tRNS boosts visual perceptual learning in participants with bilateral macular degeneration.

Perceptual learning (PL) has shown promise in enhancing residual visual functions in patients with age-related macular degeneration (MD), however it requires prolonged training and evidence of generalization to untrained visual functions is limited. Recent studies suggest that combining transcranial random noise stimulation (tRNS) with perceptual learning produces faster and larger visual improvements in participants with normal vision. Thus, this approach might hold the key to improve PL effects in MD. To test this, we trained two groups of MD participants on a contrast detection task with (n = 5) or without (n = 7) concomitant occipital tRNS. The training consisted of a lateral masking paradigm in which the participant had to detect a central low contrast Gabor target. Transfer tasks, including contrast sensitivity, near and far visual acuity, and visual crowding, were measured at pre-, mid and post-tests. Combining tRNS and perceptual learning led to greater improvements in the trained task, evidenced by a larger increment in contrast sensitivity and reduced inhibition at the shortest target to flankers' distance. The overall amount of transfer was similar between the two groups. These results suggest that coupling tRNS and perceptual learning has promising potential applications as a clinical rehabilitation strategy to improve vision in MD patients.

Neural correlates of transfer of learning in motor coordination tasks: role of inhibitory and excitatory neurometabolites.

We aimed to investigate transfer of learning, whereby previously acquired skills impact new task learning. While it has been debated whether such transfer may yield positive, negative, or no effects on performance, very little is known about the underlying neural mechanisms, especially concerning the role of inhibitory (GABA) and excitatory (Glu) (measured as Glu + glutamine (Glx)) neurometabolites, as measured by magnetic resonance spectroscopy (MRS). Participants practiced a bimanual coordination task across four days. The Experimental group trained a task variant with the right hand moving faster than the left (Task A) for three days and then switched to the opposite variant (Task B) on Day4. The control group trained Task B across four days. MRS data were collected before, during, and after task performance on Day4 in the somatosensory (S1) and visual (MT/V5) cortex. Results showed that both groups improved performance consistently across three days. On Day4, the Experimental group experienced performance decline due to negative task transfer while the control group continuously improved. GABA and Glx concentrations obtained during task performance showed no significant group-level changes. However, individual Glx levels during task performance correlated with better (less negative) transfer performance. These findings provide a first window into the neurochemical mechanisms underlying task transfer.

Transfer and Retention Effects of a Motor Program in Children With Autism Spectrum Disorders.

The current study examined the acquisition, retention, and transfer effects of a motor program. Children with autism spectrum disorder participated in a 9-week program that targeted 13 fundamental motor skills based upon the Test of Gross Motor Development-3. Assessments were conducted before and after the program, as well as at 2-month follow-up. Significant improvements were found on not only the trained fundamental motor skills (acquisition) but also the untrained tasks on balance (transfer). The follow-up tests revealed continuous improvement on the trained locomotor skills (retention), as well as the untrained skills on balance (retention + transfer). These findings highlight the importance of continuous support and long-term participation on motor practices.

Transfer of learning in histology: Insights from a longitudinal study.

All anatomical educators hope that students apply past training to both similar and new tasks. This two-group longitudinal study investigated the development of such transfer of learning in a histology course. After 0, 10, and 20 sessions of the 10-week-long course, medical students completed theoretical tasks, examined histological slides trained in the course (retention task), and unfamiliar histological slides (transfer task). The results showed that students in the histology group gradually outperformed the control group in all tasks, especially in the second half of the course, η2 = 0.268 (p < 0.001). The best predictor of final transfer performance was students' retention performance after 10 sessions, ß = 0.32 (p = 0.028), and theoretical knowledge after 20 sessions, ß = 0.46 (p = 0.003). Results of eye tracking methodology further revealed that the histology group engaged in greater "visual activity" when solving transfer tasks, as indicated by an increase in the total fixation count, η2 = 0.103 (p = 0.014). This longitudinal study provides evidence that medical students can use what they learn in histology courses to solve unfamiliar problems but cautions that positive transfer effects develop relatively late in the course. Thus, course time and the complex relationship between theory, retention, and transfer holds critical implications for anatomical curricula seeking to foster the transfer of learning.

Procedural simulation in venipuncture for medical undergraduates and its transfer to the bedside: a cluster randomized study.

