Effect of a Hybrid Simulation-based Patient Safety Education Program on Patient Safety Knowledge, Attitudes, Performance Confidence and Decision-Making Abilities in Undergraduate Nursing Students

Hyun-Sook Jeong; Mi Yang Jeon

doi:10.7739/jkafn.2025.32.4.432

J Korean Acad Fundam Nurs > Volume 32(4); 2025 > Article

Jeong and Jeon: Effect of a Hybrid Simulation-based Patient Safety Education Program on Patient Safety Knowledge, Attitudes, Performance Confidence and Decision-Making Abilities in Undergraduate Nursing Students

Original Article

J Korean Acad Fundam Nurs 2025; 32(4): 432-443.

Published online: November 30, 2025

DOI: https://doi.org/10.7739/jkafn.2025.32.4.432

Effect of a Hybrid Simulation-based Patient Safety Education Program on Patient Safety Knowledge, Attitudes, Performance Confidence and Decision-Making Abilities in Undergraduate Nursing Students

Hyun-Sook Jeong¹⁾

, Mi Yang Jeon^2),

¹⁾Assistant Professor, Department of Nursing, Sehan University, Yeongam, Korea

²⁾Professor, College of Nursing ‧ Sustainable Health Research Institute, Gyeongsang National University, Jinju, Korea

Corresponding author: Jeon, Mi Yang College of Nursing, Gyeongsang National University 15 Jinju-daero, 816 beon-gil, Jinju 52727, Korea Tel: +82-55-772-8261, Fax: +82-55-772-8209, E-mail: myjeon68@gnu.ac.kr

*This article is a revision of the first author's doctoral thesis from Gyeongsang National University.

Received May 26, 2025 Revised August 14, 2025 Accepted November 16, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

This study aimed to develop a hybrid simulation-based patient safety education program and verify its effectiveness among Undergraduate Nursing Students.

Methods

The research employed a nonequivalent control group pretest-posttest non-synchronized design. Participants included 60 second-year nursing students at M University in M City, 30 assigned to the control group and 30 to the experimental group. The program consisted of two sessions of theoretical education covering patient safety information and the error reporting system and two sessions of practical education using standardized patients and high fidelity patient simulations. The intervention was conducted once a week for 60∼90 minutes, over four weeks. Data were collected over five months from July to November 2017, and analyzed using SPSS 24.0. The effectiveness of the program was evaluated through repeated measures ANOVA.

Results

Significant interactions between time and group were observed for all outcome variables. The experimental group showed greater improvements than the control group in patient safety knowledge (F=65.28, p<.001), attitude (F=18.86, p<.001), performance confidence (F=11.14, p<.001) and decision-making ability (F=18.13, p<.001).

Conclusion

The findings support the implementation of hybrid simulation-based patient safety education as an effective strategy for enhancing nursing students’ competencies in patient safety knowledge, attitudes, performance confidence, and decision-making abilities.

Key words: Decision making, Patient safety, Patient simulation, Student, Nursing

INTRODUCTION

Patient safety involves lowering the risk of unnecessary medically related injury to the minimum allowed level [1]. Patient safety accidents threaten patient safety within a hospital and include medication errors, falls, and infection-related incidents. These errors, mistakes, and accidents occur in the hospital regardless of the extent of injury to the patient due to the accident [2]. According to a recent systematic review [3], 12% of patients experience harm across different medical care settings. The severity of around half of patient harm extends beyond mild injuries and temporary harm. As much as 12% of adverse events cause permanent disability or patient death [3]. The pri-mary types of harm were predominantly related to medication (65%), followed by other forms of care (15%), medical devices (14%), and surgical or procedural issues (6%) [4]. In South Korea, due to changes in the medical environment, such as increased patient severity and an aging pop-ulation, patient accidents are continuously increasing from 9,250 cases in 2018 to 13,919 cases in 2020 and 20,273 cases in 2023 [5].

