Volume 26 Number 3

Key messages

• Real patient simulation boosted students’ confidence in diabetic foot assessments.
• Real patient use created an authentic and immersive learning experience.
• Thematic analysis showed emotional and professional growth through hands-on learning.

Introduction

Emphasis on patient safety often restricts nursing students’ direct involvement in clinical care.¹ To address this, nursing programs integrate laboratory-based training and simulation exercises, providing a safe and structured environment for students to develop clinical skills and gain practical experience.² Among these, standardised patient simulations (SPS)—where trained individuals portray patient scenarios—are widely used in nursing education.^3,4 Standardised patients (SP) simulate physical, emotional and behavioral characteristics of real patients to support clinical teaching and assessment.⁵ SPS help students acquire core nursing competencies that may be difficult to practice on real patients.⁶ However, integrating certain clinical skills, such as invasive procedures or comprehensive physical exams, into SPS remains a challenge.⁷ This limitation can restrict the range of skills practiced and create instructional difficulties in designing realistic, skill-based scenarios.

Financial constraints and a shortage of professionally trained SP present challenges in implementing SPS in nursing education.^8,9 Studies indicate that SP roles are often filled by nursing students, nurses or volunteer educators.^10,11 In some cases, the SP is someone personally known to the students, which can further diminish the sense of realism. However, achieving authenticity is essential for meeting the learning objectives of simulation-based education. Both the International Nursing Association for Clinical Simulation and Learning (INACSL) and the Association of Standardised Patient Educators stress the importance of adequately training SP in role portrayal, educational preparation, student feedback and the use of assessment tools within simulations.^12,13 However, in specific areas, such as diabetic foot assessment and wound care, achieving a realistic portrayal through SPS remains challenging due to difficulties in replicating physical and sensory findings, ethical restrictions on invasive procedures, limited tactile feedback and the cost and complexity of moulage techniques.^14,15

Background

SP are trained individuals who portray patient roles in clinical education. SPS refer to structured learning activities in which SP interact with students in realistic, scenario-based encounters.⁵ SP offer students not only anatomically interactive experiences but also portray a range of physical symptoms, emotional expressions, personality traits and body language aligned with specific scenarios.¹⁶ Unlike mannequin-based simulations, SPS allow for a more nuanced assessment of both physical and psychosocial conditions.^4,17 This distinction lies in the ability of SPS to deliver higher levels of conceptual, physical, and psychological fidelity.¹³ Additionally, SPS are typically conducted face-to-face, enabling real-time interaction and communication.

Research on the effectiveness of SPS highlights their positive impact on nursing education, particularly in enhancing students’ knowledge, psychomotor skills, attitudes, and overall learning outcomes. In 2020 Byrne et al¹⁸ found that nursing students who participated in SPS training focused on end-of-life care demonstrated more positive attitudes toward death, reported feeling emotionally better prepared, used more appropriate language when communicating with dying patients, and applied their clinical skills more effectively.¹⁸ Other studies examining SPS scenarios that are less commonly encountered during clinical placements—such as elder abuse and the care of individuals with disabilities—found that SPS significantly improved students’ knowledge, attitudes, communication skills, and assessment abilities.^19,20 Similarly, in 2024 Orgun et al²¹ reported that SPS sessions focused on patient education planning and implementation were perceived by nursing students as authentic learning experiences, offering a valuable alternative to traditional clinical instruction. Through these hands-on simulations, students not only gained practical skills but also reported feeling more like qualified nurses. Additional research supports these findings, noting that SPS fosters self-confidence, critical thinking and readiness for real-world clinical situations.^22,6 Incorporating real patients alongside SP in nursing education has been associated with promoting positive student attitudes toward patient-centered care.¹⁹ Although this approach is thought to enhance communication skills and foster greater empathy, the evidence regarding its overall effectiveness remains inconclusive.^23-25

Although SPS have been employed as an effective instructional strategy in nursing education for decades, the integration of simulation into wound assessment and care education remains in its infancy.²⁶ While several reviews have examined the effectiveness of clinical simulation in wound care education, only a limited number of studies have focused specifically on the use of SPS or real patients acting as SP in this context.^14,15 Among these, studies that address diabetic foot ulcer assessment is almost nonexistent. To address this gap, the present study qualitatively explored senior nursing students’ experiences and perceptions of a SPS designed to teach diabetic foot ulcer assessment—a skill that is clinically significant but often underrepresented in clinical placements. Diabetic foot ulcer assessment was selected because it requires a combination of wound care knowledge, psychosocial sensitivity and communication competence, making it particularly suitable for simulation-based learning. The findings of this study are expected to offer valuable insights and inform the future integration of SPS into undergraduate nursing curricula.

