Simulation-Based Learning for Emergency Preparedness in Nursing Education: A Systematic Review and Meta-Analysis of Gastrointestinal Scenarios

Summary

This study examines how simulation-based learning (SBL) prepares nurses to manage high-risk gastrointestinal emergencies. Overall, SBL improved nurses’ knowledge, teamwork skills, and self-confidence compared with traditional teaching, while its effects on technical skills and professional responsibility were variable. These findings support the integration of simulation training into emergency nursing education.

Abstract

Simulation-based learning (SBL) is increasingly being incorporated into nursing education to enhance preparedness for emergency situations. Gastrointestinal (GI) emergencies represent high-stakes clinical scenarios that require rapid assessment, effective decision-making, and coordinated teamwork. This systematic review and meta-analysis evaluated the effectiveness of SBL in emergency nursing education, with particular relevance to GI-related clinical scenarios. Searches of PubMed, Scopus, Web of Science, and Embase identified studies comparing SBL with non-simulation-based teaching approaches. Standardized mean differences (Hedges’ g) were pooled using random-effects models with restricted maximum likelihood (REML) estimation and Knapp–Hartung adjustment. Heterogeneity was assessed using Q, τ², and I² statistics, and publication bias was evaluated using funnel plots and Egger’s regression test. Eight studies involving 986 participants were included. Pooled analyses demonstrated positive effects of SBL on knowledge acquisition (g = 0.31, 95% CI: 0.12–0.50), teamwork ability (g = 0.66, 95% CI: 0.18–1.14), and self-confidence (g = 1.05, 95% CI: 0.62–1.49). Effects on clinical thinking (g = 0.17, 95% CI: -0.21–0.55), professional responsibility (g = 0.27, 95% CI: -0.11–0.65), and skill performance (g = -0.39, 95% CI: -0.85–0.07) were inconsistent and did not reach statistical significance. Heterogeneity was substantial across all outcome domains (I² > 97%). Overall, SBL may improve knowledge, teamwork, and self-confidence in emergency nursing education, including competencies relevant to GI-related clinical scenarios. However, the small number of included studies and the extreme heterogeneity observed across outcomes warrant cautious interpretation of the findings. The effects of SBL on technical skills, clinical thinking, and professional responsibility remain uncertain and require further investigation.

Introduction

Gastrointestinal emergencies such as acute upper gastrointestinal (GI) bleeding, perforation, or rapid drops in blood pressure due to GI losses require swift decision-making and prompt action. When such cases occur, the role of the nurse becomes essential, beginning with an initial examination and continuing with follow-up, helping with the procedure, and keeping the care team updated. A number of studies have explored the importance of simulation training in equipping nurses to handle such high-intensity situations. Nielsen et al. demonstrated that validated endoscopy simulators can effectively distinguish between novices and experts¹. Rong and Ning reported that nursing interns who used blended teaching models incorporating simulation showed improvements in both theoretical knowledge and practical skills². Wang et al. observed significant gains in knowledge and clinical practice after students participated in in situ emergency simulations³. Moreover, according to Yang and Liu, cooperative scenario simulation combined with problem-based learning can be more effective in terms of critical thinking, professional responsibility, and teamwork⁴.

Gastrointestinal emergencies differ from many other acute clinical conditions. They are frequently chaotic as they have hemodynamic instability, metabolic imbalance, and possible multi-organ involvement. Clinical symptoms can be vague, and unless patients receive prompt intervention, they tend to worsen quickly. Compared with some trauma or cardiac emergencies, which often follow more standardized step-by-step protocols, GI emergencies require heightened clinical judgment, situational awareness, and interdisciplinary teamwork. Here, simulation-based training offers a controlled environment whereby clinicians can train rapid decision-making and team-based reactions in uncertain situations. But even with the continuing use of simulation in nursing education, most of the available research concentrates on topics like cardiopulmonary resuscitation, trauma care, or overall emergency preparedness. Evidence on GI-related emergency situations remains limited and fragmented. Therefore, this review synthesizes evidence from both GI-focused and mixed emergency simulation studies to better understand educational outcomes relevant to gastrointestinal emergency nursing.

Gastrointestinal emergencies also involve educational requirements that differ from those in many other emergency care settings. Nurses managing acute gastrointestinal bleeding, perforation, bowel obstruction, or endoscopy-related complications must integrate rapid patient assessment, hemodynamic monitoring, procedural assistance, blood product administration, and continuous communication with multidisciplinary teams. These scenarios often require simultaneous technical, cognitive, and teamwork competencies under conditions of diagnostic uncertainty and clinical instability. Consequently, educational interventions that are effective in broader emergency nursing contexts may not fully address the unique challenges associated with gastrointestinal emergency care. A focused evaluation of simulation-based learning within this context is therefore justified to identify competencies that may particularly benefit from simulation training.