Nurses are healthcare professionals who provide care to patients and play an important role in identifying risk factors in the medical settings and in ensuring patient safety [6]. Interventions are needed to improve nurses’ knowledge and awareness of patient safety to prevent incidents and enhance their decision-making abilities in resolving issues when such incidents occur. To improve nurses’ patient safety management capabilities, it is necessary to provide education related to patient safety in the nursing department curriculum. Patient safety competency refers to the knowledge, skills, and attitudes that nursing person-nel must possess to protect patients from unnecessary injuries [7]. The patient safety accidents experienced by nursing students in clinical practice occur in various situations, it is necessary to increase not only the knowledge, attitude, and performance confidence about patient safety but also decision-making ability of nursing students [8,9].

Simon's decision-making model [10] explains the decision-making process in three stages: exploring the problem (intelligence), designing alternatives to solve the analyzed problem (design), and evaluating various alternatives to select effective alternatives (choice). To improve a nursing students’ decision-making skills, it is necessary to develop an educational program designed to enable them to experience the three stages outlined in Simon's decision-making model.

Simulation-based education is a teaching and learning method that allows learners to practice simulated situations related to patient safety accidents while appropri-ately coping with stress and anxiety. There are various methods of simulation, including high-fidelity simulators, low-fidelity simulators, standardized patients, virtual reality (VR), augmented reality (AR), and mixed reality (MR). Recently, hybrid simulations, which combine two or more of these methods, have been applied in education. Hybrid simulations involve using multiple simulation types within the same session and are utilized in various ways, such as combining high-fidelity simulators with standardized patients [11], VR with high-fidelity simulators [12], and VR with standardized patients [13]. High-fidelity simulators, commonly used in nursing education, are a valu-able educational tool for recognizing realistic scenarios through the physiological responses of computerized full-body mannequins [14]. However, they have limitations in implementing verbal and nonverbal communication [15]. Standardized patient-based simulation is an effective educational method for expressing the feelings and emotions involved in clinical interactions by simulating clinical situations with individuals trained to act out emotional and physical characteristics like real patients [16]. However, it cannot confirm the physiological responses of patients. Hybrid simulations that combine these two types can ef-fectively achieve educational goals [15].

Examining previous studies aimed at improving the patient safety competencies of nursing students, one study developed and applied 12 training modules related to patient safety, which enhanced students’ knowledge, skills, and perceptions of quality and safety competencies [17]. Another study reported improvements in patient safety performance confidence following a patient safety education program utilizing the ROE (Room of Errors) techni-que based on simulation [18]. Additionally, a study focusing on high-fidelity simulator-based education found that, after participating in the simulation program, students showed statistically significant improvements in their attitudes toward patient safety, confidence in patient safety, academic self-efficacy, and academic engagement [19]. The majority of previous studies have reported changes in patient safety knowledge, attitudes, and performance confidence. However, as patient safety incidents occur in various situations, it is necessary to enhance not only the knowledge, attitude, and performance confidence regarding patient safety but also the decision-making abilities of nursing students.

Therefore, this study aims to develop and apply a hybrid simulation education program that uses a high-fidel-ity simulator and standardized patients to enhance the patient safety capabilities of nursing students, and to verify its effectiveness so that it can be used as a patient safety education program for nursing students in the future.

METHODS

1. Study Design

This study used a nonequivalent control group pretest-posttest non-synchronized design to determine its effectiveness. To minimize the diffusion effect of the treatment, the experiment was conducted during vacation periods to separate the experimental times. Data were first collected from the control group so that the control group could not obtain experimental information from the experimental group. The experiment was then conducted on the experimental group.

2. Participants

The participants were sophomore students from the Department of Nursing at a single university located in Munkyung city. The inclusion criteria were individuals who completed at least two semesters of fundamental nursing practice. The exclusion criteria were individuals who experienced receiving patient safety training, completed healthcare-related courses at a different university, and had experience serving as a medic in the military.

