9-point global rating scale, segmented by 3 descriptors: unsatisfactory (1-3), satisfactory (4-6), and outstanding (7-9). A rating of 4 for each domain was defined as meeting the minimum passing score. Prior to students' clinical assessment, faculty raters were given the training to calibrate and clarify their scoring to ensure scoring reliability.

The team-based OSCE was conducted using 2 stations, with scenarios developed in consideration of the learning outcomes. The scenarios included a sequence of events that required the team to perform a nursing assessment using the ABCDE approach, apply decision-making skills for data interpretation, initiate and perform procedural skills, communicate with a doctor and a team member using ISBAR, and manage workload and delegate task. As illustrated in the Supplemental Digital Content Figure (available at:, the students were teamed in pairs to work at the 2 stations while being observed and evaluated by 2 assessors. The pair took turns to play the role of an in-charge nurse or an assist nurse. While the in-charge nurse was assessed on team communication, critical thinking, management of care, and professionalism, the assist nurse was assessed on technical skills and patient safety aspect of the procedure. The time allocated for each pair at the 2 stations was 60 minutes.

Design and Sample

An exploratory, qualitative research design was employed to evaluate the SBML program after approval from the Department of Ethics Review Committee. A purposive sampling technique was used to recruit final-year nursing students at a nursing school in Singapore who were enrolled in a bachelor of science (nursing) (honors) program. Undergraduate nursing students (n = 28) who met the inclusion criteria voluntarily agreed to participate in the study. They were allocated into 4 focus groups consisting of 6 to 8 participants each. They were given a participation information sheet that stated the study's objectives and the anonymity and confidentiality of their data.

Data Collection

The focus groups were conducted after the completion of the Transition to Professional Practice Experience clinical practicum. They were conducted in conducive meeting rooms located in the university, and the sessions were facilitated by an experienced research team member (S.Y.L.) using a semistructured interview guide in the presence of a notetaker who was the student researcher (K.-A.Z.Y.T.). The interview guide was validated and revised after conducting a pilot test on a new graduate before the focus group interviews could be performed. Prior to each interview, written consents were obtained from all the participants. Each focus group lasted between 60 and 90 minutes, with a summary given by the notetaker to seek further clarification. All focus group interviews were audio-recorded for verbatim transcription.

Data Analysis

The data were subjected to a thematic analysis. The transcripts were read several times and coded by 2 researchers (K.Z.Y.T. and L.F.W.). Codes with similar meanings were consolidated to form emergent subthemes, and similar subthemes were then merged to form themes. The researchers compared their emergent themes and reorganized them through merging and regrouping. Field notes that were taken down during the interview were also referred to during the researchers' discussion. Any disagreements were discussed with a third researcher (S.Y.L.) to reach a consensus on the final set of themes.


A total of 28 nursing students between the ages of 21 and 25 years were recruited into this study. The majority of the participants were female (85.71%) and Chinese (82.1%). Three themes emerged from the data analysis: authenticity of simulations; self-efficacy in clinical practice; and application of cognitive tools.

Authenticity of Simulation

As simulations provide opportunities to replicate activities and environments, many participants reported similarities between their simulations and clinical experiences and thus enabling them to handle real-life clinical experience. One participant said: “I saw some similarities, like they rang a bell or I've done them in simulation before and I knew what to do.”

Several participants mentioned that the incorporation of SPs, which mimicked actual clinical experience, provided a more authentic experience. However, in the simulation-based education, they were only given the opportunity to manage workload and perform care delivery of 2 patients. Participants highlighted that, in reality, the clinical work is more complex than what was portrayed in the simulated lesson as nurses care for more patients, requiring them to be well-equipped with better management skills. One participant stated: “In the simulation there were only 2 patients. But in the real ward setting there are like 6 patients. So in terms of time management and resource management, I don't really feel they were integrated in the simulation program.”

