Limited exposure to patients with variable conditions results in nursing students not receiving the necessary experience to become competent and confident practitioners [1]. This poses a problem in the clinical setting to newly qualified nurses as they are expected to demonstrate certain skills and attributes. Reinhardt et al. [2] assert that for a student to assume a nurse’s role, he or she should possess a positive self-disposition. This is attained by focussing on both technical and non-technical skills during simulation, such as critical thinking, confidence and teamwork. It is therefore appropriate that nursing institutions take on the responsibility of implementing teaching strategies that promote learners’ confidence and competencies [3].

Confidence during simulation is further influenced by emotions elicited during the simulation experience. Bandura [4] asserts that emotional arousal affects perceived self-belief and abilities when the individual is faced with threatening situations. Simulation can be a catalyst for the student to deal with emotions such as fear, anxiety and stress, which they may encounter in the real clinical environment [5]. Participants from several studies highlighted how simulation helped to reduce anxiety and fear experienced regarding certain procedures in the clinical environment [6, 7], One study, interestingly, also found that simulation can cause students to experience fear and anxiety [8]. These emotions are said to be elicited by exposure to simulation for the first time and being consciously aware of being watched. Finding educational experiences challenging or stressful may, in fact, produce positive changes in learners that may beneficially influence their preconceived assumptions and opinions [9]. Hall [10] affirms that the more students improve their competencies and skills, the more motivated they are to become competent in those skills. Tuzer et al. [11] posit that the development of psychomotor skills is important in the development of nurses’ competencies. If students are unable to obtain confidence in skill performance, it becomes impossible to transfer the skill to the clinical environment [2].

Differing simulation fidelities can be used to expedite the transfer of skills to the clinical environment, from task trainers to high-fidelity simulation. Part task trainers, which are low fidelity, are valuable for the attainment of technical skills but do not address the attainment of non-technical skills such as communication [12]. A comparative study conducted by Tuzer et al. [11] on the use of Standardised Patients (SP) and high-fidelity simulators found that High-Fidelity Simulation (HFS) enhances transferability of skills. Participants who were exposed to HFS found the mannequin convincing as it had audible lungs and heart compared to the standardised patient SP which could not demonstrate such physiological phenomena. Furthermore, Master of Nursing students in a study by Kowitlawakul et al. [13] found the use of SP restrictive as they were not able to display physiological changes. Experiencing such challenges can interfere with the transferability of skills to the clinical environment.

The creation of an authentic simulation environment is important both for attaining the ultimate simulation experience and for meeting the learning objectives. Several studies have been conducted to evaluate the realism of differing levels of fidelity in [14-16]. Participants in these studies perceived simulations that involved standardised patients, community volunteers and hybrid simulators as more realistic than high-fidelity simulators. They considered actors wearing masks more realistic than mannequins [14]. This is in direct contrast to studies that only evaluated the realism of HFS [17, 18]. The participants in these studies affirmed the realism of the high-fidelity simulation. The participants found the simulation immersive, as the mannequin could speak and had an audible heart and lungs.

In order to be authentic, simulation equipment commonly used in practice needs to be of a kind that students can relate to [19]. This is keeping with Gaba’s [20] words that ‘simulation is a technique, not a technology’ – meaning that emphasis should not be on the equipment itself but on the valid use of the equipment. Argani, et al. [21] state that the biggest mistake that training institutions make is to furnish the simulation laboratory before designing the learning programme. Designing the simulation environment should take into consideration who the learners are and what their learning needs are. The simulation environment should be designed in such a manner that it resembles the real world, from the clock on the wall telling the correct time to the type of documentation used. Studies have demonstrated how seemingly mundane items such as charts and documents can be an important part of a simulation environment [14, 15, 22]. The participants in the study by Luctkar-Flude et al. [15] did not perceive the simulation as real and therefore did not see the importance of the documentation. This contrasts with the findings of another study [14] where 78% of their participants perceived charts and documents used in simulation as being similar to the clinical environment.