In this study, patient safety education program was provided at sophomore students before the clinical practice, based on the findings of Stevanin et al. [20]. Junior and senior students have the opportunity to receive patient safety education and gain experience in patient safety nursing activities during clinical practice, thus they were excluded from the study subjects. To recruit participants, notices were posted on the nursing department's bulletin board, website, and student chat rooms. Students who ex-pressed a desire to participate and met the selection criteria were chosen as subjects.

The study's sample size was calculated using G*Power 3.1.9.7 [21]. The G*Power program sets the default values for repeated-measures ANOVA with an effect size of 0.25, a significance level of 0.05, a power of 0.90, two groups, three measurements, and a correlation coefficient of 0.30 [22]. The required sample size was determined to be 60. 60 participants were finally enrolled. Among the 60 who met the selection criteria, 30 who wished to participate in the program were assigned to the experimental group, and 30 who could not consistently participate were assigned to the control group. Among the applicants who met the selection criteria, students 1∼30 who applied first were assigned to the control group, and students 31∼60 were assigned to the experimental group.

3. Outcome Measurements

1) Patient safety knowledge

Patient safety knowledge was measured using the patient safety knowledge tool that Park and Park [23] developed to measure the patient safety knowledge of nursing students and Choi and Lee [24] revised and supplemented to make it suitable for nursing students. This tool was developed by incorporating the concept of patient safety into the patient safety assurance activities outlined in the accreditation evaluation criteria. These criteria include patient identification, communication, drug safety, correct site and surgery/procedure, infection control, fall pre-vention, facility and environmental safety, and patient error reporting [25]. This tool consists of ten items, each an-swered with "Yes," "No," or "Don't know." Correct answers were scored as 1 point, while incorrect answers and "Don't know" responses were scored as 0 points. The total score was calculated by summing the scores for all ten items. The scores ranged from 0 to 10 points. Higher scores indicated more patient safety management knowledge. The reliability of the tool in Choi and Lee [24] was Cronbach's ⍺=0.65. Meanwhile, the Cronbach's ⍺ in this study is 0.67.

2) Patient safety attitude

Patient safety attitudes were measured using the tool developed by Park et al. [15] for hospital medical staff, which was later revised and supplemented by Choi and Lee [24] to suit nursing students. This tool covers 10 items rated on a 5-point Likert scale, where each item is scored as 1="strongly disagree," 2="disagree," 3="neutral," 4= "agree," and 5="strongly agree." The total scores range from 10 to 50 points. Higher scores indicated more positive attitudes toward patient safety. The reliability of the tool in Choi and Lee [24] was Cronbach's ⍺=0.67 while the Cronbach's ⍺ in this study is 0.67.

3) Patient safety performance confidence

Patient safety performance confidence was measured using the the patient safety/medical fallibility assessment curriculum survey (HSPPSACS) developed by Madigosky et al. [27] to assess medical students’ the knowledge, attitudes, and performance related to patient safety management. This tool was revised and supplemented by park [28], with reference to the international patient safety goals, to make it more suitable for nursing students. This tool includes 10 items rated on a 5-point Likert scale, where each item is scored as 1="not confident at all," 2="not confident," 3="neutral," 4="confident," and 5= "very confident." The scores ranged from 10 to 50 points. Higher scores indicated higher performance confidence. The reliability of the tool in Park [28] was 0.85 while in this study, it was 0.95.

4) Decision-making ability

Decision-making ability was measured using the Korean version of the Clinical Decision-Making in Nursing Scale, which was originally developed by Jenkins [29] and translated by Baek [30]. This tool consists of 40 items on a 5-point Likert scale. The scores ranged from 10 to 50 points. A higher score indicates better decision-making. The reliability of the tool in Baek [30] was Cronbach's ⍺=0.77 and in this study, the Cronbach's ⍺ was 0.90.