In addition to SPs, simulated physicians and enrolled nurses (known as licensed practical nurses in the United States) were included in the simulation to provide interprofessional and intraprofessional team training. However, some participants felt that the authenticity in the team-based simulation was lacking due to the unrealistic portrayal of the different roles and the inability to replicate hierarchical relationships. A participant highlighted that the simulation portrayed nurses as having the authority to make decisions; however, this does not reflect the reality as the physicians are often the main decision makers: “The simulation actually empowered me to make a lot of decisions by myself. But when we went to the hospitals, the decision making became the doctors.”

Self-efficacy in Clinical Practice

Although most participants agreed that the use of SBML to prepare for clinical practice has its limitations, they acknowledged that it built their self-efficacy through repetitive skills practice and developed their motor and procedural skills. Many participants reported that the opportunity to practice a wide range of clinical skills in the simulation enhanced their readiness to perform the skills in a real-life clinical setting. One participant stated:

I wasn't very confident in all of the basic skills ... but after that SDL session where we practiced every possible skill that we should know, I was very satisfied with my performance during clinical practicum when I was asked to perform nasogastric tube insertion.

Several participants also highlighted the importance of team-based OSCE, which provided them feedback to enhance their self-efficacy in clinical skills. One participant also described how the feedback led to better retention of knowledge:

It [team-based OSCE] built up our confidence also because at the end of the assessments I'm sure all of us are able to pinpoint where did we go wrong ... we remember it better, and when it comes to the real situation, we can remind ourselves of the assessment.

In addition to repetitive practice for procedural skills, some participants reported that the self-efficacy gained from practicing the simulation scenario impacted their clinical experience as they were able to recognize and respond to patient deterioration. One participant said: “During my clinical practice, I had a lot of deterioration cases, and the OSCE actually did prepare me quite well for how to handle deterioration cases. If we didn't have OSCE to prepare us, we would definitely become traumatized.”

Application of Cognitive Tools

The ABCDE framework applied during the simulations provided a cognitive aid to facilitate nursing students' abilities to assess and manage clinical deterioration in clinical practice. One participant captured this by saying: “I think OSCE was great in helping me to like drill all the ABCDE into my brain.”

The participants also reported that the opportunity to practice using the ISBAR framework during the simulation facilitated communication with physicians in their clinical practice. One participant shared her encounter of using ISBAR to convey critical information to physicians for the first time: “I think it was a bit nerve-wracking because it was my first time calling doctors.... I think the practice really helped me to make my message very concise.”

The 5 rights of medication management, which were reinforced in the simulation, were useful to some participants as they were ingrained in them; hence, they could perform the safety checks effortlessly in their clinical practice. One said: “The safety checks ... the whole SDL reinforced the steps. Then when we went to the hospital, it was automatic for us to just go and do all the steps instead of cutting the steps.”


The mastery learning features identified by McGaghie et al14 were incorporated into developing and implementing the SBML program to facilitate final-year nursing students' transition to the clinical practice. In addition, the evaluation outcomes on the impact of SBML on clinical practice identified the educational benefits of the program and provided strategies to optimize its effectiveness for better transfer of learning from simulation to clinical practice.

A key educational benefit of the program is the evidence of knowledge transfer. As reported by the nursing students, the authenticity of the simulation resembled real patients and allowed them to apply what they have learnt to clinical practice. According to Herrington et al,15 the authenticity of the learning environment to reflect the knowledge and skills required in a clinical setting provides deep and meaningful learning. The degree of fidelity in the simulation, including functional, physical, psychological, and sociological, is critical in creating meaningful simulations.16,17 The findings in this study demonstrated the use of high fidelity of simulation scenarios and SPs. The simulation scenarios were constructed on the basis of actual clinical practices to achieve functional fidelity, and the SPs were trained to provide emotional and stress-inducing situations to achieve psychological fidelity. Despite best efforts to achieve high fidelity, the scope and complexity of the simulation, which included evolving scenarios and workload allocation, could not replicate the actual demands of real-world nursing tasks. Thus, future simulations could introduce an increased patient load with evolving scenarios to further increase the fidelity of the simulated clinical immersion learning activity.

