An Action Research on Improving Clinical Nursing Skills of Nursing Students by Intervening With the SimCapture Cloud Management System
Phase: NA
Conditions: Motivation, Clinical Skills Training, Nursing Students, OSCE (Objective Structured Clinical Examination)
Sponsor: China Medical University Hospital

Official Title of the Study: 
Enhancing Clinical Nursing Skills of Undergraduate Nursing Students Through the 
Integration of the SimCapture Cloud-Based Management System: An Action 
Research Study 
 
 
NCT Number: 
Nil 
 
Date of the Document: 
[Aug 19, 2025] 
 
Document Type: 
Document Type: Study Protocol 
 
Sponsor / Institution: 
China Medical University  
 
Principal Investigator: 
Kwo Chen Lee, professor] 
 

1.Research Motivation 
Nursing skills form the cornerstone of developing core competencies in nursing 
education and serve as a crucial medium for nurse–patient interactions, playing an 
essential role in the delivery of professional nursing care. To ensure quality and 
safety, nurses must perform clinical skills in accordance with nursing care principles, 
with confidence and competence (6). Although substantial time and resources have 
been devoted to teaching nursing techniques, both students and newly graduated 
nurses often lack confidence in performing basic clinical skills (7). 
Traditionally, nursing skills education has relied on a teacher-centered approach in 
which the instructor explains the theoretical principles, demonstrates the procedures 
on a simulated patient, and subsequently allows students to practice. Learning 
outcomes are typically assessed through skills examinations or Objective Structured 
Clinical Examinations (OSCEs). However, with generational changes in learners and 
advancements in educational technology, such traditional methods no longer meet the 
demands of modern nursing education or clinical practice (8). In recent years, blended 
learning (9), immersive virtual reality (VR) instruction (10), and simulation-based 
teaching (8) have increasingly replaced traditional approaches, better preparing 
students for real-world clinical environments. 
Over the past several years, our clinical skills teaching team has adopted blended 
learning and simulation-based methods to support students’ skill acquisition. While 
these methods initially improved students’ technical performance, performance scores 
have declined over the past three years as learning styles have shifted. Analysis of 
course data shows a downward trend in OSCE scores for second-year nursing students 
in the Clinical Nursing Skills I course between the 2019 and 2021 academic years 
(Table 1). This highlights an urgent need to develop innovative strategies for nursing 
skills instruction. 
To explore possible causes, the principal investigator conducted end-of-semester 
interviews with students in the 2021 academic year. Among students in the bottom 
15% of OSCE scores, the most frequently cited reasons for poor performance were 
nervousness, mental blanks, insufficient practice, and forgetting procedural steps. In 
contrast, students in the top 15% attributed their success to diligent practice, peer 
collaboration, error correction, and exchanging feedback (Table 2). Overall, poor 
performance appeared to be linked not only to insufficient practice but also to 
difficulties in memorizing detailed procedural steps, low learning motivation, lack of 
peer feedback, and low self-confidence. 

Table 1. OSCE Performance in Clinical Nursing Skills I, 2019–2021 Academic Years 
Academic Year Midterm Score Final Score Overall Average 
2019 
70.4 
52.6 
61.5 
2020 
70.0 
51.2 
60.6 
2021 
68.2 
52.3 
60.25 
Table 2. Experiences and Perceptions of Students in the Top and Bottom 15% of 
OSCE Scores 
Performance 
Group 
OSCE Perceptions 
Learning Experiences 
Top 15% 
Nervousness, high pressure, 
focus on execution, avoiding 
distraction by teacher 
Frequent practice, peer collaboration, 
error-sharing, attentive listening, 
targeted improvement on mistakes 
Bottom 15% 
Nervousness, mental blanks, 
inability to recall steps, lack 
of confidence 
Minimal practice, unclear causes of 
errors, low interest, low self-
confidence 
Nursing skills are frequently acquired through observational learning, also known as 
modeling, whereby individuals acquire new behavioral patterns by observing and 
imitating the actions, attitudes, or emotional responses of others (11). This process 
combines generalized imitation, conditional reinforcement, and rule-governed 
behavior to enhance learners’ self-efficacy and achieve learning goals (12). Prior 
studies have shown that observational learning is particularly effective in disciplines 
that require demonstration of procedural skills (13). 
In the 21st century, shaped by rapid developments in information and communication 
technology (ICT), Industry 4.0, and 5G networks, students tend to process visual 
content more effectively than text and prefer interactive, student-centered learning 
environments (14, 15). Modern learning spaces should therefore employ multimodal, 
flexible, and ICT-based teaching strategies tailored to students’ styles, interests, and 
needs. 
SimCapture, developed by the Norwegian medical education company Laerdal (well 
known for the “Resusci Anne” manikin and emergency simulation scenarios), is an 
advanced medical education management platform that integrates audio, video, 
annotations, patient monitor data, and simulator outputs into a unified web interface. 

