Results of the virtual simulation teaching method on autonomous learning competencies of undergraduate nursing students

Background: With the continuous development of information technology, most universities use mobile teaching platforms for classroom teaching. With the help of the national virtual simulation experimental teaching project sharing platform, students can enhance self-directed learning through the virtual simulation operations of the project. Purpose: To explore the application of virtual simulation experiment in teaching the fundamentals of nursing practice based on the Platform of the National Virtual Simulation Experiment Teaching Project during the COVID-19 pandemic analyze the impact of this teaching method on the autonomous learning ability of undergraduate nursing students. Methods: Convenience sampling was used to select 121 nursing undergraduates from Y University’s School of Nursing; the online teaching of fundamentals of nursing practice was conducted to the students. After taking the course, questionnaires were distributed to the undergraduate nursing students to collect their perceptions regarding the use of the virtual simulation experiment platform and autonomous learning competencies. Results: Most students expressed their preference for the virtual simulation teaching platform, and their satisfaction with the project evaluation was high 83.05%. They hoped to promote the application in future experimental teaching. Undergraduate nursing students believed that the virtual simulation teaching platform was conducive to cultivating clinical thinking ability, could stimulate learning interest, enhanced autonomous learning competencies. Conclusion: During the pandemic, the virtual simulation teaching platform for a lecture on in nursing education has achieved good results in both the aspects of teaching and student learning. Teachers efficiently used their training time and reduced their teaching burden. Moreover, the laboratory cost was also reduced. For undergraduate nursing students, the system was conducive to cultivating clinical thinking ability, stimulating their interest in learning, enhancing their learning and comprehension abilities and learning initiative.


Introduction
To prevent the spread of coronavirus in China, the start of school in March 2020 was postponed [1,2] and the Chinese Ministry of Education recommended that schools and higher education institutions switch to online classes [3].The teaching of colleges and universities was also gradually changing to a comprehensive development of informatization, networking, and digitization [4].
Both the school site and the professors were completely unprepared for non-face-to-face online classes, causing great confusion in the educational field [5][6][7][8].Designing educational content is not an easy task, but university professors have proposed plans to improve the quality of online education [5,9].In China, the continuous development of information technology has led to the use of various mobile teaching platforms, such as the Chinese University Massive Open Online Course (MOOC) [10], Wisdom Tree Online Course [11], Chaoxing Learning Communication Platform [12] and Rain Classroom, in classroom teaching in recent years.Among these platforms, Chaoxing Learning Communication Platform is a professional mobile learning platform, is widely used in various colleges and universities [12].
Beijing Century Chaoxing Information Technology Development Co., Ltd developed the Chaoxing Learning Communication Platform for use on mobile devices, such as smartphones and tablets.The Chaoxing Learning Communication Platform has a wealth of teaching resources.Users can query its library collections, search and download electronic resources, sign in according to the teacher's teaching curriculum, vote, test, and conduct group discussions.Chaoxing Learning Communication Platform can improve the quality of teaching, based on problems, taking students as the main body and teachers as the leading factor, so that teachers and students can better complete a course [12,13].
In China, content materials produced by famous university professors are uploaded on the Chinese University MOOC, and online classes are conducted using existing content.Most courses offered by nursing schools combine theoretical and practical education.This course enables students to master the fundamentals of nursing knowledge and practices necessary for the practice of the profession.Whether it is the interview of medical institutions, the clinical skill assessment, or various types and nature of nursing skill competitions, it is the basic skill to examine the fundamentals of nursing.Lectures on the fundamentals of nursing theory are available online, but online lectures are in urgent need of practice.
During the COVID-19 pandemic, identifying the ways to improve students' practical skills through online experiment courses is extremely urgent, and the development of a teaching platform for a virtual simulation experiment is crucial [13].Virtual simulation teaching is a 3D virtual simulation environment, which is built on internet technologies, for educational purposes; students can intuitively feel the fidelity of the virtual environment.Combining data networks and practical technologies has become an important method for students to learn independently and can better stimulate their interest in learning [14].Virtual simulation in China started relatively late compared with that in developed countries, such as the United States, Japan, and South Korea.The research and development of virtual simulation systems is still in its infancy in China.
Most nursing colleges abroad have taken the cultivation of undergraduate nursing students' autonomous learning competencies as one of their educational goals.Self-directed learning refers to individuals who take the initiative to judge their own learning needs with or without the help of others, formulate learning goals, and determine the manpower for learning.The process of selecting and implementing appropriate learning strategies and evaluating learning outcomes [15].
This study was conducted during the COVID-19 pandemic when schools are unable to carry out the practical teaching of the fundamentals of nursing and relied on the "Sharing Platform of the National Virtual Simulation Experiment Teaching Project" [16].This platform was applied to the virtual simulation experiment on nasal feeding and urinary catheterization in the practical course of the fundamentals of nursing.Nasal feeding and urinary catheterization were among the practical skills that nurses must learn.We used the nasal feeding and urinary catheterization on the sharing platform which undergraduate nursing students enhanced their autonomous learning through virtual simulation systems.
This study cultivates undergraduate nursing students' autonomous learning competencies through virtual simulation experiment teaching and evaluates the final exam and clinical skills training results during the pandemic.It aims to understand the level of undergraduate nursing students' autonomous learning competencies and its influencing factors, and explore countermeasures to improve autonomous learning competencies in education.In order to provide reference for improving the quality of nursing education.
The hypothesis of this study is that undergraduate nursing students who have experienced virtual simulation experiment have a higher level of autonomous learning competencies than students who have not performed virtual simulation experiment.

