Training Based on Simulation Pedagogy: Evaluation of Participants’ Satisfaction with the First National Forum on Simulation in Nursing in Morocco

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Introduction
Simulation in the feld of health sciences is an innovative pedagogy. It can help students to apply their knowledge in clinical settings, thus reducing the gap between "knowing" and "doing" [1,2]. Simulation is widely used in the teaching of nursing students in developed countries [2,3]. In Morocco, simulation is not yet integrated into the nursing training programs [4][5][6]. Te nursing literature presents simulation pedagogy as a teaching and learning method that facilitates the transfer of knowledge acquired in academic settings to the clinical settings and allows students to acquire technical and nontechnical skills that are essential to the nursing practice [4,7]. Terefore, it is considered to be an active teaching strategy for the development and shaping of clinical reasoning among student nurses [7,8].
Indeed, simulation-based learning can help nurses provide quality care with positive health outcomes and increase patient satisfaction and confdence in health care services. Scientifc evidence and randomized controlled trials in health sciences have proven the educational efectiveness of simulation-based training (Sim) compared to non-Sim in clinical case management [9]. Furthermore, simulation-based nursing education improves patient outcomes [2,3,10,11].
Although human simulation methodology has its origins in medical education, nursing education has increased its use to improve education for nursing students [12]. Confronted with concrete professional situations, learners are faced with genuine clinical problems in usual working conditions. Learners are thus subjected to the performance of technical acts without any risk. Simulation allows student nurses to develop, synthesize, and apply their knowledge in a replica of real experience [2]. Te essential components of a successful simulation include briefng, simulation, and debriefng exercises. Te main elements are matching the simulation to the clinical reality and the relevant curriculum, providing academic support for briefng and debriefng, and managing the scenario in individual and team settings [2,13]. As a result, this pedagogy helps to improve novice nurses' practice and avoid professional errors toward patients [14].
Tus, training workshops and interprofessional and multidisciplinary forums on simulation in the health sector constitute a scientifc opportunity to share knowledge and understanding, and a refection on care practices [1,2,15]. It is in this context that a National Forum on Nursing Simulation was held for the frst time in Morocco to raise awareness among practitioners on the educational value of such an initiative in the feld of nursing. In this study, we describe the unfolding (organization of the committees, workshops, and of the Sim Nurse-Maroc competition) of the frst National Forum on Nursing Simulation in Morocco and we assess the overall satisfaction of the participants with the diferent aspects of this national event, namely organizational aspects, Master Class training workshop, duration of the event, usefulness, and applicability of the knowledge in the nursing profession Te fndings of this scientifc event could be of great interest to the organizers of future nursing simulation fora in the Maghreb region and Africa more generally, and serve as a model.

Design and Organization of the 1st National Forum on Simulation in Nursing and Health Techniques in Morocco.
Te training of nurses and health technicians is essentially provided by the Ministry of Health and Social Protection (MSPS) in the Higher Institute of Nursing Professions and Health Techniques (HINPHT). Tese institutes have 10 centers and 13 annexes ( Figure 1). Tese institutes are also forum places for scientifc events and continuing education for health professionals of all categories. In recent years, the Ministry has outlined a strategy for developing the skills of the healthcare workforce as a lever for the redesign of the Moroccan national health system by ensuring the quality of training as a guarantee of the quality of care and patient safety.
Being part of a process of continuous quality improvement in their health systems implies a long-term commitment from managers. Tese later will require organizational reform and the development of the skills of health professionals through quality training. In response to these requirements, the Ministry introduced the so-called BMD (Bachelor-Master-PhD) training system in 2013 to meet the training needs of nurses. Tis new training system has paved the way for transforming the Institutes of Health Career Training (IHCT) into Higher Institute of Nursing Professions and Health Techniques (HINPHT) which are classifed as higher education institutions that are not reporting to universities but whose calling is to advance knowledge and deepen research in terms of healthcare and quality of health services.
