*Article* **Perception of E-Resources on the Learning Process among Students in the College of Health Sciences in King Saud University, Saudi Arabia, during the (COVID-19) Outbreak**

**Reham AlJasser 1,\*, Lina Alolyet <sup>2</sup> , Daniyah Alsuhaibani <sup>2</sup> , Sarah Albalawi <sup>2</sup> , Md. Dilshad Manzar <sup>3</sup> and Abdulrhman Albougami <sup>3</sup>**


**Abstract:** Aim: to assess the impact of e-learning through different e-resources among health sciences students. Methodology: A cross-sectional design was conducted among health science students (*n* = 211; 134 female and 77 male) at King Saud University, Saudi Arabia. The data was collected using a previously used structured questionnaire to assess the impact of e-resources on learning. Results: The four most frequently used e-resources were: Zoom (38%), YouTube (31%), Google applications (29%), and Blackboard (27%). More than one-third of the students (35%) reportedly used e-resources for three or more hours daily. The majority of the students (55.9%) recognized a gender-related and age-related difference among faculty members in terms of e-resources usage. The majority of the students (58.2%) believe that online resources recommended by faculty members were credible. The majority of students believed that their academic performance was primarily influenced by these features of the e-resources: organization/logic of the content (64.5%), the credibility of the video (64.5%), and up to date "look and feel" of the video (60.6%). The study identified the most frequently used e-resources, gender, and age-related differences in faculty members' use of e-resources, students' overwhelming reliance on faculty feedback regarding the credibility of e-resources, and three most important characteristics (organization, credibility, and updated status) of e-resources. Conclusion: e-learning resources had a significant impact on participating students' education as they were used very frequently during their health sciences' courses.

**Keywords:** e-resources; e-learning; credibility; academic performance; health sciences education

#### **1. Introduction**

Recently, the outbreak of the pandemic situation due to Coronavirus (COVID-19) had led to massive loss of human life worldwide. The result of this massive loss spurred economic and social disruption. Therefore, it was recommended to limit social gathering and apply social distancing with increased precaution protocols to control this virus's transmission. This recommendation was also applied globally at different levels of all educational systems as physical classes were stopped.

UNESCO estimates suggested that over 1.5 billion learners were affected during this period in the education system [1–3]. Therefore, alternatives have immediately been investigated and gathered to resume teaching and learning at different levels of education throughout the world.

Many educational institutes took the initiative to transfer traditional onsite learning to online education. This initiative was done in order to maintain the safety of their students and to fulfill their basic needs for education through distance learning.

**Citation:** AlJasser, R.; Alolyet, L.; Alsuhaibani, D.; Albalawi, S.; Manzar, M.D.; Albougami, A. Perception of E-Resources on the Learning Process among Students in the College of Health Sciences in King Saud University, Saudi Arabia, during the (COVID-19) Outbreak. *Healthcare* **2022**, *10*, 40. https://doi.org/ 10.3390/healthcare10010040

Academic Editors: Luís Proença, José João Mendes, João Botelho, Vanessa Machado and Daniele Giansanti

Received: 11 November 2021 Accepted: 24 December 2021 Published: 26 December 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

Distance education, also known as distance learning, is defined as the education of students who may not always be physically present at a school [1,2]. Traditionally, this usually involved correspondence courses wherein the student corresponded with the school via mail, and today it usually involves online education.

Technological innovation has not only impacted social change in recent years but has been the prime driver of educational transformation [4–7]. There has been a growing interest in using Internet-based learning by universities over the past decade to supplement or replace traditional learning [8]. The development of new technologies marks the growth of the internet. E-learning is the use of internet-based resources in education. Internetbased learning for health professional education is increasing [9]. It offers advantages over traditional learning approaches, enables learning to be completed conveniently for the user, and improves accessibility, especially where facilities are geographically disparate [9,10]. It can also deliver a broad array of solutions that enhance knowledge and performance [8], increase accessibility to education, and improve self-efficacy [11] and clinical skills.

This results in improving practitioners' capabilities [12], cost-effectiveness, learner flexibility [7], satisfaction and promotion of student-to-student and student-to-instructor interactions [13]. Therefore, it is of utmost importance to integrate e-learning to acquire knowledge in the study of health sciences.

Some barriers can affect the development and implementation of online learning in education, such as poor technical skills, inadequate infrastructure, absence of institutional strategies and support, and negative attitudes of stakeholders [14–16]. On the other hand, the practical nature of health science education demands direct contact between students, instructors, and patients [17]. Therefore, traditional teaching methods in health sciences are essential.

The use of digital devices in the college of health sciences for teaching and learning purposes has been widely accepted in universities [18]. As a result of this development, it has become apparent in recent years that Internet-based learning or electronic learning (E-learning) has increased its attraction to students at large [19]. E-learning has recently been proposed as a primary complementary tool to improve medical and dental education [20], which has been defined as learning while "utilizing electronic technologies to access educational curriculum outside of a traditional classroom" [21,22]. These interactive teaching strategies have enhanced students' focus, amplified their attention, and maximized their long-term knowledge retention [20]. Therefore, most higher education institutions classify online learning as crucial for their educational strategy [23].