4. Development of the Hybrid Simulation-based Patient Safety Education Program for Nursing Students

1) Development of the hybrid simulation-based patient safety educational program

To select the contents of the hybrid simulation-based patient safety educational program utilizing standardized patients and high fidelity patient simulation for nursing students, we categorized and organized educational topics related to patient safety in previous studies that we had found [23,28-30]. Consequently, the training methods for the patient safety management competency-enhancement program consisted of lectures, discussions, and videos. We selected the following topics related to patient safety: definition of patient safety, methods of patient safety, terms related to patient safety categorization (red light, injury, and close error), types of errors, communication for reporting patient safety errors, and reports of patient safety errors. Practice education consists of case-based learning, which provides the opportunity to experience patient safety problems through cases. Patient safety cases to be used for case-based learning were developed based on cases of patient safety accidents that nursing students had experienced (patient identification, falling, pricking by needle of an injection syringe, drug administration error, and hospital infection). Standardized patient and high-fi-delity simulators were used to reconstruct the scenario.

2) Scenario development

The patient safety scenario was created by a researcher with experience on a hospital patient safety management committee and reviewed by another researcher experienced in patient safety education.

3) Content validation

The scenario's content validity was confirmed by two clinical nurses working as patient safety nurses and two nursing professors with research experience in patient safety. Experts were reviewed the scenarios and added or modified content to align with the learning objectives. Researchers reviewed the scenarios, incorporating the ex-perts’ feedback, and finalized the scenario content.

4) Standardized patient

The standardized patient was chosen from actors who are members of the Korean Psychodrama Association, matched the gender and age of the scenario patient, and had over three years of experience as standardized patients in clinical assessments and simulation classes in the Gyeongsangbuk-do region. Training was conducted by the researcher over six hours, emphasizing the need for consistent responses, accuracy, and confidentiality. The first session covered the training script and requirements, the second provided medical histories and physical assessment training, and the third included final practice and rehearsal.

In this study, the program was conducted once a week for four weeks, equivalent to four sessions. Each session consisted of 60 minutes of lecture and 90 minutes of practice education. In each session, except for the first and last sessions, the participants watched a video of a case related to patient safety for 10 to 15 minutes and then talked about the movie and their feelings for 20 to 15 minutes, for a total of 40 minutes (Table 1, Figure 1).

Figure 1.

Flow diagram of the study.

Table 1.

Content of a Hybrid Simulation-based Patient Safety Education Program for Nursing Students

Session (week)	Theme	Program contents	Time (minute)	Method
1	Patient safety instruction 1– lecture based	Definition of patient safety	40	Lecture
		Patient safety law
		Patient safety classified terminology
		- Warning sign
		- Hazardous event
		- Proximity error
		Class study	15	Practice
		- Offering patient safety case
		- Exploring patient safety problem
		Quiz	10	Evaluation
		Question & answer	5	Finishing
2	Patient safety case 1-simulation based	Patient safety case 1	15	Lecture
		- Patient check
		- Falling accident
		- Healthcare-associated infections
		Patient safety case 1 analysis	20	Case analysis
		- Exploring patient safety problem
		- Designing patient safety nursing intervention
		- Selecting patient safety nursing intervention
		Patient safety case base using standardized patients and high-fidelity patient simulator	10	Practice

		- Practice: 5 people 1 group, total 6 group
		- Performing patient safety behavior
		Evaluation	20	Evaluation
		- Reflection note
		- Debriefing
		Question & answer	5	Finishing
3	Patient safety case 2-simulation based	Patient safety case 2 information offer	15	Lecture
		- Healthcare-associated infections (Wound management)
		- Medication error
		Patient safety case analysis	20	Case analysis
		- Exploring Patient safety Problem
		- Designing Patient safety Nursing Intervention
		- Selecting Patient safety Nursing Intervention
		Standardized patients and high-fidelity patient simulator using based on patient safety	10	Practice

		- Practice: 5 people 1 group, total 6 group
		- Performing patient safety behavior
		Evaluation	20	Evaluation
		- Reflection note
		- Debriefing
		Question & answer	5	Finishing
4	Patient safety error instruction 2-lecture based	Types of error	40	Lecture
		Patient safety error report
		- Error reporting category
		- Error reporting method
		- Writing error reporting
		Communication for reporting patient safety error
		Writing patient safety error report	10	Practice
		Quiz	5	Evaluation
		Question & answer	5	Finishing

5. Data Collection

The data collection procedure of this study included a pretest, experimental manipulation, posttest 1, and posttest 2.

