Implications of clinical simulation in motivation for learning: scoping review

Henrique-Sanches, Barbara Casarin; Cecilio-Fernandes, Dario; Costa, Raphael Raniere de Oliveira; Almeida, Rodrigo Guimarães dos Santos; Etchegoyen, Federico Ferrero; Mazzo, Alessandra

doi:10.31744/einstein_journal/2024RW0792

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Review • Einstein (São Paulo) 22 • 2024 • https://doi.org/10.31744/einstein_journal/2024RW0792 copy

Implications of clinical simulation in motivation for learning: scoping review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To identify, synthesize, and analyze the scientific knowledge produced regarding the implications of using clinical simulation for undergraduate nursing or medical students' motivation for learning.

Methods:

The search for articles was conducted between July 28 and August 3, 2022, on the PubMed/MEDLINE, Scopus, Web of Science, and SciELO databases. The following was used for the search: P - undergraduate students attending Nursing or Medicine courses; C - motivation for learning, and C - skills and clinical simulation laboratory. The following research question guided the study: “What are the implications of clinical simulation on the motivation for learning of undergraduate students of nursing and medicine?” Of the 1,783 articles found, 13 were included in the sample for analysis. All stages of the selection process were carried out by two independent evaluators. The results were presented as charts and a discursive report.

Results:

The studies analyzed indicated the beneficial effects of clinical simulation on students' motivation, in addition to other gains such as competencies, technical and non-technical skills, knowledge, belonging, autonomy, clinical judgment, critical and reflective thinking, self-efficacy and decreased anxiety, self-management, and improvements in learning and learning climate.

Conclusion:

Clinical simulation provides a positive learning environment favorable to the development of technical and interpersonal skills and competencies, and raising the level of motivational qualities.

Keywords:
Motivation; Simulation training; Education, nursing; Education, medical; Learning; Learning health system

