Educators’ decision-making in simulation-based learning with a bachelor’s degree in a nursing program at a Saudi Arabian nursing college

doi:10.21203/rs.3.rs-7450599/v1

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Research Article

Educators’ decision-making in simulation-based learning with a bachelor’s degree in a nursing program at a Saudi Arabian nursing college

https://doi.org/10.21203/rs.3.rs-7450599/v1

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Background

Educators use simulation-based learning (SBL) to complement other teaching strategies to achieve undergraduate program learning objectives. Previous studies in Saudi Arabia focused on the environment of the SBL and lacked an in-depth understanding of educators’ decision-making. The aim of this study was to explore educators’ lived experience with decision-making in SBL in a bachelor’s degree nursing program.

Method

This study used van Manen’s hermeneutic phenomenological approach. Data were obtained from 8 educators and were interpreted via cognitive continuum theory (CCT).

Results

The themes that emerged from the inductive analyses were decision-making as a deliberate craft of preparation, decision-making as negotiating readiness and challenge, decision-making as responsive attunement in the moment, decision-making as shaping assessment and feedback, and decision-making amid curriculum and programmatic influences.

Conclusion

Educators’ decision-making is a dynamic balance between analytical and intuitive modes shaped by context. This study is among the first to explore the lived experiences of nursing educators’ decision-making in simulations, an area often overlooked in favor of student outcomes.

Simulation-based Learning

Decision-Making

Phenomenology

Cognitive Continuum Theory

Nursing

Saudi Arabia

Gulf Region

Nursing education increasingly relies on simulation-based learning (SBL) to bridge the gap between theoretical knowledge and practical application, particularly in contexts where traditional clinical placements are limited or where access to high-fidelity simulation technologies is restricted (Albagawi et al., 2024). An earlier study by Zakari et al. (2017) provided phenomenological insight into Saudi simulation educators’ experiences within the cultural and institutional context. They reported that effective simulation requires clear educator roles and processes. The study by Almotairy et al. (2023) serves as an environmental scan of SBL, highlighting the gaps in training and preparation for faculty facilitators and the lack of professional development and institutional support. This study lacked the explanatory and narrative depth of the “lived experience” of educators’ decision-making in the bachelor of nursing program.

Simulation educators’ decisions affect the creation of realism and the effectiveness of simulation. Educators’ decisions often involve determining the dimensions and levels of fidelity, designing and delivering a cue, and ensuring cost efficacy (Jeffries, 2020). Expert educators frequently rely on their accumulated experience and implicit knowledge to make rapid, effective instructional choices, often preceding more analytical considerations (Okoli & Watt, 2018). Such intuitive judgments, akin to "gut feelings" in other professional domains, enable educators to quickly recognize situational demands and operationalize competencies into effective learning experiences (Dexter, 2023; Vincent, 2021). For simulation to be an evidence-based practice, the decision-making approach used by educators needs to be understood, which is beyond the current published data (Cant et al., 2022). Hammond argued that decision-making is neither rational nor intuitive but rather exists on a continuum. Cognitive continuum theory (CCT) is a unified decision-making theory that recognizes the application of knowledge for research purposes and for educators (Hammond, 1996). An educator, the decision maker, may shift along the continuum depending on the task environment, ill- or well-structured; cues available; time available; and level of expertise. The CCT consists of six dimensions, including the modes of cognition. A decision maker may use any of the cognitive modes ranging from intuition to analysis during decision-making processes, depending on the other dimensions. In the context of this study, the CCT was used to interpret the findings.

This study used van Manen’s hermeneutic phenomenology qualitative (van Manen, 1997) and explorative study with a semistructured interview method to collect data about SBL in a bachelor’s degree nursing program at Saudi Arabian University.

Participants and study setting

The study was conducted at simulation laboratories located at the College of Nursing of a university in Riyadh. Purposive sampling was used to recruit female educators via email involving a bachelor’s degree in the nursing programme. Following their expression of interest, educators were then contacted individually and face-to-face by the researcher. No refusal or withdrawal was received. Eight national and international female educators, with an average age of 48 years and a BSN or higher level of education, participated.