Electronic and virtual applications and sources can be compelling and entertaining in several educational fields. However, this can be very challenging in terms of application, especially in health science education which focuses on proper care, prevents the spread of diseases, and improves the lives of every patient to ensure the longevity of life or improvement in the life expectancy of individuals.

This field should provide students with technical skills, proper health care competencies, and various opportunities to obtain the knowledge needed for growth and development in the health sector [1]. It also aims to improve physical, mental, emotional, and social health by increasing their knowledge and influencing their attitudes by caring for their well-being [1,3].

King Saud University was one of the first universities in Saudi Arabia to transfer courses from traditional onsite to online education. Lectures were mainly given through live webinars to ensure proper interaction between the lecturer and the students. Assignments, quizzes, and exams were conducted through the BlackBoard website, which was previously activated during traditional education as a supportive tool for the educational process of the students. After the adoption of the online education system, the website became the backbone of the educational process.

With the ongoing spread of the coronavirus, online learning resources have become increasingly essential to ensure uninterrupted educational delivery to isolated students. This opportunity has expanded the learning offering beyond the limitations of the traditional methods. The literature revealed that learning technology has positively supported the health sciences curriculum [20]. Hence, it is crucial to evaluate its proper applicability in each specific education field and make a positive adjustment for maximum learning experience.

This study aims to assess the impact of e-learning through different e-resources among health sciences students attending King Saud University.

The objectives of the present study are as follows:


Therefore, the Null hypothesis is that there is no positive impact of e-learning through different e-resources among health sciences students attending King Saud University.

The Alternative Hypothesis is that there is a positive impact of e-learning through different e-resources among health sciences students attending King Saud University

#### **2. Materials and Methods**

#### *2.1. Ethical Considerations*

Institutional review board approval was obtained from King Saud University, Riyadh, Saudi Arabia (E-20-5052). Informed consent was required for the participants to proceed to answer the questionnaire. Therefore responses without the participants' consent were not recorded. The purpose and objectives of this study were explained, and the participants were informed that the information obtained was to be used for research purposes only, and the outcome would be presented in anonymous charts, figures, and tables.

#### *2.2. Setting and Application*

The survey was offered to undergraduate medical sciences students which included medical, dental, pharmacy, applied medical sciences, and nursing students from both female and male sections. An online survey was used, with all participants anonymously completing the survey at an opportune place and time for them.

A web-based survey with a link provided was distributed to participants through an e-mail and an invitation through social media platforms. Participants used a device and a browser of their choice and convenience. Investigators cannot identify participating students, and the survey was completely anonymous. Students were informed that they had the right to discontinue the study at any point in time without any consequences. The participation was sought to be voluntary, and the confidentiality of responses was maintained.

The proposed survey did not take more than five minutes to complete for the majority.

#### *2.3. Sample Size Determination*

The study focused on undergraduate students attending colleges of health sciences in King Saud University, Saudi Arabia. The sample size was determined by G Power software (Hinnerup, Denmark). The confidence level was set at 95%. The power level was set at 80% with a moderate effect size and a final sample size of 180 students. However, a larger sample was recruited to avoid the possibility of a low response rate that could affect the sample size. A final sample of 211 students was recruited using purposive sampling because the goal of this study focused on students in the college of health sciences [24].

#### *2.4. Instrument to Be Used*

A modified version was used after obtaining permission of the primary author of the survey for Student's Perception of the Impact of E-Learning on Dental Education [14].

The survey was comprised of 14 questions, including seven multiple-choice questions, two fill-in-the-blank questions, two open-ended questions, and three Likert scale questions. The purpose of the two open-ended questions was to allow students to share the applications they used during their dental education, their perceived impact on their academic achievement, and their opinion of online education.

The first part contains questions related to demographic information.

The second part contains questions related to students' use of E-learning resources (e-resources) and their perceptions of these resources.

The third part contained questions that asked students to mention the top three eresources used for academic purposes. The questions explored several factors influencing the use of these e-resources which included the following: the time spent on these resources, the credibility of the e-resources recommended by faculty members, the influence of certain factors regarding e-resources on students' academic achievement, the effect of e-resources on students' ability to understand academic topics, students' observation of faculty members integration of e-resources in their courses and its relationship with the faculty members age, the relationship that the students observed between the faculty member's age and their dependence on social media for communication, the students' attendance preference, and finally the effects of e-resources on students' academic performance.

The modified version was sent to survey experts in the dental field to receive feedback and opinion about its clarity and easiness and recommendations for further adjustments. As a second step, a small sample of 20 students were chosen to pre-test the final version. This step showed that the questionnaire needed to become shorter and more straightforward. The participants also offered some amendments to the questionnaire which were considered and noted. The questionnaire was finalized after an in-depth discussion among the authors. The modified version was administered to a sample of 50 students in a pilot study. K value for the inter-participants' agreement was calculated to as 0.91, indicating an "almost perfect agreement" according to Cohen [25].

#### *2.5. Statistical Analysis*

Descriptive Kolmogorov–Smirnov, and Shapiro–Wilks tests were applied to check the normal data distribution. The data was entered and analyzed using SPSS 24.0 version statistical software (IBM Inc., Chicago, IL, USA). Findings were presented through frequencies, percentages, mean, and standard deviation values. The following elements were evaluated: participants' demographic characteristics, most frequently used electronic resources/applications by students, the average duration of daily electronic resources/applications used for academic performance, students' observations of incorporation of e-learning by faculty members and the age of faculty members, and the relationship between faculty members' dependence on social media for communication and their age.