Design of the simulation space is dependent on the cost of the simulation equipment and its availability Gaba, Smith et al. [20, 23]. state that the cost of the simulation is dependent on the target population, the purpose of the simulation and the technology used. Lapkin et al. [24] conducted a study on the cost-utility analysis of high-fidelity mannequins versus low-fidelity mannequins. The study found that medium-fidelity simulation was cost-effective in helping to impart non-technical skills, such as clinical reasoning, knowledge acquisition and student satisfaction. This is in contrast to the results of a study conducted by Basak et al. [25] comparing HFS and Low-Fidelity Simulation (LFS). The students exposed to LFS scored low in simulation design, concentrating on fidelity amongst other things, compared to the students exposed HFS

There are limited studies that investigate the effect of medium-fidelity simulation on student midwives. Most of the literature found is based on High Fidelity Simulation (HFS) using high-fidelity mannequins. Progressive and comparative studies that have been conducted in low, medium and high-fidelity simulation investigated communication, knowledge and clinical readiness [16, 26, 27]. Comparative studies investigating the use of high and low fidelity simulation on student nurses’ confidence showed that high–fidelity mannequins increase student confidence more than low–fidelity mannequins [2, 25]. The participants in a study conducted by Fuselier et al. [28] asserted having gained confidence during simulation using mannequins. Furthermore, findings from several studies indicate that HFS enhances confidence in learners [5, 9]. Studies have shown that repeated exposure to HFS increases students’ confidence [5]. The aim of the study is to explore the lived experiences of student midwives after exposure to medium-fidelity simulation concerning confidence and satisfaction

An Essential Steps in Management of Obstetric Emergency (ESMOE) post-partum haemorrhage (PPH) video was sent on-line through Blackboard to all fourth-year student midwives in order to demonstrate the process. Management of PPH is one of the contents that are taught in the midwifery high-risk module. The student midwives had an opportunity to watch the video repeatedly in order to thoroughly comprehend the demonstrated skill. The day before simulation the six bedded simulation laboratory was prepared for the PPH simulation. Only four-bed spaces were used for the simulation. The advanced OB Susie a Gaumard simulator with an audible foetal and maternal pulse was filled with simulated blood and urine and was positioned in the centre of the bed. Four large dressing trolleys were prepared with all the equipments needed for the management of PPH. Each bed space had an oxygen outlet with an oxygen mask and two drip stands and a blood pressure machine and relevant ward documentation. The Nursing Science Department recruit members of the community to pretend to be SPs for some of the undergraduate practical program. The SPs were provided with a scenario. Critical points of the scenario were explained to the SPs such as when to call for the nurse, when to pass out and when to regain consciousness, what question to ask. The SPs clad in hospital gown were positioned above the OB Susie torso to create a hybrid. The hybrid was draped with green towels. On the day of the simulation, the students were given the simulation scenario to read prior to the simulation. The ESMOE video was played for the group a second time before the demonstration of the simulation. The students decided among themselves which roles to play during the simulation.

The super-ordinate theme sense of fulfilment elicited the following subthemes:

There is mounting evidence that teaching students complex skills in a relaxed, conducive and safe environment increases students’ sense of confidence regarding the various skills required in the clinical environment [6]. The use of simulation to teach concepts relevant in midwifery has been widely implemented in order for such skills to be transferred to the clinical environment [30]. The effectiveness of learning transfer during simulation is further stressed by Rush et al. [31].

The use of a standardised patient during the simulation instead of a mannequin has prepared participants for the real clinical environment. This is consistent with the findings of Pike and O’Donnell [32] in their study on the authenticity of the simulation experience, where participants found it difficult to transfer the skills they had acquired after using mannequins. The use of mannequins was reported to have a negative impact on the credibility of the simulation. On the other hand, in a study conducted by Choi [33], student nurses found it difficult to apply the skills they had learned in a psychiatric simulation using a standardised patient. This was attributed to the fact that the real psychiatric patient is not scripted, and therefore will not give the predictable responses and behaviour that the standardised patient gives. A study conducted by Reinhardt et al. [2] supported the use of low fidelity intravenous training arm in teaching students basic clinical skills such as intravenous line insertion. .Lapkin’s [24] comparative study found no significant difference between medium and high-fidelity simulation on knowledge acquisition and satisfaction.

The findings of this study showed that after being involved in the simulation, participants became more inquisitive regarding the management of the simulated condition. This is consistent with the findings of the study done by Rush et al. [31] on the effect of simulation -- where third-year Bachelor of Nursing students found simulation thought-provoking, instigating them to reflect on the care they gave to patients. Similarly, Straub et al. [9] found that an increase in the confidence of students during simulation encouraged them to learn more about obstetric emergencies, which ultimately would improve patient care. Having been exposed to the use of mannequins in the management of obstetric emergencies, one participant in this study felt completely prepared to deal with such emergencies in the clinical environment. This is congruent with the findings of the study done by Brady et al. [16] on the use of varied levels of simulation fidelity, in which students were exposed to progressive-fidelity simulation repeatedly, scoring higher in tests than students exposed only once to one level of simulation fidelity.

