Enhancing Nursing Students' Critical Thinking and Clinical Reasoning Abilities in Post-Operative Care by Scenario-Based Simulation: A Randomized Controlled Trial

Enhancing Nursing Students' Critical Thinking and Clinical Reasoning Abilities in Post-Operative Care by Scenario-Based Simulation: A Randomized Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Enhancing Nursing Students' Critical Thinking and Clinical Reasoning Abilities in Post-Operative Care by Scenario-Based Simulation: A Randomized Controlled Trial Sadia Sultana Tonny, Sadia Alam Aivey, Nahida Akhter, Sovannara Hour, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7740598/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Simulation-based education is essential in nursing education to build clinical competencies. However, in Bangladesh, teaching remains mostly traditional with limited simulation-based learning. This gap hinders the development of critical thinking (CT) and clinical reasoning (CR), significant for safe patient care. This study aims to evaluate the effectiveness of scenario-based simulation in improving CT and CR among nursing students in post-operative care in Bangladesh. Methods This prospective, open-label, parallel (1:1) randomized controlled trial was conducted from January to March 2025 with second-year nursing students in a nursing college. After lectures, participants were randomly allocated into an intervention group (IG) or a control group (CG) based on knowledge pre-test scores. The IG received scenario-based simulation training for one week, while CG received traditional skills training. Post-test evaluations measured knowledge, skills, CT, CR, and reflection using the researcher-developed questionnaires. Quantitative data were analyzed with descriptive statistics, independent t-tests, and the Mann–Whitney U test. Quantitative data was done by content analysis. Results Out of 64 students, 58 (IG = 29, CG = 29) completed the study, mostly females aged 18 to 23 with no prior clinical and post-operative practice experience. The primary outcome as the overall total score of CT, CR and skill was statistically significant between the groups (p < 0.001). The IG showed statistically significant improvements in knowledge, skills, CT and CR (all, p < 0.001). Reflections highlighted that IG students reported more confidence, engagement, and were willing to apply their skills and knowledge during clinical practice, while CG students noted knowledge gain but struggled with skills development. Conclusions Scenario-based simulation significantly enhanced CT and CR among nursing students. Future studies should explore its impact across specialties and in long-term practice. With sufficient resources and institutional support, it recommended a significant strategy for nursing education in resource-limited settings such as Bangladesh. Trial registration: ClinicalTrials.gov, NCT06751446, 2024-12-20 Critical thinking Clinical reasoning Nursing education Scenario-based simulation Traditional skill training Post-operative nursing Figures Figure 1 Figure 2 Figure 3 Background Critical Thinking (CT) refers to the process of purposeful, self-regulatory judgment involving the analysis, interpretation, and evaluation of information to make informed decisions in patient care [ 1 ]. Clinical Reasoning (CR) is a cognitive and reflective process that enables nurses to assess patient conditions, identify actual or potential problems, and implement appropriate clinical interventions [ 2 ]. Subsequently, CR is closely linked to CT, which directly influences clinical performance, patient outcomes, and nursing professional development. Although both CT and CR are vital competencies for nursing students, several barriers inhibit their development during the academic period, particularly in developing countries such as Bangladesh. These barriers include insufficient clinical exposure, trained educators, simulation resources, and a lack of opportunities for hands-on learning [ 3 ]. In contrast, the traditional skills training method is primarily foundational, often emphasizing rote learning and task execution rather than decision-making and problem-solving [ 4 ]. Thus, students may struggle to effectively apply theoretical knowledge in clinical practice. Many developed countries have overcome this gap by implementing modern educational strategies, such as scenario-based simulation training [ 5 ]. Although this learning process is increasingly integrated into nursing curricula worldwide, structured scenario-based simulation training has received limited attention in nursing education in Bangladesh. Therefore, newly graduated nursing students were poorly prepared for the complexities of the modern healthcare system, particularly in demanding rigorous assessment, proactive decision-making, and quick clinical judgement [ 6 ]. Post-operative care is a major critical aspect of nursing practice, often need to quickly recognize the right interventions and provide care effectively to save patients' lives [ 7 ]. However, several nursing students reported feeling unprepared and lacking confidence in managing post-operative patients due to limited clinical exposure and the unpredictable nature of surgical complications, and judgment errors in such situations placed patient safety at serious risk, highlighting the need for teaching methods that extended beyond traditional lectures and demonstrations [ 8 ]. Scenario-based simulation replicates realistic clinical scenarios that challenge students to think critically, make clinical decisions, and reflect on their actions in a safe, controlled setting. This immersive experience fosters both CT and CR by offering repeated exposure to complex situations, promoting reflection, and building confidence without compromising patient safety [ 9 ]. A conceptual framework (Fig. 1 ) was developed to evaluate the effectiveness of scenario-based simulation training compared with traditional skill training in enhancing nursing students’ CT and CR abilities. It shows how scenario-based simulation training helps turn insufficient CT and CR skills into strengthened abilities. Traditional skill training in nursing education focuses on developing core technical skills through direct instruction, procedural demonstrations, and hands-on practice. Furthermore, it emphasizes the mastery of essential nursing tasks and accurate patient assessments through standardized protocols. However, the scenario-based simulation immerses students in realistic clinical environments, which enrich their decision-making and problem-solving skills. In this framework, CT involves cognitive domains such as observation of data, comparing findings with expected standards, identification of status, and generating judgement for patient outcomes. Consecutively, CR includes practical domains such as identifying current problems, linking with previous history, interpreting data, and recommending appropriate care actions. To introduce these cognitive and practical domains, an educational intervention was designed to facilitate the integration of theory into practice, leading to more effective decision-making and problem-solving during actual clinical patient care. Thus, the scenario-based simulation training was applied instead of traditional skill training, focusing on the development of CT and CR among nursing students from a selected nursing college in Bangladesh. This study hypothesizes that the students who receive scenario-based simulation training can demonstrate higher performance in CT, CR and knowledge on post-operative nursing care compared to other students who receive traditional skills training. Methods Study design, area and participants A prospective, open-label, parallel-group (1:1) randomized controlled trial (RCT) with block randomization was conducted from January to March 2025. Study participants were purposively selected from second-year Bachelor of Science (BSc.) in Nursing students at Grameen Caledonian College of Nursing (GCCN) in Dhaka, Bangladesh. They were enrolled according to the enrolment criteria. The inclusion criteria were: i) the student was registered for the “Adult Medical and Surgical Nursing” course during the study period, ii) the student did not have the experience of clinical practice in a post-operative ward. The student who had already completed both theoretical and practical courses on post-operative care was excluded from the study. Sample size The sample size for this study was intended using G*Power version 3.1.9.2, with an effect size of 0.8, an alpha (α) error probability of less than 0.05, and a power (1-β error probability) of 0.80, resulting in a required sample of 52 participants. Considering a 10% dropout, a total of 57 participants was determined. However, all 2nd year students who were registered for the “Adult Medical and Surgical Nursing” course (n = 64) were purposively recruited to maximize participation. Randomization and allocation Two lecture sessions (2 hours each session) on post-operative nursing management were conducted using a PowerPoint slide for all participants, immediately after consent. These pre-intervention lectures were delivered to provide the theoretical foundation for managing post-operative patients. The content included the purpose, phases of post-operative nursing care, post-operative nursing assessment on the vital body systems (such as respiratory, cardiovascular, neurological, metabolic and gastrointestinal), pain, temperature control and fluid and electrolyte balance. Overview of CT and CR, including complications and reporting had also taught them. Then, a pre-knowledge test was administered as baseline data. The researcher considered the baseline knowledge test scores as a base for block randomization to ensure equal distribution among the participants. A block size of 2 resulted in 32 blocks and was assigned to the intervention group (IG) and control group (CG). The block randomization was done by a person who was not involved in the study. Study procedure and data collection Figure 2 outlines the study flow and procedure. In the first week, all the students were informed regarding the ethical considerations of this study, such as purpose, procedures, voluntary nature of participation, the right to withdraw at any time without academic penalty, and the anonymized data used for research purposes. Next, written informed consent was obtained from all participants before enrolment. The data collection was conducted twice, at baseline and endline. Subsequently, all students participated in post-intervention tests such as skills evaluation, CT and CR assessment, knowledge and