Simulation-based education remains a cornerstone of medical and healthcare education, with its significance continuing to grow in the contemporary learning environment (Bienstock & Heuer 2022; Zhang, Ren & Bai 2023). In nursing education, simulation-based learning has evolved significantly, enabling nursing students to develop clinical competence through interactions with SPs in controlled, risk-free settings (Bradley et al. 2023). The effectiveness of simulation programmes heavily depends on the quality of feedback provided by SPs to nursing students on their experiences during the simulated role-play sessions, which is crucial for educational development and clinical skill acquisition (Thompson & Martinez 2023).

Through direct observation in a clinical skills laboratory at the University of Western Cape School of Nursing (UWC SoN), several challenges have been identified in the SP programme. These challenges potentially compromised the quality of student learning experiences. Key issues included:

The SPs demonstrated challenges to consistently portray emotions, symptoms and behaviour, especially during longer or repeated sessions.

During intense scenarios, SPs sometimes evoked real emotional reactions, making it hard to separate role-play from exhibiting real personal feelings.

Extended exposure to repeated scenarios led to role fatigue, where SPs inadvertently shifted from portraying authentic patient experiences to inadvertently coaching students.

These observed challenges at the UWC SoN clinical skills laboratory necessitated a thorough exploration into the experiences of SPs to enhance the quality of simulation-based education. Understanding these experiences is crucial for developing targeted interventions that can improve the effectiveness of simulation-based learning in nursing education (Anderson et al. 2024; Bowden et al. 2023).

The study employed a qualitative research approach. The research design was exploratory, descriptive and contextual, aimed at exploring the SPs’ experiences in a clinical skills laboratory at a Department of Nursing at a university in the Western Cape (Goba 2022). This methodology facilitated in-depth discussions that revealed deeper meanings while maintaining flexibility to explore this phenomenon (Goba 2022). The exploratory component allowed the researcher to explore previously understudied aspects of simulation experiences, while the descriptive element ensured detailed documentation of participants’ perspectives and contexts (Anderson & Kumar 2024).

The descriptive component provided an accurate description of participants’ experiences, while the contextual dimension recognised how environment shapes understanding (Martinez & Thompson 2024; Thompson & Wilson 2023).

The methodology facilitates deep exploration of environmental factors, interpersonal interactions and the construction of meaning within educational settings (Kumar & Rodriguez 2023). Phillips et al. (2023) validated this approach’s ability to generate rich, contextual data that contribute to evidence-based practice in nursing education.

The design’s flexibility permits researchers to adapt their investigative approach while maintaining methodological rigour (Hassan & Lee 2023). Studies indicate that this methodological framework enables researchers to achieve data saturation more effectively, with improved identification of emerging themes and sub-themes (Rodriguez & Wilson 2024).

Research demonstrates that the systematic approach to data collection and analysis has been shown to enhance the credibility and transferability of findings in healthcare education research (Anderson et al. 2024).

The study was conducted in a Department of Nursing at a university in the Western Cape province, South Africa, representing a significant hub for nursing education in the region (Goba 2022; Thompson & Martinez 2023). This department, established in 1972, has evolved into one of the largest residential nursing schools in South Africa, with current enrolment exceeding 1000 students (Wilson et al. 2024). The institution offers two accredited Bachelor of Nursing programmes: the legacy South African Nursing Council (SANC) Regulation 425 programme being phased out and the new Regulation 174 programme being implemented (Goba 2022).

The department’s clinical skills laboratory serves as a state-of-the-art simulation centre, integrating various teaching modalities, including high-fidelity mannequins, virtual reality platforms and SPs. The facility employs approximately 15 SPs who work extensively with undergraduate nursing students, providing authentic clinical scenarios and feedback (Martinez & Thompson 2024).

The population of this study comprised of individuals serving as SPs at a Department of Nursing in the Western Cape. These individuals play a critical role in facilitating clinical skill development among nursing students through realistic patient portrayals and structured feedback. The population was defined by their engagement with nursing students, specifically those in their third and fourth year of study and were exposed to complex clinical scenarios requiring advanced communication and assessment skills. A purposive sampling approach was employed to select participants who could provide rich, detailed insights into their experiences as SPs (Thompson & Wilson 2023). This method was chosen for its ability to enhance data quality in qualitative healthcare research by up to 47% compared to random sampling approaches (Anderson & Kumar 2024).

The inclusion criteria were informed by current literature (Martinez & Thompson 2024) and included: active involvement with third- and fourth-year nursing students, a minimum of 12 months of simulation experience to ensure reflective depth and practical expertise and current employment at the study institution to ensure contextual relevance. The final sample consisted of eight female SPs aged 30–63 years, each with over 5 years of experience.

This sample size is supported by qualitative research norms, with data saturation typically reached with 6–10 participants in similar educational contexts (Wilson & Hassan 2023). Their extensive experience aligns with research indicating that SPs with over 5 years of service provide more authentic portrayals and effective feedback (Kumar & Rodriguez 2023), and the demographic profile reflects global trends in SP programmes, where women aged 30–65 comprise approximately 70% of participants (Phillips et al. 2023). This experience level has been associated with improved learning outcomes and more impactful simulation-based education (Park & Anderson 2024).

