Learners to Leaders: Impact of Instructor Roles on Nursing Students’ Professional Development in Clinical Simulations

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors,

 Thank you very much for your effort in crating this interesting research.

Kindly please provide some changes:

Introduction -please shortly explain differences in nursing education aroud the globe, for example your study lasts for 4 years, but it not the same in all countries..

Methods

What roles students had in simulation in your university?

Rows 100-102- you mention elective course you didn't mention before – please explain and mention it and also explain in introduction.

Data collection – who conducted interviews?

Results

Row 357- you mentioned students are involved early in clinical simulation, this student mentions he would like to be involved earlier? Please explain in correlation with information in row 99.

 Conclusion – row 484?

 Looking forward to see you corrections.

Author Response

Dear Reviewer,

We sincerely appreciate your detailed and constructive feedback on our manuscript titled "Learners to Leaders: Impact of Instructor Roles on Nursing Students' Professional Development in Clinical Simulations." Your thoughtful comments have provided us with valuable insights and have greatly contributed to enhancing the clarity, rigor, and overall quality of our work.

In the following sections, we address each of your comments in detail, outlining the modifications made to the manuscript. The changes have been highlighted in red within the revised version of the manuscript for clarity. We have carefully incorporated your suggestions to ensure that our study meets the highest academic standards and provides a clearer and more comprehensive contribution to the field.

Dear authors,

Thank you very much for your effort in crating this interesting research.

Kindly please provide some changes:

Introduction -please shortly explain differences in nursing education around the globe, for example your study lasts for 4 years, but it not the same in all countries…

Thank you very much for your thoughtful and constructive feedback on our manuscript. In response to your recommendation to elaborate on the differences in nursing education globally, we have made the following modifications to the Introduction section:

1. Global Overview of Nursing Education: We have included a discussion on the diversity in nursineducation frameworks worldwide, emphasizing variations in duration, structure, and pedagogical approaches. This addition highlights how these differences reflect cultural, economic, and healthcare policy contexts, providing a broader understanding of the global landscape.
2. Regional Examples: We have incorporated examples from the United States, Canada, Europe, and Asia to illustrate these differences:
• In the United States and Canada, we discuss advanced frameworks emphasizing leadership, research, and clinical expertise.
• In Europe, we describe the alignment with the Bologna Process, noting how this standardization has influenced nursing education, particularly in Spain and Austria.
• In Asia, we include distinctive approaches in Japan and South Korea, showcasing their unique contributions to nursing education.
3. Contextual Relevance to Simulation-Based Education: We have linked these global disparities to the increasing role of clinical simulation as a harmonizing educational strategy, emphasizing its transformative potential in bridging theoretical and practical knowledge gaps.

These additions provide a comprehensive background, contextualizing the significance of our study within the broader international context. We believe this enhancement addresses your request and strengthens the manuscript’s introduction.

Methods

What roles students had in simulation in your university?

Rows 100-102- you mention elective course you didn't mention before – please explain and mention it and also explain in introduction.

Thank you for your insightful feedback. Regarding your comment about the elective course mentioned in lines 100-102, we have added a detailed explanation in both the Introduction and the Methods sections to provide clarity and context.

In the Introduction, the elective course is briefly introduced to highlight its role in the study. The added text reads:

"In the fourth year of the UVic-UCC nursing program, students can enroll in the elective course Advanced Clinical Simulation, representing a pivotal opportunity to assume instructional roles in simulation-based activities. Prior to this course, students participated as active participants in clinical scenarios and observers analyzing peer performance. This innovative course allows students to alternate between observer and instructor roles, fostering the development of leadership, pedagogical, and reflective skills essential for professional success”

In the Methods section, we expanded on the course structure and its objectives. The revised text is as follows:

"The elective course 'Advanced Clinical Simulation,' offered during the fourth year of the nursing program at UVic-UCC, is a 3-ECTS course designed to provide an in-depth understanding of simulation-based education. The course integrates theoretical instruction on simulation pedagogy, scenario development, leadership, and feedback strategies with practical application, where students alternate between observer and instructor roles. As instructors, students are responsible for scenario planning, simulation facilitation, and leading debriefing sessions. This hands-on experience allows students to develop critical leadership, communication, and reflective skills, complementing their clinical education."