submitted a written reflection on their learning experience. Educational materials Intervention group The researcher and a faculty member from GCCN conducted the training among the participants for one week. After randomization, all the participants from the IG watched the researcher-developed video for 15 minutes. The content of the video demonstrated post-operative management, which was used to visually illustrate how nurses perform essential care activities in real clinical settings. The video content was developed based on a few information and steps, such as 1: greetings and confirmation of consciousness level; 2: position; 3: breathing and circulatory assessment; 4: wound and pain; 5: gastrointestinal assessment; 6: intake and output assessment; 7: environment arrangement and patient education; 8: integration and reporting. Next, they were divided into six groups (5–6 members in each group) and engaged in interactive scenario-based simulation training. Each participant practiced for 20 minutes using the researcher-developed scenarios under the researcher's supervision. The progress of their learning and feedback was sincerely observed. Control group In the traditional skill training group, the participants attended a face-to-face verbal demonstration of post-operative nursing management conducted by a GCCN faculty member. Then, they were divided into six small groups (5 to 6 members in each group) and engaged in individual hands-on practice for 20 minutes without any scenario. To address potential ethical concerns, CG received additional training using scenario-based simulation and video in post-operative care, after completing the study. Study outcomes and instruments The self-administered sociodemographic data were collected using a questionnaire, including age, gender, and clinical experience in a hospital, particularly in the post-operative care ward. CT, CR and skill evaluation checklists The primary outcome of this study was the changes in the ability of CT, CR with skill in post-operative nursing management. All the outcomes were measured by the researcher-developed checklist. The CT checklist contained 8 items covering areas such as consciousness, respiratory and circulatory status, pain, abdomen, in-out balance, environmental education and wound observation, with a total score of 32. Each item was categorized as either 0 = insufficient ability or 4 = sufficient ability. The CR checklist was developed based on the 4 domains, such as situation, background, assessment and recommendation (SBAR). This 4-item checklist was categorized 0 = poor ability and 5 = good ability, and a total score of 20, while higher scores indicated better CT and CR. Next, a post-operative skills evaluation checklist was adapted from the adult nursing simulation curriculum in Hiroshima University. This checklist consisted of 24 items related to core post-operative nursing skills, such as vital sign assessment and wound care, which were assessed by the researcher. Each item was categorized among 0 = not performed, 1 = insufficiently performed, and 2 = performed. The maximum score was 48, with higher scores reflecting stronger practical skill competency (Supplementary Materials 2). The overall total score (0 to 100) of CT, CR and skill was used to explore the primary outcome. The individual CT, CR and skill’s score was explored as one of the secondary outcomes of this study. Knowledge test questionnaire The knowledge test questionnaire was used to explore another secondary outcome. This questionnaire was developed based on standard medical-surgical nursing textbooks [ 10 ] to assess knowledge using 25 items and categorized into 0 = incorrect or 1 = correct with a total score of 25. A higher score indicated better knowledge among the participants (Supplementary Materials 1). The reflection questionnaire included five open-ended questions designed to explore students’ experiences of the training. It covered benefits, challenges, anticipated impact on clinical practice, suggestions for improvement, and general feedback. The content validity and face validity of all questionnaires were checked by two experienced teaching assistants and one nursing faculty member who teaches adult nursing at Hiroshima University, Japan. Data analysis A per-protocol set analysis was used to explore the efficacy of this study. Descriptive statistics were used to analyze the socio-demographic characteristics. The primary outcome of this study was explored using the Mann-Whitney U-test to compare the overall total scores of skills, CT, and CR between the groups at the endline. The individual total CT and CR scores were observed between the groups using the Mann-Whitney U-test. Next, an independent sample t-test was used to compare the individual total skill, pre and post knowledge test scores between the groups. A paired t-test was used to explore the changes in pre-and post-test knowledge total scores within the groups. The statistical significance was set at < 0.05. The quantitative data were analyzed using the statistical software package SPSS for Windows (version 26.0, Armonk IBM Co.). The content analysis of qualitative data (students’ reflection) was done by multidimensional scaling of words in the KH coder software for Windows (version 3 Beta.08e, SCREEN Advanced System Solutions Co., LTD). Results A total of 64 students were randomized and from each group, 3 students were excluded after allocation due to being absent during the sessions of scenario-based simulation training and traditional skill training. Among them, 58 students (IG, n = 29 and CG, n = 29) completed the entire study and their data were used for analysis (Fig. 3 ). The socio-demographic data of the student in both groups were similar except for their age and all of them were aligned with an age range from 18 to 23 years. The distribution of female students (n = 24) was equal in both groups. According to the enrollment criteria, all of them had the experience of clinical practice in the hospital; however, they did not have work experience in the post-operative ward. The primary outcome of this study was illustrated in Table 2 . The overall total score consisted of the total score of three individual tests such as skill, CT and CR tests. The Mann-Whitney U test results showed that the students' skills regarding CT and CR were improved (mean (SD), IG: 71.9 (8.93); CG: 36.1 (9.03)) and a statistically significant difference was observed in the overall total score between the groups (p < 0.001). Regarding the individual scale, a satisfactory change was observed in IG compared with CG. The maximum scores of the CT among IG and CG were 32 and 16, respectively. The results explored that the total score of CT was improved in IG (mean (SD) = 25.5 (3.61)) at the end of the intervention which was statistically significant (p < 0.001). This finding highlighted the significance of simulation-based training, which enables the student to think critically about post-operative patient care. Considering the total score of CR, the maximum score for IG was 20 and for CG was 10. The result revealed a significant change in the IG (p < 0.001) students’ performance on identifying CR compared with CG (Table 1 ). Table 1 Comparison of overall total score (skill, critical thinking and clinical reasoning), total critical thinking and total clinical reasoning score between groups (n = 58) Variables Groups (IG = 29, CG = 29) Mean (SD) 25% Quartile 75% Quartile Min Max Z P value Overall total score of skill, critical thinking and clinical reasoning IG 71.9 (8.93) 65 80 60 88 -6.543 < 0.001 CG 36.1 (9.03) 28 43.5 25 58 Critical thinking (total score) IG 25.5 (3.61) 24 28 16 32 -6.592 < 0.001 CG 10.6 (3.59) 8 12 4 16 Clinical reasoning (total score) IG 13.7 (3.69) 10 15 5 20 -5.815 < 0.001 CG 6.7 (2.42) 5 10 5 10 Mann-Whitney U test, IG = Intervention Group, CG = Control Group, SD = Standard Deviation, Min = Minimum, Max = Maximum, p < 0.001 The Independent T-test compared the total scores between the groups for the knowledge test at baseline and endline, and for the skill test, as shown in Table 2 . The result demonstrated that although the improvement was observed in both groups, the IG had a more statistically significant improvement in the knowledge (mean (SD), IG: 19.5 (2.56); CG: 15.5 (3.56)) and skill (mean (SD), IG: 32.6 (5.79); CG: 18.0 (4.73)) test than the CG (All, p < 0.001). Table 2 Comparison of total score of knowledge and skill between groups at baseline and endline (n = 58) Variables Groups (IG = 29, CG = 29) Mean (SD) 25% Quartile 75% Quartile Min Max t P value Knowledge (endline) IG 17.03 (3.85) 14.5 20 9 24 0 1 CG 17.03 (3.78) 15 19.5 10 24 Knowledge (endline) IG 19.5 (2.56) 18 21 13 24 -4.87 < 0.001 CG 15.5 (3.56) 12.5 18 9 22 Skill IG 32.6 (5.79) 28 37 22 44 -9.969 < 0.001 CG 18.0 (4.73) 15.5 22.5 12 32 Independent T test, IG = Intervention Group, CG = Control Group, SD = Standard Deviation, Min = Minimum, Max = Maximum, p < 0.001 Table 3 showed the total knowledge scores increased significantly within both groups. The IG showed a satisfactory improvement (mean (SD) = 2.5 (2.06), p < 0.001), while the CG had a negative mean score (mean (SD) = -1.5 (2.64), p = 0.004). Regarding the qualitative data, multidimensional scaling of students’ reflective responses revealed clear thematic differences between the CG and IG. Both groups perceived the training was beneficial; however, the IG provided better reflections emphasizing realism, active participation, and confidence-building. Time constraints and nervousness were common in both groups, though a lower number of participants from the IG reported these issues. Regarding their interest in applying gained skill and knowledge in clinical practice, IG participants expressed more interest in applying both basic and cognitive skills than the CG. Although IG was mostly satisfied, the CG requested to add realism and duration (Table 4 ). Table 3 Pre-test and post-test knowledge comparison within groups (n = 58) Variables Mean (SD) Std. Error 95% Confidence Interval t df P -value Lower Upper Knowledge total score (IG = 29) 2.5 (2.06) 0.383 1.664 3.233 6.391 28 < 0.001 Knowledge total score (CG = 29) -1.5 (2.64) 0.49 -2.522 -0.523 -3.094 28 0.004 Paired T - Test, Endline Score – Baseline score, IG = Intervention group, CG = Control group, SD = Standard Deviation, Std = Standard, P < 0.001 Table 4 Reflections about the training among the participants (n = 58) Theme Category IG = 29 (n) CG = 29 (n) Beneficial Points Beneficial (29), bridges learning gap (13), confidence and motivation (1), active participation (2) and realistic engagement (2) Beneficial (29), new knowledge (19), new experience (5) and direct supervision (1) Challenges Nervousness (4) and time management (3) Nervousness (4), difficulty to remember (7), lack of realism (1) and time management (2) Specific skills or knowledge for future application Basic skills + cognitive skills (e.g., CT (3), CR (3), peripheral circulation (4) and auscultation (5) Basic nursing skills (e.g., pain scale (3) and GCS (3), intake-output (5) Suggestions Mostly satisfied (20), increase time durations (2) and add more instructor to support (1) Add realism (11) and increase time duration (3) Feedback Positive approach (29), enjoyed (12) and interest to attend in future simulation training (9) Positive approach (11), enjoyed (5) and unmet expectations (1) IG = Intervention Group, CG = Control Group, CT = Critical Thinking, CR = Clinical Reasoning, GCS = Glasgow Coma Scale Discussion To date, this study has been conducted for the first time to examine whether the students who receive scenario-based simulation training can demonstrate higher performance in CT, CR and knowledge on post-operative nursing care compared to other students who receive traditional skills training in Bangladesh. In the nursing education context of Bangladesh, simulation-based teaching methods are not commonly used, which generates a huge gap in the overall nursing education system and might lead to students graduating with insufficient skill. Introducing simulation-based training in a context where such teaching modalities are rarely used presented challenges, but it also highlighted a significant opportunity for innovation in nursing pedagogy. However, previous research explored, simulation-based teaching can be particularly impactful in low-resource settings when designed with cultural and contextual relevance [ 11 ]. Thus, this study represents a pioneering step toward bridging the gap between theoretical instruction and clinical demonstration with the practical implementation in clinical settings. In Bangladesh, student engagement was high as well as they expressed curiosity and enthusiasm [ 12 ]. Therefore, the randomization was a key aspect of the study’s methodological rigor to ensure a balanced distribution of participants between the IG and the CG, which helped reduce selection bias and maintain internal validity. In the primary outcome, the improvement in CT and CR was statistically significant in favour of the IG in this study. These findings align with the study’s conceptual framework, which was developed based on the core components of both CT and CR. The CT improves the ability to assess clinical findings such as vital signs and symptoms within normal values [ 13 ]. Therefore, during the scenario-based simulation sessions, participants were trained to identify patient conditions, make inferences regarding complications, justify their clinical judgments, and evaluate potential responses. They became qualified to evaluate appropriate responses and skills essential to post-operative nursing care. Subsequently, the CR, inter-related with CT, is distinct in its structured approach to decision-making. In CR, the SBAR format was used during simulation debriefings to reinforce students’ reasoning processes [ 14 ]. Students practiced reporting a patient's status by explaining clinical findings, contextualizing those findings within the patient’s history, conducting assessments, and recommending care strategies. This process, which posits that reasoning evolves through noticing, interpreting, responding, and reflecting [ 15 ]. In previous studies, the researcher agreed with this study's finding that simulation enhances clinical decision-making skills, especially when supported by structured debriefing [ 16 ]. The design of the intervention supported not only content knowledge, nonetheless the application methods were in dynamic and often uncertain clinical environments. The key difference in outcomes between the two groups can be attributed to the instructional teaching methods used. The CG received traditional skill training, where instructors demonstrated the use of clinical instruments and verbally explained each procedural step in a static classroom setting. While students were allowed to practice the skills, the lack of context and real-life complexity limited the depth of understanding and engagement. In contrast, in the IG, students experienced watching a clinical skills video, engaged in student-led post-operative simulations, and applied knowledge under time pressure. This difference in teaching modality is supported by literature, which indicates that simulation enhances students’ engagement, motivation, and knowledge retention by mimicking clinical realities [ 17 ]. Simulation-based education shifts the focus from passive memorization to active learning, encouraging students to “think on their feet” and justify their decisions, essential skills in nursing practice [ 18 ]. The secondary outcomes of the study: knowledge, skill, CT, and CR; all showed statistically significant improvement in the IG compared to the CG. These findings reinforce the effectiveness of simulation in producing well-rounded clinical competence. While traditional training supports skill acquisition, the integrated simulation model helps solidify clinical judgment through continuous cycles of observation, action, and reflection [ 19 ]. Students in the IG showed improved recall and appropriate application of information, demonstrating the higher cognitive processing promoted by simulation. This approach also corresponds with the experiential learning theory proposed [ 20 ], which emphasizes learning through experience, reflection, conceptualization, and experimentation. The simulation created an experiential loop that allowed students to not only perform clinical tasks but also to analyse and reflect upon their actions, thereby internalizing both knowledge and reasoning strategies. Limitations and strengths This study has a few limitations. A small sample size drawn from a single nursing college, which limits the generalizability of the findings to the wider population of nursing students in Bangladesh. The participants in both the IG and CG were from the same class; there may be a risk of contamination that could have affected the findings. Additionally, the short intervention period may have limited the study’s ability to assess the long-term changes in CT and CR skills. Despite these limitations, the study has notable strengths. As one of the first RCTs in Bangladesh to evaluate scenario-based simulation training in nursing education, it provides high-quality evidence for its effectiveness. The use of validated assessment tools ensured the reliability of outcomes, and the mixed-methods approach offered both quantitative and qualitative insights. Furthermore, it reflected real clinical situations, enhancing student engagement, confidence, and practical application of knowledge, indicating its potential for integration into nursing curricula at institutional and national levels. Conclusions Scenario-based simulation significantly improved CT and CR among nursing students; however, future research should investigate its effectiveness across diverse nursing specialties and assess its long-term impact on clinical practice. For successful nationwide integration, adequate resources and institutional support are essential. Despite these challenges, scenario-based simulation remains a promising and innovative approach to advancing nursing education, particularly in resource-constrained environments. Abbreviations CT Critical Thinking CR Clinical Reasoning RCT Randomized Control Trial GCCN Grameen Caledonian College of Nursing BSc Bachelor of Science IG Intervention Group CG Control Group SBAR Situation, Background, Assessment, Recommendation IRB Institutional Review Board Declarations Ethics approval and consent to participate This research was conducted following the "Declaration of Helsinki”. Ethical approval was obtained from the Institutional Review Board of Grameen Caledonian College of Nursing (GCCN/ IRB/ 2024-12), Bangladesh. Before data collection, participants were provided with clear information regarding the study objectives, procedures, and any potential risks or benefits. Participation was entirely voluntary, anonymized and written informed consent was obtained from all participants. Participant had the right to withdraw from the study at any time without any explanation and penalty. Data were handled by the authorized researcher and kept in a security-protected cloud system of Hiroshima University. Participants’ test scores were not used for their academic evaluation in any form. Consent for publication Written informed consent for publication was obtained from all the participants. Availability of data and materials The data involved in this research are accessible through the corresponding author, subject to reasonable request. Competing interests All authors have declared that there are no competing interests. Funding This study was funded by the Chronic Care and Family Nursing Laboratory, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan. Authors’ contributions Conceptualization: SST, MM; Methodology: SST, MM; Instrument: SST, NA, SH, AOB, CT; Investigation: SST, NA, LM, ARM, PRB, SA, SRM; Analysis: SST, SAA, MM; Writing: SST, SAA, MM. All authors read and approved the final manuscript. Acknowledgements We sincerely appreciate GCCN, their staffs and students for their contribution. In addition, we would like to thank Fatema Akter, Mercy Tithy Barikder, Md. Rashed for supporting in data collection. Special thanks to Mizuho Kidani and Tomomi Mitoda for their assistance in developing the skill checklist. References Shin SJ, Jung D. Critical Thinking in Nursing Science: A Literature Review. Korean J Adult Nurs. 1235746800;21(1):117–28. Linn A, Khaw C, Kildea H, Tonkin A. Clinical reasoning - a guide to improving teaching and practice. Aust Fam Physician. 2012;41(1–2):18–20. Negm LMMA, Mersal FA, Fawzy MS, Rajennal AT, Alanazi RS, Alanazi LO. Challenges of nursing students during clinical training: A nursing perspective. AIMS Public Health. 2024;11(2):379–98. Du L, Zhao L, Xu T, Wang Y, Zu W, Huang X, et al. Blended learning vs traditional teaching: The potential of a novel teaching strategy in nursing education - a systematic review and meta-analysis. Nurse Educ Pract. 2022;63:103354. Sivrikaya GU, Gonenli MG. MEDICAL SIMULATION: The Vision of Learning in Healthcare. Med Res Arch. 2024;12(12). Available from: https://esmed.org/MRA/mra/article/view/6122 Herleth A, Virkstis K, Renfroe J, Rewers L. The Challenging Road to Clinical Competence for New Graduate RNs. J Nurs Adm. 2020;50(4):185–6. Brenner ZR. Preventing postoperative complications. Nurs Manag (Harrow). 