Nurse Education Today 33 (2013) 584–589

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

The impact of simulation-based learning on students' English for

Nursing Purposes (ENP) reading proficiency: A quasi-experimental study
Hsiao-Yun Annie Chang a,⁎, Luke Chan b, Betty Siren b
a
School of Nursing, Fooyin University, Taiwan
b
English Department, Fooyin University, Taiwan

a r t i c l e i n f o s u m m a r y

Article history: Aim: This is a report of a study which evaluated simulation-based learning as a teaching strategy for improv-
Accepted 21 June 2012 ing participants' ENP reading proficiency in the senior college program of students whose first language is
Chinese, not English.
Keywords: Background: Simulation-based learning is known to be one of most effective teaching strategies in the
Simulation-based learning healthcare professional curricula, which brings a clinical setting into the classroom. However, developing En-
English for nursing purposes (ENP)
glish reading skills for English written nursing journals through simulation-based learning in the nursing cur-
English as a foreign language (EFL)
Reading proficiency
ricula, is largely unknown.
A quasi-experimental study Method: We used a quasi-experimental approach with nonequivalent control group design to collect the caus-
al connections between intervention and outcomes. 101 students were enrolled in this study (response rate
92.6%) of these 48 students volunteered for the intervention group, and 53 students for the control group.
Results: The findings indicated that the intervention group had significantly higher mean scores in ENP read-
ing proficiency with unknown words in the article (p = .004), vocabulary (p b .001), and comprehension
(p b .001) compared to the control group. Also, the intervention students showed more improvement in
their English reading, both from quantitative and qualitative findings.
Conclusion: Simulation-based learning may have some advantages in improving the English reading ability on
English written nursing journals among nursing students. However, the benefits to the students of this study
is still to be determined, and further exploration is needed with well designed research and a universal method
of outcome measurement.
© 2012 Elsevier Ltd. All rights reserved.

Introduction
One of the fundamental requirements of higher education in Taiwan is
the need for students to develop English reading proficiency (Lin, 2009).
Especially, evidence-based practice has become a profession-wide move-
ment in the discipline of nursing (Earle-Foley, 2011) which is to promote
the quality of nursing care by making appropriate decisions through inte-
gration of the best available evidence from literature (Melnyk et al.,
2011). When comparing the number of nursing journals published in Chi-
nese to those published in English we found that journals published in
Chinese (21 journals) (Chinese Electronic Periodical Services, 2011) are
far fewer in number than those in English (760 journals) (Cumulative
Index to Nursing and Allied Health Literature Databases, 2011). Even
the Journal of Nursing Research published by the Taiwan nursing associ-
ation is written in English. It is clear that ENP (English for Nursing Pur-
poses) reading proficiency at the academic level has become a
requirement to health care professionals in order to communicate
⁎ Corresponding author at: 151 Jinxue Rd., Daliao Dist., Kaohsiung City 83102, Taiwan.
Tel.: +886 986502206.
E-mail address: chang@gmail.com (H.-Y.A. Chang).
efficiently and share information in the world today. In addition, patient
records in Taiwan are written in English which is also used in regular
communication among nurses, doctors, and other professional healthcare
personnel (Chen and Chiou, 2010). As a result of workplace requirements
and resources available in Taiwan, nurses are increasingly faced with the
challenge of reading English documents as an important component for
providing evidence-based competent care.
English for Nursing Purposes (ENP) is defined as an intensive train-
ing course based on the professional-oriented teaching or learning of
English to achieve the necessary competence (Lee, 1998; Yang, 2005).
Reading proficiency refers to performance on readability using compre-
hension questions to test whether students have competently under-
stood what they have read (Fakeye and Ogunsiji, 2009; Lin, 2009).
While reading professional English-written nursing journals can be
challenging for all nursing students worldwide, it is particularly prob-
lematic for those who only speak English as a foreign language (EFL)
which is well documented in literature (Salamonson et al., 2010;
Suliman and Tadros, 2011). Studies have shown that EFL students
with lower levels of English language proficiency found it difficult to un-
derstand and process complex, which resulted in a decline in academic
achievement (Fakeye and Ogunsiji, 2009; Salamonson et al., 2008). The

