Introduction
The PICO question for this study is: “In training nursing students how does using simulation compared to traditional classroom instruction affect their knowledge, skills and confidence within 4 months?” The literature review conducted to obtain relevant articles for this question focused on databases such as EBSCOHost and Google Scholar. In total 7 articles were retrieved and 5 selected for use. Search terms and keywords used to obtain the articles were: “simulation,” “nursing education,” “high-fidelity simulation training,” “instruction effectiveness,” and “simulation vs. traditional classroom.” The articles selected were:

· Briscoe, Mackay and Harding’s (2017) “Does Simulation Add Value to Clinical Practice?: Undergraduate Student Nurses' Perspective”

· Kapucu’s (2017) “The Effects of Using Simulation in Nursing Education: A Thorax Trauma Case Scenario”

· Afrasiabifar and Asadolah’s (2019) “Effectiveness of Shifting Traditional Lecture to Interactive Lecture to Teach Nursing Students”

· Unver et al.’s (2018) “Integrating Simulation Based Learning into Nursing Education Programs: Hybrid Simulation”

· Fernandez-Ayuso et al.’s (2018) “The Modification of Vital Signs According to Nursing Students’ Experiences Undergoing Cardiopulmonary Resuscitation Training via High-Fidelity Simulation: Quasi-Experimental Study”

This paper will provide a synthesis of the literature collected for this project.

Literature Synthesis

The study by Briscoe et al. (2017) conducted a Level VI study using the qualitative descriptive approach to obtain data from a focus group consisting of 10 nursing students. The nursing students discussed and gave their opinion on the role that simulation plays in preparing a nursing student for the real world of nursing, and the participants all felt that simulation exercises were valuable methods of learning. One of the problems that the researchers found, however, was that nursing students were generally unaware of or uninterested in the learning outcomes of simulation exercises. They were more interested in simply have the experience that simulation offered. Thus, even though prior research had noted that objectives are what help to guide the learning process, objectives had not played a significant part in the simulation experience for these nurses. The implications of this study are that it helps to show that nursing students welcome simulation as a way to gain experience, which is good for the EBP; however, what is bad for the EBP is that the study shows that simulation learning disconnected from awareness of learning objectives can prevent the maximum or desired effect of the educative process from being attained. This information is helpful to know for this EBP so that when the project is conducted and the PICO tested, the participants can be evaluated to see whether they are aware of the learning objectives associated with the simulation.

There were no evident factors in the article that might be detrimental to the study’s reliability or validity. The method was clearly described and the participants’ backgrounds were sufficiently explained. The focus group measured what the study aimed to measure and as the method was sufficiently described it would be possible to duplicate it in order to see if a similar set of findings was obtained from a similar focus group. Potential limitations of the study were that all the nurses came from one nursing school, which means the findings might reflect more on that one school’s methods of teaching—i.e., not connecting the learning objectives to simulation—than on the whole of the nursing school field in general (so possibly a reliability issue). A second limitation was the qualitative nature of the study and the fact that all descriptions were subjective and self-reported. No confounding variables were identified.

Kapucu (2017) conducted a similar Level VI qualitative study, though in this one the data was collected not by focus group but by the interview method. Seven nursing students participated and their views on the effectiveness of a high-quality hybrid simulation exercise were obtained. The strengths of this study were that the researcher was able...…The level is only that of a Level III, and while higher than a Level VI, of course, it still lacks the randomized-controlled trial characteristics that mark higher level studies. No confounding variables were identified, though there could be some other reasons for high anxiety: the researchers excluded students who were on medication for anxiety—but other factors were not discussed. Overall, study results showed that the students from both groups were made nervous by the simulation but that in general nerves were able to be calmed as the simulations went on and students began to feel more confident about what they were doing.

Conclusion

These studies all come together to inform the EBP project by providing insights into how simulations can impact students (i.e., by elevating stress levels), how types of simulation can distress or benefit certain types of students (i.e., some students may be happy with hybrid simulations—others may not feel it is realistic enough and thus may question its benefit), and how important it is to connect learning objectives to the simulation so that students know why the simulation is being conducted in the first place. Though students may be aware that the simulation itself is helpful because it provides experience for the nursing student, if they do not have a sense of the learning objective they are not receiving the fullness of the lesson. Thus for this EBP it is important that these findings be incorporated into the manner in which the EBP project is constructed so that participants are aware of the learning objective, so that the simulation is realistic as possible, and so that stress levels are not made into seeming like they are higher than they should be. This EBP Project can proceed, however, under the helpful guidance of these studies, assured that a hypothesis of finding simulation to increase students’ confidence will not be rejected.