Simulation is accepted as an effective method of learning procedural skills. However, the translational outcomes of skills acquired through simulation still warrants investigation. We designed this study to assess if skills laboratory training in addition to bedside learning (intervention group [IG]) would provide better learning results than bedside learning alone (control group [CG]) in the context of venipuncture training. This prospective, cluster-randomized, single-blind study took place at the Faculty of Medicine, University of Kelaniya, Sri Lanka. Seventeen clusters of second-year medical students were randomly assigned to either IG or CG. The IG trained on venipuncture in the skills laboratory, receiving instruction after modified Payton's Four Step Method. Following the training, students of both IG and CG underwent bedside learning for one month. Afterward, students of both groups performed venipuncture on actual patients in a clinical setting. An independent, blinded assessor scored students' performance using the Integrated Procedural Protocol Instrument (IPPI) and a checklist. Patients assessed students' performance with the Communication Assessment Tool (CAT). Eight and nine clusters were randomized to the intervention and control groups, respectively. IG completed significantly more single steps of the procedure correctly (IG: 19.36 ± 3.87 for checklist items; CG: 15.57 ± 4.95; p < 0.001). IG also scored significantly better on IPPI ratings (median: IG: 27 (12) vs. CG: 21 (8); p < 0.001). Rated by patients, students' communication skills did not significantly differ between the two groups. Simulation-based venipuncture training enabled students to perform the procedure on actual patients with a higher technical accuracy than students who learned venipuncture at the bedside. Students were able to transfer the skills acquired through venipuncture training at the skill laboratory to the bedside.

Assessing the Efficacy of ChatGPT in Solving Questions Based on the Core Concepts in Physiology.

Background and objective ChatGPT is a large language model (LLM) generative artificial intelligence (AI) chatbot trained through deep learning to produce human-like language skills and analysis of simple problems across a wide variety of subject areas. However, in terms of facilitating the transfer of learning in medical education, a concern has arisen that while AI is adept at applying surface-level understanding, it does not have the necessary in-depth knowledge to act at an expert level, particularly in addressing the core concepts. In this study, we explored the efficacy of ChatGPT in solving various reasoning questions based on the five core concepts applied to different modules in the subject of physiology. Materials and methods In this study, a total of 82 reasoning-type questions from six modules applicable to the five core concepts were created by the subject experts. The questions were used to chat with the conversational AI tool and the responses generated at first instance were considered for scoring and analysis. To compare the scores among various modules and five core concepts separately, the Kruskal-Wallis test along with post hoc analysis were used. Results The overall mean score for the modules (60 questions) was 3.72 ±0.26 while the average score obtained for the core concepts (60 questions) was 3.68 ±0.30. Furthermore, statistically significant differences (p=0.05 for modules and p=0.024 for core concepts) were observed among various modules as well as core concepts. Conclusion The significant differences observed in the scores among various modules and core concepts highlight the varying execution of the same software tool, thereby necessitating the need for further evaluation of AI-enabled learning applications to enhance the transfer of learning among undergraduates.

Impact of Daily Choral Singing and Creative Writing Activities on the Cognitive Development of Second-, Third-, and Fourth-Grade French Children from Low Socioeconomic Backgrounds.

In France, around one-fifth of children have reading difficulties, and school results are highly dependent on their socio-economic status. In this context, the need for alternative and innovative teaching techniques holds importance, and more artistic approaches are promising. The aim of this study was to assess the impact of a daily choral singing or creative writing practice on the cognitive and linguistic development of French children from disadvantaged backgrounds. Eighty children participated in this longitudinal study, for whom we measured several cognitive and linguistic skills at the beginning (pre-test) and end (post-test) of the school year. The results showed that children in "singing" classes improved both their reading skills and processing speed, while those in "writing" classes improved their reading skills and vocabulary. These results open up new avenues of learning support, specifically for children with difficulties.

Promoting learning transfer in science through a complexity approach and computational modeling.