In contrast to participants' views on the SPs and scenarios, they revealed that the inclusion of interprofessional teamwork within the simulation scenarios did not seem to replicate real clinical dynamics. In this simulation program, the team training is solely based on the application of team and communication strategies (eg, ISBAR), which may have ignored the sociocultural factors affecting the collaborative practice. In addition, the faculty and peers were made to role-play different team members, which may not be accurately presented. The term “sociological fidelity” was introduced by Sharma et al,18 who emphasized the need for a simulation scenario to address the sociological issue (eg, power, hierarchy, professional boundaries) to reflect the reality of interprofessional care. Our findings suggested a need to increase the sociological fidelity in the design and practice of interprofessional simulated learning if its transferability to collaborative practice has to be improved. To provide sociological context to learning, there is a need to incorporate interprofessional participants and faculty members within an interprofessional simulated learning.17 It should also include real-life interprofessional tensions, hierarchies, and boundaries.18

The findings strongly highlighted that the practice of clinical skills using the simulation program built the students' self-efficacy in clinical practice. In this study's simulation, practice sessions for essential procedural skills were mapped across the SBML program to allow students to engage in focused repetitive skills practice and receive instructors' feedback in the laboratory. These procedural skills were also integrated and practiced alongside other skills, such as teamwork in the simulated clinical immersion using an instructor-facilitated experiential learning approach. The competency of selected procedural skills was evaluated in the team-based OSCE. Given the positive outcomes of the nursing students' self-efficacy in clinical practice, this study highlighted the relevance and effects of deliberate practice in simulation education for the nursing students' transition to clinical practice.19,20

In addition to procedural skills performance, our study identified the effective use of deliberate practice in the simulation program to develop students' performance in recognizing and responding to a more complex case of a deteriorating patient. The deteriorating patient scenarios were not only incorporated into the simulation learning and assessment to provide hands-on practice but also incorporated into the computer-based simulation. The concept of deliberate practice was introduced into the instructional design of the computer-based simulation in the forms of multiple scenarios for repetitive practice, self-debriefing checklists for performance feedback, and online quizzes for self-assessment.21 In all, the use of hands-on and computer-based simulation as a blended learning strategy for deliberate practice appears to improve the students' clinical performance and judgment in recognizing and responding to a deteriorating patient in the clinical setting. This qualitative finding supported an earlier quantitative study on the use of both virtual simulation and high-fidelity simulation to achieve higher level of mastery through deliberate practice.22

The cognitive tools applied and practiced in the simulation program significantly impacted the students' clinical practice. Derived from best practice guidelines,23 these served as prompts to guide nurses to perform nursing tasks, including recognizing and responding to a deteriorating patient's situation using ABCDE, communicating to a doctor using ISBAR, and administering medication using 2 patient identifiers and 5 rights. In addition, the use of cognitive aids (eg, algorithms, checklists, and mnemonics) in health care has been shown to guide clinicians through a sequence of steps and preventing them from omitting critical actions.21,23 In this study, cognitive tools to guide clinical practice lend support to previous studies on best practices for using simulation to develop mental models underlying performances.24

A strength of this study was the evaluation of the SBML program based on the students' real-life clinical experience that enabled them to compare and contrast their simulation and real-life practice. However, the data collected and the findings in this study were limited to students who were willing to participate; hence, the findings may not be representative of all students.


An SBML program was developed and implemented to facilitate final-year nursing students' transition to clinical practice. The qualitative evaluation of the impact of simulation program on clinical practice highlighted the complexity of real-life clinical practice that called for the educators to create high-quality SBML that could foster better transfer of learning to real-life settings. These included focusing on the fidelity and authenticity of the simulation, providing deliberate practice for procedural skills, and applying relevant cognitive tools to facilitate mental model formation. The resources including faculty time to facilitate simulation learning and assessment were clearly intensive. This evaluation study prepares us for the better use of SBML in the subsequent implementation before we embark on more rigorous outcomes studies including long-term learning outcomes.


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clinical practice; mastery learning; simulation; simulation-based mastery learning; transfer of learning; transition to practice

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