Study design and sample
This was a descriptive study to evaluate the effect of online simulation practice.A convenient sampling method was used to recruit 121 undergraduate nursing students (29 males and 92 females; average age = 20.10 ± 0.85 years old) in June 2020.The undergraduate nursing students participated in the course on the "Fundamentals of Nursing Practice 2" offered in the second semester of their second year.This study analyzed data from 59 students who could perform the virtual simulation on a computer, volunteered to participate, and could complete the relevant research.
Ethics approval: This study was obtained from the study university and the Institutional Review Board (Approval no.YBU202110150123) and all participants were assigned a study number to manage their data which were stored safely.The IRB approved a request to waive the documentation of informed consent.

Instruments
This study used the satisfaction questionnaire developed by Li [17].Its contents included items on theoretical learning, operational skills, and learning interest.Open questions were added based on references.The Cronbach's value of the questionnaire was 0.874 in the previous study and 0.911 in this study.
The autonomous learning competencies of nursing undergraduates scale was compiled by Lin Yi et al [18].The scale includes 10 items of self-managing competencies, 11 items of information competencies, and 7 items of learning together competencies.It is formed from 3 dimensions and has a total of 28 items.A 5-point scale is used (1 point = completely inconsistent, 2 = basic non-conformance, 3 = average, 4 = basic agreement, 5 = complete agreement), with a score range of 28 -140 points, of which self-management competencies is 10 -50 points, 11 -55 points for information competencies, and 7-35 points for learning together competencies.The higher the score, the better the independent learning ability, the better the content and construct validity of the scale, and the Cronbach's value is 0.86.This scale is widely used in the research on the autonomous learning competencies of nursing students in China.

Data collection
The data collection period was from June 20, 2020 to June 30, 2020.The evaluation of virtual simulation teaching platform questionnaire for this study was conducted on the June 2020.The autonomous learning competencies scale was conducted on June 30 after the final exam.It's made available on a Chinese survey site (www.wenjuan.com),so that participants could answer it anytime and anywhere.Participants could access it using a computer or mobile phone by clicking the URL of the questionnaire or scanning the QR code.Submit a manuscript: https://www.tmrjournals.com/in

The fundamentals of nursing practice
The "Fundamentals of Nursing Practice 2" was a highly practical experiment course.This compulsory course enables undergraduate nursing students to master the basic nursing knowledge and skills necessary for the practice of professional nursing [13,17,19].undergraduate nursing students would earn 1.5 credits in taking this course, which would provide them 48 hours of practical knowledge.This course was divided into two classes among the 121 undergraduate nursing students from March to June 2020.Classes were given twice a week; each class lasted for 90 minutes.During the epidemic, online practice was conducted in the order of sharing practice videos on basic nursing skills and presentation materials, followed by watching and discussing real-time online quizzes and lecture videos.The insertion of nasal feeding tube and foley catheters, which is widely used in clinical practice, was conducted as a simulation lecture.

