Nursing Students’ Experiences in Clinical Simulation at the End of Life: A Look at the Professional and Family Role

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript addresses a relevant and timely topic in nursing education. The qualitative approach provides valuable insights into nursing students' experiences during end-of-life simulation.  However, several methodological and conceptual aspects would benefit from further clarification and strengthening before the manuscript can be considered for publication. The most critical points requiring revision are outlined below.

1. Missing Simulation Scenario Description (Methods)

The manuscript lacks a detailed description of the simulation experience. Essential information is missing: scenario content, patient/family characteristics, duration, student roles, simulation modality (standardized patients, manikins), debriefing structure, and learning objectives. As the simulation constitutes the central context of the study, this information is critical for understanding the context of students' experiences and for potential replication.

2. Methodological coherence between design and analysis (Methods)

The study is described as having an "exploratory-descriptive phenomenological design" (line 115), yet data analysis employs thematic analysis following Braun and Clarke's framework. This creates methodological inconsistency. The authors should either clarify how thematic analysis was adapted to maintain phenomenological principles or reconsider the design description to align with the analytical approach used (e.g., "qualitative descriptive design"). Clarifying this point will substantially strengthen the methodological rigor of the study.

3. Conceptual distinction between Palliative Care and End-of-Life Care (Introduction)

Throughout the manuscript, "palliative care" and "end-of-life care" are used interchangeably. These terms are related but not synonymous: palliative care can begin early in illness, while end-of-life care refers to a more circumscribed period. Clarifying this distinction and ensuring consistent terminology would strengthen conceptual clarity and improve interpretation of the findings.

 

4. Research Gap Articulation (Introduction)

Although the manuscript reviews relevant literature on simulation-based learning in palliative and EOL care, the specific research gap addressed by this study remains somewhat implicit.. Lines 101-104 mention previous research foci, but what specifically remains unexplored? The unique contribution of this study (subjective experiences of first-year nursing students in EOL simulation contexts) should be more explicitly stated to justify its relevance. A clearer articulation of this gap would reinforce the study’s originality and justification.

 

5. Theme Overlap in Results (T1 and T2)

Themes 1 (Family as a pillar of care) and 2 (Relationship with the family) show conceptual overlap. Both address family-related aspects, and the distinction between "family's role" and "relationship with family" could be more clearly articulated. Consider whether these themes could be merged or whether clearer boundaries should be established with supporting rationale.

6. Terminology Inconsistency: "Gamification Activity" (Results)

Line 240 references a "gamification activity," but this term was not introduced or defined in the Methods section. If gamification elements were incorporated into the simulation, this should be described in Methods. If this is an error, it should be corrected to "simulation activity" or "clinical simulation" for consistency.

7. Expanded discussion of limitations (Discussion)

While limitations are acknowledged, this section could be strengthened by addressing additional issues, such as self-selection bias (participating students may have been more engaged); social desirability bias (positive experiences reported to please researchers); immediate data collection (capturing only initial reactions); lack of comparison group; and the translation process. A more comprehensive limitations discussion would strengthen the manuscript demostrating methodological reflexivity and transparency.

8. Conclusions alignment with objectives

The conclusions do not address all stated objectives (lines 105-112). Specifically, "adapting communication to specific clinical contexts" and "understanding of the nursing role" are not explicitly addressed. Additionally, Theme 2 (Relationship with the family), which includes rich findings about empathy and trust-building, is notably absent from the conclusions. The authors should ensure alignment between objectives, results, and conclusions. Strengthening this alignment would improve internal coherence.

 

9. Typographical Errors Throughout

Several typographical errors require correction: Line 49: "managingomplex" → "managing complex"; Lines 69-70: "nsufficient" → "Insufficient"; Lines 84-85: "BLS" → "SBL"; Line 147: "FG)nd" → "FG) and"; Line 239: Section "2.2" → "3.2"; Lines 242-243 and 455-457: Theme 5 is duplicated as both "Emerging emotions" and "Learning through simulation." Please review the entire text and correct all typographical errors. While these issues are editorial in nature, their frequency warrants careful revision.