With this goal in mind, the organization of the frst National Forum on Simulation in Nursing and health techniques at the HINPHT institute of Fez was carried out to promote the use of simulation-based pedagogy in the feld of nursing and to innovate nursing training in Morocco. In fact, a strong collaboration between the Education Division of the Ministry of Health and Social Protection and the HINPHT institutes as well as with the stakeholders represented by the Moroccan Association of Medical Simulation were the key elements to make this scientifc event successful on a national scale. Tus, four committees were established to carry out the organization of this national event on nursing simulation: (a) a pedagogical committee, (b) a communication committee, (c) a logistics committee, and (d) an internal steering committee made up of the management staf of the HINPHT institute of Fez.

Sampling and Data Collection Tool.
At the end of the scientifc event, all participants were invited to fll in a satisfaction questionnaire covering all the activities and pillars of the frst national event on simulation in nursing.
Te data collection tool was a self-administered questionnaire previously tested and validated with a representative sample of 12 participants with the same characteristics and excluded from the study population. Reliability and consistency between sections of the questionnaire were checked by calculating Cronbach's alpha coefcient, which was found to be in the order of α � 90.36%, indicating an excellent level of reliability. In fact, the questionnaire was composed of four sections to collect data regarding: (a) the characteristics of the participants; (b) the satisfaction with the organizational aspects of the frst forum; (c) the satisfaction with the "Master Class" training workshop on simulation pedagogy and its implementation in the nursing profession; and (d) the strengths and areas for improvement in the future, as well as whether those persons in the sample would attend a similar event again and whether they would recommend it to their colleagues. Each of these parameters was evaluated by means of fve criteria according to the Likert scale (very unsatisfactory, unsatisfactory, neither satisfactory nor unsatisfactory, satisfactory, and very satisfactory). In fact, for all four parameters, subitems were developed. For the organization parameter, these criteria are the type of welcome provided to participants, cofee/dinner breaks, orientation/signposting, accommodation, room(s), and choice of training venue (HINPHT). For the training parameter, the subitems concern: the rhythm and sequences of the theoretical course and the hands-on cases, the didactic tools, the technical and logistic material used, and the composition and size of the training team. Te duration parameter concerns: compliance with the time schedule, the time allocated to learning, the duration of the "Master Class," the duration of the competition, and the duration of the forum. Finally, concerning the parameter of usefulness and applicability of the acquired knowledge with regard to the profession, we used the following subitem: the ability of participants to transfer the acquired knowledge and to conduct training sessions by using simulation.

Data Processing and Analysis.
All the information collected was entered and organized in an Excel fle. To calculate the satisfaction scores of the participants, we based the calculation on the diferent items used in the questionnaire. In addition, we coded the participants' answers based on the Likert scale from 0 to 4 for the diferent criteria, including "0" very unsatisfactory; "1" unsatisfactory, "2" neither satisfactory nor unsatisfactory, "3" satisfactory, and "4" very satisfactory. To facilitate the processing and analysis of the satisfaction data, we converted the Likert scale into three criteria: satisfactory, unsatisfactory, and neither satisfactory nor unsatisfactory. After processing the data, the neither satisfactory nor unsatisfactory criterion was found to be weakly represented (1/163) in the order of 0.61% of the overall percentage of participations. Terefore, we did not consider the neither agree nor disagree criterion when presenting the results. Descriptive and correlation statistics were carried out for the presentation of the results and we also calculated the Pearson correlation coefcient to determine the absence or presence of a signifcant linear relationship between variables. For the correlation coefcient to be signifcant, the value must be less than 0.05 (value <0.05). Te calculations of the correlation coefcient and of the value are carried out using the R-Project software version 4.2.1.

Ethical Considerations.
In the present study, all ethical and deontological rules were complied with. Indeed, confdentiality was preserved throughout the study process through the coding and anonymity of the information collected from the respondents. Also, oral consent was obtained from the participants before they completed the satisfaction survey. We limited ourselves to oral consent since this is an observational and noninterventional study. In addition, approval for this project was obtained from the internal steering committee composed of the management staf of the HINPHT institute of Fez.