#### **3. Results**

#### *3.1. Participants' Characteristics*

In this study, health science students (*n* = 211; 134 females and 77 males) with a mean age of 21 years ± 3 years participated. About two-thirds of the participating students were enrolled in dentistry and the college of allied health sciences (Table 1). The majority of the study sample comprised of female students (63.5%).

**Table 1.** Participants' characteristics.



**Table 1.** *Cont.*

#### *3.2. Most Frequently Used E-Resources*

Table 2 presents the descriptive summary of the item that required students to record their three most frequently used e-resources. Regarding preferred resources perceived by students to improve their academic performance, 16 different e-resources were identified. The four most frequently used were: Zoom (38%), followed by YouTube (31%), Google applications (29%), and Blackboard (27%) (Table 2). E.E.E., Saudi Digital Library, and Dropbox were the three least used electronics resources, with all the three being reported to be used by less than 1% of the participating students. More than one-third of the students identified 'others' as one of the resources.

**Table 2.** Frequency distribution of students' most frequently used electronic resources/applications in decreasing order.


#### *3.3. Electronic Resources: Daily Use by Students, Gender and Age Pattern among Faculty Members*

About 65 respondents (30.8%) used e-resources for two to three hours every day (Table 3). Most of the participating students reported either no gender-related difference or 'I do not know' in incorporating e-resources by faculty members (74%). However, the biggest group of students recorded that faculty members who more prevalently used eresources were under 50 years of age (Table 4). Similarly, almost half of the students replied that there was a relationship between faculty members' dependence on social media for communication and their age because it was more commonly seen in those under 50 years of age (Table 5).


**Table 3.** Students' average duration of daily electronic resources/applications for academic performance.


**Table 4.** Students' observations of incorporation of e-learning by faculties and the age of faculties.

**Table 5.** Relationship between faculty's dependence on social media for communication and their age.


*3.4. Online Applications/Animations: Student's Perceived Academic Performance and Reliance on Faculty Recommendations*

Students regarded e-resources recommended by faculty members with a high level of credibility; this is indicated by a majority (58.2%) replying that they were greatly influenced by teachers' feedback on such matters (Figure 1). Organization/logic of the content, credibility of the video, and up-to-date "look and feel" of the video were the three most influential factors on the students' perceived academic performance with 64.5%, 64.5%, and 60.6%, respectively. While online presentation under 15 min was perceived to be least

*Healthcare* **2022**, *10*, x 7 of 10

*on Faculty Recommendations*

influential in academic performance, most students (55.9%) recorded a response of 'neutral' or 'least influence' for this factor (Table 6). tral' or 'least influence' for this factor (Table 6).

*3.4. Online Applications/Animations: Student's Perceived Academic Performance and Reliance* 

Students regarded e-resources recommended by faculty members with a high level of credibility; this is indicated by a majority (58.2%) replying that they were greatly influenced by teachers' feedback on such matters (Figure 1). Organization/logic of the content, credibility of the video, and up-to-date "look and feel" of the video were the three most influential factors on the students' perceived academic performance with 64.5%, 64.5%, and 60.6%, respectively. While online presentation under 15 min was perceived to be least influential in academic performance, most students (55.9%) recorded a response of 'neu-

**Figure 1.** The "level of credibility" is given by students to e-resources recommended by faculty members. **Figure 1.** The "level of credibility" is given by students to e-resources recommended by faculty members.


**Table 6.** Influence of online applications/animations on the students' perceived academic perfor-**Table 6.** Influence of online applications/animations on the students' perceived academic performance.

#### **4. Discussion 4. Discussion**

The present study's results highlighted that e-learning resources significantly impacted education during the coronavirus pandemic (COVID-19) outbreak when used by health sciences students at King Saud University. Findings revealed that the most frequently used e-resources were Zoom, followed by The present study's results highlighted that e-learning resources significantly impacted education during the coronavirus pandemic (COVID-19) outbreak when used by health sciences students at King Saud University.

YouTube, Google applications, and Blackboard. This sequence in preference could be attributed to the increasing urge for a videoconferencing technology to augment online learning, which unfolded at the pandemic's peak when people were adjusting to the new normal. Zoom is one of the most helpful resources to enhance effective and synchronous Findings revealed that the most frequently used e-resources were Zoom, followed by YouTube, Google applications, and Blackboard. This sequence in preference could be attributed to the increasing urge for a videoconferencing technology to augment online learning, which unfolded at the pandemic's peak when people were adjusting to the new normal. Zoom is one of the most helpful resources to enhance effective and synchronous e-learning since it allows visual interaction between the students and instructors. It was established that Zoom could accommodate 1000 participants in one meeting. This application can be downloaded and used for free (Ismawati, Iis, et al. 2021, Wibawanto, 2020) as cited by Kasman et al. [24,25] One could infer that due to its ability to accommodate a large number of participants, its simple interface and low cost explains the dominance of this e-resource compared to other applications.

In contrast, this result was supported by the findings from a previous study [14], we discovered that the second most used e-resource is YouTube. Before the pandemic, YouTube was globally the go-to site for virtual learning. However, recent authors [26,27] established that the COVID-19 outbreak pushed all universities to incorporate the use of video conferencing technology (V.C.T.) to supplement learning management systems for e-learning, including YouTube.