The available research is promising; however, the evidence is inconsistent. Simulation-based learning (SBL) is believed to enhance knowledge acquisition and learner confidence more often than the research results on technical skills and professional behaviors, which is supported by systematic reviews^5,6. Several studies have reported improvements in self-confidence after simulation-based interventions, but others show no or little change^7,8. The outcomes of technical skills follow the same pattern, with certain interventions reporting effectiveness and others reporting inconclusive or poor outcomes⁹. These discrepancies could be explained by differences in study design, participant characteristics, simulation fidelity, outcome measurement instruments, and educational environment. Consequently, educators and policymakers are challenged to identify the overall efficacy of SBL in GI emergency nursing. To address these uncertainties, a meta-analytic approach was undertaken. Meta-analysis enables the integration of available quantitative evidence to provide a more accurate estimate of the aggregate impact of simulation across various competency domains. Thus, the purpose of this study was to assess the impact of SBL on emergency preparedness and response in nursing education, with particular emphasis on competencies relevant to gastrointestinal emergency care. Six outcome domains were evaluated: knowledge acquisition, skill performance, teamwork ability, clinical thinking, professional responsibility, and self-confidence.

Scalability and cost-effectiveness are also important considerations, particularly in low- and middle-income countries (LMICs) and other resource-limited settings. Although high-fidelity simulators may enhance realism, lower-fidelity approaches, such as standardized patients, tabletop scenarios, and blended models, may provide more cost-effective and logistically feasible alternatives. These considerations are especially relevant in contexts such as China, where nursing education systems must balance educational quality, accessibility, and scalability.

Protocol

Study design and reporting
This systematic review and meta-analysis was conducted to evaluate the effectiveness of simulation-based learning (SBL) for emergency preparedness and response in nursing education, with a particular focus on gastrointestinal (GI)-related emergency scenarios. The objective was to synthesize standardized effect sizes across six predefined learning domains: knowledge acquisition, skill performance, teamwork ability, clinical thinking, professional responsibility, and self-confidence. The review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines¹⁰.

Data sources and search strategy
The literature search involved a systematic search in PubMed, Scopus, Web of Science, and Embase. A combination of controlled vocabulary terms and free-text keywords was used, including nursing, simulation-based learning, emergency or acute care, and gastrointestinal conditions. Boolean operators were applied to improve precision (e.g., “nursing” AND “simulation” AND “emergency” AND (“gastrointestinal” OR “GI bleeding” OR “abdominal pain”)). In addition, manual screening of reference lists from eligible studies was performed to identify any further relevant articles.

The search covered all records available in the selected databases from inception to March 2026. Complete database-specific search strategies, including keywords, Boolean operators, and search filters, are provided in Supplementary Table 1.

The initial database search identified 540 records. After removing 180 duplicate records, 360 articles were screened based on title and abstract. Of these, 300 records were excluded due to irrelevance. Sixty full-text articles were assessed for eligibility, of which 52 were excluded (28 due to insufficient quantitative data and 24 due to full-text unavailability or non-English language). A total of eight studies met all eligibility criteria and were included in the final systematic review and exploratory quantitative synthesis. Two reviewers independently screened titles and abstracts, followed by full-text assessment of potentially eligible studies. Disagreements regarding study eligibility were resolved through discussion and consensus.

Eligibility criteria
Studies were included if they enrolled nursing students or practicing nurses and evaluated simulation-based learning interventions targeting emergency response. Eligible studies involved either gastrointestinal-focused simulation scenarios or broader emergency nursing simulation programs with relevance to gastrointestinal assessment, management, procedures, or patient care. Comparator groups included lecture-based instruction, standard teaching, or routine clinical training. Studies were required to report extractable post-intervention outcome data for at least one predefined domain, including knowledge, skill performance, teamwork ability, clinical thinking, professional responsibility, or self-confidence. Randomized controlled trials, quasi-experimental studies, and other controlled comparative designs were eligible for inclusion.

Data extraction and outcome harmonization
Two reviewers independently extracted data using a standardized extraction form. Extracted information included author name, year of publication, country, study design, sample size, participant characteristics, details of the simulation intervention and comparator, and reported outcome measures. Quantitative data included post-intervention means, standard deviations, and sample sizes for each study group.

