Simulation-based mastery improved nursing skills in BSc Nursing Students: a quasi-experimental study

Background: Clinical education is an essential part of nursing education. Selected clinical teaching methods inuence quality of education. Simulation-based mastery learning has been used to improve clinical skills among nursing students and may provide a novel way to enhance nursing skills. This study aimed to assess the effect of the simulation-based mastery learning on the clinical skills of undergraduate nursing students from 2017 to 2019. Methods: This quasi-experimental study was conducted with two groups (the control and intervention). After written consent was received, 105 students were selected by random convenience sampling. The intervention group participated in a simulation-based mastery learning intervention, and the control group received no intervention except for traditional training. The students of both groups completed the demographic information questionnaire and the checklist before and after the intervention. The results were analyzed by SPSS version 21, and descriptive and inferential statistics. Results: The results showed no signicant differences between the two groups before the intervention (p> 0.05). In addition, students’ performance in the intervention and control groups improved signicantly at the post-test compared with the baseline (p<0.05). Furthermore, Cohen test implied that the simulation-based mastery model used by the intervention group was signicantly more effective than the traditional training used by the control. Conclusion: These ndings showed that mastery learning was more effective in improving clinical skills in undergraduate nursing students. The results suggest that other nursing and health programs can be developed by implementing mastery-based learning model.


Introduction
Clinical education is an essential part of nursing and midwifery education [1]. The nursing educators try to create professional learning behaviors in nursing students and respond appropriately to speci c clinical situations [2]. There is a trend in nursing education to adopt competency-based education (CBE) models. Anima and McCoy de ne competency as acquiring integrated knowledge, skills, values, and attitudes required for a competent nurse [3]. In addition, development of nursing students with professional competence is one of the aim of nursing education [4]. Mastery is one of the competencybased models.
Mastery models differ from traditional curricula in de ning progression as achieving a series of competencies [5] . Educators make a valuable contribution to the learning process by creating competency-based models that can enhance training [6]. In conclusion, students acquire the ability to do clinical skills [7].
Mastery is a new applied method for training students in medical sciences, and it is one of the individual learning styles [8]. It originates from Carroll's belief that if su cient time is given to the full extent of education, the right level of education will be achieved [9]. Mastery learning features the use of frequent formative assessments to provide feedback and to evaluate whether students have mastered an instructional standard [5]. However, some studies indicated that it was time-consuming [11] and created anxiety in students because of frequent evaluations [10] . Furthermore, Salvin indicated that mastery learning had essentially no effect on student achievement but it was necessary to be assessed by scholars and practitioners well-equipped in mastery learning until questionable aspects of this method were elucidated [12].
Şenel Elaldı found that mastery learning model enhanced students' understanding of what they have learned and it was an opportunity for students' development of learning [13]. Mastery models engage learners in deliberative practice by increasing di culty of the repetitive tasks while providing coaching to guide their progress [14]. Furthermore, this method makes students more involved in teaching-learning process [15]. For students failing to attain mastery, the assessment provides a diagnostic tool to develop an individualized learning plan to guide corrective action and to address de ciencies. Students, who initially fail to demonstrate this skill have more opportunities (According to the curriculum) to take and pass the course [16]. Using a mastery model offers the potential for greater accountability, exibility and focus on the learning [17].
The advantages of this method are that students perform clinical skills correctly and ful l professional responsibilities in the future [18]. Wayne et al. showed that mastery learning in uenced CPR skills [19] .
Frogameni etal. also indicated that symbolic mastery learning was an effective strategy in training residents how to manage mechanical ventilator. Relying on traditional teaching methods in ICU may leave residents ill-equipped to safely manage patients receiving mechanical ventilation [20]. Cohen showed that the mastery learning method led to the acquisition of nasogastric tube skills in nursing students [21]. Based on the ndings of a study, the mastery learning method is useful in nursing education [22]. In addition, Simulation-Based Mastery Learning improved central line maintenance skills of ICU nurses [23]. However, Roh showed that mastery learning method did not have a signi cant effect on knowledge , self-e cacy scores and the number of errors related to cardiopulmonary resuscitation skills in nursing students [24].
However, nursing students must combine knowledge from sociobiological and nursing sciences to make clinical decisions and manage different situations in the clinical settings [25]. Moreover, Nurses, as the largest group of caregivers who deal directly with the patients , can provide high quality care through mastery in nursing skills [24].
However, there is little in the nursing literature about mastery model-based programs. In addition, most Iranian nursing educators apply traditional learning-teaching methods, which are subject-centered, timebased with summative evaluation and little feedback, and they do not apply the mastery method to train skills. Furthermore, Iranian educators do not have much information about mastery models. Regarding the bene ts of the method mentioned above, the research team decided to assess the effects of simulation-based mastery on the clinical skills of B.Sc. nursing students.