Results
A total of 250 people participated in the frst National Forum on Simulation in Nursing and Health Techniques in Morocco, which was held at the HINPHT institute of Fez ( Figure 2). Te institutes of origin of the participants were Tetouan, Rabat, Casablanca, Marrakech, Fez, Meknes, Oujda, Agadir, Laâyoune, Beni Mellal, Errachidia, and Settat (ISSS). All participants were invited to take part in our satisfaction survey, 163 of which responded favorably and agreed to complete the questionnaire. Te response rate was 65.2%. Te participants included directors of nursing and technical health education institutes 11 (6.7%), nursing teachers 64 (39.3%), nursing students 68 (41.7%), and health professional guests interested in the event 20 (12.3%) ( Table 1).
Indeed, the participants greatly appreciated the forum and the organization of such a national initiative on nursing simulation. Tey stated that they would recommend and invite their colleagues to participate in this type of event, (163 of them, i.e. 100.0% of the total sample) and that they would like to participate again if such an event were organized in the future (148 of them, i.e., 90.8% of the total sample). On the other hand, when asked what was the main strength of this National Forum on Nursing Simulation, the most frequent answer was the relevance of the content (75 of the participants, i.e., 46.0% of the total sample), followed by the team spirit among the members of the organizing committee (57 of the participants, i.e., 35.0% of the total sample), then the focus chosen for the forum (53 of the participants, i.e., 32.5% of the total sample). When asked about areas for improvement in the future, the most common response was the proposal to increase the number of trained teachers (62 of the participants, i.e., 38.0% of the total sample), to integrate simulation pedagogy into the nursing education programs (58 of the participants, i.e., 35.6% of the total sample), to expand simulation to all nursing options and specialties (56 of the participants, i.e., 34.4% of the total sample), to increase the time allocated to the "Master Class" training workshop (22 of the participants, i.e., 13.5% of the total sample), and to use more efcient logistical and technical equipment (12 of the participants, i.e., 7.4% of the total sample) ( Table 1).
Te analysis of the results of the participants' satisfaction survey showed that there was an overall satisfaction of about 130 persons (80.8% of the total sample) ( Table 1). Per category, the highest satisfaction scores were recorded among the directors of the participating institutes 10 (90.9%), followed by the teachers 53 (82.8%), then the students 54 (79.4%), and fnally the guests 15 (75.0%) ( Table 1).
In addition, participants evaluated the event and reported higher satisfaction with the organizational aspects (132 of the participants, i.e., 81.12% of the total sample), the Master Class workshop on simulation pedagogy (142 of the participants, i.e., 87.60% of the total sample), the duration of the event (131 of the participants, i.e., 80.37% of the total sample), and the usefulness and applicability of the knowledge in the profession (125 of the participants, i.e., 76.68% of the total sample) ( Table 2).
Further analysis of participants' responses revealed that participants' satisfaction was positively correlated with the category of directors (p � 0.001). Our results also revealed that there was a signifcantly positive correlation between teacher category and satisfaction with the Master Class training workshop (p � 0.003). Students reported high satisfaction with the usefulness and applicability of the knowledge (p � 0.004). Other participants reported higher satisfaction with the organization (p < 0.001). More detailed results on the satisfaction of participants according to the diferent pillars of the First National Forum on Nursing Simulation in Morocco are presented in Table 2.

