Students' satisfaction with simulated clinical experiences: validation of an assessment scale

OBJECTIVE: validate an assessment instrument of nursing students' satisfaction with simulated clinical experiences. METHOD: a 17-item scale was applied to students from the Teaching Diploma Program in Nursing, after a set of simulated clinical experiences. Factorial analysis with orthogonal varimax rotation was used, and the internal consistency was estimated to determine the validity of the scale. RESULTS: in a sample of 181 students, we found a high correlation between practically all items and the total scale, with an Alpha coefficient of 0.914. The scale items were divided in three factors: practical dimension, realism dimension and cognitive dimension, with good internal consistency coefficients of 0.89; 0.88 and 0.73, respectively. CONCLUSION: the scale complies with the validity requisites, revealing a high potential for use in research.


Introduction
The construction of nursing knowledge and the way it is transmitted to the students have evolved over the years, permitting the progressive construction of a scientific corpus that sustains nursing as a science (1) .
The evolution of science in general and of technology itself, associated with the growing health requirements of society lead to increasing pressure in nursing schools and their teachers, with a view to the development of more and better prepared professionals (2) .
Nursing faculty and teachers are confronted with challenges that drive them to create new pedagogical approaches that promote the students' self-discovery and stimulate their active search in the development of learning itself (3) .
Thus, nursing is experiencing the use of new active teaching methods. The study of clinical cases, the creation of clinical scenarios, laboratory practice and simulation are examples, with particular interest and highlight, whether because of their specific teaching characteristics or the benefits they offer for the students' education.
These changes in the teaching/education paradigms currently put the students at the heart of their learning, in which they are the engine of their development. As a result, traditional teaching methods like lectures and oral presentations are considered less appropriate to develop some kinds of learning (3) .
Scientific evidence in the field of simulation demonstrates that, when used in teaching, it enhances and promotes the development of significant learning in the students, and that it can reach its culmination if the participants consider it as legitimate, authentic and realistic (2) . Furthermore, there is strong evidence that the students appreciate the simulation and the opportunities created to practice it in a safe and risk-free environment (4) .
The results of simulation in health education are more beneficial when associated with the most modern sound and image technologies, realistic environments, high-fidelity simulators and a structured reflection after each scenario about the learning and the decisions taken (debriefing), core concepts to talk about a simulated clinical experience (1) .
Various authors have analyzed the students' satisfaction with the simulation (5)(6)(7)(8)(9)(10)(11)(12)(13) , although the results of the satisfaction scores obtained in the different groups of students who used different simulators did not all converge.
These contradictory results and the fact that none of them represented the Portuguese reality stimulates the development of further research in the area and theme.
Students' satisfaction is an important result as it is associated with greater involvement in the process and greater motivation for learning.
Hence, it seemed pertinent to elaborate an instrument that would allow us to assess the nursing students' satisfaction with simulated practice in a Portuguese reality. Therefore, the objective in this study is to validate a scale of satisfaction with the simulated clinical experiences.

Study subjects
In a population of 318 fourth and final-year students from the Teaching Diploma Program in Nursing, all of whom complied with the eligibility criteria, 181 students were included in the sample. Having participated in the practical classes on emergency nursing and accepting to participate in the study were established as the inclusion criteria.

Data collection process
In the fourth year, as part of the Curricular Unit Emergency Nursing, with an hour load of 18 theoreticalpractical hours and 18 practical hours, the students apply

Ethical considerations
The study received authorization from the School

Construction process of the scale
To construct the scale, two previously developed studies were important, one with a phenomenological approach, addressing the students' experiences in simulated practice using high-fidelity manikins, in which For the purpose of this study and to guarantee more robust results, we considered ten participants for each item of the scale that is to be analyzed (14) .

Sample
The sample consists of 181 fourth-year students from the Teaching Diploma Program in Nursing, who in April 2012 volunteered to participate in the study, on the final class day of the curricular unit on Emergency Nursing.
The subjects' ages varied between 20 and 32 years, with a larger percentage in the age group between 21 and 23 years (87.29%), a mean age of 22.11 years and a standard deviation of 1.90 years.

Construct validity
For the construct validity, the factor analysis of the main components of the correlations among the variables was used to summarize as much of the information as possible in as few factors as possible. After defining the three factors, the factor loadings for each item were verified, excluding those with factor loading less than 0.45 (Table 3). In addition, the rational coherence of the proposed solution was verified, guaranteeing a conceptual translation of the mathematical proposal. that the students consider it as legitimate, authentic and realistic (2) .

Internal consistency of the scale dimensions
After analyzing the internal consistency coefficient of the ESECS as a whole, it is coherent to analyze each of the dimensions separately in the same manner. We  (Table 4).

Descriptive results of the ESECS
Based on the analysis of Table 5

Discussion
In Portugal, simulated practice in nursing teaching is a reality in a significant part of the curricular units Olkin measure showed that the sample was appropriate for the factor analysis of the items (14) .
The Varimax orthogonal rotation was chosen to make the empirical result more easily interpretable, without affecting the statistical properties (15) . To interpret the value of each variable in the definition of each factor, a correlation between the variable and the factor >0.45 was assumed as the minimum acceptable value.
In the validation process, a high correlation coefficient was verified between practically all items and the total scale, with a good reliability ratio (Alpha = 0,914), indicating that the scale seems to measure the students' satisfaction with the simulated practice. Based on statistical support to guarantee the appropriateness of the factor analysis, a clear division in three factors stood out, with good reliability ratios for each isolated factor, close to 0.90.
The students' satisfaction level with the practice in a simulated context is high, which stimulates the school to invest in this teaching strategy, always looking for the best results.
The students appreciated more the realism and the cognitive satisfaction. The lower coefficients in the practical dimensions seem to be related with the insufficient time dedicated to the practical component.
Even this variation can be considered as a validity criterion of the scale though, due its ability to distinguish among different dimensions of the concept.

Conclusion
In this study, we aimed to present the results of the validation process of a scale to assess the nursing students' satisfaction with the simulated clinical experiences developed in the academic context.
The ESECS shows high reliability and validity coefficients, which allow us to affirm that it has the potential to analyze/assess the nursing students' satisfaction with the simulated practice. Its application in students at other teaching levels, in different nursing colleges and different courses where the practical components are a teaching/learning strategy is pertinent. Therefore, the current results should be interpreted with some caution.
Another score in favor of the ESECS' reliability is related to the agreement with the proposed factorial division, deriving from the mathematical analysis and its coherent rational meaning.  The scale has good conceptual and psychometric properties. It is considered a simple instrument that is easy to answer, which contributes to its application in future studies. Nevertheless, this study comes with some limitations, such as the small sample size and the sole focus on the satisfaction with simulated practices using medium and high-fidelity manikins and in the specific context of emergency nursing, which should be broadened to the entire practice in the laboratory context.
Future studies can contribute to reinforce the reliability of the ESECS as a research instrument.