As a mobile learning technology, SimCapture enables students to record their practice 
sessions, upload the videos to a cloud platform, and receive targeted instructor 
feedback alongside peer performance reviews (15, 16). By facilitating visual and 
interactive learning, SimCapture aligns closely with the principles of observational 
learning, enabling students to model correct procedures, self-reflect, and progressively 
improve their clinical skills and confidence. 
2.Research Theme and Objectives 
The purpose of this study is to design a SimCapture-based instructional approach 
grounded in the theory of observational learning, in order to enhance nursing 
students’ performance in clinical technical courses. The specific objectives of the 
intervention are as follows: 
 
To improve students’ OSCE scores in clinical technical skills. 
 
To increase students’ learning motivation. 
 
To enhance students’ self-efficacy. 
3.Literature Review 
(1). Observational Learning 
Observational learning, sometimes referred to as modeling or social learning, is a 
process by which individuals acquire knowledge and skills through observing and 
imitating the behaviors of others. During this process, reinforcement, punishment, or 
conditional control can lead to behavioral changes, whether the observation occurs 
intentionally or incidentally. Within observational learning, coding and rehearsal are 
essential concepts. Coding involves transforming observed behaviors into internal 
representations that can be stored and later reproduced, while rehearsal refers to the 
practice of these internalized behaviors. Particularly, symbolic coding—in which 
observed behaviors are encoded using numbers or letters and immediately 
rehearsed—has been shown to yield the most effective results. Coding without 
symbolic rehearsal, or symbolic rehearsal without coding, is insufficient to achieve 
optimal learning outcomes. 
The process of observational learning consists of four key stages: attention, 
retention, reproduction, and motivation (Figure 1). Coding and rehearsal are therefore 
critical mechanisms that enable individuals to convert observed behaviors into 
internal codes that can be memorized and imitated, forming the foundation for 
learning and behavioral modeling. 

Empirical studies support the effectiveness of observational learning in 
procedural skill acquisition. For instance, Huun (2023) demonstrated that medical 
students who viewed instructional videos on high-risk patient assessment showed 
improved accuracy, higher satisfaction, and greater confidence. Another study 
involving nursing students learning intramuscular injection techniques compared three 
groups: one observed instructor demonstrations only; one observed and conducted 
self-evaluation followed by instructor discussion; and one observed, self-evaluated, 
engaged in instructor discussion, and participated in peer group evaluations. The third 
group, which combined observation, self-assessment, and peer feedback, performed 
significantly better than the other two groups. 
(2). Theory of Learning Motivation 
Motivation is defined as the process that initiates, directs, and sustains goal-
oriented behaviors, guiding individuals to act in order to achieve objectives or satisfy 
needs. Learning motivation, in particular, provides learners with the drive to persevere 
in their studies despite difficulty and challenge. It serves as a powerful force that 
directs learners toward their academic goals. Students’ level of motivation is reflected 
in their degree of engagement: highly motivated students participate actively without 
requiring external rewards, whereas students with lower motivation often require 
extrinsic incentives to participate. Factors that support motivation include challenge, 
curiosity, control, imagination, competition, collaboration, and recognition. 
According to Ryan and Deci’s (2000) self-determination theory, motivation can 
be categorized into intrinsic and extrinsic forms. Intrinsic motivation drives 
individuals to engage in academic activities for enjoyment, challenge, or uniqueness, 
without external rewards or pressures. Such motivation is highly self-sustaining and 
long-lasting. Extrinsic motivation, in contrast, is driven by external influences such as 
rewards, obligations, or punishments. Although extrinsic motivation may foster short-
term persistence and effort, it does not provide the same durability as intrinsic 
motivation. Importantly, both intrinsic and extrinsic motivation play roles in learning: 
extrinsic factors may initiate motivation in the early stages of learning, but should 
ideally transition into intrinsic motivation as the learning process deepens. 
In summary, motivation represents a cornerstone of the learning process. 
Students must cultivate strong intrinsic and extrinsic motivation to face challenges, 
comprehend processes, and apply knowledge effectively in practical contexts. 
(3). Theory of Self-Efficacy 