Authorship	Objectives	Materials and methods	Data collection instruments	Characterization of the clinical simulation used	Country, population, and sample size
Roh et al.(¹⁶16 Roh YS, Kim SS. Integrating Problem-Based Learning and Simulation: Effects on Student Motivation and Life Skills. Comput Inform Nurs. 2015;33(7):278-84.)	To assess motivation and life skills (communication, problem-solving, and self-direction) before and after interventions with clinical simulation and problem-based learning	Quasi-experimental, pre- and post-intervention (pre-test)	Motivated Strategies for Learning Questionnaire (MSLQ)(³⁰30 Pintrich PR. A manual for the use of the Motivated Strategies for Learning Questionnaire. Washington, D.C.; Education Resources Information Center; 1991.)	A simulated urgency and emergency scenario with a high-fidelity simulator	South Korea, 83 second-year undergraduate nursing students
Thoma et al.(¹⁷17 Thoma B, Hayden EM, Wong N, Sanders JL, Malin G, Gordon JA. Intrinsic motivation of preclinical medical students participating in high-fidelity mannequin simulation. BMJ Simul Technol Enhanc Learn. 2015;1(1):19-23.)	To compare intrinsic motivation related to participation in curricular clinical simulation sessions with predetermined learning objectives and extracurricular clinical simulation sessions with learning objectives determined by the students	Non-randomized crossover study	Intrinsic Motivation Inventory(³¹31 Ryan RM. Control and information in the intrapersonal sphere: an extension of cognitive evaluation theory. J Pers Soc Psychol. 1982;43(3):450-61.)	A simulated urgency and emergency scenario with a high-fidelity simulator	United States, 22 first-year undergraduate medical students
Fawaz et al.(¹⁸18 Fawaz MA, Hamdan-Mansour AM. Impact of high-fidelity simulation on the development of clinical judgment and motivation among Lebanese nursing students. Nurse Educ Today. 2016;46:36-42.)	To evaluate the impact of clinical simulation on clinical judgment and students' motivation	Multicenter, post-test, quasi-experimental, case-control study	Lasater Clinical Judgment Rubric;(³²32 Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing. J Nurs Educ. 2006;45(6):204-11.) Motivated Strategies for Learning(³⁰30 Pintrich PR. A manual for the use of the Motivated Strategies for Learning Questionnaire. Washington, D.C.; Education Resources Information Center; 1991.)	A simulated urgency and emergency scenario with a high-fidelity simulator	Lebanon, 56 first-year undergraduate nursing students
Jeppesen et al.(¹⁹19 Jeppesen KH, Christiansen S, Frederiksen K. Education of student nurses - a systematic literature review. Nurse Educ Today. 2017;55:112-21. Review.)	To explore the literature on the connection between teaching and learning strategies for nursing students to clarify which methods provide optimal learning outcomes	A systematic literature review that included quantitative and qualitative studies	Does not apply	Does not apply	Denmark, Nursing.
Park et al.(²⁰20 Park HR, Park JW, Kim CJ, Song JE. Development and validation of simulation teaching strategies in an integrated nursing practicum. Collegian. 2017;24(5):479-86.)	To evaluate the effects of clinical simulation on critical thinking, skills development, self-efficacy, and motivation for learning	Quasi-experimental, pre- and post-test study, with no control group	The Self-Efficacy Scale;(³³33 Sherer M, Maddux JE, Mercandante B, Prentice-Dunn S, Jacobs B, Rogers RW. The Self-Efficacy Scale: construction and Validation. Psychol Rep. 1982;51(2):663-71.) Instructional Materials Motivation Scale;(³⁴34 Keller JM. Development and use of the ARCS model of instructional design. Journal of Instructional Development. 1987;10(3):2-10.) and Institutional protocol for testing individual skills	A simulated urgency and emergency scenario with a high-fidelity simulator	South Korea, 69 fourth-year undergraduate nursing students
