Mixed methods evaluation of megacode simulation training to enhance clinical reasoning and decision making in critical care nursing

Background

Effective clinical judgment is essential for critical care nursing, yet few studies have comprehensively examined how simulation training impacts both technical and cognitive development. This study evaluated the effectiveness of megacode simulation training, coupled with structured debriefing, in enhancing clinical reasoning and decision-making among fourth-year Bachelor of Science in Nursing (BSN) students.

Materials and methods

A convergent parallel mixed methods design was employed. Quantitatively, 150 BSN students completed pre- and post-tests using the Lasater Clinical Judgment Rubric (LCJR), analyzed with non-parametric tests. Qualitatively, ten focus groups and 20 interviews were thematically analyzed under a constructivist paradigm. Findings were integrated through data triangulation.

Results

Quantitative findings demonstrated significant improvements across all LCJR domains (p < .001), with large effect sizes (Cohen's d ≥ 1.01), particularly in prioritizing data and skillful intervention. Qualitative analysis revealed six themes, including growth from chaos to clarity, increased confidence under pressure, improved communication, and enhanced critical thinking. Students described transformative learning experiences that bridged the gap between theoretical knowledge and clinical application. Integration of findings confirmed that megacode simulations foster both technical proficiency and cognitive-emotional development.

Conclusion

Megacode simulation training significantly enhances students' clinical judgment, critical thinking, and teamwork. Despite limitations in sampling and short-term outcome evaluation, the findings affirm the value of experiential, reflective simulation learning. Systematic integration of simulation across nursing curricula and longitudinal follow-up studies are recommended to maximize and sustain clinical competence development.