1) Pretest

General characteristics, patient safety knowledge, patient safety management attitude, patient safety performance confidence, and decision-making ability were measured using a structured survey before the experimental manipulation for the control and experimental groups. The survey lasted for 15∼20 minutes.

2) Posttest

For the control group, posttest 1 was conducted four weeks after the pretest. Posttest 2 was conducted four weeks after posttest 1. Posttests 1 and 2 measured the same items, after excluding the general characteristics, and used the same methods as the pretest.

6. Data Analysis

For this study, we used the SPSS 24.0 program to analyze participants’ general characteristics with means, standard deviations, frequencies, and percentages; and χ² test, Fisher's exact test, and independent t-test for the homogeneity of the general characteristics and research variables between the experimental and control groups. Repeated measure ANOVA and independent t-test were used to identify the effect of the patient safety education program and Cronbach's ⍺ for the internal consistency reliability of the measurement tool.

7. Ethical Considerations

Ethical approval for this study was obtained from the Gyeongsang National University Ethics Committee (approval number: GIRB-A17-0039), and institutional permission was obtained from the institution where the study was conducted. All participants were informed of the pur-pose of the study and that they could withdraw at any time. Informed consent was obtained from all participants, and all data were anonymized. After the study was completed, the participants were informed of the group to which they belonged, and the 20 control group students who wished to participate in the program were adminis-tered the Hybrid Simulation-based Patient Safety Education Program in the same way as in the experimental group.

RESULTS

1. A Homogeneity Test

The results of testing the homogeneity of participants’ general characteristics showed no difference between the experimental and control groups in terms of sex (χ²=0.00, p>.999), grades (χ²=5.69, p=.111), satisfaction with practice (χ²=1.00, p=.506), and experience with safety accidents during basic nursing practice (p >.999) (Table 2). Although there were no significant differences between the two groups in patient safety management knowledge (t=1.95, p=.056), patient safety management attitude (t=-0.10, p=.925), or decision-making ability (t=0.16, p=.877) before the experiment, there was a significant difference in confidence in patient safety management performance (t=2.41, p=.019) (Table 2).

Table 2.

Homogeneity Test of General Characteristics and Research Variables (N=60)

Variables	Characteristics	Categories	Exp. (n=30)	Cont. (n=30)	χ²	p
Variables	Characteristics	Categories	n (%) or M± SD	n (%) or M± SD	χ²	p
Participants’ general characteristics	Gender	Men	7 (23.3)	7 (23.3)	0.00	＞.999
	Gender	Women	23 (76.7)	23 (76.7)
	Academic performance (last semester)	＞4.0	4 (13.3)	3 (10.0)	5.69	.111
		4.0∼3.5	12 (40.0)	19 (63.3)
		3.5∼3.0	10 (33.4)	8 (26.7)
		＜3.0	4 (13.3)	0 (0.0)
	Safety accident experience^†	No	29 (96.7)	30 (100.0)	-	＞.999
	Safety accident experience^†	Yes	1 (3.3)	0 (0.0)
Outcome variables	Knowledge		5.63±1.40	4.93±1.14	1.95	.056
	Attitude		38.00±3.93	38.10±4.20	-0.10	.925
	Performance confidence		39.03±5.24	34.57±8.67	2.41	.019
	Performance confidence
	Decision-making ability		133.93±13.66	132.79±14.60	0.16	.877
	Decision-making ability

Attitude=patient safety attitude; Performance confidence=patient safety performance confidence; Cont.=control group; Exp.=experimental group; Knowledge=patient safety knowledge; M=mean; Pre=pretest; Post1=posttest1; Post2=posttest2; SD=standard deviation.