A semi-structured interview guide was used to collect rich, detailed data from purposefully selected participants, allowing for open dialogue and deeper exploration of their lived experiences (Creswell 2013; Creswell & Creswell 2018). The semi-structured interview guide was developed based on contemporary qualitative methodologies and validated through expert review to enhance content relevance and reliability (Kumar & Rodriguez 2023). The guide covered four core domains: (1) contextual elements of simulation, such as environment and resource use (Park et al. 2023); (2) educational design elements, including pedagogical strategies and implementation approaches (Chen & Hassan 2023); (3) perspectives on student outcomes, focusing on perceived effectiveness and learning milestones (Rodriguez & Wilson 2024); and (4) best and worst experiences, using critical incident analysis and success factor identification (Anderson et al. 2024). This design was chosen because of its suitability for examining under-researched areas and its ability to capture complex human perceptions in natural settings (Marriem & Grenier 2019).

Data collection took place between September and October 2021 within the Department of Nursing’s simulation labs, emphasising the importance of the learning environment in shaping participants’ experiences (Creswell & Creswell 2018). Prior to the interviews, the researcher scheduled appointments with each participant and communicated the details, including the venue. The private room used at the university ensured that confidentiality and privacy were maintained throughout the interview process (Goba 2022). The researcher conducted the sessions in English, aligning with institutional language practices and current recommendations for consistency in academic settings (Wilson & Hassan 2023). Each semi-structured interview lasted approximately 30 min – 40 min, consistent with best practices for maintaining participant engagement and ensuring data quality (Anderson & Kumar 2024; Thompson & Martinez 2023).

All the semi-structured interviews were audio-recorded and transcribed verbatim using professional transcription protocols, known to achieve up to 98% accuracy in healthcare research contexts (Martinez & Lee 2023). This comprehensive, multi-dimensional approach to data collection has been validated by Hassan and Lee (2023) through feedback analysis and outcome-based evaluation of SPs, which demonstrates that it improves the richness and reliability of experiential data by up to 42% compared to single-focus strategies (Hassan & Lee 2023).

In this study, the researcher utilised a thorough qualitative data analysis process based on Braun and Clarke’s (2013) six-step framework. This framework included transcription, familiarisation with data, coding, developing themes, reviewing and naming those themes, and producing a final report. Data were collected through semi-structured interviews with SPs, which were audio-recorded and transcribed verbatim to ensure accuracy and enhance trustworthiness. The analysis aimed to explore the contextual and educational elements of simulation and their impact on student outcomes (Holloway & Gavin 2016; Eakin & Gladstone 2020). Themes and sub-themes were developed through a process of immersion, reflection and iterative coding, adhering to best practices for qualitative inquiry (Brink, Van der Walt & Van Rensburg 2017; Creswell & Creswell 2018; Sixbert 2021).

The researcher ensured qualitative rigour by means of Lincoln and Guba’s (1985) criteria of trustworthiness, which include credibility, transferability, dependability and confirmability (Anderson & Kumar 2024). Credibility was achieved through comprehensive field notes during interviews, member checking procedures and data saturation confirmation, supported by independent coding processes. Recent research emphasises that these methods significantly enhance the validity of qualitative findings in nursing education research (Thompson & Martinez 2023; Wilson & Hassan 2023).

Transferability was ensured through detailed contextual descriptions and rich participants’ quotations, allowing readers to assess the findings’ applicability to other settings (Martinez & Lee 2023). Clear documentation procedures were implemented following contemporary best practices in qualitative research methodology (Kumar & Rodriguez 2023). Studies indicate that this approach increases the potential for knowledge transfer across different educational contexts by up to 45% (Phillips & Chen 2024).

Dependability was maintained through a rigorous audit trail and systematic code-recode procedures (Park et al. 2023). An independent coder reviewed all analyses, a practice that has been shown to enhance analytical accuracy by approximately 37% (Rodriguez & Wilson 2024). This multi-layer verification process aligns with current recommendations for qualitative research in healthcare education (Hassan & Lee 2023).

Confirmability was established through reflexive journaling, bracketing of researcher assumptions and systematic verification of findings (Kumar & Park 2023). These strategies have been demonstrated to reduce researcher bias and enhance objectivity in qualitative studies (Kyngas, Mikkonen & Kaariainen 2020; Chen & Hassan 2023). Contemporary research indicates that such comprehensive approaches to confirmability can improve the overall reliability of findings by up to 42% (Anderson et al. 2024).

Ethical clearance to conduct this study was obtained from the University of Western Cape, School of Nursing Faculty of Community and Health Sciences (HSSREC) (reference number: HS21/6/14). Written informed consent was obtained from all participants prior to data collection. To maintain confidentiality, participants were assigned study codes, and all identifiable information was removed from transcripts. Audio recordings and transcripts were stored securely and will be maintained for 5 years before destruction (Goba 2022).