Research Design and Setting
This quasi-experimental study was conducted with a pretest-posttest two-group design in nursing department of Kerman University of Medical Science in Iran from 2017 to 2019. Kerman University of Medical Science is the biggest university in the Southeast of Iran. The university provides education for undergraduate, postgraduate and PhD nursing students.

Sampling Method
Students were selected by using convenience sampling and were then randomly divided into control and intervention groups by numerical table.
The inclusion criteria included the seventh-and eighth-semester nursing students who were not educated with simulation-based mastery method previously. In addition, students had to pass the theoretical and practical courses such as medical surgical, pediatric nursing, community health nursing, intensive care, psychology-nursing courses.
In this study, the research population consisted of 115 eligible BSc students, who met the inclusion criteria. Ten participants were excluded because of absence in training sessions.
In nursing department of KMU, all nursing students had to pass prerequisite courses before taking internship course, including theoretical and practical courses. Theoretical course includes the workshop on patient communication, nosocomial infections, nursing ethics, and a practical course includes common nursing skills trained in pro ciency workshop, where advanced special moulage and other equipment are available for nurse students to practice the special nursing skills.
Students will take the practical course after completing the workshops. In addition, taking the internship course depends on passing (80 percent of the checklist) the clinical exam. All students of nursing department had to take the same curriculum.
The research team selected nursing skills commonly used in nursing and agreed on the following four practical skills: suction, nasogastric tube feeding, packed cell transfusion, change of uid box.
First, the study goals were explained to the participants. The students participated in the study with full consent and agreement. They were explained that attending or not participating in the study would not affect their educational process. The instructors in the two groups completed the demographic characteristic questionnaire and checklist skills before the intervention, and common nursing skills were assessed in two groups by a checklist.
Intervention group procedure The intervention began on the second day of course. The members of the intervention group experienced a simulation-based mastery intervention in four common clinical skills (suction, nasogastric tube feeding, packed cell transfusion, change of uid box).
First, the instructor performed each skill on the advanced moulage in pro ciency workshop. Then, the students practiced these skills and were assessed by the instructor, who could identify whether the students learned the skill or not (diagnostic feedback) and what they needed to learn better (prescriptive feedback).
A list of student's mistakes was provided for the relevant instructor and student. The instructors set speci c goals for each student based on the de ciencies identi ed in the rst stage. In this program, the instructor used supervisory and observational methods. The instructor observed students and completed checklists every day. The instructor re-evaluated the students through a checklist and re-identi ed some de ciencies listed in the checklist daily for 12 days (two days a week). In addition, students, who initially fail to demonstrate the skill, have three more opportunities to pass the course. At the end of the course, the clinical skill scores were checked.
To determine the observer's accurate judgment on the examination based on the checklist, two observers assessed the inter-rater reliability of the assessors' scoring for each of the skills. A single-blind method was used, so that the students involved in this study were not informed of the type of teaching methods and how they were placed in each group. In this study, the intervention group experienced simulated mastery learning method.