^† =Fisher's exact test

2. The Effects of the Hybrid Simulation-based Patient Safety Educational Program

In order to conduct repeated measures ANOVA of patient safety management knowledge, attitude, performance confidence, and decision-making ability, the assumption of sphericity was confirmed. As a result of Mauchly's sphericity test, the sphericity assumption was met as the significance level was 0.05 or higher. The patient safety knowledge scores of the experimental and control groups after the hybrid simulation-based patient safety education program showed a significant interaction between time and group (F=65.28, p<.001). In the experimental group, the post1 score increased statistically significantly compared to the pre score (t=-9.68, p＜.001), and the post 2 score increased statistically significantly compared to the post 1 score (t=-6.15, p＜.001).

The patient safety attitude scores of the experimental and control groups after the hybrid simulation-based patient safety education program showed the interaction between time and group (F=18.86, p<.001). In the experimental group, the difference between the pre-value and the post-first value (t=-4.64, p＜.001) was statistically significant.

After the hybrid simulation-based patient safety education program, there was a significant difference in patient safety performance confidence scores between the experimental and control groups (F=24.59, p< .001) and the interaction between time and group (F=11.14, p<.001). In the experimental group, the post1 score increased statistically significantly compared to the pre score (t=-6.39, p ＜.001), and the post 2 score decreased statistically significantly compared to the post 1 score (t=8.92, p＜.001).

The decision-making ability scores of the experimental and control groups did not show a significant difference after the hybrid simulation-based patient safety education program (F=3.02, p=.087), and the interaction between time and group showed significant differences (F=18.13, p<.001).

In the experimental group, the post1 score increased statistically significantly compared to the pre score (t=-7.38, p＜.001), and the post 2 score decreased statistically significantly compared to the post 1 score (t=11.95, p＜.001) (Table 3).

Table 3.

Effects of a Hybrid Simulation-based Patient Safety Education Program (N=60)

Variables	Groups	Pre	Post 1	Post 2	Effect of group-by-group time-by-time		Effects of program
		Pre	Post 1	Post 2	Pre vs Post 1	Post 1 vs Post 2		F (p)
		M± SD	M± SD	M± SD	t (p)	t (p)		F (p)
Knowledge	Exp. (n=30)	5.63±1.40	8.56±0.77	9.70±0.46	-9.68 (＜.001)	-6.15 (＜.001)	Time	79.12 (＜.001)
	Cont. (n=30)	4.93±1.14	5.56±1.35	5.23±1.27	-2.07 (.047)	1.43 (.161)	Group	183.29 (＜.001)
							T×G	65.28 (＜.001)
Attitude	Exp. (n=30)	38.00±3.93	42.60±4.11	42.90±3.06	-4.64 (＜.001)	-0.39 (.695)	Time	9.17 (＜.001)
	Cont. (n=30)	38.10±4.20	38.96±4.87	36.30±3.16	-1.09 (.284)	4.81 (＜.001)	Group	18.44 (＜.001)
							T×G	18.86 (＜.001)
Performance confidence	Exp. (n=30)	39.03±5.24	45.23±3.90	38.73±2.77	-6.39 (＜.001)	8.92 (＜.001)	Time	48.56 (＜.001)
	Cont. (n=30)	34.56±8.60	34.73±9.42	30.40±6.93	-0.20 (.843)	5.34 (＜.001)	Group	24.59 (＜.001)
							T×G	11.14 (＜.001)
Decision-making ability	Exp. (n=30)	133.96±13.66	156.41±15.36	120.82±11.00	-7.38 (＜.001)	11.95 (＜.001)	Time	58.80 (＜.001)
	Cont. (n=30)	132.79±14.60	142.13±14.09	123.17±12.51	-3.32 (.002)	6.09 (＜.001)	Group	3.02 (.087)
							T×G	18.13 (＜.001)

Attitude=patient safety attitude; Performance confidence=patient safety performance confidence; Cont.=control group; Exp.=experimental group; Knowledge=patient safety knowledge; M=mean; Pre=pretest; Post 1=posttest 1; Post 2=posttest 2; SD=standard deviation; G×T=group×time.