This article concerns the synergy between science learning, understanding complexity, and computational thinking (CT), and their impact on near and far learning transfer. The potential relationship between computer-based model construction and knowledge transfer has yet to be explored. We studied middle school students who modeled systemic phenomena using the Much.Matter.in.Motion (MMM) platform. A distinct innovation of this work is the complexity-based visual epistemic structure underpinning the Much.Matter.in.Motion (MMM) platform, which guided students' modeling of complex systems. This epistemic structure suggests that a complex system can be described and modeled by defining entities and assigning them (1) properties, (2) actions, and (3) interactions with each other and with their environment. In this study, we investigated students' conceptual understanding of science, systems understanding, and CT. We also explored whether the complexity-based structure is transferable across different domains. The study employs a quasi-experimental, pretest-intervention-posttest-control comparison-group design, with 26 seventh-grade students in an experimental group, and 24 in a comparison group. Findings reveal that students who constructed computational models significantly improved their science conceptual knowledge, systems understanding, and CT. They also showed relatively high degrees of transfer-both near and far-with a medium effect size for the far transfer of learning. For the far-transfer items, their explanations included entities' properties and interactions at the micro level. Finally, we found that learning CT and learning how to think complexly contribute independently to learning transfer, and that conceptual understanding in science impacts transfer only through the micro-level behaviors of entities in the system. A central theoretical contribution of this work is to offer a method for promoting far transfer. This method suggests using visual epistemic scaffolds of the general thinking processes we would like to support, as shown in the complexity-based structure on the MMM interface, and incorporating these visual structures into the core problem-solving activities. Supplementary Information: The online version contains supplementary material available at 10.1007/s11251-023-09624-w.

The effects of retrieval versus study on analogical problem solving.

We report four experiments, wherein subjects engaged in either problem-solving practice or example study. First, subjects studied an example problem. Subjects in the example study condition then studied two more analogous problems, whereas subjects in the problem-solving practice conditions solved two such problems, each followed by correct-answer feedback. In Experiment 1, subjects returned 1 week later and completed a posttest on an analogous problem; in Experiments 2-4, subjects completed this posttest immediately after the learning phase. Additionally, Experiment 3 consisted of a control condition, wherein subjects solved these same problems, but did not receive feedback. Experiments 3 and 4 also included a mixed study condition, wherein subjects studied two examples and then solved one with feedback during the learning phase. Across four experiments, we found that the training conditions (i.e., problem-solving practice, mixed, and example study) performed equally well on the posttest. Moreover, subjects in the training conditions outperformed control subjects on the posttest, indicating that the null findings were due to the training conditions learning and transferring their knowledge equally well. After the posttest in Experiment 4, subjects were asked to solve repeated problems from the learning phase. Subjects in the problem-solving practice and mixed study conditions performed better on repeated problems than subjects in the example study condition, indicating that they better learned the solution strategies for these problems than subjects in the example study condition. Nevertheless, this benefit was insufficient to produce differential transfer of learning among the training conditions on the posttest.

Learning strategy impacts medical diagnostic reasoning in early learners.

Relating learned information to similar yet new scenarios, transfer of learning, is a key characteristic of expert reasoning in many fields including medicine. Psychological research indicates that transfer of learning is enhanced via active retrieval strategies. For diagnostic reasoning, this finding suggests that actively retrieving diagnostic information about patient cases could improve the ability to engage in transfer of learning to later diagnostic decisions. To test this hypothesis, we conducted an experiment in which two groups of undergraduate student participants learned symptom lists of simplified psychiatric diagnoses (e.g., Schizophrenia; Mania). Next, one group received written patient cases and actively retrieved the cases from memory and the other group read these written cases twice, engaging in a passive rehearsal learning strategy. Both groups then diagnosed test cases that had two equally valid diagnoses-one supported by "familiar" symptoms described in learned patient cases, and one by novel symptom descriptions. While all participants were more likely to assign higher diagnostic probability to those supported by the familiar symptoms, this effect was significantly larger for participants that engaged in active retrieval compared to passive rehearsal. There were also significant differences in performance across the given diagnoses, potentially due to differences in established knowledge of the disorders. To test this prediction, Experiment 2 compared performance on the described experiment between a participant group that received the standard diagnostic labels to a group that received fictional diagnostic labels, nonsense words designed to remove prior knowledge with each diagnosis. As predicted, there was no effect of diagnosis on task performance for the fictional label group. These results provide new insight on the impact of learning strategy and prior knowledge in fostering transfer of learning, potentially contributing to expert development in medicine.

Co-actors represent each other's task regularity through social statistical learning.