Sarikoc et al.(²¹21 Sarikoc G, Ozcan CT, Elcin M. The impact of using standardized patients in psychiatric cases on the levels of motivation and perceived learning of the nursing students. Nurse Educ Today. 2017;51:15-22.)	To assess the impact of using standardized patients in simulated psychiatric cases on students' levels of motivation and perceived learning, when compared to traditional teaching	Quantitative, randomized and controlled study, pre- and post-test	Motivated Strategies for Learning Questionnaire (MSLQ);(³⁰30 Pintrich PR. A manual for the use of the Motivated Strategies for Learning Questionnaire. Washington, D.C.; Education Resources Information Center; 1991.) Perceived Learning Scale;(³⁵35 Rovai AP, Wighting MJ, Baker JD, Grooms LD. Development of an instrument to measure perceived cognitive, affective, and psychomotor learning in traditional and virtual classroom higher education settings. Internet High Educ. 2009;12(1):7-13.) and Educational method evaluation(²¹21 Sarikoc G, Ozcan CT, Elcin M. The impact of using standardized patients in psychiatric cases on the levels of motivation and perceived learning of the nursing students. Nurse Educ Today. 2017;51:15-22.)	A simulated scenario with simulated patients	Turkey, 86 third-year undergraduate nursing students
Walters et al.(²²22 Walters B, Potetz J, Fedesco HN. Simulations in the Classroom: An Innovative Active Learning Experience. Clin Simul Nurs. 2017;13(12):609-15.)	To evaluate knowledge retention and the perception of the learning climate (autonomy, competencies, relationships, and motivation) after simulated practices	Longitudinal case-control study	Learning Climate Questionnaire;(³⁶36 Williams GC, Deci EL. Internalization of biopsychosocial values by medical students: a test of self-determination theory. J Pers Soc Psychol. 1996;70(4):767-79.) Basic Psychological Needs at Work Scale.(³⁷37 Kasser T, Davey J, Ryan RM. Motivation and employee-supervisor discrepancies in a psychiatric vocational rehabilitation setting. Rehabil Psychol. 1992;37(3):175-88.) The Situational Motivation Scale(²⁹29 Guay F, Vallerand RJ, Blanchard C. On the Assessment of Situational Intrinsic and Extrinsic Motivation: The Situational Motivation Scale (SIMS). Motivation and Emotion. Motiv Emot. 2000;24(3):175-213.)	Hybrid simulation using low-fidelity simulators and simulated patients	United States, 199 third-year undergraduate nursing students
Guerrero-Martínez et al.(²³23 Guerrero-Martínez IM, Portero-Prados FJ, Romero-González RC, Romero-Castillo R, Pabón-Carrasco M, Ponce-Blandón JA. Nursing Students' Perception on the Effectiveness of Emergency Competence Learning through Simulation. Healthcare (Basel). 2020;8(4):397.)	To evaluate students' learning in a simulated emergency scenario	Pre- and post-test quasi-experimental study	Adapted questionnaire called “Encuesta de calidad y satisfacción de simulación clínica en estudiantes de enfermería”(³⁸38 Astudillo Araya Á, López Espinoza MÁ, Cádiz Medina V, Fierro Palma J, Figueroa Lara A, Vilches Parra N. Validación de la encuesta de calidad y satisfacción de simulación clínica en estudiantes de enfermería. Cienc Enferm. 2017;23(2):133-45.)	Hybrid Multiple Casualty Incident simulation with standardized patients and low- and medium-fidelity simulators	Spain, 47 fourth-year undergraduate nursing students
Schulte-Uentrop et al.(²⁴24 Schulte-Uentrop L, Cronje JS, Zöllner C, Kubitz JC, Sehner S, Moll-Khosrawi P. Correlation of medical students' situational motivation and performance of non-technical skills during simulation-based emergency training. BMC Med Educ. 2020;20(1):351.)	To analyze the level of intrinsic motivation in the performance of non-technical skills	Prospective and cross-sectional cohort study	The Situational Motivation Scale (SIMS)(²⁹29 Guay F, Vallerand RJ, Blanchard C. On the Assessment of Situational Intrinsic and Extrinsic Motivation: The Situational Motivation Scale (SIMS). Motivation and Emotion. Motiv Emot. 2000;24(3):175-213.) Non-technical skills classification tool(²⁴24 Schulte-Uentrop L, Cronje JS, Zöllner C, Kubitz JC, Sehner S, Moll-Khosrawi P. Correlation of medical students' situational motivation and performance of non-technical skills during simulation-based emergency training. BMC Med Educ. 2020;20(1):351.)	A simulated urgency and emergency scenario with a high-fidelity simulator	Germany, 449 students from first to fourth year of the medicine undergraduate course