Control group procedure
Common nursing skills were trained to the students of the control group in pro ciency workshop during two sessions a week for six weeks.
The routine teaching method was as follows: the students were divided into groups of three individuals, and clinical skills were performed on the advanced moulage under the supervision of the instructor. In case of any question or mistake, the instructor, a facilitator, would address it. In this method, the instructor taught students according to time-based and summative evaluation with little feedback.
The demographic information questionnaire and the checklist were used in this study to collect the data.

Instruments
The demographic questionnaire contained information about age, sex, scale median, passed credits, grade point average of last semester.
The researchers used four nursing skill checklists for both groups (control and intervention). The checklists were extracted from a nursing book: Skill checklists for Tylor's clinical nursing skills [26].
The content validity of the checklists was con rmed by the broad consensus, and their reliability was 0.82 by using a pilot study and the Cronbach's alpha coe cient showing a good reliability.
In addition, medical surgical nurses, pediatric nurses and intensive care nurses in Kerman have attempted for ve months to prepare and select nursing skill checklists.

Data analysis
The collected data were analyzed using descriptive (frequency, percentage, mean and standard deviation) and inferential statistics. According to the results of the Kolmogorov-Smirnov test, the data of this study had a normal distribution. Thus, parametric tests were used. Furthermore, independent-t test was employed to compare the mean scores of skills between the intervention and control groups before and after the intervention. The paired samples t-test was also used to compare the mean scores of skills in each group before and after the intervention. P-values were considered statistically signi cant.

Results
The participants in this study were 105 BSc nursing students of Kerman University of medical science. The participants were divided into two groups of intervention (N=53) and control (N=52). The mean ages of students in the intervention and the control groups were 23.88±2.06, and 23.38±1.78, respectively.
Most of the participants were female (38 individuals in the intervention group and 39 individuals in the control group). A majority of the participants were native (43 individuals in the intervention group and 42 individuals in the control group), most of them had no history of diseases and took good grade point averages in the last semester. No signi cant difference was found between the control and intervention groups in their demographic data (Tables 1).
The total mean scores of clinical skills of the participants in the intervention group were 101.6±3.69 and 141.6±3.13 before and after the intervention, respectively. In addition, the total mean scores of clinical skills in the control group were 88.17±6.11 and 109.36 ± 4.71, respectively. Independant samples t-test showed a statistically signi cant difference between two groups after the intervention (P <0.05). Cohen test also showed a statistically signi cant difference between them after intervention (d=5.6).
In addition, the results of this study showed that the mean score of each of the clinical skills was not statistically signi cant between the control and the intervention groups before the intervention. However, a statistically signi cant difference was found between them after the intervention (table 2).
The mean suction scores of the participants in the intervention group were 26.46±1.51, and 37.20±0.95 before and after the intervention, respectively. The mean scores of suction in the control group were 24.9 ±1.11and 27.85±1.30, respectively. Independant samples t-test showed a statistically signi cant difference between two groups after the intervention (P <0.05).
By comparison, the mean scores of ng tube feeding in the intervention group were statistically signi cant before (23.46±1.79) and after the intervention (37.41± 0.49) (p <0.05).
Furthermore, the results showed that the mean nasogastric tube feeding scores in the control group were 23.85±1.30 and 28.075±1.5 before and after the intervention, respectively. Independent samples t-test indicated statistically signi cant difference between two groups after the intervention (P <0.05).
The mean Pack cell Transfusion scores of the participants in the intervention group were 17±1.33 and 25.52±1.05 before and after the intervention, respectively. The mean scores of Pack cell transfusion in the control group were 17.79±1.26 and 20.79±0.71, respectively. Independant samples t-test showed a statistically signi cant difference between two groups after the intervention (P <0.05).
The mean changing uid box scores of the participants in the intervention group were 25.68±0.4 and 41.47±0.64 before and after the intervention, respectively. The mean scores of changing uid box scores in the control group were 24.63±1.23 and 33.57±1.46, respectively. Independant samples t-test showed a statistically signi cant difference between two groups after the intervention (P <0.05).