We believe this addition provides the necessary detail to clarify the elective course's role and its connection to the study's objectives.

Data collection – who conducted interviews?

Thank you for your valuable comment. We have now clarified who conducted the interviews, as well as the focus group and non-participant observations, in the Methods section of the manuscript. The revised text is as follows:

"All data collection activities, including semi-structured interviews, the focus group, and non-participant observations, were conducted by a member of the research team with prior experience in qualitative research and training in data collection techniques. The researcher ensured methodological rigor throughout the process, aligning all activities with the study objectives and fostering a neutral and comfortable environment to encourage open and honest communication. The semi-structured interviews and focus group were guided by pre-designed thematic frameworks and open-ended questions to explore participants' experiences in-depth. Similarly, during the non-participant observations, the researcher acted as an external observer, maintaining a non-intrusive stance to objectively record interactions and behaviors. Structured observation sheets were used to document aspects such as scenario planning, facilitation strategies, and participant dynamics. These procedures followed established qualitative research standards, ensuring the credibility and depth of the data collected."

We hope this addition provides sufficient clarity and addresses your concern.

Results

Row 357- you mentioned students are involved early in clinical simulation, this student mentions he would like to be involved earlier? Please explain in correlation with information in row 99.

Thank you for this valuable observation. We have clarified in the Results section how the curriculum at UVic-UCC integrates clinical simulations from the first year of the nursing program, as noted in row 99. However, some participants expressed a desire for even earlier and more frequent exposure to simulation-based activities, as reflected in row 357.

This feedback suggests that, although simulations are already introduced early, students perceive significant benefits from increasing both the frequency and depth of these activities. To address this, we have revised the Results section to include the following explanation:

"While the curriculum at UVic-UCC includes clinical simulations from the first year of the nursing program, some students expressed a desire for even earlier or more extensive exposure to these activities. This feedback likely reflects a perception of the value of simulations as an essential educational tool. Students emphasized the importance of being exposed to simulation-based learning at the very start of their studies, along with a higher frequency of simulations throughout the program. This aligns with broader recommendations to enhance simulation-based education by embedding it more systematically and frequently within nursing curricula to maximize its impact."

Additionally, we have integrated specific student quotes to illustrate these perceptions. We hope this revision addresses your concern and provides greater clarity on the students' feedback and its alignment with the curriculum design.

Conclusion – row 484?

Thank you for pointing this out. We apologize for the oversight. The placeholder text from the journal template—"This section is not mandatory but can be added to the manuscript if the discussion is unusually long or complex."—has been removed from the manuscript.

We appreciate your attention to detail and your feedback, which has helped us improve the clarity of our submission.

Looking forward to see you corrections.

Thank you once again for your time and effort in reviewing our manuscript and for helping us improve it. We remain open to any additional suggestions you may have to further refine our work.

Sincerely,

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Interesting subject with fourth year nursing students leading simulations.  A clear and well set out manuscript.  Study design and method well documented and explained with limitations due to low number of participants and single site acknowledged.  The use of participant comments strengthens understanding with discussion and conclusion highlighting potential benefits of implementing program into curriculum.  

Author Response

Dear Reviewer,

I would like to extend my heartfelt gratitude for your thoughtful and encouraging review of our manuscript titled "Learners to Leaders: Impact of Instructor Roles on Nursing Students' Professional Development in Clinical Simulations"

We greatly appreciate the time and effort you dedicated to evaluating our work. Your positive feedback regarding the clarity and organization of the manuscript, the thorough documentation of the study design and methodology, and the acknowledgment of our study's limitations were highly encouraging. We are also pleased that you found the use of participant comments to enhance understanding and the discussion on the potential benefits of implementing the program into the curriculum to be valuable contributions.