Materials and methods

Study design

In this study, a qualitative descriptive design was employed to explore senior nursing students’ experiences and perceptions of using real patients as SP in simulation-based education. The data were analysed using a descriptive qualitative analysis method. To ensure comprehensive and transparent reporting, the Consolidated Criteria for Reporting Qualitative Research (COREQ) Checklist was used as a guideline for reporting the study methods and findings (Appendix 1).

Participants

The study population comprised all final-year students enrolled in the Simulation in Nursing course during the Fall semester of the 2021–2022 academic year. The simulation sessions were held in the clinical simulation training laboratory of a nursing faculty at a state university in Ankara, Türkiye, in December 2021. Inclusion criteria were: enrollment as a traditional final-year student and native-level Turkish proficiency. Eleven students met the criteria and agreed to participate. All participants had prior experience with mannequin-based simulation and were familiar with simulation as a learning method; however, they had no previous exposure to simulation involving real SP. None withdrew from the study.

Scenario

The simulation-based experience was designed in accordance with the INACSL Best Practice Standards.¹² The scenario was developed using the simulation scenario design template and reviewed by the second researcher, an expert in simulation-based education.²⁷ It focused on assessing a diabetic foot ulcer in an outpatient wound care setting and was based on real patient cases.

Two real patients with diabetes, each having a history of toe amputation and current foot ulcers, participated as SP. One was a 44-year-old single woman; the other a 57-year-old retired man. Both had neuropathic symptoms and sensory loss. After consenting to participate, they underwent a one-hour preparatory session in which the simulation scenario, the stages of the simulation, expected roles, the simulation environment were explained, and their questions were addressed. The SP participated simultaneously in separate simulation rooms.

Procedure

Theoretical training

All participants received two 45-minute sessions of theoretical instruction on the development and assessment of diabetic foot ulcers. The training included PowerPoint presentations, instructor explanations, video materials, interactive questions and answers sessions and group discussions. Participants were informed about the researchers’ background and motivation to improve wound care education. At the end of the training, students were informed about the study and consent was obtained.

Skills training

Following the theoretical component, students participated in a hands-on skill training session. The Diabetic Foot Assessment Form (DFAF), developed by the researcher, based on current literature, was introduced as a learning aid to guide the assessment process. Its use was demonstrated by the first researcher through a sample assessment. It is important to note that the DFAF was not used as a data collection tool in this study. Students were then divided into two groups and practiced diabetic foot assessment skills at two separate stations in the clinical simulation laboratory. During this training, students worked with mannequins and each other to practice the assessment skills. The skill session lasted two 45-minute periods and was facilitated by the first researcher, who guided student practice and answered questions.

Standardised patient simulation

One week after the skills training, each student participated in a SPS. Before the simulations, students attended a 10–15 minute pre-briefing, where the scenario, roles, objectives, and simulation environment were explained. During the simulations, each student, acting as the nurse responsible for conducting the assessment, performed a diabetic foot evaluation in one of the simulation rooms with a real patient serving as the SP, while a researcher portrayed a senior nurse facilitating the process. Each simulation lasted approximately 20 minutes. After all simulations were completed, a group debriefing session (approximately 30 minutes) was held, using the plus/delta technique to encourage reflection and feedback.

Student interview

Individual online interviews were conducted by the first researcher within ten days following the simulations. Appointments were scheduled at the students’ convenience. Each interview lasted approximately 15–20 minutes and began with verbal consent for audio recording. Data were collected through semi-structured interviews using a interview guide developed by the research team in line with the study objectives. The guide included eight open-ended questions and three follow-up probes designed to explore students’ reflections on their simulation experience (Appendix 2). This guide helped structure the conversation to explore students’ perceptions and experiences of working with SP.