In addition to acquiring effective learning skills, students must also develop the 
confidence to perform these skills. Self-efficacy is defined as an individual’s belief in 
their capability to organize and execute the actions required to achieve specific goals. 
For nursing students, this refers to their perceived ability and confidence to perform 
technical tasks and achieve competence. Self-efficacy can be enhanced through four 
pathways: successful mastery experiences, vicarious experiences (observing others’ 
successes), verbal persuasion, and maintaining willpower and persistence. Previous 
studies have identified self-efficacy as a mediating factor between learning strategies 
and academic achievement. For example, a longitudinal study of 87 Italian university 
students found that self-efficacy mediated the relationship between learning strategies 
and academic performance. Similarly, Chen et al. (2018), analyzing the Taiwan 
Education Panel Survey, reported that students’ self-efficacy was significantly 
associated with learning achievement, and that higher self-efficacy at the beginning of 
a course positively influenced both the rate and level of learning achievement. 
Bandura’s (1980) self-efficacy theory emphasizes that self-efficacy is not merely 
the possession of skills but the confidence in applying them across diverse contexts. It 
can be differentiated along three dimensions: 
 
Level: the perceived ability to perform tasks of varying difficulty. For instance, 
students may select tasks appropriate to their capability, with efficacy 
expectations differing according to task difficulty. 
 
Generality: the transferability of self-efficacy beliefs from one learning context 
to other similar or distinct contexts. Some experiences yield limited success, 
while others generalize across multiple situations. 
 
Strength: the resilience of efficacy beliefs when faced with obstacles. Stronger 
efficacy beliefs increase persistence and the likelihood of task completion, 
whereas weaker beliefs are easily undermined by failure. 
4. Instructional Objectives and Methods 
This study will be implemented in the mandatory courses Clinical Nursing Skills 
I and Clinical Nursing Skills II (2 credits each, 4 hours per week) for second- and 
third-year undergraduate nursing students. Each course covers 16 essential nursing 
techniques. The instructional objectives are as follows: 
 
To perform nursing procedures accurately. 
 
To demonstrate humanistic care, empathy, and communication skills when 
performing nursing procedures. 
 
To apply critical thinking to problem-solving in clinical practice. 

 
To exhibit professionalism and responsibility in the execution of nursing tasks. 
4.1. Course Design and Planning 
The curriculum is aligned with the Fundamentals of Nursing course, which is 
structured according to Gordon’s 11 Functional Health Patterns. Each week, the 
clinical skills course corresponds to the same week’s theoretical content. The 
remaining five weeks cover techniques that are not directly linked to weekly 
theoretical content, such as vital sign measurement, medication administration, and 
injection techniques. Two additional weeks are allocated for skills examinations.The 
course content integrates theoretical and technical components. The theoretical 
component includes anatomy, physiology, pathology, pharmacology, health 
assessment, and ethical considerations related to each nursing skill, incorporating the 
concept of evidence-based practice. The technical component relies on instructional 
videos produced by faculty members, covering equipment preparation, procedural 
steps, and key considerations. The main reference text is the OSCE skills manual co-
authored by the clinical faculty. 
Teaching activities include both online and in-person sessions. Online learning 
allows students to independently review theoretical content and instructional videos 
outside of class. In-person sessions (4 hours per week) are held in the skills 
demonstration laboratories, where nine faculty members provide demonstrations and 
guided practice in small groups. Faculty members evaluate each student’s 
performance using structured checklists, providing individualized feedback on 
strengths and areas for improvement. 
During practice, instructors emphasize patient perspectives, encouraging students 
to demonstrate empathy, compassion, and communication skills. As observational 
learning accumulates from peer performances, later-performing students often 
demonstrate improved techniques. At this stage, instructors introduce potential 
procedural challenges, guiding students to apply critical thinking and develop 
problem-solving abilities. Following each class, students are provided with two hours 
of independent practice time in the laboratory (without instructor supervision or 
course credit), and they are encouraged to post questions and engage in online 
discussions when encountering difficulties. 
4.2. Student Assessment and Evaluation Tools 
Student performance will be assessed using the following tools: 
 