Your insights have been invaluable in reinforcing the quality and rigor of our research. We are motivated to continue refining our study and exploring further avenues to contribute to the field of nursing education.

Thank you once again for your valuable support and for recognizing the significance of our work.

Sincerely,

Reviewer 3 Report

Comments and Suggestions for Authors

A qualitative study was conducted to describe how assuming the instructor role within clinical simulations impacts the professional development of senior nursing students. The transition of nursing students to the instructor role in simulations is a novel teaching strategy and worth the investigation into the outcomes of this type of learning experience. The study aim and related research questions were articulated clearly. The choice of interpretive phenomenology was appropriate to achieve the stated aim. Three approaches to data collection were used and helped support a comprehensive description of the student’s experiences. The application of the phases of Braun and Clarke’s thematic analysis was described in detail (and is a good example for future teaching purposes). Three strategies were employed to build the trustworthiness of the findings. The themes were described succinctly with useful exemplars. The discussion was thorough and the limitations appropriate. Overall, this was a well written report that would be of interest to those in teaching and research roles related to nursing education and simulation. There are a few minor edits that are suggested below.

1.      Line 102 – It would be helpful to spell out ETCS credits for the international readers.

2.      Line 103 – Reference is made to heterogeneity of academic backgrounds. Please explain this further since all students were from the nursing program.

3.      Line 143 – It is not clear what was meant by ‘planning and development of clinical cases by the instructors’. Does this mean that the student developed the simulation case or simply planned how the simulation would be implemented?

4.      Line 214 – The authors have noted the use of 3 strategies to support the ‘reliability and validity of the analysis’. Since this is a qualitative study, the more appropriate term would be trustworthiness and related concepts.

5.      Page 6-8 – The quotes from students are listed as separate paragraphs. Suggest integrating them into the paragraph about each theme to make it easier to follow…not critical but a helpful format suggestion. As well, suggest removing the data source (interview vs. focus group etc.) as well as the minutes as this is not necessary for the reader.

6.      Line 446 – Implications section – Suggest avoiding bulleted lists and instead create sentences that flow in a paragraph. This would reflect standards for academic writing.

1.      Conclusion- line 484 – There seems to be ‘notes’ left here that should be deleted i.e., ‘This section is not mandatory but can be added to the manuscript if the discussion is unusually long.’  On line 487, reference is made to ‘significant impact’. It is suggested that a more tentative tone be used given that this was a study of only 9 students e.g., ‘could have an impact…’

Author Response

A qualitative study was conducted to describe how assuming the instructor role within clinical simulations impacts the professional development of senior nursing students. The transition of nursing students to the instructor role in simulations is a novel teaching strategy and worth the investigation into the outcomes of this type of learning experience. The study aim and related research questions were articulated clearly. The choice of interpretive phenomenology was appropriate to achieve the stated aim. Three approaches to data collection were used and helped support a comprehensive description of the student’s experiences. The application of the phases of Braun and Clarke’s thematic analysis was described in detail (and is a good example for future teaching purposes). Three strategies were employed to build the trustworthiness of the findings. The themes were described succinctly with useful exemplars. The discussion was thorough and the limitations appropriate. Overall, this was a well written report that would be of interest to those in teaching and research roles related to nursing education and simulation. There are a few minor edits that are suggested below.

Dear Reviewer,

We sincerely appreciate your detailed and constructive feedback on our manuscript titled "Learners to Leaders: Impact of Instructor Roles on Nursing Students' Professional Development in Clinical Simulations."  We are pleased to hear that you found our study well-written and valuable to those involved in teaching and research roles related to nursing education and simulation.

We appreciate your positive feedback on the clarity of our study aim and research questions, the appropriateness of our methodological approach, and the comprehensive description of our data collection and analysis processes. Your recognition of the strengths in our thematic analysis, trustworthiness strategies, and overall discussion is highly encouraging.

In the following sections, we address each of your comments in detail, outlining the modifications made to the manuscript. The changes have been highlighted in red within the revised version of the manuscript for clarity. We have carefully incorporated your suggestions to ensure that our study meets the highest academic standards and provides a clearer and more comprehensive contribution to the field.

