Recent studies have suggested a concerning gap in the emergency care abilities of nursing students, emphasizing the need for enhanced educational and training approaches within their curriculum (Gutiérrez-Puertas et al., 2021; Roel & Bjørk, 2020). Traditional methods of clinical skill acquisition involving direct patient interaction for emergency decision-making are increasingly viewed as suboptimal, particularly for teaching skills, such as cardiopulmonary resuscitation and handling pre-arrest patients, which are not well-suited for learning in real clinical settings (Chow et al., 2023).

Simulation-based education (SBE) is a complement to the traditional teaching method. It allows nursing knowledge to be practically applied and reduces the gap between “knowing” and “doing” (Cant & Cooper, 2010; Li et al., 2022; Norman, 2012; Walsh & Sethares, 2022). Through this SBE, learners can engage with realistic scenarios that mirror real-world elements, facilitating a deeper understanding and application of emergency care procedures in a controllable and risk-free setting (Lateef, 2010; Weldon et al., 2020). Situated simulation has been recognized as a non-threatening and non-harmful teaching method to teach nursing students essential emergency management concepts (Hanshaw & Dickerson, 2020).

One study showed that simulated scenarios, particularly those utilizing video and high-fidelity simulations for teaching Advanced Cardiac Life Support (ACLS) and Mega Code, are more effective than traditional lecture-based methods (Adams et al., 2015). Another study found that simulation training could significantly improve nursing students’ knowledge acquisition, retention, and confidence in ACLS (Tawalbeh & Tubaishat, 2014). These findings also aligned with the positive perception of emergency clinical simulation reported by nursing students (Guerrero-Martínez et al., 2020).

Kolb's Experiential Learning Theory (1984) suggested that learners engaged actively in a learning experience should exhibit enhanced learning outcomes and clinical performance compared to their less-engaged counterparts. Learners must be involved to make learning effective, but the opportunity for every learner to participate as an “active” participant in simulation exercises is limited (Lai et al., 2016). In addition, SBE has a few constraints, such as limited space, time constraints, and equipment availability, especially when managing a large group of learners. Consequently, students are inevitably assigned to serve as either performers or observers. Nevertheless, if observers are appropriately engaged or activated, students serving as observers in simulations might still derive significant learning benefits (Bullard et al., 2019).

There is a notable scarcity of research examining the comparative effectiveness of SBE between active participants and observers, particularly in scenarios simulating life-threatening clinical situations (Bullard et al., 2019; Kaplan et al., 2012). This literature gap highlights the need for targeted research to guide the design and implementation of SBE, with a particular emphasis on emergency care training to foster optimal learning outcomes. In addition, there is a belief among some medical institutions that novice nurses face challenges in discerning the appropriate segments of their knowledge to apply, necessitating further clinical experience to manage complex and distinctive clinical situations. This need may be addressed by an increase in ward-based simulations within university curricula (Bisholt, 2012; Graf et al., 2020). Another gap involves determining the optimal roles within simulations to maximize learning outcomes. Typically, learners are assigned to the roles of participant or observer in simulations (Bullard et al., 2019; Johnson, 2019; Kang & Yu, 2018). This leads to the question of whether learning outcomes will differ when students are allowed to choose their roles in simulation activities. To address these identified needs, this prospective, mixed-methods study was designed to compare the effectiveness, satisfaction, and knowledge gains among nursing students who engaged as active performers compared to those who participated as observers in a third-year emergency nursing course using SBE. Furthermore, this study aimed to explore the perceptions of SBE from the perspectives of both performers and observers.

This study draws upon Kolb's Experiential Learning Theory, encompassing four stages: concrete experience, reflective observation, abstract conceptualization, and active experimentation (Kolb, 1984). Healthcare educators recognize that SBE can enhance student teamwork by offering an interactive and active learning environment conducive to knowledge exchange and problem-solving within a simulated context (Matlala, 2021).

SBE involves designing scenarios, introducing simulated data, and observing the results. The process comprises active learning, observation, post-event debriefing, and feedback between students and faculty. These components are crucial for student learning, and research indicates that debriefing and student-faculty feedback sessions are essential for students to consolidate their knowledge and assess their clinical readiness (Abelsson & Bisholt, 2017).

The Kirkpatrick's four-level evaluation model can be used to evaluate the effectiveness of SBE interventions (Adamson et al., 2013; Johnston et al., 2018). Level 1 (Reaction) assesses participants’ perceptions or satisfaction with the training programs. Level 2 (Learning) evaluates outcomes such as the acquisition of knowledge and skills post-simulation. Level 3 (Behavior) examines learner behavior change outside the learning environment. Level 4 (Results) measures the impact of learners’ actions on patient outcomes (Johnston et al., 2018). Notably, evaluations at the behavior and results levels are less common in nursing education (Delisle et al., 2019).