 

Table 1. The process of thematic analysis

 

Data analysis

The data analysis was conducted by researchers, using a qualitative thematic analysis approach as outlined by Braun and Clarke.²⁸ The recorded interviews were transcribed in Microsoft Word, after which both researchers independently read and reviewed the transcripts, noting initial ideas and coding the data. The transcripts were not returned to participants for comment or correction, as this step was not considered during the study design. Thematic analysis followed Braun and Clarke’s six-phase process: (1) familiarisation with the data, (2) production ofinitial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report (Table 2). Themes and subthemes were finalised through collaborative discussion and consensus. An audit trail was maintained to enhance transparency, and transcripts were anonymised to protect confidentiality. Participants were not asked to provide feedback on the findings.

 

Table 2. Themes and subthemes

 

Trustworthiness and rigour

The quality and trustworthiness of qualitative descriptive studies are commonly evaluated using four key criteria: credibility, confirmability, dependability and transferability.^28,29 In this study, methodological rigour was ensured through strategies that enhanced transparency, consistency, and reflexivity throughout the research process. To enhance credibility, a trust-based relationship was established with participants, who voluntarily engaged in the study over an extended period. An empathic and non-judgmental approach encouraged them to share personal experiences freely, with reassurance that there were no right or wrong answers. Prolonged engagement and careful listening supported authentic data generation. To ensure confirmability, two researchers independently analysed the data to reduce bias and enhance objectivity. An audit trail was maintained to document coding decisions and theme development, and all transcripts were anonymised during analysis. Dependability was supported through a transparent and consistent methodology, including a standardised interview guide and a clear description of recruitment, data collection and analysis procedures. For transferability, thick descriptions of the setting, participant characteristics, and context were provided, allowing readers to assess the relevance of the findings to other settings. Throughout the research, the team engaged in ongoing reflexive discussion to critically examine their own assumptions, strengthen analytical depth, and ensure a faithful representation of participants’ perspectives.

The authors bring complementary expertise to this study: the first author has extensive experience in wound care, while the second author is highly experienced in research methodology. Both authors share a strong motivation and commitment to advancing knowledge in the field of wound care education, which informed the study design, data collection, and analysis processes.”

Ethical considerations

Ethical approval was obtained from the University of Health Sciences Gülhane Scientific Research Ethics Committee (Approval No: 2020-387). Additional permission was received from the institution where the study was conducted. The purpose and methodology of the study were explained to the students, and only those who voluntarily agreed to participate were included. Written informed consent was obtained from all participants. To protect their identities, participants were assigned code numbers (such as P1, P2) in the research report. Participation in the study was entirely voluntary, with no impact on academic performance or final grades for those who chose not to participate or decided to withdraw at any stage. Participants were also informed that they could leave the study at any time. Students were also informed that they had the option to participate in the simulation without being included as study participants, if they preferred.

The study adhered to the principles of the Declaration of Helsinki (2013) for ethical research involving human subjects and complied with the relevant provisions of Türkiye Personal Data Protection Law No. 6698 and the General Data Protection Regulation for data protection and confidentiality.

Results

A total of 11 senior nursing students participated in the study, including 10 females and one male. All participants were in their final year of undergraduate nursing education and had completed clinical placements in internal medicine, surgery and community health nursing prior to the simulation. For all students, this was their first exposure to a SPS, and they had not previously worked with real patients in a simulated setting. Thematic analysis revealed four main themes and 12 sub-themes representing the nursing students’ experiences with SPS conducted with real patients (Table 2).

Emotions experienced

This theme is based on the changes in the emotions of the participants toward the teaching methods used in diabetic foot assessment education. Two subthemes were identified: negative emotions experienced at the beginning of the simulation and positive emotions that emerged as the session progressed.

Negative emotions

Many of the participating students reported feeling tension, anxiety and fear at the beginning of the simulation exercise. They expressed concerns about potentially harming the patient, experiencing communication problems, making mistakes during the procedure or providing incorrect information. They also feared that the patient might give them negative feedback while communicating with them. Another negative emotion frequently mentioned at the beginning of the simulation was a sense of uncertainty about what to do. Additionally, excitement was a shared emotion experienced by all participants at the beginning of the simulation.

Selected student excerpts illustrating these emotional responses are presented below:

P1: First of all, just knowing that you’re dealing with a real person adds a completely different dimension to the situation. When you know it’s a mannequin, if you make a mistake, it won’t hurt, and you think you won’t do anything wrong to it. But when it’s a real patient, if I say something wrong, they could be negatively affected. The thought that they might face different problems because of me makes me feel tense, of course.