When the students were asked about the duration spent on e-resources, most of the respondents reported using e-resources for at least 3 h at a time. This relatively long duration can be explained by the nature of health sciences lectures and seminars, which usually require a significant amount of time.

Regarding the observed relationship between using e-resources and faculty members' age, the majority of the respondents reported that the faculty members who prevalently used e-resources were more likely to be under the age of 50 years old. This may be due to the fact that the majority of this age category have been more exposed to recent technologies and more enthusiastic than the older age category. This result coincides with the results of the research work carried out by Turkyilmaz et al. [14], in which they discovered that faculty members that frequently used e-resources were under 50 years of age. They are more likely to have been exposed to technology in their education and early career stages. Therefore, they may be more inclined to use technology in learning settings and communication. Several investigators discovered that only a few faculty members use advanced online learning tools.

Faculty members hesitated to shift their teaching style to e-learning due to several reasons which included: low perceived benefit, difficulty in using these online resources, frequency of students' usage, and the time required to invest in the process [24]. However, even faculty members over 50 years of age were compelled to use the e-resources in a limited fashion. This observation can also be explained by the variation of exposure to eresources by different generations and the ubiquity of computers and the internet in modern academic environments. Moreover, this trend will keep increasing as more educators bring technology-based activities into the classrooms [14].

Furthermore, when faculty members' gender was observed, results revealed that about 44% of the students did not perceive a gender-related pattern regarding incorporating eresources. These findings were supported by a recent study where authors also discovered that the students in their study observed no gender-related pattern in incorporating distance learning [14].

Concerning students' perceived academic performance and reliance on faculty members' recommendations, the results indicated that most students viewed online applications recommended by faculty members with a high level of credibility. It was discovered that the organization/logic of the content, credibility and up-to-date "look and feel" of the video were the three most influential factors on the students' perceived academic performance. These findings were contrary to the results of previous studies that reported the e-learning system's efficacy on organization and attractiveness of the course content [12,13].

Several limitations have been observed in the present study, including statistical bias, as samples were not evenly distributed. Half of the sample size predominantly included dental students, while the other half contained medicine, nursing, pharmacy, and applied medical sciences. The present study is a cross-sectional study within one university which may limit the inference of the findings to other regions of the country or the world. Likewise, the study did not evaluate the students' actual academic performance but rather their perceived performance, which may be subjective rather than objective. It should be highlighted that present findings were based only on surveys without structured interviews with faculty members. Therefore, future studies with a well-controlled and improved methodology are recommended to confirm present study findings.

In summary, the findings of this study helped understand the perception of health science students in adopting E-learning resources, the effect of E-learning on their ability to comprehend academic topics, and its influence on their academic performance.

#### **5. Conclusions**

E-learning resources were frequently used during the present study and they had significant impact on the participating health science students' education. Most e-resources used were Zoom, followed by YouTube, Google applications, and Blackboard. The faculty members' age was a significant factor affecting their use and reliance on e-resources. Organization, credibility, and updated status of e-resources were also significant contributors to health sciences students' academic performance. In conclusion, incorporation of e-learning resources training and application in the schools' curriculum is essential to improve health sciences students' and faculty members' distance learning experience and outcomes.

**Author Contributions:** Conceptualization, R.A.; methodology, R.A., L.A., D.A. and S.A.; software, R.A.; validation R.A., L.A., S.A. and D.A.; formal analysis, M.D.M.; investigation, L.A., D.A. and S.A.; resources, R.A.; data curation, M.D.M.; writing—original draft preparation, All authors; writing—review and editing, All Authors; visualization, R.A.; supervision, A.A. project administration, R.A. and A.A.; funding acquisition, R.A. and A.A. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** Institutional review board approval was obtained from King Saud University, Riyadh, Saudi Arabia (E-20-5052).

**Informed Consent Statement:** Informed consent was required for the participants to answer the questionnaire. Therefore responses without the participant's consent were not recorded.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author. The data are not publicly available due to ethical and institutional restrictions.

**Acknowledgments:** The authors would like to thank the College of Dentistry Research Center at King Saud University, Riyadh, Saudi Arabia for all the support provided for this study in terms of revising the manuscript and distributing the surveys.

**Conflicts of Interest:** The authors declare no conflict of interest. The funder had no role in designing the study, data collection, analyses, interpretation, writing of the manuscript, or decision to publish the results.

#### **References**


### *Article* **Improving Humanization Skills through Simulation-Based Computers Using Simulated Nursing Video Consultations**

**Diana Jiménez-Rodríguez 1,\*, Mercedes Pérez-Heredia <sup>2</sup> , María del Mar Molero Jurado <sup>3</sup> , María del Carmen Pérez-Fuentes 3,4 and Oscar Arrogante <sup>5</sup>**