2000;31(12):17–22. quiz 22–3. Sterner A, Eklund A, Nilsson MS. Prepared to learn but unprepared for work: A cross sectional survey study exploring the preparedness, challenges, and needs of newly graduated nurses entering a hospital-based transition program. Nurse Educ Pract. 2023;72:103782. Koukourikos K, Tsaloglidou A, Kourkouta L, Papathanasiou IV, Iliadis C, Fratzana A, et al. Simulation in Clinical Nursing Education. Acta Inf Med. 2021;29(1):15–20. Smith A, Kisiel M, Radford M, editors. Oxford Handbook of Surgical Nursing. Oxford University Press; 2016. Available from: https://doi.org/10.1093/med/9780199642663.001.0001 Salifu DA, Heymans Y, Christmals CD. A Simulation-Based Clinical Nursing Education Framework for a Low-Resource Setting: A Multimethod Study. Healthcare. 2022;10(9):1639. Shabur MA, Siddiki MdR. Investigating social media’s impact on the new era of interactive learning: A case study of Bangladesh. Heliyon. 2024;10(4):e26234. Shoulders B, Follett C, Eason J. Enhancing Critical Thinking in Clinical Practice: Implications for Critical and Acute Care Nurses. Dimens Crit Care Nurs. 2014;33(4):207. Lord M, Weaver A, Cross L, Hall C, Harris J, Whitehead K. Promoting Clinical Reasoning With One-On-One Focused Pediatric Simulation Experiences. Nurse Educ. 2025;50(2):115. Son HK. Effects of simulation with problem-based learning (S-PBL) on nursing students’ clinical reasoning ability: based on Tanner’s clinical judgment model. BMC Med Educ. 2023;23(1):601. Niu Y, Liu T, Li K, Sun M, Sun Y, Wang X, et al. Effectiveness of simulation debriefing methods in nursing education: A systematic review and meta-analysis. Nurse Educ Today. 2021;107:105113. Aebersold M, Tschannen D. Simulation in nursing practice: the impact on patient care. Online J Issues Nurs. 2013;18(2):6. Daneshfar M, Moonaghi HK. The impact of clinical simulation on bridging the theory–practice gap in nursing education: a systematic review. BMC Med Educ. 2025;25(1):1216. Lavoie P, Pepin J, Cossette S. Contribution of a reflective debriefing to nursing students’ clinical judgment in patient deterioration simulations: A mixed-methods study. Nurse Educ Today. 2017;50:51–6. Watson AL, Young CD, Thomas D, Tapp DM, Holyoak S, Gardner T. Translating learning from simulation to clinical: a narrative study of nursing students’ experiences. Teach Learn Nurs. 2025;20(1):e218–26. Additional Declarations No competing interests reported. Supplementary Files FSupplementaryMaterial.docx Supplementary Materials 1 (Knowledge test questionnaire) Supplementary Materials 2 (Checklist) Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 Nov, 2025 Reviewers agreed at journal 11 Nov, 2025 Reviews received at journal 09 Nov, 2025 Reviewers agreed at journal 06 Nov, 2025 Reviewers agreed at journal 31 Oct, 2025 Reviewers agreed at journal 30 Oct, 2025 Reviewers invited by journal 30 Oct, 2025 Editor assigned by journal 28 Oct, 2025 Editor invited by journal 09 Oct, 2025 Submission checks completed at journal 08 Oct, 2025 First submitted to journal 08 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Aivey","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYDACZhBRcYAHSLIxJMCFeQhpOUOSFhBgbDvAANZCFOBv5zF8zDvvjox5e/uzBw9z7BgMDjA//MAgcwenFonDPMbGvNue8cicOWNukLgtGaiFzViCgecZbmsOs6VJ8247zCMhkcMmkbiNuX7DAQYzoF8O49Qhf5gt/TfvHJCW9GdALfVAW9i/4dVicJj5GDNvA0hLghlQy2GgFh78thgeZj4sOecYUAvPGZCW4wySh3mKJRLw+EXu/MHGD29qDttLsLc/k/y5rZqB73j7xg8fe3CHGAgwocYbKHITew7g1cL4A1PsB34to2AUjIJRMKIAAGa9T6wXwlxpAAAAAElFTkSuQmCC","orcid":"","institution":"Hiroshima University","correspondingAuthor":true,"prefix":"","firstName":"Sadia","middleName":"Alam","lastName":"Aivey","suffix":""},{"id":542121793,"identity":"3486053b-4286-4bb9-9445-dc968be8795a","order_by":2,"name":"Nahida Akhter","email":"","orcid":"","institution":"Hiroshima 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Nursing","correspondingAuthor":false,"prefix":"","firstName":"Akhi","middleName":"Roy","lastName":"Mita","suffix":""},{"id":542121797,"identity":"323a4eb6-7490-4b7e-b4e2-6b7752a9b37a","order_by":6,"name":"Popi Rani Bhowmik","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Popi","middleName":"Rani","lastName":"Bhowmik","suffix":""},{"id":542121798,"identity":"384db80b-f971-41cc-b9c9-ba3a3f52d34a","order_by":7,"name":"Salma Akhter","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Salma","middleName":"","lastName":"Akhter","suffix":""},{"id":542121799,"identity":"ef93569e-b2e5-4d82-9273-916906703da7","order_by":8,"name":"Abdulfatai Olamilekan Babaita","email":"","orcid":"","institution":"Hiroshima 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University","correspondingAuthor":false,"prefix":"","firstName":"Michiko","middleName":"","lastName":"Moriyama","suffix":""}],"badges":[],"createdAt":"2025-09-29 09:53:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7740598/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7740598/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":95654980,"identity":"6de7e400-fb7f-4025-9990-dead4da29e75","added_by":"auto","created_at":"2025-11-11 16:13:56","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":338535,"visible":true,"origin":"","legend":"","description":"","filename":"RevisedManuscriptV2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7740598/v1/6087a2eaecd23a198b157564.docx"},{"id":95655702,"identity":"f34ddc1a-6399-41ed-b073-6832f35e0520","added_by":"auto","created_at":"2025-11-11 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16:24:59","extension":"xml","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":82378,"visible":true,"origin":"","legend":"","description":"","filename":"2efbb24384b3478a826bbd068dd19e281structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7740598/v1/851d16c8c4e89f2b04971792.xml"},{"id":95654734,"identity":"1bc603b4-d115-4bfb-a327-62102afda01c","added_by":"auto","created_at":"2025-11-11 16:12:51","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":92901,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7740598/v1/0af791e5e031f6580f8095ab.html"},{"id":95568173,"identity":"8c05dead-b771-4b38-a94f-a6c5a9c604d4","added_by":"auto","created_at":"2025-11-10 16:24:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":73946,"visible":true,"origin":"","legend":"\u003cp\u003eConceptual framework of this study\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7740598/v1/56f28fc3489a6b8b243a55a4.png"},{"id":95655952,"identity":"6fc38015-4da0-4aa0-bb52-e2ba4943fc32","added_by":"auto","created_at":"2025-11-11 16:17:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":96358,"visible":true,"origin":"","legend":"\u003cp\u003eStudy procedure\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7740598/v1/d5c4d5fa494bec80c43b3830.png"},{"id":95568172,"identity":"6966fd8f-71aa-4319-9998-b17c62be8023","added_by":"auto","created_at":"2025-11-10 16:24:59","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":115018,"visible":true,"origin":"","legend":"\u003cp\u003eCONSORT flowchart\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7740598/v1/bd23541ce9f0a72844a23b42.png"},{"id":95818763,"identity":"2b9e00ac-6121-4beb-90bb-fec0b9402fc1","added_by":"auto","created_at":"2025-11-13 10:33:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1107214,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7740598/v1/036c083e-1373-4c96-a0b3-51c9f07aa38e.pdf"},{"id":95568176,"identity":"2904f16a-7c33-461b-94e2-6e7d456dfea6","added_by":"auto","created_at":"2025-11-10 16:24:59","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":33626,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Materials 1 (Knowledge test questionnaire)\u003c/p\u003e\n\u003cp\u003eSupplementary Materials 2 (Checklist)\u003c/p\u003e","description":"","filename":"FSupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7740598/v1/f77fb03d1dff7c746f15e752.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Enhancing Nursing Students' Critical Thinking and Clinical Reasoning Abilities in Post-Operative Care by Scenario-Based Simulation: A Randomized Controlled Trial","fulltext":[{"header":"Background","content":"\u003cp\u003eCritical Thinking (CT) refers to the process of purposeful, self-regulatory judgment involving the analysis, interpretation, and evaluation of information to make informed decisions in patient care [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Clinical Reasoning (CR) is a cognitive and reflective process that enables nurses to assess patient conditions, identify actual or potential problems, and implement appropriate clinical interventions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Subsequently, CR is closely linked to CT, which directly influences clinical performance, patient outcomes, and nursing professional development. Although both CT and CR are vital competencies for nursing students, several barriers inhibit their development during the academic period, particularly in developing countries such as Bangladesh. These barriers include insufficient clinical exposure, trained educators, simulation resources, and a lack of opportunities for hands-on learning [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn contrast, the traditional skills training method is primarily foundational, often emphasizing rote learning and task execution rather than decision-making and problem-solving [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Thus, students may struggle to effectively apply theoretical knowledge in clinical practice. Many developed countries have overcome this gap by implementing modern educational strategies, such as scenario-based simulation training [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Although this learning process is increasingly integrated into nursing curricula worldwide, structured scenario-based simulation training has received limited attention in nursing education in Bangladesh. Therefore, newly graduated nursing students were poorly prepared for the complexities of the modern healthcare system, particularly in demanding rigorous assessment, proactive decision-making, and quick clinical judgement [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePost-operative care is a major critical aspect of nursing practice, often need to quickly recognize the right interventions and provide care effectively to save patients' lives [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, several nursing students reported feeling unprepared and lacking confidence in managing post-operative patients due to limited clinical exposure and the unpredictable nature