Data collection

The semistructured interview method was carried out by the principal researcher to ensure the validity of the questions asked. The interviews were conducted for 45–60 minutes in a quiet room located at the College of Nursing. A digital audio recorder was used to record information provided confidentially. The following questions were asked: How do you feel about SBL? How do you train students in SBL for essential procedures and clinical skills? What do you think about the students participating in SBL? How do you evaluate the students’ performance in SBL? How do you measure the effectiveness of simulation practices?

Ethical considerations

Ethical approval No. E-17-2661 was obtained from the IRB. The aims were explained to the educators and potential participants, and their participation did not affect their annual evaluation of their work. They were asked to provide their voluntary written consent for data collection. Confidentiality in data management was guaranteed. Educators voluntarily participated after being informed.

Rigor

To maintain rigor, a semistructured interview guide was utilized to ensure consistent questioning and allow the participants to elaborate on topics that resonated with them.

Data analysis

The audio-recorded data were transcribed verbatim by a professional transcriber. The data were analyzed inductively via van Manen’s hermeneutic phenomenological approach, which emphasizes a reflective interpretation of lived experiences. The analysis involved immersion in the transcripts, highlighting significant statements, and engaging in thematic reflection to identify patterns of meaning related to educators’ decision-making. Writing and rewriting were used as part of the analytic process, ensuring that interpretation remained closely tied to the phenomenon under study. The six activities described by van Manen (1990) guided the process: turning to the phenomenon, investigating experience as lived, reflecting on essential themes, writing, maintaining a strong relation to the phenomenon, and balancing parts and the whole (see Table 1). For example, the raw data “The scenarios help the students to participate in nursing work at the hospital… so they know what is going on” (educator X). Reflective interpretation: Facilitation is experienced as creating opportunities for students to engage in real-world practice, requiring decisions about how scenarios are used to simulate authentic clinical engagement. Finally, the emerging theme of decision-making is responsive attunement in the moment.

Table 1
**Van Manen’s research activity applied in this study**
	Processes	Details
1	Turning to the nature of lived experience	The focus of the study was established as the lived experiences of nursing educators’ decision-making in simulation-based learning. The researcher maintained orientation to this central phenomenon throughout the study.
2	Investigating experience as we live it	In-depth interviews were conducted with nursing educators, who shared first-person accounts of their experiences with planning, facilitating, and assessing simulation. Rich descriptions and anecdotes were collected
3	Reflecting on essential themes	Transcripts were read and reread, and significant statements were highlighted. The researcher engaged in thematic reflection to uncover patterns of meaning, identifying structures such as deliberate preparation, responsive attunement, negotiating readiness and challenge, and shaping assessment and feedback
4	Writing and rewriting	Writing was used as an analytic tool. Themes were developed through cycles of drafting, reflecting, and rewriting, allowing meaning to emerge and deepen. Narrative and interpretive language was employed to capture the essence of participants’ experiences.
5	Maintaining a strong relation to the phenomenon	Throughout analysis, the researcher returned to the guiding question: What is it like to experience decision-making as an educator in simulation? This ensured that interpretations remained grounded in the phenomenon rather than drifting into abstraction
6	Balancing the research context by considering parts and whole	Analysis moved back and forth between individual excerpts, themes, and the overall text. Each part was considered in light of the whole, leading to the synthesis of an essence statement capturing the lived meaning of educators’ decision-making

The purpose of this study was to explore the lived experiences of nursing educators as they make decisions in the context of SBL. In keeping with van Manen’s hermeneutic phenomenology, the focus of analysis was on uncovering the meaning of decision-making as it was experienced by the educators. Through immersion in narratives, thematic reflection, and iterative writing can occur. The five structures of decision-making that emerged were deliberate craft of preparation; responsive attunement in the moment; negotiating readiness and challenge; shaping the flow of feedback and reflection; and curriculum and programmatic influences. These aspects do not stand as rigid categories but as interpretive insights that illuminate the essence of what it is like to make pedagogical decisions in simulations. Together, these themes portray decision-making as a lived tension between planning and spontaneity, analysis and intuition, responsibility and care.