	- Avenida Reina Victoria 28, 28003 Madrid, Spain; oscar.arrogante@cruzroja.es

**Abstract:** During the COVID-19 confinement, we converted our clinical simulation sessions into simulated video consultations. This study aims to evaluate the effects of virtual simulation-based training on developing and cultivating humanization competencies in undergraduate nursing students. A quasi-experimental study was conducted with 60 undergraduate nursing students. A validated questionnaire was used to evaluate the acquisition of humanization competencies (self-efficacy, sociability, affection, emotional understanding, and optimism). The development of humanization competencies in this group composed of undergraduate nursing students was evaluated using virtual simulation-based training, comparing the levels obtained in these competencies at baseline (pre-test) and after the virtual simulation experience (post-test). After the virtual simulation sessions, students improved their levels in humanization total score and the emotional understanding and self-efficacy competencies, obtaining large effects sizes in all of them (rB = 0.508, rB = 0.713, and rB = 0.505 respectively). This virtual simulation modality enables training in the humanization of care with the collaboration of standardized patients in the form of simulated nursing video consultations and the performance of high-fidelity simulation sessions that comply with the requirements of best practices. Therefore, this methodology could be considered as another choice for virtual simulation. Additionally, this virtual modality could be a way to humanize virtual simulation.

**Keywords:** COVID-19; high fidelity simulation training; nursing education; remote consultation; telemedicine

#### **1. Introduction**

During the COVID-19 pandemic, governments around the world have declared social distancing measures to ensure the confinement of the population, including the closure of schools and universities. In this sense, this pandemic represents a challenge not only to health services but also to nursing education. In response to this exceptional situation, simulation-based education had to adapt through the use of virtual simulation modalities, thus highly increasing its use, leading to virtual simulation becoming a primary teaching strategy to provide simulated experiences [1] using online platforms, specific software or mobile devices [2,3]. Virtual simulation modalities comprise immersive simulation, screenbased simulation, serious games, virtual reality, virtual simulation/virtual patients, virtual reality simulation, and web-based simulation [4]. All these modalities provide students with near-reality, interactive virtual simulation learning experiences when face-to-face simulations are not possible [3].

**Citation:** Jiménez-Rodríguez, D.; Pérez-Heredia, M.; Molero Jurado, M.d.M.; Pérez-Fuentes, M.d.C.; Arrogante, O. Improving Humanization Skills through Simulation-Based Computers Using Simulated Nursing Video Consultations. *Healthcare* **2022**, *10*, 37. https://doi.org/10.3390/ healthcare10010037

Academic Editors: José João Mendes, Vanessa Machado, João Botelho and Luís Proença

Received: 2 December 2021 Accepted: 24 December 2021 Published: 26 December 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

To adapt our high-fidelity clinical simulation sessions to virtual simulation, we implemented simulated nursing video consultations in our university during the COVID-19 confinement [5,6]. Additionally, we considered that nursing students should practice simulated video consultations to train in this healthcare modality that has become both popular and necessary during this pandemic. In this sense, among the different telemedicine modalities, video consultations have been significantly increased [7,8], implementing them in many countries has been a digital health strategy to provide healthcare [9,10]. This modality of healthcare has multiple benefits such as avoiding agglomerations owing to social distancing restrictions, patient satisfaction, and cost reduction [11,12]. However, we were concerned about virtual interactions between nursing students and a standardized patient using virtual simulation sessions, since the distancing between them and the inability to perform an in-person consultation could lead to providing dehumanized and depersonalized nursing care training.

According to David Gaba, considered to be one of the fathers of clinical simulation, simulation is a technique not a technology [13], because simulation sessions must not be exclusively based on the use of technological equipment or devices. A simulation setting can help train students in nursing clinical skills, procedures, or techniques, and also the art of nursing generally [14]. Additionally, it can help students recognize the totality of the human being, providing patient-centered care [15]. This approach to healthcare is closely linked to the humanization of care construct [16].

Nowadays, humanization of care is a fashionable construct within healthcare services, possibly owing to society perceive they are dehumanized and depersonalized [16]. In short, humanizing healthcare means putting the human being at the center to promote and protect the health, cure diseases, or provide the best care [17]. However, there is not a consensus on the humanization of care definition to date, but most approaches to this construct offer a definition based on responding to patient's needs [16]. The humanization of care construct implies a set of personal competencies that healthcare professionals should have to care for patients effectively and humanely [18]. In this sense, Pérez-Fuentes et al. [18] have recently proposed a humanization of care model which comprises 5 competencies required in healthcare clinical practice: optimism (to generate positive future expectations), sociability (to relate to others appropriately with assertiveness and empathy), emotional understanding (to empathize cognitively with others, placing ourselves in their place), self-efficacy (to manage successfully complex and stressful situations), and affection (to empathize emotionally with the affective state of another person).

Previous studies have demonstrated the effectiveness of simulation-based training mainly in the self-efficacy [19] and empathy [20] competencies, but no research to date has studied the effects of simulation training in all competencies required to provide humanized nursing care. Specifically, this could represent a significant challenge if this training is conducted through a virtual simulation modality, owing to the virtual interaction and distancing between nursing students and virtual patients. Therefore, this study aimed to evaluate the effects of virtual simulation-based training on developing and cultivating humanization competencies in undergraduate nursing students.

#### **2. Materials and Methods**

#### *2.1. Research Context and Setting*

A quasi-experimental study was conducted using a single-group pre-test post-test design. The development of humanization competencies in this group composed of undergraduate nursing students was evaluated using virtual simulation-based training, comparing the levels obtained in these competencies at baseline (pre-test) and after the virtual simulation experience (post-test).