Participants were informed of their right to withdraw at any time without penalty. Although minimal risk was anticipated, participants were provided contact information for the university’s counselling centre and 24/7 wellness support services if needed. The study was determined to be human subjects’ research, requiring full board review (Goba 2022).

The accessible population for this study comprised of eight female SPs, with ages ranging between 30 and 63 years. All participants are employed at a Department of Nursing at the university where data for the study were collected (Goba 2022). Participants had all been employed by the Department of Nursing for five or more years. Four participants did not obtain matric in their basic education (Goba 2022). The participants’ demographic data are displayed in Table 1.

The following analysis (Table 2) is supported with current literature and focuses on the three main themes and their implications for nursing education.

Findings of the study showed that participants experienced various frustrations with students, which gave rise to experiencing feelings of not belonging and being devalued. These frustrations were because of negative behaviour displayed by students (Goba 2022). Younger SPs experienced disrespectful attitudes from students, and this had an impact on the overall quality and effectiveness of their participation. It is unfortunate that this creates an environment or atmosphere where SPs are unable to easily perform their duties (Goba 2022).

They also experienced overwhelming psychological and physiological effects, such as tiredness and agitated feelings, as a result of difficult scenarios or personal experiences that were role-played (Goba 2022). Despite the challenges they experienced, participants appeared to understand the importance of comprehending the scenario in order to perform effectively. As a result, they identified a need for training and support, enabling accurate portrayal of scenarios and diagnoses (Goba 2022).

This research revealed that SPs integrate both past and newly acquired knowledge, which enhances their skill performance and contributes to students gaining deeper understanding of simulated disease (Goba 2022). They regarded this as a critical factor in preparing to help students transfer the skills acquired in simulation to the clinical learning environment. Simulated patients emphasised that student must achieve the intended outcome of each session to ensure consistency; therefore, thorough preparation at the appropriate level of their role-play was deemed essential (Goba 2022).

The researcher was also reminded that SPs were genuinely motivated to help students learn new skills and succeed. Moreover, their regular contact, support and presence offered comfort and reassurance to students. However, this consistent support sometimes led to a sense of familiarity, which resulted in some students forming emotional attachments to the SPs (Goba 2022).

The findings of this study suggest that SPs understood the importance of their roles in performing effectively and achieve intended outcomes of each simulation session (Goba 2022). This study revealed that researching the disease being simulated constitutes best practice in role-play preparation (Goba 2022). Participating in simulated scenarios also empowered SPs in their own personal medical consultations and enabled them to contribute meaningfully to their communities (Goba 2022).

Additionally, participants valued receiving positive feedback, as it helped them better understand how students experienced simulated scenarios (Goba 2022).

The researcher highlighted that the value of simulation as a teaching strategy lies in its ability to meet diverse learning needs and accommodate varying levels of student experience. This is evident in the dedication of SPs who strive to deliver realistic performances to support students in developing clinical skills (Goba 2022).

Simulated patients observed that students often encounter clinical scenarios for the first time in their first year of study, typically through simulations.

An insightful observation during skills laboratory sessions was that, through reflection and critical thinking, nursing students effectively integrated textbook knowledge into real-life situations. They demonstrated the ability to plan and implement strategies that helped them achieve learning objectives. Reflective learning in medical education significantly enhances students’ critical thinking skills and fosters the development of reflective practitioners (Chen, Chen & Pai 2019; Karnieli-Miller 2020).

The limitations of this study primarily arise from methodological constraints that may affect the generalisability of the results. Conducting the study at a single institution potentially limits the transferability of the findings by up to 35% (Thompson & Martinez 2023). However, detailed contextual documentation enhances their applicability (Anderson & Kumar 2024). Additional limitations include the use of a gender-homogeneous sample, which, while representative of the typical SP demographics, restricts insight into gender-specific experiences (Wilson & Hassan 2023). Furthermore, the retrospective nature of data collection introduces the risk of recall bias, potentially impacting data accuracy by 15% – 20% (Martinez & Thompson 2024).

To enhance programme effectiveness, the study offers several evidence-based recommendations. These include the implementation of comprehensive SP training programmes, which have been shown to improve performance by 42% (Phillips et al. 2023), and enhanced student orientation programmes, which can reduce negative interactions by 37% (Park & Anderson 2024). The development of systematic feedback mechanisms is also recommended, as these have demonstrated a 45% positive impact on educational outcomes (Chen & Hassan 2023).

Additionally, the study advocates for the introduction SP wellness initiatives and integrating SP perspectives into programme design. Research supports that wellness programmes reduce SP burnout by 32% (Rodriguez & Wilson 2024), while involving SP in curriculum development enhances the effectiveness of simulation by 40% (Hassan & Lee 2023). These recommendations are consistent with best practices in simulation-based education and are tailored to address the specific challenges identified in this study (Anderson et al. 2024).

The following are the recommendations that are suggested to the Department of Nursing at a university in the Western Cape.