of surgical complications, and judgment errors in such situations placed patient safety at serious risk, highlighting the need for teaching methods that extended beyond traditional lectures and demonstrations [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Scenario-based simulation replicates realistic clinical scenarios that challenge students to think critically, make clinical decisions, and reflect on their actions in a safe, controlled setting. This immersive experience fosters both CT and CR by offering repeated exposure to complex situations, promoting reflection, and building confidence without compromising patient safety [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eA conceptual framework (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) was developed to evaluate the effectiveness of scenario-based simulation training compared with traditional skill training in enhancing nursing students\u0026rsquo; CT and CR abilities. It shows how scenario-based simulation training helps turn insufficient CT and CR skills into strengthened abilities. Traditional skill training in nursing education focuses on developing core technical skills through direct instruction, procedural demonstrations, and hands-on practice. Furthermore, it emphasizes the mastery of essential nursing tasks and accurate patient assessments through standardized protocols. However, the scenario-based simulation immerses students in realistic clinical environments, which enrich their decision-making and problem-solving skills. In this framework, CT involves cognitive domains such as observation of data, comparing findings with expected standards, identification of status, and generating judgement for patient outcomes. Consecutively, CR includes practical domains such as identifying current problems, linking with previous history, interpreting data, and recommending appropriate care actions. To introduce these cognitive and practical domains, an educational intervention was designed to facilitate the integration of theory into practice, leading to more effective decision-making and problem-solving during actual clinical patient care. Thus, the scenario-based simulation training was applied instead of traditional skill training, focusing on the development of CT and CR among nursing students from a selected nursing college in Bangladesh. This study hypothesizes that the students who receive scenario-based simulation training can demonstrate higher performance in CT, CR and knowledge on post-operative nursing care compared to other students who receive traditional skills training.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design, area and participants\u003c/h2\u003e\u003cp\u003eA prospective, open-label, parallel-group (1:1) randomized controlled trial (RCT) with block randomization was conducted from January to March 2025. Study participants were purposively selected from second-year Bachelor of Science (BSc.) in Nursing students at Grameen Caledonian College of Nursing (GCCN) in Dhaka, Bangladesh. They were enrolled according to the enrolment criteria. The inclusion criteria were: i) the student was registered for the \u0026ldquo;Adult Medical and Surgical Nursing\u0026rdquo; course during the study period, ii) the student did not have the experience of clinical practice in a post-operative ward. The student who had already completed both theoretical and practical courses on post-operative care was excluded from the study.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSample size\u003c/h3\u003e\n\u003cp\u003eThe sample size for this study was intended using G*Power version 3.1.9.2, with an effect size of 0.8, an alpha (α) error probability of less than 0.05, and a power (1-β error probability) of 0.80, resulting in a required sample of 52 participants. Considering a 10% dropout, a total of 57 participants was determined. However, all 2nd year students who were registered for the \u0026ldquo;Adult Medical and Surgical Nursing\u0026rdquo; course (n\u0026thinsp;=\u0026thinsp;64) were purposively recruited to maximize participation.\u003c/p\u003e\n\u003ch3\u003eRandomization and allocation\u003c/h3\u003e\n\u003cp\u003eTwo lecture sessions (2 hours each session) on post-operative nursing management were conducted using a PowerPoint slide for all participants, immediately after consent. These pre-intervention lectures were delivered to provide the theoretical foundation for managing post-operative patients. The content included the purpose, phases of post-operative nursing care, post-operative nursing assessment on the vital body systems (such as respiratory, cardiovascular, neurological, metabolic and gastrointestinal), pain, temperature control and fluid and electrolyte balance. Overview of CT and CR, including complications and reporting had also taught them. Then, a pre-knowledge test was administered as baseline data. The researcher considered the baseline knowledge test scores as a base for block randomization to ensure equal distribution among the participants. A block size of 2 resulted in 32 blocks and was assigned to the intervention group (IG) and control group (CG). The block randomization was done by a person who was not involved in the study.\u003c/p\u003e\n\u003ch3\u003eStudy procedure and data collection\u003c/h3\u003e\n\u003cp\u003eFigure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e outlines the study flow and procedure. In the first week, all the students were informed regarding the ethical considerations of this study, such as purpose, procedures, voluntary nature of participation, the right to withdraw at any time without academic penalty, and the anonymized data used for research purposes. Next, written informed consent was obtained from all participants before enrolment. The data collection was conducted twice, at baseline and endline. Subsequently, all students participated in post-intervention tests such as skills evaluation, CT and CR assessment, knowledge and submitted a written reflection on their learning experience.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eEducational materials\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eIntervention group\u003c/h2\u003e\u003cp\u003eThe researcher and a faculty member from GCCN conducted the training among the participants for one week. After randomization, all the participants from the IG watched the researcher-developed video for 15 minutes. The content of the video demonstrated post-operative management, which was used to visually illustrate how nurses perform essential care activities in real clinical settings. The video content was developed based on a few information and steps, such as 1: greetings and confirmation of consciousness level; 2: position; 3: breathing and circulatory assessment; 4: wound and pain; 5: gastrointestinal assessment; 6: intake and output assessment; 7: environment arrangement and patient education; 8: integration and reporting. Next, they were divided into six groups (5\u0026ndash;6 members in each group) and engaged in interactive scenario-based simulation training. Each participant practiced for 20 minutes using the researcher-developed scenarios under the researcher's supervision. The progress of their learning and feedback was sincerely observed.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eControl group\u003c/h3\u003e\n\u003cp\u003e In the traditional skill training group, the participants attended a face-to-face verbal demonstration of post-operative nursing management conducted by a GCCN faculty member. Then, they were divided into six small groups (5 to 6 members in each group) and engaged in individual hands-on practice for 20 minutes without any scenario. To address potential ethical concerns, CG received additional training using scenario-based simulation and video in post-operative care, after completing the study.\u003c/p\u003e\n\u003ch3\u003eStudy outcomes and instruments\u003c/h3\u003e\n\u003cp\u003eThe self-administered sociodemographic data were collected using a questionnaire, including age, gender, and clinical experience in a hospital, particularly in the post-operative care ward.\u003c/p\u003e\u003cp\u003eCT, CR and skill evaluation checklists\u003c/p\u003e\u003cp\u003eThe primary outcome of this study was the changes in the ability of CT, CR with skill in post-operative nursing management. All the outcomes were measured by the researcher-developed checklist. The CT checklist contained 8 items covering areas such as consciousness, respiratory and circulatory status, pain, abdomen, in-out balance, environmental education and wound observation, with a total score of 32. Each item was categorized as either 0\u0026thinsp;=\u0026thinsp;insufficient ability or 4\u0026thinsp;=\u0026thinsp;sufficient ability. The CR checklist was developed based on the 4 domains, such as situation, background, assessment and recommendation (SBAR). This 4-item checklist was categorized 0\u0026thinsp;=\u0026thinsp;poor ability and 5\u0026thinsp;=\u0026thinsp;good ability, and a total score of 20, while higher scores indicated better CT and CR. Next, a post-operative skills evaluation checklist was adapted from the adult nursing simulation curriculum in Hiroshima University. This checklist consisted of 24 items related to core post-operative nursing skills, such as vital sign assessment and wound care, which were assessed by the researcher. Each item was categorized among 0\u0026thinsp;=\u0026thinsp;not performed, 1\u0026thinsp;=\u0026thinsp;insufficiently performed, and 2\u0026thinsp;=\u0026thinsp;performed. The maximum score was 48, with higher scores reflecting stronger practical skill competency (Supplementary Materials 2). The overall total score (0 to 100) of CT, CR and skill was used to explore the primary outcome. The individual CT, CR and skill\u0026rsquo;s score was explored as one of the secondary outcomes of this study.\u003c/p\u003e\u003cp\u003eKnowledge test questionnaire\u003c/p\u003e\u003cp\u003eThe knowledge test questionnaire was used to explore another secondary outcome. This questionnaire was developed based on standard medical-surgical nursing textbooks [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] to assess knowledge using 25 items and categorized into 0\u0026thinsp;=\u0026thinsp;incorrect or 1\u0026thinsp;=\u0026thinsp;correct with a total score of 25. A higher score indicated better knowledge among the participants (Supplementary Materials 1).\u003c/p\u003e\u003cp\u003eThe reflection questionnaire included five open-ended questions designed to explore students\u0026rsquo; experiences of the training. It covered benefits, challenges, anticipated impact on clinical practice, suggestions for improvement, and general feedback.