1. Line 102 – It would be helpful to spell out ETCS credits for the international readers.

Thank you for bringing this to our attention. We acknowledge the importance of ensuring clarity for all readers, especially those who may not be familiar with the European Credit Transfer and Accumulation System. In the revised manuscript, we have spelled out the acronym "ECTS" at its first occurrence as follows:

“The elective course "Advanced Clinical Simulation", offered during the fourth year of the nursing program at the University of Vic – Central University of Catalonia (UVic-UCC), is a 3-credit course based on the European Credit Transfer and Accumulation System (ECTS), a standardized system within the European Higher Education Area (EHEA) designed to facilitate the recognition and transfer of academic credits across Europe. This course is designed to immerse students in the fundamentals of simulation-based education.”

We believe this clarification will enhance the manuscript's accessibility and comprehension for an international audience.

2. Line 103 – Reference is made to heterogeneity of academic backgrounds. Please explain this further since all students were from the nursing program.

We sincerely appreciate your thoughtful and constructive feedback on our manuscript. Your observation regarding the reference to the heterogeneity of academic backgrounds in Line 103 has prompted us to refine and clarify this section of the introduction. Specifically, we have expanded on this concept to provide a broader perspective on the global variations in nursing education, emphasizing differences in program duration, structure, and pedagogical approaches.

In the revised introduction, we now discuss how these variations reflect diverse cultural, economic, and healthcare policy frameworks worldwide. We also highlight how these differences influence the adoption and implementation of methodologies like clinical simulation. For instance, we have elaborated on the role of the Bologna Process in Europe, the competency-based approaches in North America, and the integration of advanced technologies in Asian nursing education. This expanded context clarifies the reference to heterogeneity and situates our study within the broader global landscape of nursing education.

By incorporating these adjustments, we believe the introduction now provides a clearer and more comprehensive context, aligning with your recommendation. These changes enhance the manuscript by better articulating the relevance and significance of our research within the diverse landscape of nursing education.

We are grateful for your insightful feedback, which has contributed to strengthening the clarity and rigor of our work.

3. Line 143 – It is not clear what was meant by ‘planning and development of clinical cases by the instructors’. Does this mean that the student developed the simulation case or simply planned how the simulation would be implemented?

Thank you for your insightful feedback. We have clarified the phrase “planning and development of clinical cases by the instructors” in the Non-Participant Observation section to specify that student-instructors were responsible for both designing original simulation scenarios and organizing the logistical aspects of implementing these simulations. The revised sentences now read:

"Student-instructors were responsible for both designing original simulation scenarios and organizing the logistical aspects of implementing these simulations. This involved creating realistic clinical situations, determining the objectives of each simulation, and ensuring that all necessary resources and materials were prepared in advance."

We believe this revision enhances the clarity of our manuscript for all readers.

4. Line 214 – The authors have noted the use of 3 strategies to support the ‘reliability and validity of the analysis’. Since this is a qualitative study, the more appropriate term would be trustworthiness and related concepts.

Thank you for your valuable feedback. We have addressed your suggestion by replacing “reliability and validity” with “trustworthiness” in the Data Analysis section. Additionally, we have aligned the descriptions of our strategies with qualitative research concepts related to trustworthiness, specifically linking data triangulation to credibility, peer review to dependability, and member checking to confirmability. The revised section now reads:

“To ensure the trustworthiness of the analysis, three strategies were employed:

• Data Triangulation: Findings from the interviews, focus group, and observations were compared and contrasted to identify consistencies and discrepancies [24]. This triangulation enhances the credibility of the results by cross-verifying information from multiple sources.
• Peer Review: An independent researcher reviewed the coding process and emerging categories, providing an additional perspective and ensuring dependability. This collaborative approach helps to minimize potential biases in data interpretation.
• Member Checking: Preliminary findings were shared with some participants to confirm the interpretation of their experiences and ensure that they accurately reflected their perceptions [25]. This process strengthens the confirmability of the study by involving participants in validating the results.”

