1. Background and Rationale

Cancer, the unwelcome guest, is characterized by rapid and abnormal cell growth that ends in death if untreated. To date, no single specific factor is known as a primary cause of cancer, and numerous factors, either avoidable or not, are known to increase the risk of cancer incidence [1]. For many decades, single therapy or concurrent therapy of surgery, radiation, immunotherapy, and chemotherapy were the only treatment options to treat cancer [2, 3]. Chemotherapy is considered one of the main treatments for cancer and is considered a high-risk carcinogenic,teratogenic, or toxic agent [4]. Accordingly, any malpractice in chemotherapy administration may lead to an increase in patient hospitalization time or may cause irreversible injuries, as well as affecting nurses through possible exposure [5, 6]. Despite due care and attention, this exposure has nevertheless occurred through extravasation, volatilization, droplets, or even contact with the patient’s excreta during the chemotherapy treatment journey [7–9].

Healthcare providers particularly oncology nurses are prone to significant risks due to occupational exposure to chemotherapy agents. Documented side effects include skin disorders [10], DNA damage [11], and effects on the reproductive system [12]. Moreover, direct exposure to chemotherapy agent may cause vertigo, headaches, hair loss, skin rashes, and burning eyes for those who administer it [13–15]. Prior literature shows varying exposure rates: 16.9% of nurses reported skin or eye exposure to chemotherapy spills [16]. Another study confirmed repeated contact in ambulatory oncology settings [17]. These findings raise the urgent need for rigorous competency in chemotherapy administration, including proper handling, personal protective equipment (PPE), and adherence to safety protocols. Therefore, comprehensive initial and ongoing training is essential to minimize exposure risks and ensure safe, effective patient care [18, 19].

Competency is defined as “a principle of professional practice that identifies the expectations required for the safe and effective performance of a task or implementation of a role” [20]. In the context of chemotherapy administration, five key safety themes were identified to guide competency assessment and development: governance, which ensures clear policies, accountability, and compliance with safety standards; process safeguards, which include protocols for preparation, administration, and disposal of hazardous drugs; communication, emphasizing accurate information exchange among healthcare professionals and with patients; interdisciplinary collaboration, which fosters teamwork among nursing, pharmacy, and medical staff to enhance safety; and education, which supports continuous learning and skills development [21]. In addition, strategies such as electronic information system usage, double checking of identity and drug using the barcode system, pharmaceutical safety protocols, and ongoing professional development through both traditional and simulated methods were considered crucial measures to improve nurse competency in chemotherapy administration [21].

Simulation is an educational method where educators recreate real patient situations within a realistic and controlled environment [22]. Simulation is widely used in clinical practice especially in chemotherapy administration competency to help trainees acquire both technical and nontechnical skills [23–25]. Moreover, prior literature has shown that simulation training enhances trainee confidence, clinical decision making, and problem-solving skills, all of which are vital for effective chemotherapy administration [24–27]. Along with advancement in educational technology, Chan et al. [28] assessed the experience of nursing students using virtual reality (VR) focused on chemotherapy administration and showed that using VR has a significant positive impact on chemotherapy competency [28]. Keddington and Moore [29] also confirmed that simulation is particularly effective for high-risk care processes and plays a vital role in boosting patient safety [29].

Simulated competency training can be conducted in different venues: primarily through in-simulation lab training (INSIM) and in situ simulation (INSITU). INSIM takes place in controlled laboratory environment designed to replicate clinical scenarios, while INSITU simulation is conducted in real clinical settings, such as patients’ room inside the hospital units using actual equipment and workflows [24]. INSITU simulation offers additional advantages by enhancing clinical realism, team communication, and system-based practice, while also identifying latent safety threats within real environments. In contrast, INSIM allows focused skills acquisition in distraction-free, controlled setting. Both methods are commonly used in nursing education, but there is limited evidence comparing their effectiveness in building chemotherapy administration competency. This study compares the two approaches to determine which better supports skills mastery and satisfaction among newly hired oncology nurses, thereby informing optimal training practice in oncology settings.