 

Concluding Remarks

The manuscript presents valuable qualitative data on an important topic in nursing education. The suggested revisions primarily aim to enhance methodological coherence, conceptual clarity, and transparency, rather than to challenge the core contribution of the study. With appropriate revisions addressing the methodological and conceptual issues outlined above, this work could make a meaningful contribution to the literature on simulation-based learning in end-of-life education for undergraduate students

Author Response

REVISOR 1

This manuscript addresses a relevant and timely topic in nursing education. The qualitative approach provides valuable insights into nursing students' experiences during end-of-life simulation. However, several methodological and conceptual aspects would benefit from further clarification and strengthening before the manuscript can be considered for publication. The most critical points requiring revision are outlined below.

1. Missing Simulation Scenario Description (Methods)

The manuscript lacks a detailed description of the simulation experience. Essential information is missing: scenario content, patient/family characteristics, duration, student roles, simulation modality (standardized patients, manikins), debriefing structure, and learning objectives. As the simulation constitutes the central context of the study, this information is critical for understanding students' experiences and for potential replication.

Thank you for this valuable comment. We agree that a detailed description of the simulation experience is essential to ensure clarity and replicability. In response to this suggestion, we have added a new subsection in the Methods section entitled “Simulation scenario and learning design.” This subsection provides a comprehensive description of the simulation modality (standardized patients), the content and characteristics of the two simulation scenarios, the duration of each scenario, student roles, the structure of the prebriefing, briefing, and debriefing phases, and the learning objectives of the simulation experience. These additions aim to strengthen the methodological transparency of the study and to facilitate a clearer understanding of the context in which students’ experiences were generated.

2. Methodological coherence between design and analysis (Methods)

The study is described as having an "exploratory-descriptive phenomenological design" (line 115), yet data analysis employs thematic analysis following Braun and Clarke's framework. This creates methodological inconsistency. The authors should either clarify how thematic analysis was adapted to maintain phenomenological principles or reconsider the design description to align with the analytical approach used (e.g., "qualitative descriptive design"). Clarifying this point will substantially strengthen the methodological rigor of the study.

Thank you for this essential methodological observation. We agree that clarity and coherence between the study design and the analytical approach are essential to ensure methodological rigor. In response to this comment, we have revised the study design description.

Specifically, we have replaced the term “exploratory–descriptive phenomenological design” with “qualitative descriptive exploratory design”, which more accurately reflects the aims of the study and the analytical procedures employed. As suggested, a thematic analysis following Braun and Clarke’s framework is well aligned with a qualitative descriptive approach, allowing for an inductive, data-driven analysis while remaining close to participants’ accounts.

We have revised the Study Design and Data Analysis sections accordingly to ensure methodological coherence and to clarify the rationale for the chosen analytical approach. These changes strengthen the transparency and rigor of the methodological framework.

3. Conceptual distinction between Palliative Care and End-of-Life Care (Introduction)

Throughout the manuscript, "palliative care" and "end-of-life care" are used interchangeably. These terms are related but not synonymous: palliative care can begin early in illness, while end-of-life care refers to a more circumscribed period. Clarifying this distinction and ensuring consistent terminology would strengthen conceptual clarity and improve interpretation of the findings.

We agree that "palliative care" and "end-of-life care" are not interchangeable. In response, we have revised the manuscript to use “end-of-life care” consistently throughout, as this term more accurately reflects the scope of the clinical scenarios addressed in the study. This change ensures conceptual clarity and improves the interpretation of the findings.

4. Research Gap Articulation (Introduction)

Although the manuscript reviews relevant literature on simulation-based learning in palliative and EOL care, the specific research gap addressed by this study remains somewhat implicit.. Lines 101-104 mention previous research foci, but what specifically remains unexplored? The unique contribution of this study (subjective experiences of first-year nursing students in EOL simulation contexts) should be more explicitly stated to justify its relevance. A clearer articulation of this gap would reinforce the study’s originality and justification.

Thank you for this comment. The research gap and the specific contribution of the study can be made more explicit. While previous research has primarily focused on learning outcomes, competency acquisition, and the effectiveness of simulation-based learning in palliative and end-of-life care, less attention has been paid to the subjective, lived experiences of nursing students at the very early stages of their training. In particular, the emotional impact, meaning-making processes, and emerging professional identity of first-year nursing students during end-of-life simulation contexts remain underexplored.

We have revised the Introduction to explicitly articulate this gap and clarify the unique contribution of the present study, which focuses on the subjective experiences of first-year nursing students participating in end-of-life communication simulations. The introduction is modified and clarified.