P8: Actually, I was very excited before going in because I had never seen a diabetic foot in real life.

P10: I was both scared and excited, to be honest. I mean, what am I going to say? How will I approach the patient? Will I be able to do it? Do I know what I’m doing? Am I medically knowledgeable? I honestly felt the fear of these things.

Positive emotions

All students reported feeling more relaxed as the simulation progressed, particularly towards the end. Positive emotions included a sense of competence, preparedness, helpfulness and overall satisfaction. Most students noted that the presence of their instructor during the simulation contributed to their sense of safety and comfort. Additionally, several students indicated that using DFAF during the simulation enhanced their confidence.

P1: I noticed that what we learned in class was directly applicable when we encountered a real patient. I realised that I could reflect my knowledge onto the patient. I was able to communicate it, and then I felt a sense of relief.

P7: The instructor’s presence didn’t make me feel stressed at all. Of course, there would be things I didn’t know, but I felt that I would be supported, and that made the moment easier for me.

P9: The patient was a positive person, and that helped me feel more at ease. Following a guide (DFAF) also reduced my anxiety. I knew how to proceed. Having a checklist was really helpful for me in that sense.

Gains achieved

The students’ responses revealed not only increased awareness, self-confidence and skill acquisition, but also indications of attitude change.

Building awareness

Many participants reported that, in addition to gaining a better understanding of diabetic foot assessment, they became more aware of how to communicate effectively and appropriately with patients, the importance of having sufficient knowledge about the procedures they perform, and the significance of demonstrating professional nursing behavior. After the simulation, students stated that they were able to recognise their communication and skill-related deficiencies more objectively, identify areas in need of improvement and reflect on what they did well.

P11: When I encountered a real patient, I saw how I should behave. I realised the areas I need to develop. I realised that I need to approach the patient with more confidence and a more assertive attitude. I also realised that I need to improve my communication with the patient.

P6: I still have shortcomings in my practice, and I also lack sufficient theoretical knowledge. I need to improve myself in these areas. Sometimes I even forget what I know when I’m in front of real patients. Practicing on a real patient made me realise that I am somewhat lacking in knowledge, and it helped me identify the areas where I need to improve.

Skill and self-confidence acquisition

All students stated that the simulation experience enhanced their self-confidence and skills. In addition to gaining competence in diabetic foot assessment, they also emphasised improvements in establishing and maintaining patient communication. Most reported feeling prepared to perform diabetic foot assessments in future encounters with diabetic patients.

P2: Because we practiced with real patients, I felt much more confident. Now, when I see an actual diabetic patient during clinical placement, I can perform the assessment confidently, without hesitation. In other simulation classes, yes, I improved my practical skills, but I still felt hesitant when it came to real patients because we hadn’t practiced on them. But with this diabetic foot assessment, I feel much more confident.

P11: I feel more confident because when a patient comes, I have learned what to say and what to do. I have learned what I did wrong, and I will pay more attention to those things. My communication with the patient will be better.

P4: Providing us with these opportunities gives us great self-confidence and also helps us gain experience.

Attitude change

Students’ reflections indicated a positive shift in their attitudes toward patient care. One student reported performing a foot assessment on a diabetic relative at home, while another conducted a diabetic foot risk assessment for a hospitalised patient in the internal medicine clinic, whose care continued under the clinical nurse’s supervision.

P4: I had a patient who had been living with diabetes for 12 years. He was a university graduate, yet he really didn’t know much—he didn’t know how to choose proper footwear or how he should be eating. I was involved in his education, and I used what I had learned in class to support his learning in certain areas.

P7: My attitude toward patients has changed. I am now more careful about involving them in their care.

P11: I realised what I had done wrong. I’ll pay more attention to those things. My communication with patients will be better.

Realism of the simulation

All participating students reported that conducting the simulation with a real diabetic patient felt highly realistic and made them feel like actual nurses. Their perceptions of realism were categorised into physical, psychological, and conceptual dimensions.

Physical fidelity

In terms of physical realism, students highlighted that the environment resembled an actual outpatient clinic, and the use of real tools—such as diapason and the DFAF—contributed to the authenticity. They emphasised that assessing a real extremity, rather than a mannequin, allowed them to feel the temperature and pulse, observe wounds and amputations, perform ankle-brachial index measurements, assess edema, and apply sensory tests such as touch or pain.