#### *2.2. Setting and Sample*

The study was performed in a public University between 20 April and 21 May 2020, including 3rd-year undergraduate students enrolled in nursing degree (66 students). These

students performed virtual simulation sessions. A total of 60 nursing students participateD in the study (90.9% response rate).

#### *2.3. Simulation Design Process*

All simulated nursing video consultations followed the INACSL Standards of Best Practice: SimulationSM [21–24]. During these simulated sessions, all stages included in highfidelity clinical simulation were accomplished: pre-briefing, briefing, simulated scenario, and debriefing. A virtual platform of online video conferences provided by the university (Blackboard Collaborate LauncherTM) was used to develop all simulation stages [5,6].

We designed six simulated scenarios related to basic healthcare at patients' homes who presented the following clinical cases: a patient diagnosed with arterial hypertension, a post-surgical patient (laparoscopic cholecystectomy), a woman with an anxiety disorder (potential case of gender-based violence), a bed-ridden patient with a pressure ulcer, a child diagnosed with attention deficit hyperactivity disorder (ADHD), and a child with a febrile syndrome.

Besides attending to each reason for consultation, adequate management and protection measures to COVID-19 were considered, since all patients were confined during this pandemic. Standardized patients played the role of patients' homes. These standardized patients were also facilitators during the simulated sessions, and they were changed during the different simulated scenarios. It should be noted a standardized patient played the role of caregiver in the clinical case of a bed-ridden patient with a pressure ulcer, and another played the role of mother when a child needed to be treated. To ensure a high-fidelity level of the simulation experience, we chose all standardized patients for their experience in clinical simulation methodology, and we trained them to play their roles according to recommendations by Lewis et al. [25].

All nursing students were divided into 4 groups of 12–16 students per group. In this sense, they formed 6 operational work teams of 2–3 students per group, performing a simulated scenario together and portraying the role of nursing professionals online. Meanwhile, the rest of the work teams were at home, observing their performance in their computer screen using the corresponding virtual platform for online video conferences. In this way, they could learn from the mistakes of their classmates who were performing a simulated scenario. Each simulated session lasted 4 h, and each student completed 3 simulation sessions (1 session of pre-briefing and 2 sessions where 6 simulated scenarios were performed), so each student completed a total of 12 h of simulation experience.

#### *2.4. Data Collection Instrument*

To evaluate the acquisition of humanization competencies, the Healthcare Professional Humanization Scale (HUMAS) [18] was used. This questionnaire consists of 19 items with a 5-point Likert response scale (from 1 = 'never' to 5 = 'always'). HUMAS comprises the 5 dimensions of humanization of care construct: self-efficacy (5 items), sociability (3 items), affection (5 items), emotional understanding (3 items), and optimism (3 items). To examine the humanization questionnaire reliability, the coefficient omega (ω) [26] was calculated. In this way, the internal consistency obtained by its creators for each dimension was satisfactory: optimism (pre-test: ω = 0.78, post-test: ω = 0.84), sociability (pre-test: ω = 0.81, post-test: ω = 0.85), emotional understanding (pre-test: ω = 0.74, post-test: ω = 0.74), self-efficacy (pre-test: ω = 0.79, post-test: ω = 0.78), affection (pre-test: ω = 0.88, post-test: ω = 0.90), and total score (pre-test: ω = 0.88, post-test: ω = 0.88). It should be noted, some items were minimally adapted since the participants were students, and not healthcare professionals (e.g., 'I feel nervous when I am caring for my patients' was changed by 'I feel nervous when I think about caring for patients during my clinical practices.' The humanization questionnaire was completed online pre- and post-virtual simulation sessions, through a link provided to the participating students.

#### *2.5. Statistical Analysis*

Descriptive statistics were calculated (minimal, maximal and mean scores, standard deviation, and percentages) to analyze the results obtained for demographic data and each item, subscale, and the total score obtained in HUMAS. Additionally, the coefficients omega (ω) were calculated to analyze the reliability of this questionnaire. Subsequently, the assumption of normality was tested using the Kolmogorov–Smirnov test, confirming that data did not follow a normal probability distribution. Consequently, to analyze the differences at baseline (pre-test) and after the virtual simulation experience (post-test), the Wilcoxon test was used. Additionally, to determine the effect size of the statistically significant differences obtained, the rank-biserial correlation (rB) was calculated, considering the following cut-off points: 0.10 (small), 0.30 (medium), and 0.50 (large) [27]. These data were analyzed using IBM SPSS Statistics version 24.0 software for Windows (IBM Corp., Armonk, NY, USA).

#### *2.6. Ethical Considerations*

This study was carried out following ethical principles for medical research of the international Declaration of Helsinki [28]. Additionally, this study was approved by the Research and Ethics Board of the Department of Nursing, Physiotherapy, and Medicine of A. University (Approval no. EFM-75/2020). All nursing students were informed about the study and who accepted to participate voluntarily, signed a written consent.

#### **3. Results**

A total of 60 nursing students participated in the study. The age of students ranged from 20 to 50 years (mean = 23.83; SD = 6.63). Most students were women (n = 52; 86.7%).

Descriptive data and reliabilities for each item, subscale, and the total score obtained in HUMAS at baseline (pre-test) and after virtual simulation sessions (post-test) are shown in Table 1. It should be noted that the reliability coefficients calculated for each subscale and the total score in HUMAS were quite similar to values obtained by its creators, indicating satisfactory reliability.