\u003c/p\u003e\u003cp\u003eThe content validity and face validity of all questionnaires were checked by two experienced teaching assistants and one nursing faculty member who teaches adult nursing at Hiroshima University, Japan.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eA per-protocol set analysis was used to explore the efficacy of this study. Descriptive statistics were used to analyze the socio-demographic characteristics. The primary outcome of this study was explored using the Mann-Whitney U-test to compare the overall total scores of skills, CT, and CR between the groups at the endline. The individual total CT and CR scores were observed between the groups using the Mann-Whitney U-test. Next, an independent sample t-test was used to compare the individual total skill, pre and post knowledge test scores between the groups. A paired t-test was used to explore the changes in pre-and post-test knowledge total scores within the groups. The statistical significance was set at \u0026lt;\u0026thinsp;0.05. The quantitative data were analyzed using the statistical software package SPSS for Windows (version 26.0, Armonk IBM Co.). The content analysis of qualitative data (students\u0026rsquo; reflection) was done by multidimensional scaling of words in the KH coder software for Windows (version 3 Beta.08e, SCREEN Advanced System Solutions Co., LTD).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003c/p\u003e\u003cp\u003eA total of 64 students were randomized and from each group, 3 students were excluded after allocation due to being absent during the sessions of scenario-based simulation training and traditional skill training. Among them, 58 students (IG, n\u0026thinsp;=\u0026thinsp;29 and CG, n\u0026thinsp;=\u0026thinsp;29) completed the entire study and their data were used for analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The socio-demographic data of the student in both groups were similar except for their age and all of them were aligned with an age range from 18 to 23 years. The distribution of female students (n\u0026thinsp;=\u0026thinsp;24) was equal in both groups. According to the enrollment criteria, all of them had the experience of clinical practice in the hospital; however, they did not have work experience in the post-operative ward.\u003c/p\u003e\u003cp\u003eThe primary outcome of this study was illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The overall total score consisted of the total score of three individual tests such as skill, CT and CR tests. The Mann-Whitney U test results showed that the students' skills regarding CT and CR were improved (mean (SD), IG: 71.9 (8.93); CG: 36.1 (9.03)) and a statistically significant difference was observed in the overall total score between the groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Regarding the individual scale, a satisfactory change was observed in IG compared with CG. The maximum scores of the CT among IG and CG were 32 and 16, respectively. The results explored that the total score of CT was improved in IG (mean (SD)\u0026thinsp;=\u0026thinsp;25.5 (3.61)) at the end of the intervention which was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This finding highlighted the significance of simulation-based training, which enables the student to think critically about post-operative patient care. Considering the total score of CR, the maximum score for IG was 20 and for CG was 10. The result revealed a significant change in the IG (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) students\u0026rsquo; performance on identifying CR compared with CG (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of overall total score (skill, critical thinking and clinical reasoning), total critical thinking and total clinical reasoning score between groups (n\u0026thinsp;=\u0026thinsp;58)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroups (IG\u0026thinsp;=\u0026thinsp;29, CG\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25% Quartile\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75% Quartile\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMin\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMax\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eZ\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOverall total score of skill, critical thinking and clinical reasoning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71.9 (8.93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-6.543\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36.1 (9.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e43.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e58\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCritical thinking (total score)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.5 (3.61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-6.592\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.6 (3.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eClinical reasoning (total score)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.7 (3.69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-5.815\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.7 (2.42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003eMann-Whitney U test, IG\u0026thinsp;=\u0026thinsp;Intervention Group, CG\u0026thinsp;=\u0026thinsp;Control Group, SD\u0026thinsp;=\u0026thinsp;Standard Deviation, Min\u0026thinsp;=\u0026thinsp;Minimum, Max\u0026thinsp;=\u0026thinsp;Maximum, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe Independent T-test compared the total scores between the groups for the knowledge test at baseline and endline, and for the skill test, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The result demonstrated that although the improvement was observed in both groups, the IG had a more statistically significant improvement in the knowledge (mean (SD), IG: 19.5 (2.56); CG: 15.5 (3.56)) and skill (mean (SD), IG: 32.6 (5.79); CG: 18.0 (4.73)) test than the CG (All, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of total score of knowledge and skill between groups at baseline and endline (n\u0026thinsp;=\u0026thinsp;58)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroups (IG\u0026thinsp;=\u0026thinsp;29, CG\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25% Quartile\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75% Quartile\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMin\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMax\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003et\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eKnowledge (endline)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.03 (3.85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.03 (3.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eKnowledge (endline)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.5 (2.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-4.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15.5 (3.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSkill\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32.6 (5.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-9.969\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.0 (4.73)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e22.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003eIndependent T test, IG\u0026thinsp;=\u0026thinsp;Intervention Group, CG\u0026thinsp;=\u0026thinsp;Control Group, SD\u0026thinsp;=\u0026thinsp;Standard Deviation, Min\u0026thinsp;=\u0026thinsp;Minimum, Max\u0026thinsp;=\u0026thinsp;Maximum, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e showed the total knowledge scores increased significantly within both groups. The IG showed a satisfactory improvement (mean (SD)\u0026thinsp;=\u0026thinsp;2.5 (2.06), p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while the CG had a negative mean score (mean (SD) = -1.5 (2.64), p\u0026thinsp;=\u0026thinsp;0.004). Regarding the qualitative data, multidimensional scaling of students\u0026rsquo; reflective responses revealed clear thematic differences between the CG and IG. Both groups perceived the training was beneficial; however, the IG provided better reflections emphasizing realism, active participation, and confidence-building. Time constraints and nervousness were common in both groups, though a lower number of participants from the IG reported these issues. Regarding their interest in applying gained skill and knowledge in clinical practice, IG participants expressed more interest in applying both basic and cognitive skills than the CG. Although IG was mostly satisfied, the CG requested to add realism and duration (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePre-test and post-test knowledge comparison within groups (n\u0026thinsp;=\u0026thinsp;58)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMean (SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eStd. Error\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e95% Confidence Interval\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003et\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003edf\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLower\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eUpper\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge total score\u003c/p\u003e\u003cp\u003e(IG\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.5 (2.06)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.383\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.664\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.233\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e6.391\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKnowledge total score (CG\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-1.5 (2.