Theme 1: Decision-making as deliberate crafts of preparation

Educators described preparation as a deliberate act of decision-making in which each choice carried responsibility for shaping the learning experience. The process of selecting modalities, setting expectations, and arranging the environment was experienced as an intentional craft, balancing pedagogical goals with available resources. One facilitator reflected on the responsibility of choosing the right modality: “Planning the simulation by choosing the correct modality or equipment on the basis of learning objectives, task trainers, fidelity manikins, etc.… Preparation for simulation in prebriefing includes role expectations, preparing the simulation area, introducing the setting and equipment, and setting rules for debriefing prior to the simulation” (Educator 2). Preparation was also lived as an act of establishing psychological and procedural readiness. Educators made decisions about how much orientation to provide, what rules to set, and how to reduce students’ uncertainty: “We gave instruction to students about the location of medication, supplies, limitation of manikins, normal sounds, and how to call the supervisor” (Educator 6). Another facilitator emphasized how the physical setup itself was part of preparation and decision-making: “We are considered as a simulated session… because we already set up the table, the bed, the manikins… if we want, for example, heart sound… there is a compound, computer, and a manikin.” (Educator 3). These accounts reveal that preparation decisions were experienced as purposeful acts of crafting the conditions for learning. Choosing modalities, orienting students, and arranging the physical and psychological environment were expressions of professional responsibility in ensuring that the simulation would unfold meaningfully.

Theme 2: Decision-making as a means of negotiating readiness and challenge

Educators experienced decision-making about scenario complexity as a constant negotiation between readiness and challenge. They recognized that simulations could be meaningful only when carefully calibrated to the learner’s developmental stage. A mismatch was perceived as a breakdown in learning, whereas alignment created the possibility of growth. One educator emphasized this need for balance: “…Because students will not appreciate the scenario if the student is at a low level and the scenario is at an advanced level… They do not understand yet.” (Educator 8). Another reflected on a moment when misalignment disrupted the learning process: “Unfortunately, I’ve been in a situation where we misleveled a scenario and all of a sudden, the students are standing there looking overwhelmed. You realize that, oh, some of the content in the scenario was actually in the next class they were taking, not in the class they had already taken. So truly making sure that the scenarios are well suited to the level of the student and what you expect that they can demonstrate. That way, they’re set up well” (Educator 1). Educators also described recognizing variation in student readiness within the same group. One educator observed that while most students grasped skills quickly, a few required more time and repetition: “Actually, I did not encounter yet students trying the steps for the second or more times, because the students are truly smart. Students got it from the first demonstration… Unless the student is truly very slow… but at the end they are ok.” (Educator 8).

The educator stated, “I advance the scenario at the learner’s pace and assess the actions and behaviors of the students” (Educator 4). During the briefing, the facilitator considered the learner’s learning needs and the time required to master a particular aspect of nursing skills or knowledge.

These reflections reveal that decision-making in simulation was not about applying a fixed level of complexity but about reading students’ capacities and adjusting expectations accordingly. The lived experience of educators was one of walking a fine line: ensuring scenarios were neither too simple to bore learners nor too complex to overwhelm them.

Theme 3: Decision-making as responsive attunement in the moment

Educators experienced facilitation in simulation as an act of engaging students with the realities of clinical practice. In these moments, their decision-making was lived as opening a space for learners to enter the world of nursing, making abstract concepts tangible through immersive scenarios. One educator explained how scenarios serve to bridge classroom learning with clinical engagement: “The scenarios help the students to participate in nursing work at the hospital… so they know what is going on” (Educator 7). Educators also reflected on how the responsiveness of the manikin influenced their satisfaction with facilitation. The ability of the technology to produce realistic cues was experienced as meaningful support for students’ engagement: “I am satisfied; I am ok with that ‘scenario’ because the manikin is responding by producing different kinds of sounds, normal sounds and abnormal sounds.” (Educator 4)

Decision-making here was also described in terms of the use of available tools to adjust and extend the learning experience in the moment. As one educator noted, “If we want to extend the problem… we want to hear the heart sounds… we can just manipulate the computer… hear the heart sounds S1 + S2 or gallops or murmurs.” (Educator 5). These findings reveal that educator decisions were lived as acts of attunement and that educators engaged students by drawing on technological resources, interpreting their responses, and adjusting the scenario to sustain learning. In these moments, decision-making was less about rigid plans and more about being responsive, crafting opportunities for students to encounter the complexity of clinical practice within the safe space of simulation.