5. Theme Overlap in Results (T1 and T2)

Themes 1 (Family as a pillar of care) and 2 (Relationship with the family) show conceptual overlap. Both address family-related aspects, and the distinction between "family's role" and "relationship with family" could be more clearly articulated. Consider whether these themes could be merged or whether clearer boundaries should be established with supporting rationale.

Although Themes 1 (Family as a pillar of care) and 2 (Relationship with the family) both focus on family-related aspects, they represent distinct dimensions of participants’ experiences and should be retained as separate themes.

• Theme 1: Family as a pillar of care emphasizes the family’s functional role in providing support, guidance, and practical assistance. It reflects how participants rely on their family as a foundation for coping with challenges.
• Theme 2: Relationship with the family focuses on the quality, dynamics, and emotional aspects of interactions with family members, including closeness, communication, and relational tensions.

Retaining these themes separately allows a nuanced understanding of family influence, capturing both the role the family plays in care and the nature of the relationship. This distinction is supported by participant narratives that highlight functional support independently of relational quality, justifying the analytical separation.

The description of both themes has been modified in the manuscript to emphasize these differences, as explained.

6. Terminology Inconsistency: "Gamification Activity" (Results)

Line 240 references a "gamification activity," but this term was not introduced or defined in the Methods section. If gamification elements were incorporated into the simulation, this should be described in Methods. If this is an error, it should be corrected to "simulation activity" or "clinical simulation" for consistency.

Thank you very much for your suggestion. The section on gamification activity has been removed.

7. Expanded discussion of limitations (Discussion)

While limitations are acknowledged, this section could be strengthened by addressing additional issues, such as self-selection bias (participating students may have been more engaged); social desirability bias (positive experiences reported to please researchers); immediate data collection (capturing only initial reactions); lack of comparison group; and the translation process. A more comprehensive limitations discussion would strengthen the manuscript demostrating methodological reflexivity and transparency.

We thank the reviewer for their valuable comments. We have revised the manuscript to provide a more comprehensive discussion of strengths and limitations. While the study highlights the innovative use of clinical simulation to enhance student learning in realistic, safe scenarios, we acknowledge additional limitations, including self-selection and social desirability biases, immediate data collection, the lack of a comparison group, and potential translation-related interpretation issues. These revisions aim to increase methodological transparency, justify the study’s contributions, and suggest directions for future research.

8. Conclusions alignment with objectives

The conclusions do not address all stated objectives (lines 105-112). Specifically, "adapting communication to specific clinical contexts" and "understanding of the nursing role" are not explicitly addressed. Additionally, Theme 2 (Relationship with the family), which includes rich findings about empathy and trust-building, is notably absent from the conclusions. The authors should ensure alignment between objectives, results, and conclusions. Strengthening this alignment would improve internal coherence.

We thank the reviewer for pointing out the need to align the conclusions with the study objectives. In response, we have revised the conclusions to explicitly address all stated objectives, including the development of communication skills adapted to specific clinical contexts, understanding of the nursing role, and the importance of the relationship with the family.

The revised conclusions now emphasize that simulation-based learning not only enhances professional competencies and emotional preparedness but also strengthens empathetic, reflective, and patient- and family-centered care. These changes ensure precise alignment among objectives, results, and conclusions, thereby improving the manuscript's internal coherence.

 

9. Typographical Errors Throughout

Several typographical errors require correction: Line 49: "managingomplex" → "managing complex"; Lines 69-70: "nsufficient" → "Insufficient"; Lines 84-85: "BLS" → "SBL"; Line 147: "FG)nd" → "FG) and"; Line 239: Section "2.2" → "3.2"; Lines 242-243 and 455-457: Theme 5 is duplicated as both "Emerging emotions" and "Learning through simulation." Please review the entire text and correct all typographical errors. While these issues are editorial in nature, their frequency warrants careful revision.

Thank you very much for your suggestions. We will proceed to modify them.

Concluding Remarks

The manuscript presents valuable qualitative data on an important topic in nursing education. The suggested revisions primarily aim to enhance methodological coherence, conceptual clarity, and transparency, rather than to challenge the core contribution of the study. With appropriate revisions addressing the methodological and conceptual issues outlined above, this work could make a meaningful contribution to the literature on simulation-based learning in end-of-life education for undergraduate students.

