The healthcare environment is constantly evolving due to significant epidemiological changes and technological and scientific advances [20]. This context calls for a competent professional capable of managing these changes. The use of simulation has become a much greater necessity in nursing education to keep up [21].

Increasingly, studies have confirmed the value of simulation in nursing education [17, 22, 23]. This teaching technique accelerates learning and gives students the necessary skills to prepare them for clinical settings. The simulation context allows reproducing scenarios as close to reality as possible, providing a framework with the freedom to make mistakes [4]. The learner applies what they have learned in a safe environment, and the debriefing they receive allows them to identify errors and adjust their learning.

The many simulation techniques can be included in cognitive, emotional, and psychomotor learning styles. Low-fidelity or partial task forms allow repetitive technical training until the gesture is mastered [10]. The more advanced versions offer a framework that combines several contextual factors to reproduce scenarios that become more difficult as they progress by actively involving the student in their resolution. Simulation thus contributes positively to the development of clinical reasoning.

Simulation has also emerged as a valuable tool for improving soft skills. Its beneficial effects on team management, communication, and even crisis management have been supported by several studies [14, 15, 19]. However, given the wide range of accessible simulation tools, it is crucial to be aware of the pedagogical intentions and practices that accompany them.

The value of simulation in the training of nursing students is indisputable. Teachers report that these resources help them to maximise their efforts [15]. However, the effective and efficient use of simulation techniques is hampered by several factors. Many studies have examined these barriers [13-24, 26]. One of the studies identified seven categories: time, training, perception of ownership of tools in the course, equipment and space planning, funding, and personnel and student engagement and involvement in simulations [27].

Simulation in its advanced forms has seized the opportunity offered by technological progress. New tools have become highly sophisticated, including high-fidelity interactive manikins and virtual reality, significant gains for simulation. However, this evolution is not always equal to the performance of practitioners. Teachers are left to their own devices to use these sophisticated instruments [26, 27], and their application often destabilises them, hence the need for support for the safe and effective use of these technologies is required [28, 29].

Seen from another angle, the integration of these advanced tools into teaching practices requires considerable knowledge. According to several studies, this implementation translates into new pedagogical requirements to achieve a convincing articulation between knowledge and methods [27]. Therefore, its success can only be ensured by careful educational restructuring in accordance with standardised norms of good practice [5].

In addition to these specific challenges, managing simulation use in training is hampered by a lack of financial resources, a lack of facilities and equipment, and a shortage of expert personnel in the field [27, 26].

The use of simulation as a teaching technique to train health professionals has developed considerably. Many countries in Europe and North America, as well as Australia, support its use as a supplement to traditional teaching and learning techniques [30] or even its formal integration into training programmes [2].

In North America, simulation reflects excellence in training and is integrated into basic and continuing education programmes. This success is supported by the field of research, which has evolved considerably. Research is interested in the study of simulation in all its aspects, including its objects and tools [10]. Studies have shown that under certain circumstances, such as the availability of sufficient experienced instructors, simulation can replace up to 50% of nursing placements [20]. These results were sustained during the unprecedented COVID-19 crisis when the simulation was widely used and able to substitute hours of internships [31].

Following the example of other countries, Morocco is part of this vast project of pedagogical development of simulation. For years, efforts have been made in this direction, through multiple partnerships with organisations to promote the use of simulation. We highlight the contribution of some non-governmental organisations and the Moroccan Society of Medical Simulation to the generalisation of simulation laboratories at the level of Higher Institutes of Nursing and Health Technicians (Ministry of Health, 2022). The training field has seen a growing interest, especially through the creation of specialised masters and university degrees for the training of trainers in simulation pedagogy.

In addition to these initiatives, the national research field is experiencing growing interest in simulation. Different publications have aimed to examine the various uses of simulation to improve the performance and capacities of health actors [32-34], its characteristics as a learning strategy [35, 36], and the perceived usefulness of learning through simulation [37].