Lee et al.(²⁵25 Lee A, Abdulhussein D, Fallaha M, Buckeldee O, Morrice R, Leedham-Green K. Whole consultation simulation in undergraduate surgical education: a breast clinic case study. BMC Med Educ. 2021;21(1):305.)	To explore, categorize, and articulate the factors that interfere with the motivation for learning during simulated clinical practice	Case study with qualitative analysis and inductive thematic approach using the Dedoose software	Debriefing session with semi-structured questions	Clinical simulation of patient consultation standardized by students	United Kingdom, 17 third-year undergraduate medical students
Mool-Khosrawi et al.(²⁶26 Moll-Khosrawi P, Cronje JS, Zöllner C, Kubitz JC, Schulte-Uentrop L. Understanding how the motivational dimension of learning is influenced by clinical teaching in medical education: A prospective cohort study. Ann Med Surg (Lond). 2021;65:102366.)	To identify and compare students' situational motivation in bedside teaching and clinical simulation	Prospective cohort, pre- and post-test, descriptive, with no Control Group	The Situational Motivation Scale(²⁹29 Guay F, Vallerand RJ, Blanchard C. On the Assessment of Situational Intrinsic and Extrinsic Motivation: The Situational Motivation Scale (SIMS). Motivation and Emotion. Motiv Emot. 2000;24(3):175-213.)	A simulated urgency and emergency scenario with a high-fidelity simulator	Germany, 145 third-year undergraduate medical students
Mool-Khosrawi et al.(²⁷27 Moll-Khosrawi P, Zöllner C, Cronje JS, Schulte-Uentrop L. The effects of simulation-based education on medical students' motivation. Int J Med Educ. 2021;12:130-5.)	To assess and compare students' motivational levels before and after clinical simulations and classic seminars	Pre- and post-test quasi-experimental and cross-sectional study	The Situational Motivation Scale(²⁹29 Guay F, Vallerand RJ, Blanchard C. On the Assessment of Situational Intrinsic and Extrinsic Motivation: The Situational Motivation Scale (SIMS). Motivation and Emotion. Motiv Emot. 2000;24(3):175-213.)	A simulated urgency and emergency scenario with a high-fidelity simulator	Germany, 164 third-year undergraduate medical students
Arizo-Luque et al.(²⁸28 Arizo-Luque V, Ramirez-Baena L, Pujalte-Jesús MJ, Rodríguez-Herrera MÁ, Lozano-Molina A, Arrogante O, et al. Does Self-Directed Learning with Simulation Improve Critical Thinking and Motivation of Nursing Students? A Pre-Post Intervention Study with the MAES© Methodology. Healthcare (Basel). 2022;10(5):927.)	To assess motivation for learning and critical thinking before and after self-directed training based on clinical simulation	Multicenter study, pre- and post-tests, cross-sectional, descriptive, quantitative, with no Control Group	Motivated Strategies for Learning Questionnaire (MSLQ-44)(³⁰30 Pintrich PR. A manual for the use of the Motivated Strategies for Learning Questionnaire. Washington, D.C.; Education Resources Information Center; 1991.) and N-CT-4 Practice (Nursing Critical Thinking in Practice Questionnaire(³⁹39 Alfaro-Lefevre R. Critical thinking, clinical reasoning and clinical judgment: a practical approach, pageburst E-book on kno. 6th ed. Philadelphia: Elsevier Health Sciences; 2016.)	Simulated emergency scenarios and non-technical skills, use of high-fidelity simulators or standardized patient	Spain, 77 third-year undergraduate nursing students