Skills Examinations: Practical OSCEs evaluating core clinical skills. 
Written Examinations: Theoretical assessments through multiple-choice and short-
answer questions. 
Quizzes: Short tests to reinforce knowledge and monitor progress. 
Independent Practice Participation: Records of students’ engagement in self-directed 
practice sessions. 
5. Research Participants and Setting 
This study will be conducted in the Clinical Nursing Skills courses for second- 
and third-year undergraduate nursing students in the 2024–2025 academic year. The 
study population will include approximately 170 students (about 85 students per year, 
with possible attrition due to withdrawal or leave of absence). 
Before class, students will engage in pre-class learning through the Moodle 
system, which includes theoretical principles of nursing skills and instructor-produced 
instructional videos, supplemented by a technical procedures manual. In the practical 
sessions, the SimCapture simulation-based training platform will be introduced to 
support course integration, management, and evaluation in a cloud-based format, 
thereby facilitating effective post-class learning. 
All participants must complete a video-recording consent form prior to 
participation. Students who decline recording will be excluded from the study and 
will not be provided with an account or password. Video recordings will capture only 
hand movements to minimize facial identification. Each student will receive a unique 
account and password, and students will only have access to their own group’s videos. 
6. Research Methods and Instruments 
This study will adopt an Action Research approach. Action research is a 
methodology designed to improve practice and address real-world problems, 
commonly applied in fields such as education, social sciences, and healthcare. It 
involves iterative cycles of problem identification and planning, action 
implementation, observation and reflection, and revision and re-planning. A defining 
feature of action research is its emphasis on practical change, participatory 
collaboration, and reflective practice.The implementation steps of this study are as 
follows: 
(1) Planning the Intervention 
The research theme is defined as “designing nursing procedural instruction based 
on observational learning theory.” The intervention plan will be grounded in relevant 
literature on symbolically coded procedural steps, enhancement of learning 
motivation, and reinforcement of self-efficacy. 
(2) Executing the Intervention 

The SimCapture teaching management platform will serve as the central tool for 
course delivery. This cloud-based system captures audio, video, annotations, and 
various types of data to facilitate effective training management, documentation, and 
evaluation. In this study, SimCapture will be applied in the following ways: 
Each faculty member and student will be provided with a personal account, and the 
platform will group participants accordingly. 
Faculty will develop digital assessment and evaluation tools for each nursing 
skill. During in-class rehearsal, instructors will annotate student performance using 
tablets on the cloud system, while students will record their own procedures on 
mobile devices and upload them to the cloud platform. Students will be able to view 
their group members’ videos, along with instructor feedback, to learn from peers’ 
strengths and correct errors, thereby improving learning outcomes. The platform will 
be accessible both in the simulation laboratory and remotely, enabling students to 
review, practice, and participate in asynchronous discussions without time or location 
restrictions. Students can document their learning progress, which enhances 
motivation, self-efficacy, and confidence in skill mastery. Faculty will be able to 
monitor student learning, respond to questions, and review learning histories to design 
individualized or remedial instructional plans. 
(3) Monitoring the Intervention (Data Collection and Feedback) 
Throughout the intervention, feedback data will be continuously collected (Table 
3), including: 
 
Student learning portfolios 
 
SimCapture backend learning records 
 
Self-efficacy questionnaires 
 
Learning motivation questionnaires 
These data will serve as the basis for reflection and revision of the action plan. 
Additionally, trained teaching assistants (TAs) and part-time assistants will serve as 
observers to support the teaching process and document observations. 
(4) Data Analysis, Reflection, and Adjustment of the Action Plan 
The feedback data collected will be preliminarily organized and analyzed to 
continuously identify areas where the technical learning process can be strengthened 
and to explore difficulties encountered by students. Based on these findings, the 
action plan will be critically reviewed, reflected upon, and adjusted accordingly. 
(5) Research Report Writing 
The results and research findings observed during the process of strengthening 
collaborative learning will be documented and compiled into a comprehensive 
research report. 
7. Research Instruments 

