Community Care Simulation Wins Praise From Nursing Students, But Anxiety and Unequal Access Persist

Clinical simulation has become one of the most transformative tools in modern nursing education, allowing students to rehearse high-stakes decisions without a single patient ever being at risk. Yet while hospital-based scenarios—emergency resuscitations, operating theatre crises, intensive care emergencies—have long dominated simulation curricula, the everyday realities of community care have remained strikingly absent. A new study from a private university in Spain, published in the open-access journal Nursing Open, offers one of the most detailed looks yet at what happens when nursing students are thrust into simulated primary care consultations, and the results reveal both the enormous promise of community care simulation and the practical frictions that can undermine it.

The research team, led by educators at Universidad San Jorge, designed a descriptive, cross-sectional study involving 103 second-year nursing students out of 162 enrolled in a Health Education course during the 2023–2024 academic year, a participation rate of 63.6 percent. Four faculty members collaboratively built four scenarios around topics that dominate real primary care consultations: hypertension, paediatric well-child visits, newly diagnosed Type 2 diabetes, and contraceptive counselling. Each scenario unfolded in the university’s high-fidelity simulation laboratory, with a lecturer playing the patient and one student per scenario acting as the primary care nurse while the rest of the group observed. Every session followed the classic three-phase architecture of simulation pedagogy: a prebriefing of five to ten minutes to establish objectives and psychological safety, ten to twenty minutes of scenario enactment, and a debriefing of twenty to thirty minutes in which participants and observers reflected together on what had happened and why.

The scenarios themselves were meticulously constructed to mirror the messy, human texture of community nursing. In one case, a 52-year-old hypertensive man on enalapril arrived visibly anxious, checking his watch and phone, having missed two appointments because he could not get time off work. Students had to measure his blood pressure, explore his beliefs about the disease, correct misconceptions, and negotiate shared goals around diet and treatment adherence. Another scenario placed a student opposite the mother of a six-month-old infant, represented by a high-fidelity paediatric mannequin, who arrived with questions about percentiles, complementary feeding, co-sleeping and vaccine reactions. A third featured an unmotivated 55-year-old smoker with newly diagnosed diabetes who often forgot his medication, and a fourth required contraceptive counselling for a 44-year-old woman with recent hormonal imbalances—a task that, in the Spanish system, midwives provide without prescribing authority.

To capture student perceptions, the researchers combined quantitative and qualitative methods. Participants completed the 20-item Simulation Design Scale, a Likert-type instrument assessing five dimensions: objectives and information, facilitator support, problem-solving opportunities, feedback and guided reflection, and fidelity or realism. The scale showed excellent internal consistency in this sample, with a Cronbach’s alpha of 0.977 for the overall questionnaire. Alongside the ratings, students wrote reflective narratives in response to five open questions probing how the experience shaped their understanding of community nursing, what challenges they faced, what they considered strengths and weaknesses, and what lessons they would carry forward. The qualitative data were coded line by line in ATLAS.ti by two analysts, with a third researcher resolving interpretive differences, and the quantitative and qualitative strands were then integrated at the interpretation stage using a convergent approach.

The numbers told a strikingly positive story. Students reported high agreement across all five SDS domains, with mean scores hovering around 4.5 on the five-point scale and an overall average of 4.53. Fidelity and realism received the highest domain rating at 4.58, with 66 percent of students strongly agreeing that the scenario resembled a real-life situation. Objectives and information scored highest among the domains at 4.54, while support received the lowest at 4.49—a subtle but meaningful signal that students wanted more individualized guidance during challenging moments. Only 15 of the 103 participants, or 14.5 percent, had no previous simulation experience, and the cohort was predominantly female at 80.6 percent, with a mean age of 23.4 years.

The reflective narratives added rich texture to those ratings, crystallizing into five themes. Students praised the realism of the cases and their power to bridge theory and practice, with one noting that the activity prepared them for scenarios they would face in day-to-day professional practice. They valued the development of clinical reasoning and communication, particularly the empathy required to educate patients effectively—one student reflected that caring for a patient is not as easy as it seems, especially the empathy involved in how you speak to them. The safe environment emerged as a double-edged theme: students treasured being able to put themselves in the situation without fear of messing up, yet performing alone in front of peers and instructors produced genuine anxiety, with some admitting that going up alone was the worst and most embarrassing part of the experience.

Organizational and pedagogical limitations also surfaced clearly. Students criticized the length of some cases and the scheduling of multiple activities on a single day, associating these conditions with fatigue and poorer performance; one suggested the hours should have been split into two sessions. Others reported feeling lost when they entered the simulation space before the relevant theory had been covered in class. Perhaps the most pointed criticism concerned participation equity: because only one student per group acted in each of the four scenarios, most students spent the sessions as observers. One participant wished for more opportunities to participate, noting that with only four cases not everyone gets a turn. The study’s authors point to evidence that observers can achieve outcomes comparable to direct participants in knowledge and skill acquisition, but only when observation is structured and active rather than passive—a design principle the researchers urge educators to embrace through explicit observer tasks and prebriefing that frames watching as meaningful learning.

The findings carry practical weight for nursing programmes worldwide, where community care remains underrepresented in simulation curricula despite demanding a distinct competency profile. Community nursing emphasizes health promotion, disease prevention, long-term follow-up and therapeutic relationships sustained over time, often with limited technological resources and considerable human variability. The authors argue that simulation instructors should maintain active clinical practice to keep scenarios authentic, or involve practising nurses as subject-matter experts when their own clinical experience is dated. They also recommend spreading sessions across multiple time points, providing preparatory materials in advance, ensuring students have covered the relevant theory before enactment, and tailoring facilitator support to individual needs, since effective facilitation and debriefing are central to high-quality simulation-based education.

The study’s limitations temper its conclusions. It was conducted at a single private university in Spain, voluntary participation may have attracted students already favourable to simulation, and the research measured perceived educational value rather than objective competence or clinical performance. Most participants had prior simulation experience, and unequal hands-on opportunities were baked into the design itself. Still, the overall verdict is unambiguous: students perceived community care simulation as a valuable strategy for developing therapeutic communication, clinical decision-making and interpersonal skills in a psychologically safe setting. As health systems worldwide shift care out of hospitals and into communities, the authors contend that simulation scenarios reflecting the complexity of frontline, first-level care should be systematically woven into nursing education—not as an afterthought, but as a core pillar of preparing confident, competent professionals for the patients they will actually meet.

Subject of Research: Nursing students' perceptions of a community care clinical simulation experience

Article Title: Nursing Students' Perceptions of a Clinical Simulation Experience in Community Care: Strengths and Limitations

Article References: Gómez‐Torres, P., Galarreta‐Aperte, S., Blázquez‐Ornat, I., Antón‐Solanas, I., & Ramón‐Arbués, E. (2026). Nursing Students' Perceptions of a Clinical Simulation Experience in Community Care: Strengths and Limitations. Nursing Open, 13(9), Article e70807. https://doi.org/10.1002/nop2.70807

Image Credits: AI Generated

DOI: 10.1002/nop2.70807

Keywords: clinical simulation, nursing education, community care, primary care, Simulation Design Scale, prebriefing, debriefing, simulation fidelity, observer role, student anxiety, health education, mixed methods