Theme 4: Decision-making as shaping assessment and feedback

Educators experienced assessment not as a detached act of measurement but as a form of decision-making that shaped the rhythm of learning. Their choices about when and how to evaluate, whether to allow repetition, and how to respond to mistakes were lived as moments of reinforcing or redirecting student growth. One educator described using checklists both as a formal tool and as a way of guiding students toward mastery: “We start with demonstration, then after… the student should hand-on practice on the manikins. At the same time, I use the checklists to check every step they perform during the simulation. They are already familiar with the checklist… the exact checklist is used during the exam. So if it is incorrect, we would put X next to the step… They can try it again… a second… or third time around… If truly need to practice, we can say truly you have to study and then come.” (Educator 2). Assessment decisions also involved interpreting subtle cues as indicators of readiness or struggle. As one educator explained, “Each time a student stares and looks lost, it means the task at hand is beyond their level.” (Educator 6). Through these reflections, assessment emerged as more than compliance with formal criteria; it was experienced as an interpretive practice, where educators made decisions about how much support to give, when to hold students accountable, and how to transform evaluation into a continuation of learning.

Theme 5: Decision-making amid the curriculum and programmatic constraints

Educators also reflected on the broader context that shaped their decisions. Assessment was sometimes guided by formal rubrics and competency tests, which provided a sense of structure and objectivity: “Moreover, we measure the student’s competency through clinical tests that are based on rubric evaluation” (Educator 3). Moreover, the absence of standardized frameworks created uncertainty and variability in how outcomes were judged. One educator explained, “Actually, we don’t have a standardized framework to assess or measure the outcomes. We measure the effectiveness of simulation through a survey of students’ points of view about the simulation provided to them… Students would write their opinions in the learner’s evaluation form” (Educator 5). This tension revealed that decision-making extended beyond the immediate simulation session to the program level, where educators grappled with the lack of shared guidelines that support decision-making. In these contexts, decisions about evaluation were lived as both necessary acts of professional judgment and as responses to systemic gaps. Educators recognized the value of student feedback as meaningful but also expressed a desire for clearer, standardized tools to guide practice.

This study explored the lived experiences of nursing educators as they made pedagogical decisions in SBL. The analysis revealed decision-making as a dynamic and multifaceted phenomenon expressed through four interrelated aspects: deliberate preparation, responsive attunement in facilitation, the negotiation of readiness and challenge, and the shaping of assessment and feedback, all within the broader constraints of the curriculum and institutional context. Taken together, these experiences portray decision-making not as a series of isolated acts but as an ongoing balancing of responsibility and care in the service of student learning. These findings echo earlier research that emphasized the complex and situated nature of simulation pedagogy (Dieckmann et al., 2012; Jeffries, 2020). Like Benner et al. (2009) work on clinical judgment, educators in this study described their decisions as influenced by both explicit knowledge and tacit, experiential understanding. This study extends the prior literature by placing the focus not on students or simulation outcomes but rather on educators’ own lived experiences in decision-making. By highlighting the perspectives of educators, the findings contribute to an understanding of how educators themselves navigate simulation as a pedagogical practice.

In light of CCT (Hammond, 1996), decision-making is not confined to either purely analytical or purely intuitive modes but rather occurs along a continuum, with many professional judgments occupying a quasirational middle ground. Educators in this study demonstrated movement along this continuum: in scenario design, they relied on structured, analytical planning aligned with curricular goals; in facilitation, they described intuitive judgments guided by experience and responsiveness to students; and in assessment, they combined formal tools such as checklists with interpretive readings of student cues, reflecting quasirational decision-making. These shifts illustrate that pedagogical decisions in simulations are fluid, context dependent, and embedded in professional responsibility. The ability of educators to create a context for learning and contribute to good judgment is considered an effective facilitator (Maestre & Rudolph, 2015). Mulli et al. (2022) argued that adequate preparation for simulation is key to reflection-in-action during students’ performance. Preparation may involve familiarizing students with the technology and equipment and prereading and assignment activities before the simulation (Mulli et al., 2022). The lived experience of decision-making in simulation was revealed as a continuous movement between responsibility, attunement, negotiation, and care. Educators did not speak of decision-making as isolated choices but as an ongoing orientation toward shaping the conditions of student learning. In preparation, decision-making was lived as a deliberate craft, a careful weighing of modalities, equipment, and expectations, where each choice carried the responsibility of setting the stage for authentic engagement (Leigh & Steuben, 2018). Educators spoke of reading students’ cues, listening for silence or hesitation, and deciding whether to intervene or step back. Recognizing these nonverbal cues is essential for identifying potential areas of confusion or disengagement, enabling timely interventions (Ghafar & Ali, 2023). These were not technical acts but embodied judgments guided by intuition and professional wisdom. Decision-making also included negotiating to calibrate complexity to student readiness, walking the fine line between challenge and overwhelm, and ensuring that learning remained possible. Educators decide to adjust SBL according to student pace and promote self-direct learning, thus allowing students to correct their cognitive errors while learning from their failure and mistakes (Yeo & Jang, 2023).