The primary aim of action research is to collect data in order to better understand 
the characteristics of the teaching context (Johnson, 2004, 2006). Accordingly, this 
study will employ multiple research instruments, including a self-efficacy scale, a 
learning motivation scale, OSCE scores, and qualitative learning portfolios. A brief 
description of the instruments is provided below: 
 
(1). Self-Efficacy Questionnaire 
Based on Bandura’s (1986) theory of self-efficacy, which encompasses the three 
dimensions of level, generality, and strength, this study will develop a self-designed 
self-efficacy scale tailored to the nursing technical skills course. To minimize the 
burden on students of responding to multiple items, the scale will consist of three 
items. The questionnaire will undergo expert review for content validity and 
subsequent revisions. 
(2). Learning Motivation Questionnaire 
This study will adopt the Learning Motivation Scale (LMS) developed by Liu 
Cheng-Hung (2010) in Taiwan. The LMS was adapted from the Motivated Strategies 
for Learning Questionnaire (MSLQ) by Pintrich, Smith, Garcia, and McKeachie 
(1991), with modifications to reflect the Taiwanese cultural context. The scale 
consists of 14 items and is widely recognized as one of the most commonly used 
instruments for evaluating learning motivation. 
(3). OSCE Scores 
Students’ technical performance will be assessed using OSCEs, administered 
twice per semester (midterm and final). Each OSCE will cover nursing skills taught 
during the course. The OSCE blueprint includes examinee guidelines, standardized 
patient instructions, examiner guidelines, scoring criteria, evaluation forms, 
equipment lists, and a demonstration video. The scoring rubric evaluates preparation, 
procedural performance, communication and caring expressions, health education 
content, and overall logical flow of operations. Exam content will be determined by 
the Clinical Nursing Skills teaching committee and validated by five clinical nursing 
experts and faculty members prior to implementation. 
8. Data Analysis 
(1) Quantitative Data 
Questionnaire data will first be organized in Excel, and the accuracy of data 
entry will be verified. Preliminary descriptive statistics will be conducted using SPSS, 
followed by appropriate statistical analyses according to the nature of each research 
question. A significance level of p < 0.05 will be adopted to determine statistical 
significance. The corresponding research questions and statistical methods are 
summarized in Table 6. 

Correspondence Between Research Questions and Statistical Methods 
Research Question 
Statistical Method 
What are the differences in self-efficacy, learning motivation, 
and OSCE performance between the two groups at the first 
measurement? 
Independent samples t-
test 
What are the trends in changes in self-efficacy between the two 
groups? 
Generalized Estimating 
Equations (GEE) 
What are the pre- and post-test changes in learning motivation 
and OSCE scores within each group? 
Paired samples t-test 
What are the post-test differences in learning motivation and 
OSCE scores between the two groups? 
Independent samples t-
test 
 
(2) Qualitative Data 
Qualitative data will be analyzed using content analysis. Learning portfolio 
records will be systematically coded and categorized, with each entry labeled by 
collection date and source (e.g., file, questionnaire, observation, or reflection). 
Students will be assigned identification codes in the format *S-n-*****. 
The principal investigator will first classify and organize the collected data, then 
repeatedly review and integrate the categorized materials. Data will be refined and 
regrouped into appropriate categories, with iterative reading and reclassification until 
the categories adequately represent distinct characteristics. This cyclical process 
ensures analytic rigor and reliability. 
To protect participants’ rights, identifiable student learning records will not be 
directly presented, and particular care will be taken to avoid any breach of 
confidentiality or learning equity. 
 
8. Ethical Considerations 
Prior to study implementation, the research protocol will be submitted to and 
approved by the Institutional Review Board (IRB) of the study site. All data will be 
de-identified before analysis. Before participation, students will be fully informed of 
the purpose of the study and the evaluation procedures. They will be explicitly 
advised that participation is entirely voluntary, that they retain the absolute right to 
refuse to answer any question, and that they may withdraw from the study at any time 
without providing a reason. Students who withdraw will still complete written 
examinations, OSCEs, coursework, and self-directed learning sign-in records and will 
remain eligible to receive course credits. Students who agree to participate will be 
asked to provide written informed consent. All questionnaires will be collected 

anonymously. Interview data will be kept strictly confidential, and all collected data 
will be coded to ensure participants’ names are not disclosed. Hard-copy data will be 
stored in locked cabinets, while electronic data will be password-protected to prevent 
unauthorized access. 
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