**Table 1.** Descriptive data (minimal, maximal and mean scores, and standard deviation) and reliabilities for each item, subscale and the total score obtained in HUMAS at baseline (pre-test) and after virtual simulation sessions (post-test) (N = 60).


<sup>1</sup> Min.: minimal score; <sup>2</sup> Max.: maximal score; <sup>3</sup> M: mean score; <sup>4</sup> SD: standard deviation.


#### **Table 1.** *Cont.*

<sup>1</sup> Min.: minimal score; <sup>2</sup> Max.: maximal score; <sup>3</sup> M: mean score; <sup>4</sup> SD: standard deviation.

The mean scores obtained in each humanization dimension at baseline (pre-test) and after virtual simulation sessions (post-test) were compared (Table 2). Statistically significant differences were obtained in emotional understanding and self-efficacy dimensions, as well as in total score for the humanization scale applied, obtaining large effects sizes in all of them (rB = 0.505, rB = 0.713, and rB = 0.508 respectively).

**Table 2.** Differences in mean scores for each humanization dimension and the total score obtained in HUMAS at baseline (pre-test) and after virtual simulation sessions (post-test) (N = 60).


<sup>1</sup> *p* < 0.01; <sup>2</sup> *p* < 0.001.

**4. Discussion**

Figure 1 shows graphically the magnitude of the statistically significant differences in emotional understanding and self-efficacy dimensions, and the total score obtained in HUMAS at baseline (pre-test) and after virtual simulation sessions (post-test). It should be noted that the rest of the humanization dimensions are not shown in this figure since only non-statistically significant differences were obtained. *Healthcare* **2022**, *10*, 37 7 of 10

**Figure 1.** Statistically significant differences in self-efficacy and emotional understanding dimensions, and the total score obtained in HUMAS at baseline (pre-test) and after virtual simulation sessions (post-test). (**a**) Self-efficaccy, (**b**) Emotional understanding, (**c**) Total score. **Figure 1.** Statistically significant differences in self-efficacy and emotional understanding dimensions, and the total score obtained in HUMAS at baseline (pre-test) and after virtual simulation sessions (post-test). (**a**) Self-efficaccy, (**b**) Emotional understanding, (**c**) Total score.

We converted our face-to-face simulated scenarios into a virtual format using simu-

Our results indicate the positive effects of virtual simulation-based training on developing and cultivating humanization competencies in undergraduate nursing students. After virtual simulation sessions, they improved their levels in humanization total score and the emotional understanding and self-efficacy competencies. It should be noted that emotional understanding is closely related to empathy [18]. Although there is a lack of studies analyzing the effects on the humanization of care of using clinical simulation methodology, improvements to empathy and self-efficacy in nursing students have been

Firstly, empathy is considered as the heart of all nurse-patient interactions [30], being a basic component of therapeutic relationships and a crucial factor in quality care [31]. Additionally, the positive impact of empathic healthcare interactions on patient outcomes has been widely demonstrated [31,32]. Numerous studies have demonstrated improvement to empathy levels using clinical simulation methodology [20]. Particularly, singlegroup studies have demonstrated a significant change in empathy between pre-test and post-test using standardized patients. However, the obtained effect sizes have been often low [30,33]. Notably, Strekalova et al. [34] used a virtual patient during simulated health history interviews and obtained emphatic responses from nursing students. In our study, we obtained increases in empathy levels and a large effect size in this humanization com-

Regarding self-efficacy, this competency consists of a future-oriented optimistic belief that increases motivation, equating to improved performance [35]. Self-efficacy is considered as a healthcare professional's skill in successfully managing complex and stressful situations [36]. In this sense, there is ample evidence in the literature to suggest simulation is effective at increasing this competency [19]. Specifically, single-group pre-test and posttest design studies have reported increases in self-efficacy after simulation sessions using standardized patients [37–39]. However, the effect sizes of simulation in self-efficacy reported by these studies are inconsistent and range from low to large. In contrast, we reported a large effect size in this humanization competence using not only standardized

petency using standardized patients during virtual simulation sessions.

finement due to the COVID-19 pandemic. We performed high-fidelity simulation sessions that complied with the requirements proposed by the INACSL Standards of Best Practice. In previous studies, nursing students expressed high satisfaction with this virtual simulation modality [5,6], perceiving that it was positively improving their learning process. However, we considered studying whether our conversion could lead nursing students to provide dehumanized and depersonalized nursing care, since virtual interactions are

not the same as simulation sessions in a laboratory room.

widely demonstrated [19,20,29].

patients but also virtual simulation sessions.

#### **4. Discussion**

We converted our face-to-face simulated scenarios into a virtual format using simulated nursing video consultations in response to the closure of universities during the confinement due to the COVID-19 pandemic. We performed high-fidelity simulation sessions that complied with the requirements proposed by the INACSL Standards of Best Practice. In previous studies, nursing students expressed high satisfaction with this virtual simulation modality [5,6], perceiving that it was positively improving their learning process. However, we considered studying whether our conversion could lead nursing students to provide dehumanized and depersonalized nursing care, since virtual interactions are not the same as simulation sessions in a laboratory room.