We believe these revisions align our terminology with qualitative research standards and enhance the methodological rigor of our study.

5. Page 6-8 – The quotes from students are listed as separate paragraphs. Suggest integrating them into the paragraph about each theme to make it easier to follow…not critical but a helpful format suggestion. As well, suggest removing the data source (interview vs. focus group etc.) as well as the minutes as this is not necessary for the reader.

We value your input on this matter. We agree with your recommendation to integrate student quotes into the narrative paragraphs corresponding to each theme. This approach enhances the flow and coherence of the manuscript, making it more accessible and engaging for readers. Additionally, we have removed references to the data sources and specific time stamps to improve overall readability and maintain focus on the thematic findings.

Specifically, we have:

• Integrated the students' direct quotes within the paragraphs discussing each theme, facilitating easier reading and comprehension of the findings.
• Removed references to the data sources (e.g., "Individual Interview," "Focus Group") and specific time stamps of the interviews, as these details do not provide essential information for the reader and may disrupt the text's flow.

These changes have been implemented on pages 6 to 8 of the manuscript, ensuring that the quotes enrich the narrative without overloading it with unnecessary methodological details.

We believe these revisions align our manuscript with qualitative research best practices, enhancing both its clarity and professionalism.

6. Line 446 – Implications section – Suggest avoiding bulleted lists and instead create sentences that flow in a paragraph. This would reflect standards for academic writing.

We appreciate your attention to this detail. We agree with your recommendation to transform the bulleted lists in the Implications section into cohesive paragraphs. This modification enhances the flow and coherence of the manuscript, aligning it with academic writing standards. Specifically, we have integrated each implication into a narrative paragraph, providing detailed explanations and ensuring a seamless transition between ideas. The revised Implications section now reads:

“The findings of this study have significant implications for nursing education. Integrating opportunities for students to assume instructor roles in clinical simulations can enrich their professional development by fostering critical competencies essential for practice. Educational institutions should consider incorporating instructor roles for advanced students, allowing senior students to design and facilitate simulations. This approach not only enhances their learning experience but also cultivates leadership and pedagogical skills. Additionally, promoting preparation and active participation is crucial; implementing strategies that encourage prior preparation and student commitment—such as specific assignments and formative assessments—can lead to more effective learning outcomes. Furthermore, integrating simulation progressively throughout the curriculum is recommended. Introducing simulation activities from the early years and gradually increasing their complexity can significantly improve the acquisition of both clinical and non-technical competencies. Lastly, advancing effective debriefing practices is essential. Training both students and instructors in debriefing techniques can enhance the quality of reflections and resultant learning, ensuring that the simulations provide maximum educational benefit.”

We believe these revisions improve the manuscript’s clarity and maintain a professional tone, effectively conveying the implications of our study’s findings.

7. Conclusion- line 484 – There seems to be ‘notes’ left here that should be deleted i.e., ‘This section is not mandatory but can be added to the manuscript if the discussion is unusually long.’  

Thank you for pointing this out. We apologize for the oversight. The placeholder text from the journal template—"This section is not mandatory but can be added to the manuscript if the discussion is unusually long or complex."—has been removed from the manuscript.

We appreciate your attention to detail and your feedback, which has helped us improve the clarity of our submission.

On line 487, reference is made to ‘significant impact’. It is suggested that a more tentative tone be used given that this was a study of only 9 students e.g., ‘could have an impact…’

We acknowledge your observation regarding the tone used in describing the study's impact. In response, we have revised the phrase from "could have a significant impact" to "could have an impact" to adopt a more tentative and scientifically cautious tone, considering the small sample size of 9 students. The revised sentence in the Conclusion section now reads:

“These findings could have an impact on nursing education by informing curriculum development and teaching strategies.”

We believe this adjustment maintains the integrity of our findings while appropriately reflecting the scope of our study.

Thank you once again for your time and effort in reviewing our manuscript and for helping us improve it. We remain open to any additional suggestions you may have to further refine our work.

Sincerely,

Author Response File: Author Response.pdf