Discussion
In an international and national context marked by demands for quality and good governance, Morocco has signed up to the 2030 Sustainable Development Goals, the third of which concerns health and stipulates that it must "ensure healthy lives and promote well-being for all at all ages." Te quality of education of health professionals was the starting point towards quality nursing care. Furthermore, scientifc forums and training workshops on simulation are essential and ofer 4 Nursing Forum nursing teachers and instructors a platform for professional development in teaching through simulation pedagogy, and an opportunity to exchange practical experiences through networking with peers and simulation experts in the feld of health sciences. It is within this framework that a national forum on simulation in nursing was held for the frst time with "Master Class" training workshops and competitions for the Moroccan "SimNurse" prize. Tis study examined the satisfaction of participants working at the HINPHT institutes regarding simulation in terms of nursing and health techniques. Tese participants were nursing and health techniques instructors and teachers from the diferent HINPHT institutes of Morocco. Indeed, the evaluation of the satisfaction of participants concerning the frst national forum on nursing simulation showed that the level of general satisfaction was 81.6%. Satisfaction per category was 90.9% for HINPHT directors, 82.8% for nursing teachers, 79.4% for students, and 75.0% for guests.
Concretely, the frst national forum lasted three days from June 3 to June 5, 2022, and was supported by the Moroccan Medical Simulation Association. Te frst day was dedicated to the "Master Class" training workshop on simulation pedagogy and its application in health and nursing. Multidisciplinary didactic conferences relevant to all participants covering theoretical and hands-on aspects and the sharing of experiences were scheduled in the evening with the signing of a partnership agreement between HINPHT and Morocco-Sim.
Simulation pedagogy for nursing educators is considered a vital teaching/learning strategy to promote quality nursing care. Currently, basic nursing education programs are focusing more on the use of pedagogical methods to develop clinical skills in nursing students [2,4]. Simulation provides real-time audio and video feedback on the quality of knowledge acquired and skills developed by students, and simulation training also ofers suggestions for improving performance. Tis very favorable innovative teaching method improves quality and patient outcomes [10]. In this context, the analysis of the satisfaction scores of participants showed that the Master Class training workshop on simulation pedagogy received the highest satisfaction score (87.6%), followed by the organizational aspects of the forum (81.12%), then the duration of the event and its activities (80.37%), and fnally the usefulness of the forum about the profession and the applicability of the knowledge acquired (76.68%). Tese results indicate that the event did improve teachers' knowledge and students' practice, and also improved participants' satisfaction. Indeed, the benefts of simulation-based learning in nursing are well recognized [16]. Nursing educators in developed countries have proven the relevance of this pedagogy in the professional development of novice nurses in academic and clinical settings. In developing countries, where health needs are enormous, health educators must be more involved in simulation-based teaching for quality training, optimization of skills, and valorization of the health personnel.
Although the lack of nursing simulation laboratories is an obstacle to student nurses receiving simulation-based learning, the lack of expertise and practitioners who are qualifed in terms of nursing simulation |in Morocco in particular and Africa as a whole is the main factor limiting the development of nurses' skills during their basic training. With this in mind, the organization of this First National Forum on Nursing Simulation in Morocco in particular and Africa as a whole was an opportunity to promote the integration of simulation as an innovative pedagogical method in the basic training curriculum for nurses and to strengthen the partnership with national and international experts to improve the process of developing nurses' skills.
On the other hand, this national forum was also marked by the organization of a national competition between nursing students for the Moroccan "SimNurse" prize. Tis competition was spread over the second and third days. Te competition took place between teams from the 12 institutes of the kingdom and each team was made up of three students. "SimNurse" simulation sessions included hands-on cases of emergencies, chronic diseases, and obstetrics.  Nursing Forum Clinical scenarios were designed and developed by expert practitioners and experienced members of the medical school. Live video recordings and real-time feedback of all simulated clinical situations were projected and shared directly with audiences and juries. As a result, the frst prize of "SimNurse" was awarded to the team of students from the HINPHT institute of Meknes, the second prize was awarded to the team from the HINPHT of Marrakech, and the third prize was won by the HINPHT of Fez.