Our results indicate the positive effects of virtual simulation-based training on developing and cultivating humanization competencies in undergraduate nursing students. After virtual simulation sessions, they improved their levels in humanization total score and the emotional understanding and self-efficacy competencies. It should be noted that emotional understanding is closely related to empathy [18]. Although there is a lack of studies analyzing the effects on the humanization of care of using clinical simulation methodology, improvements to empathy and self-efficacy in nursing students have been widely demonstrated [19,20,29].

Firstly, empathy is considered as the heart of all nurse-patient interactions [30], being a basic component of therapeutic relationships and a crucial factor in quality care [31]. Additionally, the positive impact of empathic healthcare interactions on patient outcomes has been widely demonstrated [31,32]. Numerous studies have demonstrated improvement to empathy levels using clinical simulation methodology [20]. Particularly, single-group studies have demonstrated a significant change in empathy between pre-test and posttest using standardized patients. However, the obtained effect sizes have been often low [30,33]. Notably, Strekalova et al. [34] used a virtual patient during simulated health history interviews and obtained emphatic responses from nursing students. In our study, we obtained increases in empathy levels and a large effect size in this humanization competency using standardized patients during virtual simulation sessions.

Regarding self-efficacy, this competency consists of a future-oriented optimistic belief that increases motivation, equating to improved performance [35]. Self-efficacy is considered as a healthcare professional's skill in successfully managing complex and stressful situations [36]. In this sense, there is ample evidence in the literature to suggest simulation is effective at increasing this competency [19]. Specifically, single-group pre-test and post-test design studies have reported increases in self-efficacy after simulation sessions using standardized patients [37–39]. However, the effect sizes of simulation in self-efficacy reported by these studies are inconsistent and range from low to large. In contrast, we reported a large effect size in this humanization competence using not only standardized patients but also virtual simulation sessions.

Logically, simulated nursing video consultations mainly promote the development of non-technical skills (mainly communication skills, active listening, presence, empathy, and teamwork) [5,6]. In this sense, humanization of care and its related competencies could be included in these skills required to provide quality nursing care and decrease burnout [40]. However, while face-to-face simulation sessions usually improve technical skill performance [19,37,39], more studies are needed to analyze non-technical skill performance using virtual simulation modalities [41].

Lastly, although simulated nursing video consultations are not included among virtual simulation modalities in the evidence [3,4], this methodology could be considered as another choice for virtual simulation, according to their high level of fidelity in compliance with the requirements proposed by the INACSL Standards of Best Practice and the high satisfaction and positive perception expressed by nursing students in previous studies [5,6]. However, Cant et al. [3] consider clarification of the nomenclature of virtual simulation to be needed in terms of fidelity, since interactions between learners and virtual patients are

different from face-to-face simulation experiences. Additionally, its use could be extended to other contexts, not only in the confinement due to the COVID-19 pandemic.

The main limitation of our study is related to the specific disadvantage of both simulated and real-life nursing video consultations: technical issues. Ensuring adequate network access and the correct functioning of virtual platforms could mitigate these potential problems [9,12]. Regarding methodological limitations, although our sample size was small, the response rate was high. Additionally, while our study did not analyze either self-efficacy or empathy using the specific validated scales, a validated scale that comprised both humanization competencies was utilized [18]. In this sense, the use of validated scales for evaluating these competencies is not consistent in the majority of the studies [19,20]. Finally, the positive effects of virtual simulation-based training on developing and cultivating humanization competencies should be confirmed by future research, so more studies are needed. These future studies should extend the sample recruited and compare it with a control group, using quasi-experimental or experimental designs and evaluating the outcomes obtained in follow-up periods (for instance, 3, 6 and/or 12 months later). Additionally, future research should also assess the acquisition of humanization of care competencies by nursing students or registered nurses using this virtual simulation modality and extend it to other settings and education centers.

#### **5. Conclusions**

This methodology allows nurses to be trained in the humanization of care using a virtual simulation format, in the form of simulated nursing video consultations by performing high-fidelity simulation sessions that comply with the requirements proposed by the INACSL Standards of Best Practice. Therefore, this methodology could be considered as another choice for virtual simulation. Additionally, this virtual modality allows the collaboration of standardized patients and, consequently, could be a way to humanize virtual simulation. Our results could be confirmed by future research projects using quasiexperimental or experimental designs and follow-up periods, recruiting more nursing students, including registered nurses, and extending this virtual simulation modality to other settings and education centers.

**Author Contributions:** Conceptualization, D.J.-R., M.d.M.M.J., M.d.C.P.-F. and O.A.; methodology, D.J.-R., M.d.M.M.J., M.d.C.P.-F. and O.A.; formal analysis, D.J.-R., M.d.M.M.J., M.d.C.P.-F. and O.A.; investigation, D.J.-R. and O.A.; data curation, D.J.-R., M.d.M.M.J., M.d.C.P.-F. and O.A.; writing original draft preparation, D.J.-R., M.d.M.M.J., M.d.C.P.-F., M.P.-H. and O.A.; writing—review and editing, D.J.-R., M.P.-H. and O.A.; supervision, D.J.-R. and O.A.; project administration, D.J.-R., M.P.-H. and O.A. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Institutional Review Board Statement:** The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Research and Ethics Board of the Department of Nursing, Physiotherapy, and Medicine of the A. University (Approval no. EFM-75/2020).

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**