Discussion
This study was one of the few studies in Iran conducted on the effect of symbolic mastery learning on the clinical skills in undergraduate nursing students.
The results of this study indicated that the mean scores of skills in the control group were statistically signi cant before (22.04±1.22) and after the training program (27.29±1.17) (P <0.05). In addition, the mean scores of skills in the intervention group were statistically signi cant before (25.4±1.27) and after the intervention (35.4±0.46) (p <0.05). The results of this study showed that mastery learning was more effective in achieving clinical skills than the traditional method (d=5.6).
Barusk indicated that the mastery learning increased the nursing student's knowledge and skills scores for physical examination . Furthermore, he reported that mastery learning promoted the general competency of the students [27].
Tang showed that mastery-learning intervention increased nurses' clinical competencies. [28]. Moreover, Schroedl reported that the mastery learning method was useful to identify the professional competence of nursing practice [14]. Extensive research evidence shows that mastery learning can have positive effects on student achievement. In addition, Amiruddin (2015) pointed to positive effects of mastery learning that can help students increase their efforts, and ultimately perform academic tasks better [29].
This result was in line with the results of the present study. Contrary to other teaching methods, this method helps the instructor know the de ciencies of the students, and the students know that they have enough time to learn the skills [30]. Educators tried to teach the students the knowledge and skills required for competent nurses. Moreover, in this teaching method, the instructors can determine students' learning needs [31]. According to this study, the instructor identi ed students' learning problems in each stage of intervention and retested them. In addition, students who initially fail to demonstrate the skill, have three more opportunities to take and pass the course.
Repeated assessments of students at given intervals improved the quality of education, and the students were active in the learning process [27]. In this study, acquiring competency was based on skills scale.
The instructors in this study also considered this approach time-consuming. They believed that this approach was challenging with a large number of nursing students and the limitations of the laboratory facilities. Roberts et al. indicated that this approach was time-consuming due to the organization of various tests and the high volume of nursing education contents [32].
Mohd Hasril concluded that mastery learning strategies were signi cantly associated with increased learning in vocational training compared with traditional mastery models. Trainees mentioned that those who received faster feedbacks were more successful. [29]. In this study, the trainees received their feedback immediately after each skill. The nursing students who received feedback could identify their de ciencies. Applying mastery learning methods is useful in clinical settings to empower nursing students and mastery learning is considered as a new paradigm in medical education [9]. In addition, the students acquired high quality skills because of giving the feedback along the teaching process. According to experiences of instructors, some students have anxiety when they receive the feedback. Thus, scienti c and psychological support to the students improves their clinical skills. Evaluating this model and examining its strengths and weaknesses predisposed different students to apply it in various educational settings.

Limitation
This study was done only in the nursing department of Kerman University of Medical Science, so that the generalizability of the study data was limited to some extent. Owing to the fact that the study method was time consuming, the effect of mastery learning method on practical course was studied. It is suggested that the effect of mastery learning method be evaluated on both theoretical and practical courses.
The results indicated that mastery learning model had more bene cial effects than the traditional method. Furthermore, our study showed that this model offered rich and deep learning opportunities for students. These results; therefore, can encourage nursing authorities to continue their training and development in the research methodology.
In addition, this study would be fruitful for future researches to examine the effect of mastery learning on self-esteem, satisfaction, and competency of students.

Conclusion
The results of the study showed that the implementation of the mastery learning method was more effective in training clinical skills in BSc students. In addition, the ndings indicated that students in mastery learning model group achieved higher grades in clinical skills than those who used traditional method. In addition, the quality of learning improved in undergraduate nursing students in simulation-based mastery learning group. Furthermore, it is a exible and successful approach and enhances students' skills.

Declarations
Ethics approval and consent to participate The approval for this study was obtained from Ethics Committee of Kerman University of Medical Sciences (IR KMUREC930241). Written informed consent was obtained from each participant. This study was performed on the fourth-year nursing students during fall and spring 2018-2019.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request