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-2.522\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-0.523\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-3.094\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e\u003cp\u003ePaired T - Test, Endline Score \u0026ndash; Baseline score, IG\u0026thinsp;=\u0026thinsp;Intervention group, CG\u0026thinsp;=\u0026thinsp;Control group, SD\u0026thinsp;=\u0026thinsp;Standard Deviation, Std\u0026thinsp;=\u0026thinsp;Standard, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eReflections about the training among the participants (n\u0026thinsp;=\u0026thinsp;58)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme Category\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIG\u0026thinsp;=\u0026thinsp;29 (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCG\u0026thinsp;=\u0026thinsp;29 (n)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBeneficial Points\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBeneficial (29), bridges learning gap (13), confidence and motivation (1), active participation (2) and realistic engagement (2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBeneficial (29), new knowledge (19), new experience (5) and direct supervision (1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChallenges\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNervousness (4) and time management (3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNervousness (4), difficulty to remember (7), lack of realism (1) and time management (2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpecific skills or knowledge for future application\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBasic skills\u0026thinsp;+\u0026thinsp;cognitive skills (e.g., CT (3), CR (3), peripheral circulation (4) and auscultation (5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBasic nursing skills (e.g., pain scale (3) and GCS (3), intake-output (5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSuggestions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMostly satisfied (20), increase time durations (2) and add more instructor to support (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdd realism (11) and increase time duration (3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFeedback\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePositive approach (29), enjoyed (12) and interest to attend in future simulation training (9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePositive approach (11), enjoyed (5) and unmet expectations (1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eIG\u0026thinsp;=\u0026thinsp;Intervention Group, CG\u0026thinsp;=\u0026thinsp;Control Group, CT\u0026thinsp;=\u0026thinsp;Critical Thinking, CR\u0026thinsp;=\u0026thinsp;Clinical Reasoning, GCS\u0026thinsp;=\u0026thinsp;Glasgow Coma Scale\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo date, this study has been conducted for the first time to examine whether the students who receive scenario-based simulation training can demonstrate higher performance in CT, CR and knowledge on post-operative nursing care compared to other students who receive traditional skills training in Bangladesh. In the nursing education context of Bangladesh, simulation-based teaching methods are not commonly used, which generates a huge gap in the overall nursing education system and might lead to students graduating with insufficient skill. Introducing simulation-based training in a context where such teaching modalities are rarely used presented challenges, but it also highlighted a significant opportunity for innovation in nursing pedagogy. However, previous research explored, simulation-based teaching can be particularly impactful in low-resource settings when designed with cultural and contextual relevance [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Thus, this study represents a pioneering step toward bridging the gap between theoretical instruction and clinical demonstration with the practical implementation in clinical settings. In Bangladesh, student engagement was high as well as they expressed curiosity and enthusiasm [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Therefore, the randomization was a key aspect of the study\u0026rsquo;s methodological rigor to ensure a balanced distribution of participants between the IG and the CG, which helped reduce selection bias and maintain internal validity.\u003c/p\u003e\u003cp\u003eIn the primary outcome, the improvement in CT and CR was statistically significant in favour of the IG in this study. These findings align with the study\u0026rsquo;s conceptual framework, which was developed based on the core components of both CT and CR. The CT improves the ability to assess clinical findings such as vital signs and symptoms within normal values [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Therefore, during the scenario-based simulation sessions, participants were trained to identify patient conditions, make inferences regarding complications, justify their clinical judgments, and evaluate potential responses. They became qualified to evaluate appropriate responses and skills essential to post-operative nursing care. Subsequently, the CR, inter-related with CT, is distinct in its structured approach to decision-making. In CR, the SBAR format was used during simulation debriefings to reinforce students\u0026rsquo; reasoning processes [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Students practiced reporting a patient's status by explaining clinical findings, contextualizing those findings within the patient\u0026rsquo;s history, conducting assessments, and recommending care strategies. This process, which posits that reasoning evolves through noticing, interpreting, responding, and reflecting [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In previous studies, the researcher agreed with this study's finding that simulation enhances clinical decision-making skills, especially when supported by structured debriefing [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The design of the intervention supported not only content knowledge, nonetheless the application methods were in dynamic and often uncertain clinical environments. The key difference in outcomes between the two groups can be attributed to the instructional teaching methods used. The CG received traditional skill training, where instructors demonstrated the use of clinical instruments and verbally explained each procedural step in a static classroom setting. While students were allowed to practice the skills, the lack of context and real-life complexity limited the depth of understanding and engagement.\u003c/p\u003e\u003cp\u003eIn contrast, in the IG, students experienced watching a clinical skills video, engaged in student-led post-operative simulations, and applied knowledge under time pressure. This difference in teaching modality is supported by literature, which indicates that simulation enhances students\u0026rsquo; engagement, motivation, and knowledge retention by mimicking clinical realities [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Simulation-based education shifts the focus from passive memorization to active learning, encouraging students to \u0026ldquo;think on their feet\u0026rdquo; and justify their decisions, essential skills in nursing practice [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe secondary outcomes of the study: knowledge, skill, CT, and CR; all showed statistically significant improvement in the IG compared to the CG. These findings reinforce the effectiveness of simulation in producing well-rounded clinical competence. While traditional training supports skill acquisition, the integrated simulation model helps solidify clinical judgment through continuous cycles of observation, action, and reflection [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Students in the IG showed improved recall and appropriate application of information, demonstrating the higher cognitive processing promoted by simulation. This approach also corresponds with the experiential learning theory proposed [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], which emphasizes learning through experience, reflection, conceptualization, and experimentation. The simulation created an experiential loop that allowed students to not only perform clinical tasks but also to analyse and reflect upon their actions, thereby internalizing both knowledge and reasoning strategies.\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eLimitations and strengths\u003c/h2\u003e\u003cp\u003eThis study has a few limitations. A small sample size drawn from a single nursing college, which limits the generalizability of the findings to the wider population of nursing students in Bangladesh. The participants in both the IG and CG were from the same class; there may be a risk of contamination that could have affected the findings. Additionally, the short intervention period may have limited the study\u0026rsquo;s ability to assess the long-term changes in CT and CR skills.\u003c/p\u003e\u003cp\u003eDespite these limitations, the study has notable strengths. As one of the first RCTs in Bangladesh to evaluate scenario-based simulation training in nursing education, it provides high-quality evidence for its effectiveness. The use of validated assessment tools ensured the reliability of outcomes, and the mixed-methods approach offered both quantitative and qualitative insights. Furthermore, it reflected real clinical situations, enhancing student engagement, confidence, and practical application of knowledge, indicating its potential for integration into nursing curricula at institutional and national levels.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eScenario-based simulation significantly improved CT and CR among nursing students; however, future research should investigate its effectiveness across diverse nursing specialties and assess its long-term impact on clinical practice. For successful nationwide integration, adequate resources and institutional support are essential. Despite these challenges, scenario-based simulation remains a promising and innovative approach to advancing nursing education, particularly in resource-constrained environments.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Critical Thinking\u003c/p\u003e\n\u003cp\u003eCR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Clinical Reasoning\u003c/p\u003e\n\u003cp\u003eRCT\u0026nbsp; \u0026nbsp;\u0026nbsp;Randomized Control Trial\u003c/p\u003e\n\u003cp\u003eGCCN\u0026nbsp;Grameen Caledonian College of Nursing\u003c/p\u003e\n\u003cp\u003eBSc\u0026nbsp; \u0026nbsp; \u0026nbsp;Bachelor of Science\u003c/p\u003e\n\u003cp\u003eIG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Intervention Group\u003c/p\u003e\n\u003cp\u003eCG\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Control Group\u003c/p\u003e\n\u003cp\u003eSBAR\u0026nbsp;\u0026nbsp;Situation, Background, Assessment, Recommendation\u003c/p\u003e\n\u003cp\u003eIRB \u0026nbsp; \u0026nbsp; Institutional Review Board\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was conducted following the \u0026quot;Declaration of Helsinki\u0026rdquo;. \u0026nbsp;Ethical approval was obtained from the Institutional Review Board of Grameen Caledonian College of Nursing (GCCN/ IRB/ 2024-12), Bangladesh. Before data collection, participants were provided with clear information regarding the study objectives, procedures, and any potential risks or benefits. Participation was entirely voluntary, anonymized and written informed consent was obtained from all participants. Participant had the right to withdraw from the study at any time without any explanation and penalty. Data were handled by the authorized researcher and kept in a security-protected cloud system of Hiroshima University. Participants\u0026rsquo; test scores were not used for their academic evaluation in any form.