Impact of High-Fidelity Simulation on the Acquisition of Spiritual Competencies in a Nursing Degree in Spain: An Experimental Pre–Post Study

Simulation is an experiential learning activity designed to immerse students in realistic scenarios that closely replicate the situations they may encounter in their professional careers (Gaba, 2004). The International Nursing Association for Clinical Simulation and Learning (INACSL) defines simulation-based experiential learning as an educational strategy that creates conditions imitating real-life situations that students may experience (Sittner et al., 2015). High-fidelity simulation involves the use of advanced technological simulators or standardized patients (trained actors) and aims to replicate authentic clinical environments to enhance the educational experience (Raurell-Torredà & Gómez-Ibañez, 2017; Wu et al., 2024). According to the INACSL Standards Committee, the structured process of high-fidelity simulation consists of three phases: preparation (prebriefing), participation (simulation scenarios), and debriefing (Jimenez, 2021).

‘Experiential learning theory’ (Kolb, 2014) serves as the theoretical framework for this study, highlighting four essential phases: concrete experience, reflective observation, abstract conceptualization, and active experimentation. By ‘learning through experience,’ the learner actively engages in the learning process, with knowledge being gained through an ongoing cycle of questioning, reflecting, analyzing, and synthesizing. Students must actively construct meaning and conceptualization from their experience by critically reflecting on it both during and after it occurs. This framework is particularly relevant in simulation-based nursing education. Students engage in simulated scenarios that foster active participation and reflection, thus bridging the gap between theory and practice (Bresolin et al., 2022). During the debriefing phase, reflective observation encourages introspection. Abstract conceptualization emerges when students connect theory to practice, and active experimentation enables the application of knowledge in subsequent simulations or real clinical practice (Ross, 2021).

In current nursing practice, patient care adopts a holistic approach that considers all dimensions: biological, psychological, social, and spiritual (Öntürk Akyüz et al., 2024). The spiritual dimension is a critical component of holistic care, and nurses are expected to address patients' spiritual needs (Soto Morales et al., 2020). Accompanying patients' spiritual needs has been associated with improving the therapeutic relationship, fostering trust, and enhancing the overall quality of care (Puchalski, 2001; Sun et al., 2021). However, a recent meta-analysis revealed that nurses' competencies and perceptions regarding spirituality and spiritual care are moderate, highlighting the need for improvement (Wang et al., 2023). There are significant barriers to providing high-quality spiritual care, one of which is the lack of adequate training (Ross et al., 2022). Therefore, it is crucial to utilize effective educational tools for developing competencies in spiritual care. Research has shown that simulation is a promising method for teaching spiritual competencies (Connors et al., 2017; Huehn et al., 2019; Wang et al., 2023). Although further studies are needed to confirm its effectiveness across various contexts (Rykkje et al., 2022). To address this knowledge gap, we posed the following research question: Is high-fidelity simulation effective in improving spiritual competencies among undergraduate nursing students?

High-fidelity simulation has become increasingly prominent in nursing education, as it provides a realistic and immersive learning environment (Arrogante et al., 2023). This educational technique has been shown to enhance self-efficacy, confidence, and competencies among nursing students (Kim et al., 2016), also enabling them to achieve an optimal level of learning and develop critical, reflective thinking skills essential for knowledge generation (Cabero Almenara & Llorente Cejudo, 2015; Raurell-Torredà et al., 2020). It is recommended to incorporate high-fisssdelity simulation across all areas of nursing education (Filomeno & Minciullo, 2021).

In contemporary nursing practice, holistic patient care encompasses biological, psychological, social, and spiritual dimensions (Öntürk Akyüz et al., 2024). The spiritual aspect of care is essential in addressing the comprehensive needs of patients, and nurses play a key role in providing this type of care (Soto Morales et al., 2020). Numerous benefits are linked to spiritual health: improved ability to cope with the psychological and physical demands of illness, a reduction in pain, stress, and negative emotions, and a lower risk of depression and suicide. The data indicate that patients who receive the right kind of spiritual care are also more satisfied with the hospital's care and treatment (Harrad et al., 2019). Nonetheless, a recent meta-analysis found that nurses’ competencies in spiritual care are moderate, indicating a need for further training (Wang et al., 2023). One of the primary barriers to effective spiritual care is insufficient training (Ross et al., 2022). Given this challenge, simulation stands out as a promising tool for developing spiritual competencies, with prior studies demonstrating its effectiveness in teaching these skills (Connors et al., 2017; Huehn et al., 2019; Wang et al., 2023). However, additional research is needed to strengthen the evidence for its effectiveness in diverse educational contexts (Rykkje et al., 2022). Before conducting the current study, the SSCRS_Sp scale was validated with nursing students. The results of the questionnaire validation have been published in a separate article.

The results are organized into four sections: (1) characteristics of participants; (2) effectiveness of simulation in improving students’ spiritual competencies; (3) relationship between religious beliefs and students’ perception of educational resources; and (4) conceptual significance of 'spirituality' for students.