Application of the sharing platform of the national virtual simulation experiment teaching project
The virtual simulation experiment for teaching nursing skills was produced by Shandong Xiehe College in the "Sharing Platform of the National Virtual Simulation Experiment Teaching Project" which can be used freely and openly [20].In this experiment, the operation process was, first, explained to the students.Before the [test], students could enter the [ Practice preparation] module-check [Assessment requirements: practice process] and then enter the [learning mode] module to be proficient in the virtual simulation experiment operation method.Then they would perform the [Test].The screenshots of the final experimental results were uploaded to the [Homework] module of the Chaoxing Learning Communication Platform.

Evaluation indicators
The results of the virtual simulation experiment are automatically reflected as the results of the virtual simulation experiment after the experiment is performed on the computer, and the full score is 100 points.The Midterm exams for 40% of the total grades, including classroom check-in, questioning, discussion, homework items accounting for 10% and experimental operation assessment for 30% to check students' learning.After the course is over, the final written examination will account for the total grade.60%, with a total score of 100.Clinical comprehensive skills training is an assessment of fundamentals nursing practices for undergraduate nursing students before clinical practice.It aims to cultivate undergraduate nursing students with solid professional theoretical knowledge, practical ability, comprehensive ability and emergency response ability.The autonomous learning competencies scale is released and evaluated to undergraduate nursing students after the virtual simulation experiment.

Data analysis
Statistical analysis was performed using SPSS 26.0 software.Data were analyzed using frequency, mean， standard deviation, percentages describe general data; t-test, variance perform statistical analysis, P < 0.05 indicates a statistically significant difference.

Participants' characteristics
The 59 undergraduate nursing students (29 males) who performed the simulation practice were aged 20.10 years on average and mostly Han Chinese students (86%).Their average grade for the simulation practice was 95.97 points; 90% of the participants obtained 90 points, and only two had a score of 70 points or less (Table 1).The minimum and maximum grades were 68 and 100, respectively.The undergraduate nursing students who performed the virtual simulation experiment had higher grades in midterm exam, final exam, total exam and clinical comprehensive skills training of scores than those who did not perform the virtual simulation experiment, and there was a statistical difference in the total exam (P = 0.042).

Undergraduate nursing students' evaluation of the virtual simulation teaching platform
The questionnaire survey was divided into objective and subjective evaluations (Table 2).Most students expressed their preference for the virtual simulation teaching platform, and their satisfaction with the project evaluation was high (83.05%).They hoped to promote the application in future experimental teaching.Students believed that the virtual simulation teaching platform was conducive to cultivating clinical thinking ability, could stimulate learning interest, enhanced independent learning ability, and improved learning efficiency.39 students satisfaction with the system, and 24 students liked the traditional method of teaching laboratory practice.
In terms of the subjective evaluation, in the open question feedback, most students agreed with the virtual simulation teaching platform.This means that they could learn plenty of knowledge and improve their practical skills through the virtual simulation platform.Some students reported that "the system was not very convenient."They said that, for example, "when inserting the gastric tube, the handle at times shakes and the mouse is not well controlled, which leads to the patient's nausea and vomiting; fluency is also a little low."Others felt bad that they could only perform this exercise on a computer (Table 3).4).

The scores of autonomous learning competencies for undergraduate nursing students
The total score and various scores of autonomous learning competencies of the nursing undergraduates who have performed the virtual simulation experiment are significantly higher than those of the students who have not performed the virtual simulation experiment.Except for the score of learning together competencies, the others are statistically significant (P < 0. 001), see the Table 5.