2. Methods

This study employed an explanatory sequential mixed methods design, in which quantitative data collection and analysis were followed by qualitative data to provide deeper insight into the findings [30]. The quantitative part was given the priority, while the qualitative part helped to delve deeper to explain and expand the quantitative results. This reporting followed the Good Reporting of a Mixed Methods Study (GRAMMS) guidelines [31].

3. Results

4. Discussion

In this study, we used a mixed methodology to evaluate the effectiveness of INSITU vs. INSIM simulations in mastering chemotherapy administration competency among newly hired oncology nurses. Our aim was to determine which type of simulation—INSITU or INSIM—is superior and more satisfactory for these nurses. Quantitatively, their performance was better in the posttest compared to the pretest. Therefore, the INSITU and INSIM groups acquired the necessary knowledge and skills to carry out chemotherapy administration safely and effectively through exposure to the simulation, either INSIM or INSITU. Additionally, both groups expressed high levels of satisfaction with their learning. This result is aligned with previous literature, which reported that nurses become satisfied after their exposure to clinical simulation [34–36]. Moreover, high levels of satisfaction were reported by participants in both groups, further supporting the positive impact of simulation on learning outcomes. The observed satisfaction is consistent with prior studies linking simulation training to increase learner satisfaction and empowerment [37, 38].

The integration of quantitative and qualitative results revealscomplementary insights. While objective competency improvement was demonstrated through instructor-rated performance assessment, the qualitative data offered a deeper understanding of how nurses experienced and internalized the learning process. For example, the perception of increased confidence and empowerment voiced by participants reinforces the improvement seen in their test scores. This integration suggests the simulation not only enhances technical competency but also positively influences affective and cognitive domains such as confidence and engagement.

It is worth noting the distinction between data sources: quantitative competency assessment was conducted by trained facilitators, whereas qualitative data were derived from the nurse self-reported experience. This methodological difference may affect interpretation of findings, as the facilitators provide an external, objective measure of performance, while interviews reflect subjective, introspective insights; this contrast enhances the depth of the findings with more careful triangulation to avoid any overreliance on self-perception.

In this study, both groups of nurses perceived an empowerment effect through simulation, which aligns with findings in existing literature [39, 40]. The empowerment reported by participants is indicative of how simulation training provides a sense of control over the learning process, allowing nurses to practice and refine skills in high-risk environment; this sense of empowerment was also linked to increased confidence in their ability to perform chemotherapy administration tasks, as confirmed by the qualitative data and the significant improvement in competency score observed in the posttest assessments.

Moreover, participants in this study consistently perceived that simulation helped them achieve the intended learning outcomes. This finding supports previous research suggesting that simulation fosters critical thinking and enhances decision-making skills [41]. The simulation provided a platform for nurses to reflect on and apply their academic knowledge, demonstrating how they were able to bridge theoretical learning with practical application; the integration of critical thinking into the simulation process not only enhanced their decision-making abilities but also contributed to the improvement in their competency test results.

The learning context emerged as a significant factor in this study, reflecting how newly hired oncology nurses engaged cognitively and emotionally during chemotherapy competency simulations; participants from both groups reported feeling that the simulation environment was safe and risk-free allowing them to practice without the fear of harming patients or themselves. This controlled setting likely contributed to the increased cognitive engagement and confidence seen in both groups, as nurses were able to focus entirely in skill acquisition and clinical reasoning. These findings align with prior research, which highlighted the benefits of a safe and supportive learning environment in fostering confidence and competency [34, 42–44].

It is also worth noting that while INSIM offers higher fidelity in simulating clinical scenarios, one participant expressed a preference for more controlled learning environment, such as that provided by INSITU. This preference was not universal, but it underscores the importance of considering individual learning preferences when designing simulation training.Despite the increased realism of INSIM, some nurses may still prefer the structured and less overwhelming nature of a controlled environment, as it offers focused opportunities to develop specific skills.. This diversity in preferences highlights the need for flexible training approaches to meet varied needs of learners.