Of the 163 participants who evaluated the Forum, 12.3% were nursing and health techniques students. Tese students evaluated all aspects of the event and gave an overall satisfaction score of 79.4%. In-depth analysis showed that student satisfaction was signifcantly correlated with the usefulness and applicability of the knowledge (p � 0.004) and with the duration of the forum and of its activities (p � 0.001). Indeed, the simulation does not allow for the inclusion of all variables associated with patient emergencies in real clinical settings [10]. However, simulation presents a controlled genuine environment that can be handled by a teacher or instructor who can stop and restart the learning process if necessary. In actual clinical situations, this option does not exist and each decision can directly infuence patient outcomes [10]. In clinical settings, the management of a patient is multidisciplinary, and teamwork in simulation allows students to acquire and develop group practice which would be a more accurate representation of working in clinical settings [10]. In order to better promote evidencebased learning and decision-making skills, simulation training should be customized and replicate a real situation so that students have an accurate picture of a clinical situation [7,10].
Concerning the perception and viewpoint of the participants towards the diferent activities of the forum, our results showed that 46.0% of the participants considered the relevance of the content as one of the strong points of the national forum, while 32.5% appreciated the choice of the focus areas and activities proposed during the three days of the event. However, 38.0% of the participants expressed the wish to increase the number of trained teachers, 35.6% suggested integrating simulation pedagogy into nursing education programs, and 34.4% recommended extending simulation to all nursing options and specialties. In addition, 13.5% of the participants expressed the wish to increase the time allocated to the "Master Class" training workshop. In this regard, studies have shown that simulation has the power to change the landscape of nursing practice and has many uses in nursing care [17,18]. New applications include basic and continuing education, nursing leadership, advanced practice, interprofessional education, and professional development [17][18][19]. Simulation has become an increasingly accepted practice in educational programs in clinical settings [18]. In addition, clinician education focuses on teamwork, crisis resource management, and error prevention [20]. Simulation-based training is not just for students but has become an approach of many international health science organizations in evidencebased training to help clinicians practice further their education and to help hospitals achieve quality and patient safety goals [16].
Nurses and managers could develop strategies that better support caregivers in identifying and providing quality nursing care that refects responsibility, caring, intentionality, empathy, respect, and advocacy [21]. Nurse educators and teachers could modify curricula to model and teach students the intrinsic qualities identifed in quality nursing care [21].
On balance, this study, which focused for the frst time in Morocco on nursing and health techniques simulation, was well received by Moroccan nursing educators. Te satisfaction scores of participants in the frst national forum on simulation in nursing, as well as in the Master Class training workshop and the competition for the best "SimNurse" in Morocco, were very encouraging for the organization of similar events in the Maghreb region in particular and Africa as a whole. Te study suggested the integration of simulation education in nursing education to actively contribute to the promotion of quality and safety of care. Te study also recommended the adoption of simulation pedagogy as a teaching strategy for nurse educators in Morocco, who are not used to using it in their teaching sessions. Tis pedagogical approach should be encouraged to stimulate the learning process of students. In addition, studies in health sciences as well as the application by medical staf have enhanced the use of simulation pedagogy among other categories of health professionals, which is another favorable aspect of this study. Terefore, improving nursing knowledge and practice through continuing education programs and workshops is essential to develop and advance the knowledge of health professionals [22,23].
Tus, nursing educators, HINPHT managers, and in collaboration with leaders in simulation-based education should translate this national success to a continental scale. It is important to set up local and regional simulation laboratories and to develop the skills of nursing students in Morocco in particular and in Africa as a whole.

Conclusion
Te main results of this study revealed that there was an overall satisfaction of 80.8%. Signifcant diferences were found in participants' satisfaction with organizational aspects (81.12%), the Master Class workshop and the duration of the event (80.37%), and the usefulness and applicability of the knowledge in the profession (76.68%). However, only a few participants were satisfed with the mediation of the Forum (8.6%), the quality of the technical and logistical material used (7.4%), and the duration of the Master Class (13.5%). Tese shortcomings must be taken into account in upcoming editions. Te data from this scientifc event may therefore serve as a model to encourage and improve the 8 Nursing Forum organization of similar fora on nursing and health techniques simulation.