The participants in the present study compared their simulation practice with previous experiences of PPH management in a clinical environment. Participants’ knowledge of the progressive steps in the management of PPH increased after exposure to PPH simulation. This concurs with Kaplan et al. [34] findings in a study on emergency preparedness disaster simulation (EPDS), where student nurses reported that the use of EPDS increased their knowledge of disaster management. Having acquired new knowledge, one participant in that study became enthusiastic about sharing his knowledge in the clinical environment with other staff members. Reinhardt et al. [2] asserted that success in the clinical environment was influenced by the student’s level of confidence in the simulation environment.

The findings of this study showed that participants’ satisfaction with simulation depended on whether the simulation activity met the student’s expectations, and if the simulation equipment resembled real clinical equipment. Smith et al. [23] stressed that the simulation environment should reflect reality as much as possible. Simulation attributes enable learning in undergraduate students [35]. The third-year midwifery students in a study conducted by Carolan-Olah et al. [36] expressed low confidence in using the resuscitation equipment. This was attributed to the fact that the student midwives found the simulation stressful, causing them to focus more on simulating the scenario than on using the equipment correctly.

The participants in this study said that the simulation enabled them to see and use some of the equipment for the first time. The participants found the experience overwhelming, but this did not deter their participation. In Kaplan et al.'s [34] study o students found the equipment realistic, shocking and overwhelming. The students in that study found the simulation more effective and realistic than others they had experienced because of the high standard of equipment used. Brady et al. [16] posit that inadequate equipment hinders simulation learning. In the present study, the participants were satisfied with the simulation because it was well-equipped - enhancing experiential learning

The realism of the simulation environment is the key determinant to how effective the simulation is. The simulation experience must be immersive enough to make the student become ‘lost in the moment’. The use of the standardised patient was seen by one participant as adequate preparation for the real clinical environment. These findings are consistent with the findings of Choi [33] on the use of standardised patients during psychiatry simulation which made the student imagine what the clinical environment would look like.

Comparing the SP with the use of a low-fidelity mannequin made participants aware of the benefits associated with the use of the SP. The fact that the SP was able to communicate helped students to understand the situation. This is comparable with the findings of Kaplan et al. [34] on the incorporation of real patients during emergency preparedness disaster simulation. The students in that study reported that increased realism help them to immerse themselves in the situation and respond more accurately. The synergy between the two simulation models, namely the task trainer and the SP, increased the realism of the simulation [23, 37]. This is consistent with the findings of this study, as one of the participants acknowledged the use of the SP and part-task trainer. The participant reported how communicating with the SP made the simulation authentic.

Participants identified the gap between theory and practice and how the PPH simulation had bridged that gap. Participants felt that the PPH simulation painted a clear picture of how things can rapidly deteriorate during real-life situations. Yardley et al. [38] suggest that the learning gaps that are identified in teaching modalities should not be used to find faults but to point to areas to focus on in practice. Simulation is the ideal tool to bridge the gap between theory and practice [18].

Successfully resolving PPH does not depend only on the time that elapses from the onset of bleeding, but also on factors such as the amount of blood loss, the cause and origin of the PPH and general maternal condition. One participant verbalised that they wasted valuable time discussing options among themselves. However, two participants felt that they had resolved the PPH within an acceptable time and that discussion had helped them to locate the cause of the bleeding. Kurrek et al. [39] posit that in a PPH emergency, time may not be an optimal indicator of performance and competence. They further argue that a set time may not work well when there are many possibilities to resolve the problem. Su [40] assert that clinicians who are caring for a pregnant woman should be skilled and knowledgeable to manage patients with PPH timeously. They further conclude that there should be a dedicated person to record the sequence of events and the timing of medical interventions.

The study focused on the lived experiences of fourth-year student midwives utilising simulation laboratories at one university, its findings cannot be generalized to other universities in South Africa. Therefore, exploring the views of the nursing students in other universities is needed.

The ultimate desired outcome of simulated experience is to increase the student confidence thus making them competent clinical practitioners. The participants were able to relate the simulation to the real clinical environment. Simulation increased the student confidence in making them feel that they can at least try to manage an obstetric emergency when confronted by it. The participant knowledge of the management of PPH was increased after exposure to the simulation.