Discussion
The virtual simulation teaching platform helps to consolidate undergraduate nursing students' basic knowledge and strengthen their understanding of experiments and the hypothesis of this study was accepted.The nursing undergraduates who performed the simulation had higher autonomous learning competencies.The emergence of virtual simulation technologies has shortened the distance between students and nursing experiments.With modern, informatized, and intelligent means, students can study independently before and then consolidate and review after experiment classes.This process helps them become more familiar with the experiment.The operation process includes grasping the details of the experiment operation, paying attention to its key points, mastering its difficulties, and keeping in mind the basic theoretical knowledge of the experiment.
Practical teaching is a priority in nursing.Overcoming the problem of limited laboratory resources has always been a major problem in experiment teaching.The emergence of virtual simulation platforms makes experiment teaching no longer confined to time and place, so that students can perform the experiment online, practice repeatedly, and strengthen their understanding of the experiment content.The virtual simulation platform can better judge the correct and wrong operation of students and help students have a comprehensive and in-depth understanding of each experiment operation.
This study revealed that almost 66%-83% of the participants believed that the virtual simulation platform can assist learning and it helps cultivate clinical thinking ability; virtual operation is conducive to entering a clinic as soon as possible and it helped improved their autonomous learning competencies and it improves learning efficiency.The results are consistent with Nie's [19] finding of over 70% satisfaction rate.These findings reveal that students respond well to virtual simulation teaching platforms, and its use could improve their learning.
Virtual simulation platform is conducive to stimulate students' interest in learning and improve their learning initiative.The nursing experiment requires the operator to concentrate.For the students who have just encountered the experiment operation, the tension and pressure in the experimental process cause them to not relax, resulting in mistakes in the operation process.The use of virtual simulation platforms can help students reduce such strangeness and fear of experiment operation by continually practicing on the platform.This platform can help achieve "zero distance" between students and experiments.Students can become familiar with various experiment operations and enhance their experience and feelings of experiments in virtual exercises.
This study showed that 74.6% of participants believed that virtual operation can stimulate learning interest; 66.1% said they liked the operating system; and 59.3% hoped to promote the use of the platform.Applying the virtual simulation teaching platform to the teaching of nursing practice offers many possibilities.Good teaching results have been achieved in online teaching during the pandemic.Good promotional effects have been produced in teachers' teaching methods and students' learning.The virtual simulation teaching platform has achieved initial success.Compared with the traditional laboratory teaching methods, a virtual platform has many advantages.Students also recognize and evaluate the teaching effects of the virtual platform.However, based on the platform, there is still room for improvement in the operation interface and mode.Participants said that technical problems occur at times and the operation process is not smooth enough.Additionally, more complex experiments still need to be developed.
As a result of comparing the autonomous learning competencies after the virtual simulation, the autonomous learning competencies of the nursing undergraduates who performed the virtual simulation was higher than that of the nursing undergraduates who did not proceed with the virtual simulation, and the learning together competencies among each item was lower than that of the nursing undergraduates who did not proceed with the virtual simulation.This result was higher than the previous study for each item and the total score [21,22].As such, it is thought that the virtual simulation helps nursing undergraduates to improve their autonomous learning competencies by increasing their self-managing and imagination.Among them, the reason for the low score in the learning together competencies item is that the virtual simulation is not teamwork, and it is considered that it does not affect the autonomous learning competencies because it is an item that is conducted alone.
For virtual means to simulate experimental operation, it is difficult for students to complete an experiment by moving their fingers.The improvement of learning efficiency by using the virtual platform is mainly reflected in the basic knowledge and experimental process.However, the experiment is not conducted on paper.Students need to improve not only their basic knowledge but also their practical skills.In this survey, only 19 (32.2%) students believed that the virtual operation platform was better than the traditional teaching method.Although the virtual platform has achieved certain results, it still needs continuous progress before it can be really used in the teaching of nursing practice.
In this study, virtual simulation platform teaching has a positive impact on autonomous learning competencies of undergraduate nursing students.It is suggested that this kind of experimental learning should be actively carried out not only during the COVID-19 pandemic, but also in the usual nursing practice in the future.

Conclusion
The emergence of virtual simulation teaching platforms has transformed the teaching of nursing practice in nursing schools, which have just begun to adopt modern technology.In this study, students give a high (above the 80%) evaluation of the virtual simulation teaching platform, which helps to improve autonomous learning competencies of undergraduate nursing students.Recently, nursing schools have employed technologies to diversify the conduct of experiments and promote the development of nursing.Technologies have become crucial in nursing teaching.
However, virtual simulation platform teaching is still in its infancy, and many of its aspects are still undeveloped.It is also not yet tightly integrated into actual teaching.In addition, virtual simulation experiment can only be carried out on a computer side and cannot be used on mobile phones.
Nursing schools should adopt and improve the virtual simulation teaching platform and employ 3D learning.Moreover, we should develop a reasonable model to make the virtual platform and experiment teaching more closely integrated, thereby improving the teaching of nursing practice.

Table 2 Objective evaluation of virtual simulation teaching platform (N = 59)
• Hope to promote the application in the future practice teaching 35 (59.32) 24 (40.68)Submit a manuscript: https://www.tmrjournals.com/in

Table 3 Subjective evaluation of virtual simulation teaching platform (N = 59)
Can solve the problem of not being able to take practice classes offline

Table 5 The scores of autonomous learning competencies for undergraduate nursing students (N = 121)
< 0.001 Submit a manuscript: https://www.tmrjournals.com/in