P4: The patient was giving feedback. It wasn’t like working with a mannequin. I didn’t think that diabetic patients would experience such an advanced level of sensory loss ... When I directly encountered the patient, I could clearly see how seriously it could lead to complications and how much harm it could cause the patient.

P10: We saw an actual diabetic foot. I mean, we saw an amputated foot or toe. Since we wouldn’t be able to see these things on a mannequin, I believe it was more appropriate and correct to work with a real patient.

Conceptual fidelity

On a conceptual level, many students reported that they momentarily forgot the scenario was simulated and felt as though they were acting as real clinical nurses during the assessment. Being able to offer advice and guidance to the patient afterward also contributed to the overall sense of realism.

P5: We don’t treat mannequins like humans. Even if we think of them as humans, it doesn’t work—we just say it’s a mannequin, it won’t feel pain, nothing will happen. ... But when it’s a real patient, you need to perform the intervention. The practice feels more real, and that makes you feel more competent.

P8: I felt like I was a qualified nurse in that moment. It truly felt realistic. Even though we try to make it feel real when working with a mannequin and speaking as if it’s a real patient, this felt completely different. This time, I understood what ‘real’ really means.

Psychological fidelity

Students felt that the patients’ responses were natural and spontaneous, and that the facilitator reacted in a realistic and consistent manner. These elements enhanced the credibility of the simulation and contributed to a deeper emotional engagement in the learning experience.

P3: Compared to a high-fidelity manikin, we communicated much better with the patient—because in this case, there was an actual person responding to me.

P6: To be honest, practicing with a real patient who had actually experienced the illness was more instructive and more enjoyable. Of course, interacting with a real person made me feel a bit more nervous, but it was definitely more educational compared to practicing on a mannequin.

Qualities of the simulation application

The views of students who participated in the simulation about the characteristics of training with a real patient were categorized into the following sub-themes: reinforcing theoretical knowledge through practice, supporting holistic care, gaining professional experience, and enhancing knowledge retention.

Ensuring the transfer of learned theoretical knowledge into practice

The most frequently expressed opinion was that the simulation provided an opportunity to apply theoretical knowledge in a practical setting, which helped consolidate their prior learning. This hands-on experience not only helped them bridge the gap between theory and practice but also reinforced and consolidated their previously acquired knowledge. By actively engaging in real patient scenarios, students were able to deepen their understanding and gain confidence in performing clinical assessments, thereby enhancing the overall effectiveness of their learning process.

P9: Even though we took this course in our second year, we definitely did a more detailed tissue examination this time ... I mean, we saw the diabetic foot in much greater detail. Sure, we studied and passed the exam with a good grade back then, but doing the assessment like this was really great.

P6: First of all, seeing the theoretical knowledge, learning it from you theoretically, and then applying it was very good for us. Of course, it was similar with the mannequin, but talking one-on-one with the patient was much better. ... After all, it was an application focused only on learning, and since there was no fear of grades involved, we honestly felt more relaxed.

Enhancing the use of a holistic approach

Students reported that the educational simulation allowed them to experience applying a holistic approach to the patient across all dimensions. They emphasised the importance of considering not only the physical aspects of the diabetic foot ulcer but also the emotional, social, and psychological needs of the patient. This comprehensive perspective helped them understand the value of treating the patient as a whole rather than focusing solely on the wound.

P5: When it’s a real patient, I ask everything I’m curious about, they answer, we talk, I can ask about everything they feel or don’t feel. This way, the scenario fully comes together, and I’m able to approach more holistically.

P3: Encouraging the patient to attend regular check-ups will help prevent more serious complications in the future. The guidance (DFAF) we provided to the patient, whose foot was amputated, may help prevent the amputation of other toes as well.

Providing an opportunity to gain professional experience

Students highlighted that the simulation allowed them to experience the nursing profession firsthand. One student mentioned that she overcame her initial discomfort with touching feet during the simulation, where she assumed the role of a nurse. She also noted that the simulation helped her understand the responsibilities inherent in the profession.

P5: I have a phobia of feet. I can’t touch feet. I even considered not coming to the class. Then I thought, since a real patient will be there, at least I can observe — even if I can’t touch, I’ll let the instructors know. ... I got really excited. Then I touched the patient’s foot; for example, I checked the temperature...  After I got used to it and that inner voice quieted down, I stopped seeing it as a foot and started seeing it like a model, and I completed the examination.