Thank you very much for your comments. We appreciate your suggestions and hope that the manuscript now has the scientific rigor necessary for publication.

Reviewer 2 Report

Comments and Suggestions for Authors

Good choice of topic.  Very original and shows that a lot of work has been put into it.  The approach of using simulation to teach such a sensitive topic is commendable. 

All the sections are well written and presented. However, do note the following:

Introduction

Line 49- managingomplex should read 'managing complex'

Line 70: nsufficient should be 'insufficient'

Line 85: BLS should be 'SBL'

Lines 89, 104, 547, and 565: There should be consistency. Use SBL instead of repeating simulation-based learning or placing it in parenthesis

 

Study Design

How did you determine which group of participants should be part of the focus group and who should contribute to 'reflective narrative'? This is not clearly stated in your design 

Lines 125-129: Be consistent in using either figures or words and not both in the same paragraph. 

Line 147: is missing "a" in 'nd' . Should read "focus group (FG) and 23" 

Data Analysis 

Line 203: Replace one of the "following" with another word. 

Result

Lines 243 and 456: You have Emerging Emotions listed as T4 and T5

Discussion

Line 522: BLS should be SBL 

References

There is a good mix of current References and those more than five years. 

Overall, good manuscript 

 

 

 

Author Response

REVISOR 2

Good choice of topic.  Very original and shows that a lot of work has been put into it.  The approach of using simulation to teach such a sensitive topic is commendable.

All the sections are well written and presented. However, do note the following:

Introduction

Line 49- managingomplex should read 'managing complex'

Line 70: nsufficient should be 'insufficient'

Line 85: BLS should be 'SBL'

Lines 89, 104, 547, and 565: There should be consistency. Use SBL instead of repeating simulation-based learning or placing it in parenthesis

Thank you very much for your suggestions. We will proceed to modify them.

Study Design

How did you determine which group of participants should be part of the focus group and who should contribute to 'reflective narrative'? This is not clearly stated in your design

Thank you for this comment. We appreciate the opportunity to clarify this aspect of the study design.

All eligible students were initially invited to participate in the qualitative study after completing the simulation experience. Participation in the focus groups (FGs) was voluntary and depended on students’ availability at the scheduled time for the group sessions. Students who were unable or unwilling to attend the focus groups were offered the option to contribute through an individual reflective narrative (RN), using the same guiding questions.

This approach was intentionally adopted to ensure inclusivity and to allow all students to share their experiences in a format that best suited their preferences and circumstances, while maintaining consistency in the data collected. Both data sources were therefore complementary and addressed the same research questions.

The manuscript has been revised to describe this decision-making process explicitly and to clarify the rationale for combining focus groups and reflective narratives within the study design (Sections 2.3–2.4).

Lines 125-129: Be consistent in using either figures or words and not both in the same paragraph.

Thank you very much for your suggestions. We will proceed to modify them.

Line 147: is missing "a" in 'nd' . Should read "focus group (FG) and 23"

Thank you very much for your suggestions. We will proceed to modify them.

Data Analysis

Line 203: Replace one of the "following" with another word.

Thank you very much for your suggestions. We will proceed to modify them.

Result

Lines 243 and 456: You have Emerging Emotions listed as T4 and T5

Thank you very much for your suggestions. We will proceed to modify them.

Discussion

Line 522: BLS should be SBL 

Thank you very much for your suggestions. We will proceed to modify them.

References

There is a good mix of current References and those more than five years.

Some references are more than 5 years old, but we believe they are still relevant for understanding the evolution of the issue we want to highlight.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Congratulations for the  thoughtful revision of the manuscript. Authors have carefully addressed the major methodological and conceptual concerns raised in the first round of review, resulting in a substantially improved and more robust study. Only minor editorial issues remain and should be corrected prior to final acceptance:

1. A typographical error persists in the Introduction (“managingomplex” should read “managing complex”).

2. In the Results section summarizing the themes (near Figure 1), Theme 5 is duplicated and should be listed only once as “Learning through simulation.”

These issues are purely editorial and do not affect the scientific quality of the manuscript.

 

Author Response

Thank you very much for your feedback. We have reviewed the text and corrected any typographical errors.
Best regards.

Author Response File: Author Response.docx