0260-6917/$ – see front matter © 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2012.06.018
 H.-Y.A. Chang et al. / Nurse Education Today 33 (2013) 584–589
low-proficiency in English was not confined only to Taiwanese nursing
students (Lin, 2009) but also to members of the nursing staff (Lu et al.,
2009). It is important to train EFL students with effective language
learning strategies to assist them in acquiring English as a second lan-
guage. Although many researchers employed different learning strate-
gies to improve students' reading comprehension, the strategies of
simulation-based learning applied in ENP reading curriculum among
EFL nursing students remains unclear. Simulation is a valid method of
teaching and learning in practice-based healthcare professions. Cant
and Cooper (2010) who systematically reviewed 12 studies involved
in simulation with other strategies for teaching and learning, found sta-
tistical improvements in knowledge/skill, critical thinking ability, and/or
perceived confidence/satisfaction with those students who had partici-
pated in simulation-based learning. Therefore, the aim of this study is to
evaluate a simulation-based learning method, as an innovative teaching
strategy to improve the ENP reading ability of nursing students, who
speak English as a foreign language, in comparison with traditional
lecture-based teaching strategies.
Literature Review
Problems in Learning English as a Foreign Language
English is of particular importance to healthcare professionals and
nursing students because it is the principal language of textbooks, not
just the international language of professionals. Healthcare profes-
sionals need English to read, comprehend and use medical terminology
and phraseology to complete medical records and to communicate with
one another (Yang, 2005). However, it is not easy to teach ENP because
one has to consider not just the students' ability in language learning
but also their specific background knowledge. Although the teaching
of English is formally built into the Taiwan school curriculum from the
fifth grade of primary school, the majority of people in Taiwan cannot
read an English newspaper or even understand short English radio pro-
gram (Tsao et al., 2011). Fang et al. (2011) found that the barriers to
learning English among nursing students were the lack of English com-
petence, inadequate grammar, insufficient vocabulary, low listening
comprehension, low speaking and pronunciation ability, low reading
comprehension and the inability to write coherently. With regard to
the reading problem, one of the researchers has pointed out that the
students become cognitively and linguistically overburdened in trying
to translate each word, each sentence, and each paragraph when they
read. Because of that, it is sometimes difficult for them to determine
critical concepts or prioritize ideas and even though they may spend
an enormous amount of time and effort, they still emerged with incor-
rect comprehension (Beaven et al., 1998). Good reading strategies in-
clude processing information, decoding language to thought, making
predictions through the reading process, and especially, processing
background knowledge, which plays a significant role in the reading
process (Carrell, 1998). As a result, upon entering university, the stu-
dents are required to enroll in the ENP curriculum with motivational
teaching strategies to help develop English reading skills in order to
master English with sufficient proficiency to read nursing journals and
reports which form the basis of a life-long learning plan.
Simulation-based Learning
Simulation-based learning offers a real life setting closely resem-
bling a clinical setting for students to practice their skills in a non-
threatening environment (Jeffries, 2005). Reported results from using
simulation-based learning indicates that students show a positive in-
crease in cognitive, psychomotor, and affective learning, such as en-
hancing knowledge, developing technical proficiency, therapeutic
communication, self-confidence and critical thinking. Also, results
showed a marked improvement in the students' decision-making pro-