Authorship	Main results and conclusions of the studies
Roh et al.(¹⁶16 Roh YS, Kim SS. Integrating Problem-Based Learning and Simulation: Effects on Student Motivation and Life Skills. Comput Inform Nurs. 2015;33(7):278-84.)	Motivation for learning and problem-solving increased from the pre-test and post-PBL compared to after the clinical simulation. Self-directed communication and learning increased from the pre- to post-test after the clinical simulation. Integrated with the clinical simulation, the PBL method significantly improved students' motivation and life skills.
Thoma et al.(¹⁷17 Thoma B, Hayden EM, Wong N, Sanders JL, Malin G, Gordon JA. Intrinsic motivation of preclinical medical students participating in high-fidelity mannequin simulation. BMJ Simul Technol Enhanc Learn. 2015;1(1):19-23.)	Extracurricular clinical simulation sessions with learning objectives determined by the students increased their perceived autonomy, although there was no difference in intrinsic motivation, competence, and belonging when compared to clinical simulation sessions devised by the facilitators. However, the level of intrinsic motivation was very high in both, indicating that clinical simulation is a motivating method independent of autonomy in choosing learning objectives.
Fawaz et al.(¹⁸18 Fawaz MA, Hamdan-Mansour AM. Impact of high-fidelity simulation on the development of clinical judgment and motivation among Lebanese nursing students. Nurse Educ Today. 2016;46:36-42.)	The clinical simulation significantly improved students' clinical judgment and motivation.
Jeppesen et al.(¹⁹19 Jeppesen KH, Christiansen S, Frederiksen K. Education of student nurses - a systematic literature review. Nurse Educ Today. 2017;55:112-21. Review.)	The skills and clinical simulation laboratories provided a positive and motivating learning environment, and developed students' critical-reflective thinking.
Park et al.(²⁰20 Park HR, Park JW, Kim CJ, Song JE. Development and validation of simulation teaching strategies in an integrated nursing practicum. Collegian. 2017;24(5):479-86.)	The simulated practice increased critical thinking, self-efficacy, and motivation for learning.
Sarikoc et al.(²¹21 Sarikoc G, Ozcan CT, Elcin M. The impact of using standardized patients in psychiatric cases on the levels of motivation and perceived learning of the nursing students. Nurse Educ Today. 2017;51:15-22.)	The students who underwent simulated practices showed increased motivation, perceived learning, and self-confidence, as well as decreased anxiety when caring for real patients.
Walters et al.(²²22 Walters B, Potetz J, Fedesco HN. Simulations in the Classroom: An Innovative Active Learning Experience. Clin Simul Nurs. 2017;13(12):609-15.)	The students who underwent simulated practices had more knowledge and a better perception of the learning environment (autonomy, competencies, relationships, and motivation).
Guerrero-Martínez et al.(²³23 Guerrero-Martínez IM, Portero-Prados FJ, Romero-González RC, Romero-Castillo R, Pabón-Carrasco M, Ponce-Blandón JA. Nursing Students' Perception on the Effectiveness of Emergency Competence Learning through Simulation. Healthcare (Basel). 2020;8(4):397.)	Clinical simulation in the emergency setting increased satisfaction, confidence, motivation, perception of decision-making, and technical skills.
Schulte-Uentrop et al.(²⁴24 Schulte-Uentrop L, Cronje JS, Zöllner C, Kubitz JC, Sehner S, Moll-Khosrawi P. Correlation of medical students' situational motivation and performance of non-technical skills during simulation-based emergency training. BMC Med Educ. 2020;20(1):351.)	High autonomous motivation levels were observed in all students, but this did not correlate with the better performance of non-technical skills in simulation-based emergency training.
Lee et al.(²⁵25 Lee A, Abdulhussein D, Fallaha M, Buckeldee O, Morrice R, Leedham-Green K. Whole consultation simulation in undergraduate surgical education: a breast clinic case study. BMC Med Educ. 2021;21(1):305.)	Integrating simulated surgical clinics into the curriculum eased skills acquisition through active learning. Enjoyment of the simulated session was identified as an intrinsic motivator. It also enabled students to recognize the importance of preparing themselves for clinical practice, rather than focusing on theoretical evaluations.
Mool-Khosrawi et al.(²⁶26 Moll-Khosrawi P, Cronje JS, Zöllner C, Kubitz JC, Schulte-Uentrop L. Understanding how the motivational dimension of learning is influenced by clinical teaching in medical education: A prospective cohort study. Ann Med Surg (Lond). 2021;65:102366.)	High autonomous motivation levels (intrinsic and identified regulation) and low controlled motivation levels (introjected and external) and demotivation were reported pre- and post-test during the simulated practices and bedside teaching. Clinical simulation had no significant effect on the different motivational qualities. Bedside teaching significantly decreased extrinsic motivation and identified motivation.
Mool-Khosrawi et al.(²⁷27 Moll-Khosrawi P, Zöllner C, Cronje JS, Schulte-Uentrop L. The effects of simulation-based education on medical students' motivation. Int J Med Educ. 2021;12:130-5.)	The different motivational qualities and motivation levels did not differ significantly when comparing simulated practices to traditional seminars.
Arizo-Luque et al.(²⁸28 Arizo-Luque V, Ramirez-Baena L, Pujalte-Jesús MJ, Rodríguez-Herrera MÁ, Lozano-Molina A, Arrogante O, et al. Does Self-Directed Learning with Simulation Improve Critical Thinking and Motivation of Nursing Students? A Pre-Post Intervention Study with the MAES© Methodology. Healthcare (Basel). 2022;10(5):927.)	After the simulated clinical practices, the students improved their general levels of motivation (self-efficacy, learning strategy, self-regulation) and critical thinking (personal characteristics, intellectual, cognitive and interpersonal skills, self-management, and technical skills).

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[1] Corresponding author: Barbara Casarin Henrique-Sanches Rua Prof. Hélio Lourenço, 3900 - Vila Monte Alegre Zip code: 14040-902 - Ribeirão Preto, SP, Brazil Phone: (55 16) 3315-4321 E-mail: barbara.henrique@usp.br