Furthermore, the study’s findings indicate that nurses in both groups demonstrated cognitive engagement during the learning process. In this context, cognitive engagement refers to the active utilization of mental capabilities by nurses to comprehend, analyze, and respond effectively to the challenges presented during the simulation. In essence, cognitive engagement represents a form of self-engagement, specifically involving mental effort and active participation in achieving desired outcomes through learning and problem-solving processes within a professional setting [44–46]. This engagement can be attributed to various factors, such as the well-prepared and controlled learning environment, the availability of resources, and the structured approach to conducting the simulation—from prebriefing and the simulation itself to debriefing afterward. These factors likely contributed to enhancing nurses’ sense of security, which in turn could boost their self-esteem and confidence, leading to increased cognitive engagement. This is consistent with previous literature, which highlighted that simulations offer a clear and convincing way to promote student engagement during training [47, 48].

Regarding confidence, nurses perceived that simulation promoted their confidence and that their confidence increased during the simulation in both modalities. Some nurses relate this to the technique of conducting simulation, especially with debriefing sessions playing an important role in enhancing their confidence. This is aligned with the results of a study by Greenspan and Loftus [49] which aimed to assess the influence of debriefing on confidence. Along the same lines, Cabañero-Martínez et al. [50] found that debriefing enhances confidence among nursing students. Additionally, it has been demonstrated that learning through simulation enhances confidence [51–53]. On the other hand, some literature revealed that only a small portion of their study participants had increased confidence [54]. This could be explained by the fact that they were exposed to negative emotions during the simulation, leading to feelings of insecurity.

Prior qualitative studies [55–57] have documented positive experiences among nurses in a simulation environment. However, this study also identified simulation-related burden, including psychological burden and physical challenges. The psychological burden can be attributed to the novelty of the simulation experience for these nurses, coupled with the complex environment of being monitored by cameras, receiving virtual guidance from simulators, engaging in role-playing, and experiencing fear of making mistakes [34, 58]. These factors collectively contribute to the psychological strain on nurses. In contrast, a few nurses from the INSITU group unexpectedly reported physical burden due to the lengthy duration of the simulation, leading to fatigue. This is in line with a study conducted by Ko and Choi [58], which revealed that their study participants reported fatigue after the simulation as well.

5. Conclusion

Simulation plays a crucial role in enhancing nursing competencies, particularly in the context of chemotherapy admiration, where precision and safety are paramount. This study demonstrated that both INSIM and INSITU simulation effectively improved chemotherapy administration competency among newly hired oncology nurse, with participants showing significant posttest improvement in their knowledge and skills. However, no definitive superiority was observed between the two simulation types in terms of overall effectiveness.

While INSIM provides a higher fidelity learning environment, this study highlights that both simulation modalities contribute positively to nurses’ confidence, decision-making abilities, and sense of empowerment in chemotherapy administration. Future research should focus on further exploring the impact of these simulation modalities specifically on chemotherapy-related competencies. In addition to examining the cognitive and psychological responses of participants in both INSIM and INSITU environments, future qualitative studies should continue to explore nurses′ experiences with simulation training—particularly the nuances involved in mastering chemotherapy administration in clinical practice.

Conflicts of Interest

The authors declare no conflicts of interest.

Author Contributions

Yahiya M. AL-Helih: conceptualization, methodology, writing – original draft, supervision, and writing – review and editing.

Sami AL-Yatim: conceptualization, methodology, and writing – review and editing.

Majeda A. AL-Ruzzieh: project administration and conceptualization.

Bahaa Shtieah: data curation and validation.

The authors affirm that the methods used in the data analyses are suitably applied to their data within their study design and context, and the statistical findings have been implemented and interpreted correctly.

Funding

No funding was received for this manuscript.