P8: I felt like a qualified nurse there. That made me very happy.

Retention

All students who participated in the simulation emphasised its contribution to knowledge retention. They frequently noted that applying the theoretical knowledge they had learned—first in the lab and then in a controlled setting with a real patient—was an invaluable and unforgettable learning experience.

P1: When you do it one-on-one, I think it sticks in your mind better. When you have to think everything through by yourself and decide what to do in that moment, it becomes a more memorable experience for you.

P2: This training really helped reinforce my knowledge. ...  I can recall everything step-by-step.

Discussion

As a result of the qualitative analysis, students who participated in the SP simulation with real patients reported that the negative emotions they initially experienced diminished by the end of the session, leading to increased self-confidence. They also described heightened awareness and positive changes in their attitudes, particularly regarding their communication with patients and their diabetic foot ulcer assessment skills. Participants indicated that the SP simulation with real patients enhanced their professional competencies and practical experience, particularly in reinforcing how to perform diabetic foot ulcer assessment, understanding potential complications in advanced stages of diabetes, and recognising the type of care and guidance needed by patients with diabetic foot ulcer, and they expressed satisfaction with the learning process.

Encountering a patient with a diabetic foot ulcer and being responsible for nursing interventions during the simulation elicited both positive and negative emotions from the students. Initially, students experienced intense stress, but this gradually gave way to satisfaction and increased self-confidence by the end of the session. This finding is supported by the literature, which indicates that communicating with SP, rather than mannequins, often induces higher levels of anxiety, with many students describing feelings of tension at the start of such simulations.^30,31 However, other studies suggest that simulations with SP can also help reduce students’ anxiety.^32,33 Emotionally engaging simulations are believed to prepare students emotionally by allowing them to experience real stress and anxiety in a controlled environment. As a result, students may be better equipped to cope with stressful situations in real patient care settings in the future.⁴ Although students experienced stress during the simulation, they compared this aspect of the experience to their initial encounters with real patients in clinical practice. They reported that this similarity helped them feel more prepared for assessing a diabetic foot ulcer in real-life environments, reinforcing their sense of being ‘qualified nurses’. These findings highlight the positive impact of SPS in teaching chronic wound assessment and care—such as diabetic foot ulcers and other types of wounds—to nurses and nursing students in realistic educational settings. To reduce student anxiety and enhance the effectiveness of simulation-based learning, providing additional time and focusing on formative assessment during the simulation process could be beneficial.²¹

The participants reported increased awareness of the knowledge and skills needed for effective communication with patients and for diabetic foot care. In addition to acquiring skills and self-confidence, their responses indicated that they also developed positive attitudes toward the care of patients with wounds. Consistent with the findings of our study, previous research has reported that SP simulation experiences enhance nursing students’ self-confidence and communication skills.^4,21,34,35 The fact that all students expressed confidence in their ability to independently perform diabetic foot assessments in future clinical settings supports the idea that SP prepare students for real-world clinical situations by adding authenticity to their learning experiences and fostering empathy.³⁶ Coleman and McLaughlin³⁷ found in 2019 that students viewed the use of simulated patients to improve nursing skills as a valuable learning method that could be directly applied in clinical practice. Working with SP not only allows students to learn and practice skills in a safe environment but also provides valuable opportunities for structured feedback during or after the simulation experience.²¹ Through this process and subsequent debriefing sessions, students can identify areas for improvement with the guidance of their instructors.³³ In this study, students reported that they were able to recognise aspects of their communication skills and diabetic foot assessment knowledge that required further development. Additionally, they found the feedback particularly valuable, as it enabled them to focus on personal growth without the pressure of being graded.

SPS involving real patients are valuable for enhancing students’ communication skills during history-taking, as well as for integrating clinical reasoning and decision-making into care planning. This effectiveness is attributed to the opportunity for real-time interaction and hands-on experiences with SP, which fosters deeper learning and practical application of knowledge.³⁸ Interviews with students revealed that the realism of the simulation significantly contributed to their excitement and the sense of having encountered a real clinical situation. All students reported that the authenticity of conducting physical exams and taking the history of a patient with a diabetic foot ulcer helped reinforce their learning. The face-to-face interactions with SP closely mirrored real clinical encounters, offering a more immersive and emotionally engaging experience.³⁹ SP simulations are particularly valuable for replicating clinical scenarios that are difficult to replicate in real settings, allowing students to receive immediate, personalised feedback on their clinical performance.^3,12,17 Research shows that effective implementation of the SP role enhances realism, with participants feeling like qualified nurses during the simulation.²¹ Overall, practicing with SP not only had an emotional impact but also helped prepare students for real-life nursing encounters. The design of such SPS, combined with the controlled inclusion of real patients in simulations, is thought to hold significant potential for teaching chronic wound assessment and enhancing nurses’ knowledge and skills.