cess, active learning strategies and their engagement in the course
585
and their satisfaction in meeting their needs (Cant and Cooper, 2010;
Cooper et al., 2011; McGaghie et al., 2011). Simulation techniques
used in teaching include: a) partial task trainers who use replica ana-
tomical models; b) peer to peer learning using case studies or clinical
role-play situations; c) screen-based computer simulator with interac-
tive software; d) virtual reality using a computer-generated environ-
ment with tactile scenario; and e) full-scale simulation using a
computerized full-body manikin (Decker et al., 2008; McNelis et al.,
2009). Role-play is a popular technique widely used for simulation,
which enables students to actively get involved in the learning experi-
ence through the action of characters in the scenario, but in a nonthreat-
ening environment (Lowenstein, 2011). Especially, it allows students to
practice in a simulated real-life situation and allows the students to in-
teract with others in certain roles to develop decision-making and
problem-solving skills, (Gropelli, 2010) as well as to develop the requi-
site competence in clinical reasoning (Nickless, 2011). Virtually, this sim-
ulation method involves an extensive amount of interaction between the
participants in the target language (Jones, 1982).
Simulation-based learning has been endorsed by many review stud-
ies including surgery skills (Alaraj et al., 2011; Miskovic et al., 2010; Tan
and Sarker, 2011), clinical nursing skills (Cant and Cooper, 2010),
communication skills (Mesquita et al., 2010), knowledge and skill
exams (Yuan et al., 2012), pre-registration nursing education (Ricketts,
2011), new nurse training (Olejniczak et al., 2010), and midwifery edu-
cation (Cooper et al., 2012). Although this effective learning tool has
been widely used in a range of clinical tasks in nursing curricula, none
of the studies has demonstrated the effectiveness of this teaching strate-
gy in improving reading skills when applied to English written nursing
journals, among ENP nursing students. There is limited information on
the impact of simulation-based learning on the reading proficiency of
students of ENP. This study evaluates simulation-based learning as a
teaching strategy for improving the reading proficiency of nursing stu-
dents, whose first language is Chinese, in the senior college program.
Method
Design
The quasi-experimental approach with nonequivalent control
group research design was employed to evaluate students' reading
proficiency in ENP after the simulation-based learning teaching strat-
egy, in comparison with traditional lecture-based teaching strategy.
In order to avoid diffusion or imitation of treatment between groups,
the experimental and control groups were recruited in different
school years. Students enrolled in the course of reading nursing liter-
ature in English in 2009 were invited into the control group voluntar-
ily and anonymously, and students enrolled in 2010 were invited into
the experimental group. Participants were informed at the beginning
of the course that their participation was voluntary without compen-
sation, and that they were able to withdraw from the study at any
time without punishment or any effect to their grade in the course.
All participants were informed of their rights as a requirement of
the University ethics committee and received an explanation of this
study.
Sample & Setting
This study was conducted at a university in southern Taiwan. The
course ‘Reading Nursing Literature in English’ was a compulsory sub-
ject in the third-year program in the nursing curriculum. Fifty-five
(55) students from the school year of 2009, volunteered for the con-
trol group and 53 students from the 2010 school year were in the ex-
perimental group. A semester usually consists of 18 weeks. Seven
nursing students (5.9%) did not enroll in this study; two from the
control group and five from the intervention group. Reasons given
for declining the offer were that they were not able to attend the
586 H.-Y.A. Chang et al. / Nurse Education Today 33 (2013) 584–589