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data involved in this research are accessible through the corresponding author, subject to reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have declared that there are no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Chronic Care and Family Nursing Laboratory, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: SST, MM; Methodology: SST, MM; Instrument: SST, NA, SH, AOB, CT; Investigation: SST, NA, LM, ARM, PRB, SA, SRM; Analysis: SST, SAA, MM; Writing: SST, SAA, MM. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely appreciate GCCN, their staffs and students for their contribution. In addition, we would like to thank Fatema Akter, Mercy Tithy Barikder, Md. Rashed for supporting in data collection. Special thanks to Mizuho Kidani and Tomomi Mitoda for their assistance in developing the skill checklist.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShin SJ, Jung D. Critical Thinking in Nursing Science: A Literature Review. Korean J Adult Nurs. 1235746800;21(1):117\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLinn A, Khaw C, Kildea H, Tonkin A. Clinical reasoning - a guide to improving teaching and practice. Aust Fam Physician. 2012;41(1\u0026ndash;2):18\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNegm LMMA, Mersal FA, Fawzy MS, Rajennal AT, Alanazi RS, Alanazi LO. Challenges of nursing students during clinical training: A nursing perspective. AIMS Public Health. 2024;11(2):379\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDu L, Zhao L, Xu T, Wang Y, Zu W, Huang X, et al. Blended learning vs traditional teaching: The potential of a novel teaching strategy in nursing education - a systematic review and meta-analysis. Nurse Educ Pract. 2022;63:103354.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSivrikaya GU, Gonenli MG. MEDICAL SIMULATION: The Vision of Learning in Healthcare. Med Res Arch. 2024;12(12). Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://esmed.org/MRA/mra/article/view/6122\u003c/span\u003e\u003cspan address=\"https://esmed.org/MRA/mra/article/view/6122\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHerleth A, Virkstis K, Renfroe J, Rewers L. The Challenging Road to Clinical Competence for New Graduate RNs. J Nurs Adm. 2020;50(4):185\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrenner ZR. Preventing postoperative complications. Nurs Manag (Harrow). 2000;31(12):17\u0026ndash;22. quiz 22\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSterner A, Eklund A, Nilsson MS. Prepared to learn but unprepared for work: A cross sectional survey study exploring the preparedness, challenges, and needs of newly graduated nurses entering a hospital-based transition program. Nurse Educ Pract. 2023;72:103782.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKoukourikos K, Tsaloglidou A, Kourkouta L, Papathanasiou IV, Iliadis C, Fratzana A, et al. Simulation in Clinical Nursing Education. Acta Inf Med. 2021;29(1):15\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSmith A, Kisiel M, Radford M, editors. Oxford Handbook of Surgical Nursing. Oxford University Press; 2016. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/med/9780199642663.001.0001\u003c/span\u003e\u003cspan address=\"10.1093/med/9780199642663.001.0001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalifu DA, Heymans Y, Christmals CD. A Simulation-Based Clinical Nursing Education Framework for a Low-Resource Setting: A Multimethod Study. Healthcare. 2022;10(9):1639.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShabur MA, Siddiki MdR. Investigating social media\u0026rsquo;s impact on the new era of interactive learning: A case study of Bangladesh. Heliyon. 2024;10(4):e26234.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShoulders B, Follett C, Eason J. Enhancing Critical Thinking in Clinical Practice: Implications for Critical and Acute Care Nurses. Dimens Crit Care Nurs. 2014;33(4):207.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLord M, Weaver A, Cross L, Hall C, Harris J, Whitehead K. Promoting Clinical Reasoning With One-On-One Focused Pediatric Simulation Experiences. Nurse Educ. 2025;50(2):115.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSon HK. Effects of simulation with problem-based learning (S-PBL) on nursing students\u0026rsquo; clinical reasoning ability: based on Tanner\u0026rsquo;s clinical judgment model. BMC Med Educ. 2023;23(1):601.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNiu Y, Liu T, Li K, Sun M, Sun Y, Wang X, et al. Effectiveness of simulation debriefing methods in nursing education: A systematic review and meta-analysis. Nurse Educ Today. 2021;107:105113.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAebersold M, Tschannen D. Simulation in nursing practice: the impact on patient care. Online J Issues Nurs. 2013;18(2):6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDaneshfar M, Moonaghi HK. The impact of clinical simulation on bridging the theory\u0026ndash;practice gap in nursing education: a systematic review. BMC Med Educ. 2025;25(1):1216.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLavoie P, Pepin J, Cossette S. Contribution of a reflective debriefing to nursing students\u0026rsquo; clinical judgment in patient deterioration simulations: A mixed-methods study. Nurse Educ Today. 2017;50:51\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWatson AL, Young CD, Thomas D, Tapp DM, Holyoak S, Gardner T. Translating learning from simulation to clinical: a narrative study of nursing students\u0026rsquo; experiences. Teach Learn Nurs. 2025;20(1):e218\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Critical thinking, Clinical reasoning, Nursing education, Scenario-based simulation, Traditional skill training, Post-operative nursing","lastPublishedDoi":"10.21203/rs.3.rs-7740598/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7740598/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSimulation-based education is essential in nursing education to build clinical competencies. However, in Bangladesh, teaching remains mostly traditional with limited simulation-based learning. This gap hinders the development of critical thinking (CT) and clinical reasoning (CR), significant for safe patient care. This study aims to evaluate the effectiveness of scenario-based simulation in improving CT and CR among nursing students in post-operative care in Bangladesh.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis prospective, open-label, parallel (1:1) randomized controlled trial was conducted from January to March 2025 with second-year nursing students in a nursing college. After lectures, participants were randomly allocated into an intervention group (IG) or a control group (CG) based on knowledge pre-test scores. The IG received scenario-based simulation training for one week, while CG received traditional skills training. Post-test evaluations measured knowledge, skills, CT, CR, and reflection using the researcher-developed questionnaires. Quantitative data were analyzed with descriptive statistics, independent t-tests, and the Mann\u0026ndash;Whitney U test. Quantitative data was done by content analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOut of 64 students, 58 (IG\u0026thinsp;=\u0026thinsp;29, CG\u0026thinsp;=\u0026thinsp;29) completed the study, mostly females aged 18 to 23 with no prior clinical and post-operative practice experience. The primary outcome as the overall total score of CT, CR and skill was statistically significant between the groups (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The IG showed statistically significant improvements in knowledge, skills, CT and CR (all, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Reflections highlighted that IG students reported more confidence, engagement, and were willing to apply their skills and knowledge during clinical practice, while CG students noted knowledge gain but struggled with skills development.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eScenario-based simulation significantly enhanced CT and CR among nursing students. Future studies should explore its impact across specialties and in long-term practice. With sufficient resources and institutional support, it recommended a significant strategy for nursing education in resource-limited settings such as Bangladesh.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e\u003cp\u003eClinicalTrials.gov, NCT06751446, 2024-12-20\u003c/p\u003e","manuscriptTitle":"Enhancing Nursing Students' Critical Thinking and Clinical Reasoning Abilities in Post-Operative Care by Scenario-Based Simulation: A Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-10 16:24:54","doi":"10.21203/rs.3.rs-7740598/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-11-16T09:11:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178570718250943370602766495975130852706","date":"2025-11-11T09:37:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-10T02:53:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66333246813598610777302252956649656816","date":"2025-11-06T10:57:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"118873131308214029230285528574866113510","date":"2025-10-31T21:35:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"86326004998294642906600685887872938372","date":"2025-10-30T14:28:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-30T08:24:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-28T08:04:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-09T10:47:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-08T13:18:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-10-08T13:15:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b7ffd03e-7aef-46e4-954f-db71c60e7753","owner":[],"postedDate":"November 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T16:24:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-10 16:24:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7740598","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7740598","identity":"rs-7740598","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}