Although moulage and technical equipment are commonly used to enhance the realism of SP scenarios, students may perceive that SP cannot fully replicate the signs and symptoms encountered in actual clinical settings.¹ A notable strength of the present study was the inclusion of real patients exhibiting authentic diabetic complications, such as neuropathy, foot ulcers and amputations. This authenticity enabled students to conduct comprehensive physical assessments and experience sensory findings—such as temperature changes or diminished sensation—that are typically limited to mannequin-based training. As a result, students not only reinforced their diabetic foot assessment skills but also developed greater clinical awareness and reported feeling more like qualified nurses with experience in wound care. When students compared previous high-fidelity simulations with SP simulations involving real patients, they stated that the latter was more memorable and effective in applying theoretical knowledge. Although advanced simulators and technologies like virtual reality contribute to nursing education, human interaction remains essential for skill development.¹ While SP can mimic social behaviors, involving real patients in selected simulation scenarios was perceived to enhance the sense of realism in wound assessment and care.

Limitations of the study

This study has several limitations that should be considered when interpreting the findings. First, the SP did not have formal professional training in simulation performance, which may have influenced the consistency or depth of the simulation experience. Second, the study involved a small number of participants from a single nursing program, which may limit the transferability of the findings to other contexts or institutions. While the small sample allowed for in-depth exploration of student experiences and more personalised learning during the simulation, future studies involving larger and more diverse student groups could provide broader insights and enhance the trustworthiness of the findings. Integrating professionally trained SPs in future research may also help ensure more consistent role portrayal and realism.

Conclusions

Wound care education, particularly diabetic foot ulcer assessment, is a vital but often underemphasised component of nursing training. This study demonstrated that SPS offer a realistic, interactive, and safe learning environment that enhances students’ clinical competence, confidence, and critical reflection in wound care. The experiential nature of these simulations allows students to better transfer theoretical knowledge into practice, especially in managing complex wounds like diabetic foot ulcers. Experiencing the stress that could be encountered in a real clinical setting within the context of the SPS in the laboratory provided most students with a sense of gaining wound care experience in a safe environment.

Incorporating SPS focused on wound care into nursing curricula can improve preparedness for real-world clinical challenges and ultimately contribute to better patient outcomes. Further studies are needed to evaluate the long-term effectiveness of simulation-based wound care training on students’ clinical performance and patient outcomes. Research should also explore optimising simulation scenarios to address diverse wound types, including diabetic foot ulcers, pressure injuries and moisture-associated skin damage. Additionally, the development and validation of standardised assessment tools for measuring wound care competencies within simulation settings will be essential to ensuring educational quality and consistency.

Implications for clinical practice

• Real patient simulation can enhance students’ clinical reasoning in wound care.
• It fosters empathy and communication skills essential for patient-centered care.
• It improves student confidence in managing complex cases like diabetic foot ulcers.

Implications for further research

• Experiential learning methods for rare wound care cases should be further explored.
• Future studies should evaluate how SP applications specifically support wound care skill development.
• Mixed-methods research can offer deeper insights into SP-based wound care education.

Acknowledgements

The authors wish to thank all the participating nursing students.

Conflict of interest

The authors declare no conflicts of interest.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

ORCID IDs

Emine Sezgünsay 0000-0003-0196-1818
Tülay Başak 0000-0001-5148-5034

Author(s)

Emine Sezgunsay*¹ RN, PhD, Tulay Basak², RN, Prof. Dr.
¹Department of Nursing, Faculty of Health Sciences, İzmir University of Economics, İzmir, Türkiye
² Gulhane Faculty of Nursing, University of Health Sciences, Ankara, Türkiye.

*Corresponding author email sezgunsay@yahoo.com

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Appendices

Appendix 1

Click here to download Appendix 1.

 

Appendix 2. Interview guide