These advances support and accompany the reforms organising the training of nurses and health technicians in Morocco. The new training architecture is part of the bachelor–master–doctorate system (LMD), with the creation of the Higher Institutes of Nursing and Health Technicians non-university higher education institutions. This strategic redesign aimed to enhance the quality of health professional training and improve the quality of care. However, despite the increased success of simulation, its use by teachers in the training of nursing students in our context remains less explored.

Our study aimed to address two objectives: (1) to explore the use of simulation in nursing education and (2) to describe the different difficulties and obstacles encountered by teachers in the implementation of simulation.

To meet the objectives, a descriptive study with a quantitative design was chosen. The target population was permanent teachers at the level of the Higher Institutes of Nursing and Health Technology.

This study was conducted in the Higher Institutes of professional nurses and health technics (ISPITS), located in different regions in Morocco. These institutes are among the establishments of higher education that are not part of the universities, and which are under the supervision of the government authority of health. The main missions of ISPITS in the new LMD architecture are: basic training (bachelor's degree, master's degree, doctorate), continuing education, and scientific research, with a view to the development of professions related to nursing sciences and health techniques.

Our choice for the study was a quantitative survey using a questionnaire. We chose this tool to cover a maximum of the target population and collect precise and easily quantifiable information. This instrument has been structured on the basis of the recommendations of the guide to good simulation practices and the mission report “State of the art (national and international) in terms of simulation practices in the field of health”, published by the Haute Autorité de Santé [38].

The questionnaire was composed of 25 items organized in three parts. The first part dealt with the general and professional characteristics of participants: gender and age, level of education, and seniority in teaching. The second part questioned the pedagogical aspects mobilised by the teachers within the framework of simulation use, including use or not of simulation, beneficiaries of simulation, semesters in which simulation was offered, methods of simulation used, the average duration of the sessions, fields of use, and supports. The last part examined the difficulties and needs related to the use of simulation. The questions were asked in closed, open and multiple-choice formats.

Before the final administration of the questionnaire, a pre-test was conducted with eight tenured teachers to check for clarity and understanding of the questions. Adjustments were deemed necessary. The questionnaire was conducted via Google Forms^® software and sent by email to the teachers and coordinators of the institutes. The data collection lasted for four months between May and August 2022.

The collected data were automatically transferred from Google Forms^® to a table in Microsoft Excel. The data processing was based on the description of the frequencies and percentages of the different categories covered by the questionnaire items. They were presented as tables and figures.

The teachers’ consent was obtained at the beginning of the questionnaire in the note presenting it, concerning the commitment to respect the anonymity and confidentiality of the data.

Ninety faculty members responded to our study. Characteristics collected from the participants included age, gender, education level, and years of experience in nursing education (Table 1).

The most represented age group was 30–40 years (63.3%), with a predominance of women (77.8%) and only 22.2% men. The training of the teachers ranged from basic training in the first cycle of paramedical studies (8.9%) to the doctoral cycle (13.3%), with a predominance of pedagogical training in nursing (77.8% of the participants had training in pedagogy). Their teaching education was also variable, that was 38.9% studied in the second cycle of paramedical studies, and 38.9% had a master’s degree in nursing and health technology pedagogy. The teaching experience of the participants varied and was as followed; less than 5 years (32.2%), between 5 and 10 years (33.3%), between 10 and 20 years (27.8%), or more than 20 years (6.7%).

A variety of barriers were reported to the implementation of simulation by teachers (Fig. 1). Resources presented the greatest obstacle: a lack of logistics (23.1%) and a lack of human resources (25%). The majority of teachers reported difficulties integrating simulation into their practices. A lack of training was reported (25%), along with a lack of accompaniment (11.5%) and a lack of research (5.8%). Notably, all the teachers wanted to benefit from simulation training and confirmed that its integration into training programmes can improve the quality of teaching services.