This research implemented and evaluated a high-fidelity simulation intervention in spiritual care for nursing students.

The results indicate that this simulation could be an effective learning activity for improving students' competencies in spiritual care. Our results align with the findings of the study by Connors et al. (2017), where students significantly increased their competence and confidence in addressing patients' spiritual care through simulation. In the same vein, the study by Huehn et al. (2019) also determined that students found the learning experience through simulation beneficial for their preparation to provide spiritual care in professional practice.

Other learning activities (case discussions, reflective practice journals, or lectures) have shown positive results regarding the learning of competencies in spiritual care. Although the recent review by Rykkje et al. (2022) suggests the use of pedagogical and reflective learning strategies allow students to apply what they have learned in the classroom and reflect on it.

Based on Kolb's (2014) experiential learning theory, which emphasizes the integration of learning through four phases (concrete experience, reflective observation, abstract conceptualization, and active experimentation) to demonstrate how individuals learn and master their experiences, our students were able to reflect on the concept of spirituality based on their experiences. The debriefings conducted after the simulation facilitated a deeper integration of their learning.

This learning objective of developing spiritual competencies through experience and reflection is also echoed by students in various studies (Bresolin et al., 2022; Ross, 2021). Additionally, the theoretical learning of spiritual care, which begins with the student's awareness of spirituality (Fernández-Pascual et al., 2020), is reinforced by the simulation activity. Particularly, through the subsequent debriefing that fosters both personal and group reflection among students.

Based on our results and those detailed in other studies, simulation solidifies its role as a highly effective learning activity for stimulating students' acquisition of spiritual competencies (Rykkje et al., 2022). On the other hand, one of the advantages of simulation is that it is an educational strategy that can be implemented throughout the nursing degree program, during students' clinical placements, and throughout their professional careers (Jones et al., 2022). This advantage would address the limitation of some learning activities regarding their long-term effects (Daudt et al., 2019). It would be advisable to regularly implement simulation activities in nursing degree and in the ongoing training of nurses, while evaluating their effectiveness longitudinally.

Although our results regarding the positive relationship between students' religious beliefs and their perception of their educational resources should be interpreted with caution, various studies indicate that spirituality is influenced by these beliefs (Fernández-Pascual et al., 2020). This conditioning is also emphasized by Torres-Contreras et al. (2022), who additionally highlight the impact of the student's cultural and geographical context. In this regard, students from Hindu, Latin, or Buddhist cultures perceive that they have greater educational resources for providing spiritual care (Al Qadire et al., 2024).

In the recent meta-analysis by Wang et al. (2023), it was identified that nurses with religious affiliations demonstrated stronger spiritual care competencies compared to nurses without religious affiliations. However, after simulation, our students agree more strongly that spirituality extends beyond being synonymous with religion. Students stated as it encompasses universal aspects such as creativity, art, and self-expression. It is important to emphasize this shift in perception among students, as nurses have identified the persistent misconception that spirituality is solely synonymous with religion as a significant barrier to addressing spirituality in practice (Ross et al., 2018).

This study was conducted using a single-group, cross-sectional design, which limits the ability to establish causality and assess long-term knowledge retention (White & Arzi, 2005). While the inclusion of a qualitative component provided valuable narrative and descriptive insights, the absence of a control group reduces the robustness of the findings. Future studies should consider employing quasi-experimental designs with a control group to enhance the validity of the results and assess the intervention's impact more effectively (Barker et al., 2024). Another limitation is the sample size, which, although sufficient for the scope of this exploratory study, may not be large enough to generalize the findings to a broader population. Larger sample sizes in future research would increase statistical power and improve the generalizability of the results across diverse educational and cultural contexts. Additionally, potential biases related to participants' self-selection and the use of self-reported measures must be considered, as these may have influenced the reported outcomes.

Implementing randomized sampling and incorporating objective assessments in future studies could help mitigate these biases. The study was also limited by its focus on a single institution, which may affect the transferability of the findings to other nursing programs or educational settings. To address this, future research should adopt international and multicenter approaches, which would provide a more diverse sample and allow for cross-cultural comparisons. Finally, the study did not assess the integration of acquired competencies into students' clinical practice. Future research should investigate how simulation-based learning in spiritual care influences students’ confidence and competence in real clinical settings, and whether these skills are retained and effectively applied over time.

High-fidelity clinical simulation has proven useful in improving students' educational resources for providing spiritual care. Additionally, through this activity, students understood spirituality as an essential part of holistic nursing care, something subjective that relates to feelings of peace, freedom, and one's perspective on life. On the other hand, students became aware that spirituality extends beyond religion, although it may be a part of it. To explore the perspectives and experiences of nursing students regarding simulation and spiritual care, a qualitative study has been conducted. The results of this qualitative study will be published in a subsequent article.