DISCUSSION

This study attempted to investigate the effects of a hybrid simulation-based patient safety education program on patient safety knowledge, attitudes, performance confidence, and decision-making abilities in second-year nursing students. In this study, data were collected at three time points to evaluate the effectiveness of the intervention program: before the program, immediately after the completion of the program, and four weeks after the program ended. The program development and its effects are discussed.

In this study, significant differences in patient safety knowledge scores were observed between the experimental and control groups. These findings are similar to those of Park and Kim [17] who conducted a quality improvement and safety competency training program for fourth-year students in a nursing department. The increase in the patient safety knowledge scores of the nursing students in our study and in the previous study is attributed to the provision of information related to patient safety through lectures. When selecting patient safety-related lecture topics, we considered items with low rates of correct responses in terms of nursing students’ patient safety knowledge [28]. Additionally, the nursing students were asked to watch videos related to patient safety after the lecture, thereby increasing their understanding of nursing students about patient safety. We provided patient safety cases, asked the students to analyze them to identify patient safety problems, and conducted quizzes on patient safety terminology to check whether they accurately understood patient safety terminologies. In addition, through the Q &A sessions, we explained the parts that students were cu-rious about or did not understand. Using these methods, we trained nursing students repeatedly. In practice, we presented patient safety cases and asked students to analyze them to explore patient safety problems based on the knowledge they learned in the lecture. Moreover, we asked the students to design possible patient safety nursing behaviors, select the optimal patient safety nursing behavior, practice these behaviors on a standardized patient, watch a video that recorded the patient safety nursing behavior they performed, complete a reflection journal, and discuss them to solve the identified patient safety problem.

In this study, there were significant differences in patient safety attitudes between the experimental and control groups. The results of this study are similar to those of Miller and Framboise [31], who conducted a quality improvement and safety training program for third- and fourth-year nursing students. Moreover, Madigosky et al. [27] trained 92 second-year medical students on topics related to medical fallibility using training methods such as lectures, discussions, and roleplays, and found that 87% of the participants showed improvement in patient safety attitudes. The enhancement in patient safety management attitudes in our study and previous studies is attributed to the process of making nursing students recognize the seri-ousness of patient safety problems by educating them about the importance of patient safety in theory and practice education, discussion, and roleplay. In the first week of the lecture, we played videos of cases that led to the en-actment of the patient safety law and cases of injuries or deaths due to patient safety accidents. Such educational materials were deemed to have contributed to improved awareness of patient safety and highlighted the importance of patient safety management. In this way, the patient safety management attitude changed positively [32]. Moreover, we asked the students to design patient safety nursing behaviors, select the optimal patient safety nursing behavior among them, practice them on a standardized patient and high-fidelity simulators, record in a reflection journal, and discuss the suitability of the patient safety nursing behavior they chose. Problems that can occur when optimal patient safety nursing behavior is not performed. This method was deemed to have resulted in a positive change in the patient safety management attitude of the experimental group, because the nursing students were trained to recognize the importance of patient safety.