Outcome measures were categorized into six predefined domains: knowledge acquisition, skill performance, teamwork ability, clinical thinking, professional responsibility, and self-confidence. Most outcomes were directly assigned according to the definitions reported in the original studies. In a small number of cases, outcomes reported under alternative labels were reclassified according to their primary educational construct to improve comparability across studies. Classification decisions were independently reviewed by two investigators and resolved through consensus. This harmonization procedure was based on established frameworks for the meta-analytic synthesis of educational outcomes¹¹. Although this approach improved consistency across studies, some degree of conceptual overlap or outcome misclassification cannot be completely excluded. The rationale for all reclassified outcomes is provided in Supplementary Table 2.

Effect size calculation
Standardized mean differences were calculated as Hedges’ g with corresponding 95% confidence intervals (CIs) for each outcome. Hedges’ g was selected to correct for small-sample bias and is appropriate for synthesizing continuous outcomes measured using different instruments¹². When necessary, reported statistics were converted to standardized mean differences using standard formulae.

Statistical analysis and data synthesis
Random-effects models were used to compute pooled effects to account for both within-study and between-study variation. To obtain more conservative and reliable confidence intervals, especially when the meta-analysis is done based on a small number of studies, Restricted Maximum Likelihood (REML) estimation with Knapp–Hartung adjustment was used. To determine statistical heterogeneity, the Cochran Q statistic, τ² (between-study variance), and I² statistic, which measures the extent of total variation due to heterogeneity and not sampling error, were used. I² values that were greater than 75% were considered to imply a great degree of heterogeneity.

Forest plots were generated to visually display individual study effect sizes and pooled estimates across outcome domains. The robustness of pooled results was investigated by sensitivity analyses to omit studies that had unclear methodological characteristics. Subgroup analyses were performed based on study design (randomized vs quasi-experimental) and simulation fidelity (high vs low), where data permitted. All statistical analyses were performed using R software (version 4.3.1) with the metafor package. A two-sided p-value < 0.05 was considered statistically significant.

Publication bias assessment
Funnel plots were used to assess visual evidence of publication bias and small-study effects, and the Egger regression test was used to assess statistical evidence of this effect. The Egger test was used to assess funnel plot asymmetry, in which the standardized effect size was regressed on its standard error; a significant intercept indicated the presence of publication bias¹³. The funnel plot asymmetry was viewed with caution, since it can also be caused by substantial heterogeneity or methodological fluctuations rather than selective publication¹⁴.

Risk of bias and certainty of evidence
Each study included was evaluated for risk of bias using a modified ROBINS-I framework. A modified ROBINS-I framework was applied to accommodate educational intervention studies. The assessment evaluated bias arising from participant selection, intervention classification, missing outcome data, outcome measurement, and selective reporting. Domains relating to deviations from intended interventions were simplified because the included studies primarily involved educational rather than clinical interventions. Risk-of-bias assessments varied across methodological domains (Table 1). Most studies demonstrated low risk of incomplete outcome data and selective reporting; however, moderate concerns were frequently identified regarding participant selection, allocation procedures, and blinding due to the educational nature of the interventions. Overall, most studies were judged to have a moderate risk of bias, whereas the prospective validation study by Nielsen et al. demonstrated a lower overall risk profile. The confidence in all the evidence for each outcome domain was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, which considers limitations of the studies, inconsistency, imprecision, and indirectness (Table 2).

Results

Study selection
The comprehensive search strategy initially identified 540 records from four databases. After the removal of 180 duplicate articles, 360 titles and abstracts were screened. At this stage, 300 records were excluded because they did not involve nursing populations, lacked simulation-based interventions, or were not focused on emergency or GI scenarios. This screening process resulted in 60 full-text articles assessed for eligibility. Of these, 28 articles were excluded due to insufficie...

Discussion

This systematic review and meta-analysis suggests that simulation-based learning (SBL) may provide selective benefits across several domains of emergency nursing education, with particular relevance to competencies associated with gastrointestinal (GI) emergency care. The most consistent positive effects were observed for knowledge acquisition, teamwork ability, and self-confidence, whereas findings for skill performance, clinical thinking, and professional responsibility were less consistent. Collectively, the findings ...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Embase	Elsevier	https://www.embase.com	Literature database
metafor package	R Foundation/CRAN	https://cran.r-project.org/package=metafor	Meta-analysis package
PubMed	National Library of Medicine	https://pubmed.ncbi.nlm.nih.gov	Literature database
R (v4.3.1)	R Foundation for Statistical Computing	https://www.r-project.org	Statistical analysis
Scopus	Elsevier	https://www.scopus.com	Literature database
Web of Science	Clarivate	https://www.webofscience.com	Literature database