first class and some of them couldn't attend the last class, because of
clinical placement. A few other participants were unable to attend at Week 7 Form a team
least 6 classes. At the completion of the 10-week study, there were 53
participants in the control group and 48 participants in the interven-
tion group. A priori power analysis was calculated using G*Power3
software with an effect size of 0.7 and a power of 90% (two-sided
test at alpha = 0.05), and 44 participants per group were required. Week 8 Search for an article

Intervention

The primary purpose of this simulation-based learning was to Week 10 Identify characters
allow students to work together using a role-play situation as the
study intervention. The intervention was administered by one nurs-
ing academic who has over 10 years' experience in nursing and one
English academic who has over 25 years' experience in teaching En-
glish as a Foreign Language, as well as curriculum design, and a re- Week 11 Simulate a scenario
searcher with data collection and research design experience.
Fig. 1 is a diagram representing the intervention process.
Each role-play consisted of three main sections: In Section 1 the
students provided the background information to the scenario, intro-
duced the characters and posted the script on the screen for the audi- Week 13 Write a script
ence. In Section 2 the students performed the 10 to 15 minute skits by
acting as they would in a real-life clinical situation. Section 3 was the
debriefing session, which was mostly conducted by the students, al-
though the teacher added some input. During each presentation,
other students who made up the audience needed to observe the in-
Week 15 Correct grammar
terplay among the characters and analyze the dynamics occurring to
give feedback to the characters. The instructor's role was to encour-
age the audience to present their observations as to the improve-
ments regarding the clinical information they witnessed, and not to
dwell on the language or acting abilities of the players.
Week 16 Make a rehearsal

Outcome Measures

For this study we used two assessment instruments. At the beginning

of the semester, two groups of students were assessed in their ENP read-
ing proficiency through an exam paper developed by Charles et al. (2007)
who published an English textbook for nursing and health care students
with an EFL background, to assist them in mastering adequate English
language skills to work in an English‐speaking clinical environment. Ten
experts with a nursing background have edited this textbook for content
validity. The exam paper used in this study called “Unit 1: The goods on
nutrition: eat to live” contained two pages of text with 494 words, and
a reading vocabulary exercise with 12 cloze tests and a reading compre-
hension exercise with 6 multiple choice questions. This textbook was
not used in this course. The students only received the exam paper in
the 1st week of this study. This was both our pretest instrument in
week 1, and our post-test instrument in week 18.
The ‘perceived self-efficacy scale on English reading strategies’ which
was developed by Yang (2004) was used only for intervention group.
The self-efficacy scale is composed of 32 items and was conducted
on179 four-year college freshmen in University. Results showed that
the internal consistency of the scale is .9415 and the 5 factors, which in-
clude getting the main idea, text structures, vocabulary ability, reading
speed, and the use of background knowledge were obtained by the ex-
ploratory factor analysis method. However, our study used the new ver-
sion of the ‘perceived self-efficacy scale on English reading strategies’
which contained 23 items. The internal consistency of the scale is .953
(pre-test) and .950 (post-test) in this study, with 5 subscales which are:
1) getting the main idea — 0.86; 2) text structure — 0.90; 3) vocabulary
ability — 0.82; 4) reading speed — 0.84; and 5) the use of background
knowledge — 0.90. The descriptive qualitative data were collected
through written feedback from participating students regarding what
simulation-based learning meant to them, through this learning process.
Week 17 Play the roles
Fig. 1. This is a diagram representing the intervention process. The intervention began
with students in teams of seven to eight people. To reinforce lecture content, each team
was asked to select an English article related to the course syllabus from English written
nursing journals published within the last five years. All the scenarios were developed
from the chosen article, for example, the article called “Helping Your Patient to Restrict Po-
tassium” which talks about the function of potassium in the human body; the symptoms
with unbalanced potassium; tailoring diets for people with renal problems; guidelines for
potassium intake; and practice in reality with special consideration. Students in a team
created the characters of physician, student nurse, nurse, nurse educator, dietitian, patient
and family, and then used the content of this article to create situations for the characters.
Students had to write their own English dialogues for their own characters from what they
had read in the article and/or other relative resources. The aforementioned activities were
completed out-of-class after group discussions, and then each student worked indepen-
dently to complete the weekly task. Next, two teachers gave 15-minute feedback on the
students progress, before class began. The feedback, which focused on the content of the
role-play, included clinical setting, clinical knowledge and English grammar. The student
used this feedback to revise their dialogues and handed in the script during week 15, for
the final grammatical check.
Data Analysis
Quantitative data with statistical calculation were performed using
the computer software SPSS 18.0 for Windows. Double-entry data
were used to import and confirm that the reliability of the data. Inde-
pendent t-tests were used to compare the groups for discrepancies.
The Wilcoxon Signed Ranks Test was used to compare the ‘perceived
self-efficacy scale on English reading strategies’ before and after inter-
vention. Analysis of the covariance with one between-subjects factor
(group membership) and one within-subjects factor (time) was used
 H.-Y.A. Chang et al. / Nurse Education Today 33 (2013) 584–589 587