In assessment, decisions carry the weight of reinforcing or redirecting growth. Educators moved between formal tools such as checklists and rubrics and informal readings of nonverbal cues, making choices about when to correct, when to allow repetition, and when to let students struggle toward competence (Meylani, 2024). Beyond the immediate encounter, decision-making extended to the programmatic level, where educators navigated institutional gaps, relied on rubrics where available, and at times turned to student evaluations as imperfect but meaningful measures of impact. This necessitates a rigorous examination of various methodologies to evaluate program effectiveness, ensuring that budgetary decisions are informed by robust evidence rather than anecdotal perceptions (Hollands et al., 2024). In sum, the essence of educators’ decision-making in simulations was not a linear process but rather a lived balancing act between analysis and intuition, structure and spontaneity, formal frameworks and embodied wisdom.

Implications for nursing education

These insights have several implications for SBL. First, faculty development should support educators not only in terms of technical preparation and structured methods such as debriefing but also in cultivating the intuitive, real-time responsiveness that is central to effective facilitation. Second, curriculum design should allow flexibility for educators to negotiate readiness and complexity, ensuring that scenarios align with learners’ developmental stages. Third, assessment practices should acknowledge the dual role of educators as evaluators and facilitators, recognizing that both formal tools and tacit judgments shape student learning. Finally, at the institutional level, the lack of standardized frameworks reported by participants points to a need for clearer policies that can guide evaluation while leaving room for professional discretion.

Strengths, limitations, and future research

A strength of this study is its phenomenological approach, which provides rich interpretive insight into educators’ experiences. By using van Manen’s hermeneutic phenomenology, the analysis captured not only what decisions were made but also what it felt like to make them. However, the study is limited by its context within a single educational system, which may constrain transferability. Future research could explore decision-making among both male and female educators across different cultural and institutional settings or compare novice and experienced facilitators to better understand how decision-making styles evolve with expertise.

This study reveals decision-making in simulation as a lived experience of balancing preparation and responsiveness, analysis and intuition, structure and flexibility. Interpreted through CCT, educators’ accounts illustrate how their judgments shift fluidly along a continuum, depending on context and pedagogical goals, with implications for faculty development and curriculum design. Ultimately, decision-making was experienced not as a technical task but as an ethical and pedagogical responsibility: the crafting of creating meaningful, safe, and challenging learning environments for nursing students. Facilitators who share their lived experiences with SBL have offered better insight into decision-making routines and challenges in simulation practices among women at the College of Nursing.

Ethics approval and consent to participate; This study obtained ethical approval from Institutional Review Board, College of Medicine, King Saud university with reference No. 17/0873/IRB and the research project No. E-17-2661.All participant in this study have consented to participate before the data collection began.
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.
Competing interests: The author declares that they she has no competing interest
Funding: not applicable
Author contribution: The only author who contributed to the conception, and design of the work; acquisition, analysis, and interpretation of data; drafted and revised the manuscript; and approved the submitted version.
Acknowledgments; This study received RAED research grant for novice researchers from the Deanship of Scientific Research, King Saud University.
Author information: The author graduated, MSN & PhD from the University of Melbourne, Melbourne, Australia

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No competing interests reported.

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You are reading this latest preprint version

Educators’ decision-making in simulation-based learning with a bachelor’s degree in a nursing program at a Saudi Arabian nursing college

Status:

Version 1

Abstract

Background

Method

Results

Conclusion

Background

Method

Participants and study setting

Data collection

Ethical considerations

Rigor

Data analysis

Results

Theme 1: Decision-making as deliberate crafts of preparation

Theme 2: Decision-making as a means of negotiating readiness and challenge

Theme 3: Decision-making as responsive attunement in the moment

Theme 4: Decision-making as shaping assessment and feedback

Theme 5: Decision-making amid the curriculum and programmatic constraints

Discussion

Implications for nursing education

Strengths, limitations, and future research

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1