In this study, there were significant differences in patient safety performance confidence between the experimental and control groups. This finding was similar to that reported by Lee and Shin [33]. Lee and Shin [33] found that the experimental group's performance confidence was significantly higher after the program than that of the control group. The increase in patient safety performance confidence or patient safety skills in our study and in a previous study can be explained as patient safety management performance confidence increasing in the process of videorecording, re-watching, and debriefing [31,33]. Performance confidence refers to one's trust in one's possibil-ities and oneself and positive thoughts about oneself [34]. The experimental group directly experienced patient safety nursing behaviors, thereby increasing their confidence in patient safety management. Park and Kim [17] conducted a quality improvement and safety education program for fourth-year nursing students and reported that the experimental group scored higher than the control group. The reason that this study and previous studies [17,33] measured confidence in patient safety performance instead of assessing the actual level of patient safety performance is that the subjects were second-year nursing students who lacked clinical practice experience and thus had no experience in directly performing patient safety management behaviors. We suggest conducting studies that directly measure the subjects’ patient safety performance using standardized patients or patient safety simulation rooms.

Although the decision-making ability scores did differ significantly between the experimental and control groups. This finding is similar to the results of Yoo et al. [35], who conducted case-based learning on nursing students using videos for two weeks and reported that the decision-making ability of the experimental group increased. The improvement in decision-making ability in our study and previous studies [35] are thought to be because nursing students analyzed the cases through case-based practices, identified patient safety problems, designed possible patient safety nursing behaviors, and performed them on standardized patients. Therefore, they repeatedly experienced the decision-making processes. Additionally, we developed a patient safety competency enhancement program based on Simon's decision-making model [10]. The reasons for the improvement in decision-making ability are as follows. First, the patient safety cases were analyzed using Simon's decision-making stages to explore the problem in theory education. Second, nursing students analyzed patient safety cases to explore patient safety problems, designed possible patient safety nursing behaviors to solve the identified problems, selected the optimal behavior among the designed patient safety nursing behaviors, applied them to standardized patients and simulators, and evaluated the team's decision making in debriefing in practice education.

Since this study did not randomly assign participants to the experimental and control groups, it is possible that selection bias may have influenced the results. Furthermore, because the participants were aware of their involvement in the study, the findings may be subject to the Hawthorne effect and the expectations of the experimenters, which could limit the generalizability of the results. However, to mitigate the risk of treatment diffusion, a nonequivalent control group pretest-posttest non-synchronized design was employed. Additionally, a single-blind approach was implemented to separate the experimental treatment from the data collection process. This ensured that the data collectors were unaware of which participants belonged to the experimental or control group, thereby enhancing the study's validity. For future research, it is recommended to conduct a randomized controlled trial to further increase the validity of the findings. Implementing a double-blind meth-od, where neither the data collectors nor the participants are aware of their group assignments, is also suggested to minimize potential biases related to participant awareness.

This study is based on data collected in 2017, and since then, the nursing education and simulation environments have undergone significant changes. Nevertheless, this study was designed to overcome the limitations of using standardized patients and high-fidelity simulators inde-pendently by employing a hybrid simulation approach. While modern simulation education actively incorporates VR/AR technologies, the hybrid simulation method con-tinues to be a meaningful approach. This underscores the ongoing educational relevance of this study. The findings of this study continue to highlight the importance of simulation education in nursing. Although the technological environment has evolved, the significance of this study lies in its demonstration that hybrid simulation education contributes to enhancing the practical skills of nursing students.

CONCLUSION

This study tested the effectiveness of a hybrid simulation-based patient safety education program for nursing students using a standardized patient and simulator to improve patient safety competency. This program was found to be an effective intervention to improve patient safety knowledge, patient safety performance confidence, and decision-making ability of nursing students and to positively change patient safety attitudes. Therefore, we suggest the use of a hybrid simulation-based patient safety education program that utilizes standardized patients and simulators on nursing students to improve nursing students’ patient safety competency.

Notes

CONFLICTS OF INTEREST

The authors declared no conflict of interest.

AUTHORSHIP

Study conception and design acquisition - Jeong H-S and Jeon MY; Data collection - Jeong H-S; Data analysis & Interpretation - Jeong H-S and Jeon MY; Drafting & Revision of the manuscript - Jeong H-S and Jeon MY.

DATA AVAILABILITY

Please contact the corresponding author for data availability.

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