to test the effectiveness of simulation-based learning in ENP reading Table 2

proficiency. Baseline value was used as the covariate in the analyses. Comparisons of pre and post-test of ENP reading proficiency test for EFL nursing stu-
dents within the group.
The significance for the outcome variables was preset at 0.05. Qualita-
tive data with written feedback using inductive analysis of the data to Variables Mean(SD*)
quantify and analyze the meaning and the relationship of such words Pre-test Post test
and concepts was performed and then inferences were made about
n (53) n (48) t p F p
the messages within the texts.
Unknown words C 59.70(39.63) 34.77(20.93) 6.75 b.001 8.86 b.004
I 59.42(33.15) 26.81(16.23) 8.51 b.001
Results Comprehension C 1.81(0.96) 2.62(1.18) −3.48 .001 41.95 b.001
I 1.94(1.08) 4.40(1.67) −7.80 b.001
Baseline in ENP Reading Proficiency Vocabulary C 4.02(2.17) 5.49(2.26) −4.23 b.001 42.13 b.001
I 4.23(2.34) 8.58(2.59) −6.48 b.001

There were a total of 101 people enrolling in this study; the typical
participants were female (94%), with a mean age of 23.6 years (SD±
1.2 years). When comparing the baseline ENP reading proficiency be-
tween the intervention group (n =48) and the control group (n =53),
we found no statistically significant differences as follows: unknown
words of the article, reading comprehension and reading vocabulary
(see Table 1). Therefore the analyses for the study outcomes were done
using analysis of the covariance with the baseline score as the covariate.
Comparison Within Groups in ENP Reading Proficiency
The results of the pair t‐test of ENP reading proficiency showed sta-
tistically significant differences within the group (see Table 2). In the
control group, analysis of pre and post test on ENP reading proficiency
on unknown words in the article (t = 6.75, p b .001), reading compre-
hension (t = −3.48, p = .001), and reading vocabulary (t = −4.23,
p b .001) all reached statistical significances after 18 weeks of classes.
However, the intervention group, showed greater improvement on un-
known words (t = 8.51, p b .001), comprehension (t =−7.80, p b .001),
and vocabulary (t = −9.70, p b .001) at the end of the course.
Comparison Between Groups in ENP Reading Proficiency
After controlling for baseline values, there were significant mean dif-
ferences from week 1 and week 18 in the ENP reading proficiency test
between the groups (see Table 2). Students in the intervention group
had significantly more understanding of the words in the article (F, =
8.86, p = .004), higher reading vocabulary (F, = 42.13, p b .001), and
better reading comprehension (F, = 41.95, p b .001) than those in the
control group. The posttest was greater for intervention group than
for the control group.
*: Standard deviation, C: control group, I: intervention group.
Feedback from EFL Nursing Students
EFL students often express a fear of English courses. In the beginning,
they felt that the ENP reading curriculum would be a boring class, getting
them read English written nursing journals only. Therefore, it was neces-
sary to find a suitable teaching strategy that would motivate the students
to read English. As Lin said, “This course was not as dull and fearful as other
English courses…not only offered us directions of reading English journals
but also gave a chance of acting an English play”. Through the teamwork
of role-play, students illustrated that they had learned several new read-
ing skills, such as “enhancing my reading speed and reading skills (Wong)”,
“quick to organize the thoughts without wasting time (Chang)”, and “Before
… I need at least several days to read an English article, but now I can grasp
the main points of an article quickly.” Student also noticed improvement in
her reading skills through the creative processes of role-play, “more
chances of training and exercising our abilities to practice English”, said
Hu. This learning strategy allowed the students to become active partic-
ipants in the reading process as the reader was able to construe meaning
through constant interaction with the text.
This simulation-based learning through role-play also enhanced stu-
dents' communication and collaboration competency with each other.
Many students claimed, that “studied in group helping us cooperate each
other and train us how to look for more articles as well as increased our read-
ing ability (Tasi)” and “we learned the weaknesses and strengths of other
classmates through different activities guided by teachers (Fang).” Hao par-
ticularly described this process of learning as she described below:
“In the process of preparing the role-play, we discussed and hel-
ped each other in providing a lot of ideas, writing the script, pre-
paring the materials, and finally performing the play. (Hao)”

Students also mentioned that this learning process help them devel-
The Perceived Self-efficacy Scale on English Reading Strategies
op some life-long learning strategies as stated, “it is a way to absorb new
knowledge (Lin)” and “we can integrate the ENP knowledge into our daily
Analyses of the 5 factors of the perceived self-efficacy scale on En-
clinical situation (Chang).” Student Hwa and Ling claimed “I have more
glish reading strategies exposed statistically significant differences be-
confidence in reading English articles by myself.” Chen pointed out an im-
fore and after the simulation-based learning among the intervention
portant reality that
group (see Table 3). EFL nursing students reported higher self-efficacy
in English reading strategies on getting the main idea, text structures, “As a healthcare professional,… English is a necessary tool for us to
vocabulary ability, reading speed, and the use of background knowledge access to more knowledge from evidence-literature and English
after the 18-week course. reading ability is also essential to us in our future workplace.”

Table 1 Table 3
Baseline comparisons of ENP reading proficiency test for ESL nursing students in the in- Comparison of the perceived self-efficacy scale on English reading strategies.
tervention and the control groups.
Items Pretest Post-test Z p
Variables Control (n = 53) Intervention (n = 48) Statistical
Mean (SD) Mean (SD)
significance
Getting the main idea 14.57(3.94) 17.29(3.49) −4.02 b.001
Mean (SD) Mean (SD) t-test p
Text structures 12.27(4.22) 15.59(3.25) −4.25 b.001
Unknown words 59.70(39.63) 59.42(33.15) 0.04 0.969 Vocabulary ability 12.12(3.61) 15.45(3.55) −4.30 b.001
Comprehension 1.81(0.96) 1.94(1.08) −0.62 0.536 Use of background knowledge 16.24(5.46) 20.63(5.34) −4.51 b.001
Vocabulary 4.02(2.17) 4.23(2.34) −0.47 0.640 Reading speed 5.98(2.14) 7.00(1.65) −2.69 .007
588 H.-Y.A. Chang et al. / Nurse Education Today 33 (2013) 584–589
Indeed, it is important to find suitable teaching strategies to em-
power students' life-long learning skills rather than just giving them
knowledge to survive the current challenge, especially in the coming
era of breathtaking changes. As Chao continued, “this activity is worth-
while for those students who want to take this course…the role-play is a
good way of learning English.”
Discussion
The significance of this study was that both quantitative and qualita-
tive findings showed that EFL students had a better ENP reading profi-
ciency and a higher self-efficacy on English reading strategies after the
simulation-based learning. In addition, students unintentionally learned
more communication, collaboration, and lifelong learning skills through
group discussions of the role-play simulation. The main purpose of this
study was to compare the effectiveness of simulation-based learning
teaching strategy and traditional lecture-based teaching strategy in im-
proving nursing students' ENP reading proficiency of those who were
enrolled in the course of reading nursing literature in English in their
senior year of the nursing program. By having a comparison group
in our quasi-experimental design, the results demonstrated that
the simulation-based learning strategy produced a greater effect on
EFL students' reading proficiency of English written nursing journals
than the traditional teaching strategy. To our knowledge, this specif-
ic finding of the effectiveness of simulation-based learning strategy
involved in ENP reading curriculum has not previously been reported
in any research. Studies often examine role-play in improving oral com-
munication skills (Lane and Rollnick, 2007; Nestel and Tierney, 2007)
and only the study of Kyriakopoulos (2008) found that participants
were able to use the English language with more effectiveness, which
is similar to our quantitative findings as well as qualitative findings.
These EFL students have enhanced their reading abilities to decode
the English texts, process the reading information and enable them-
selves to derive meaning from the article after the simulation-based
learning.
The perceived self-efficacy scale on English reading strategies indicat-
ed that EFL students from the intervention group showed great improve-
ment in their reading strategies of getting the main idea from the article;
understanding the text structures; learning new vocabulary; improving
reading speed; and to be able to make use of background knowledge to
understand the texts. This strategy enabled the students to have greater
competency and self confidence after the simulation-based learning.
There is some difficulty in comparing this study with a previous study
(Yang, 2004) which developed this scale; however, Yang found that EFL
students perceived higher self-efficacy on English reading strategies,
and demonstrated better English academic performance, which is similar
to our findings. The intervention group showed a better performance on
ENP reading proficiency tests, with a significant improvement in their
reading strategies. Unfortunately, the control group did not survey this
scale, which makes it difficult to generalize whether the simulation-
based learning teaching strategy is better than traditional lecture-based
teaching strategy in improving the perceived self-efficacy scale on English
reading strategies.
Recommendations
Our study provides preliminary evidence on a simulation-based
learning approach, and its' effectiveness in helping EFL nursing stu-
dents to improve their English reading strategies through simulated
role-play in clinical situations. Although this study recognizes the
benefits of simulation-based learning in improving the reading ability
of EFL nursing students with the reading of English written nursing
journals, the traditional lecture-based approach continues to be the
predominant method in many universities, primarily due to the fact
that the teaching of simulation-based learning strategies needs
extra-hours of preparation time to accommodate all students and it
is difficult for a teacher to deal with 50 to 60 students in a class.
Thus there is an urgent need for team teaching in the ENP curriculum
with more than one teacher involved in classroom instruction; for ex-
ample, one teacher would have the expertise in teaching English as a
foreign language and the other would have the expertise in nursing
and clinical knowledge. In addition, despite the improvement of
ENP reading proficiency among intervention students demonstrated
in this study, EFL students don't usually become good readers over-
night. They require the continuity of intensive and constant ENP read-
ing training to improve their reading proficiency. Therefore, it would
be worthwhile to do some follow up with this group of students to
determine if this intervention has any long-term impact on their
reading skills, or to conduct another research to examine the transfer-
ability of this teaching strategy. However, further studies should be of
well-designed research with less methodological weaknesses to
quantify the simulation education outcomes.
Limitations
Determining the effectiveness of the simulation-based teaching
methods as compared to traditional-based methods, on the ability of
EFL nursing students to read English written nursing journals, was com-
plicated. The main limitation of this study was determining the sampling
bias from the inclusive bias of the convenience sample; however, the
baseline comparison was done to test the heterogeneity between the
groups. The instrumental bias came from the lack of reliability of the
ENP reading proficiency tests and the lack of data on the perceived
self-efficacy of English reading strategies from the control group, which
weakened the outcomes of simulation-based learning in this study. Nev-
ertheless, the findings both from quantitative and qualitative data have
consistently confirmed that this teaching approach resulted in effective
reading strategies among the EFL students. The other limitation is the
procedural bias from students who volunteered for the course credit.
The researcher did clearly explain at the beginning of the class, that
this participation was without compensation and even though they par-
ticipated in this study, 5% of the participants failed to pass this course.
Conclusion
The focus of teaching and learning in nursing education is to enable
students to apply the knowledge and skills that they learn in the class-
room to a clinical practice setting. Simulation education offers a safe envi-
ronment where students can work on improving their skills in the
following areas: observing others, learning how to provide nursing care,
and sharpening clinical decision-making skills, without putting real pa-
tients at risk. The results of this study have added more evidence as to
the effectiveness of this teaching strategy, and not just its usefulness for
skill-task learning, but also its ability to improve the reading skills of nurs-
ing students who speak English as a foreign language. Simulation educa-
tion has been shown as a superior teaching method with regard to its
accruement of knowledge and competence compared with the traditional
lecture method as the sole means of teaching in this study.
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