Numerous joint action studies have demonstrated that certain low-level aspects (e.g., stimuli and responses) of a co-actor's task can be automatically and implicitly represented by us as actors, biasing our own task performance in a joint action setup. However, it remains unclear whether individuals also represent more abstract, high-level aspects of a co-actor's task, such as regularity. In the first five experiments, participants participated alongside their co-actors and responded to a mixed shape sequence generated by randomly interleaving two fixed order sequences of shapes in both the pre- and post-test sessions. But different intermediate practice sessions were undergone by participants across experiments. When practicing their own fixed order sequences in a mixed shape sequence, either together with another person (Experiment 1) or alone but informed that their partner was performing the same practice task in a different room (Experiment 4), participants exhibited a learning effect on their co-actors' practiced sequences. This indirect learning effect was absent when one of the co-actors did not participate due to either being removed from the practice (Experiment 2) or sitting still without offering responses (Experiment 3), as well as when the two co-actors practiced together but responded to two distinct properties of stimuli (e.g., colour and shape, respectively), with one having regularity and the other not. Finally, participants exhibited comparable direct learning effects on their own practiced sequences for Experiments 1-5 as when performing the pre-test, practice, and post-test sessions alone for Experiment 6. These results demonstrate that, when practicing together, or even when believing that they are acting together with a partner, co-actors do represent the task regularity of one another through social statistical learning and transfer this learned regularity to subsequent task performances. The present study extends our understanding of co-representation in the joint action context in terms of the more abstract and high-level task features people co-represent, such as a co-actor's task regularity.

The effect of nonlinear pedagogy on the acquisition of game skills in a territorial game.

Introduction: Nonlinear Pedagogy (NP), underpinned by Ecological Dynamics, provides a suitable pedagogical approach for practitioners (e.g., Physical Educators, coaches) to encourage exploratory learning that is learner-centered even in Traditional Sporting Games (TSG) that could be represented by invasion or territorial-like games. NP involves the manipulation of constraints which form boundaries for interacting components to self-organize, facilitating the emergence of goal-directed behaviours. Key pedagogical principles relating to representativeness, manipulation of constraints, awareness of focus of attention instructions, task simplification and the functional role of noise can encourage exploratory learning that helps develop 21st century competencies. This is in contrast to a Linear Pedagogy (LP) approach that is more teacher-centered and focuses on repetition in practices to promote movement form consistency in enhancing the acquisition of movement skills. Little is known about the effectivity of NP in the learning and transfer of invasion games. The aims of this study were to: (a) determine the impact of NP on the teaching and learning of an invasion game in the Physical Education (PE) context; (b) examine the transferability of game skills to other games in the same game category (i.e., floorball as a territorial game in this study). Methods: 224 (between 12 to 13 years old) students underwent a 10-week intervention program to learn to play an invasion game (football) with either a NP or LP approach (i.e., repetitive and prescriptive drills). Results: Performance outcome data were measured during Pre, Post, Retention, Transfer test 1 (larger playing area) and Transfer test 2 (floorball). Significant improvements in several performance outcome and game play measures in football was observed for the NP condition. Fewer improvements in the same measures were found for the LP condition. Discussion: Evidence for transfer of learning for NP was not as strong as anticipated although there was still some potential for encouraging transfer of learning. The key findings from this study further challenge the "one-size fits all" philosophy in the teaching of PE. Both LP and NP approaches would have a role to play in supporting teaching and learning which could be context dependent.

Critical design choices in healthcare simulation education: a 4C/ID perspective on design that leads to transfer.

BACKGROUND: Healthcare simulation education often aims to promote transfer of learning: the application of knowledge, skills, and attitudes acquired during simulations to new situations in the workplace. Although achieving transfer is challenging, existing theories and models can provide guidance. RECOMMENDATIONS: This paper provides five general recommendations to design simulations that foster transfer: (1) emphasize whole-task practice, (2) consider a cognitive task analysis, (3) embed simulations within more comprehensive programs, (4) strategically combine and align simulation formats, and (5) optimize cognitive load. We illustrate the application of these five recommendations with a blueprint for an educational program focusing on simulation activities. CONCLUSIONS: More evidence-informed approaches to healthcare simulation might require a paradigm shift. We must accept that a limited number of simulations is not enough to develop complex skills. It requires comprehensive programs that combine simulation sessions with workplace learning.

Task-specificity and transfer of skills in school-aged children with and without developmental coordination disorder.

AIM: To compare the effects of two Active Video Game (AVG) protocols on transfer of learning in children with and without Developmental Coordination Disorder (DCD). METHODS: Fifty children, aged 6-10 years were randomly allocated to either group A or B. Children in group A participated in a set of Nintendo Wii ball games whereas group B played agility games (8 DCD and 17 typically developing children (TD) per group). Participants in each group practiced Wii games for 20 min twice a week for 10 weeks. All children also practiced ball and agility games in real-world settings, once per week. RESULTS: Both protocols yielded positive effects with the largest effect sizes shown on agility and balance items of the PERF-FIT and KTK tests. No interaction was found on learning real-world games and the virtual protocol, except for a Ping-Pong game. A significant interaction of time by protocol group indicated that the Ball group improved more on BOT-2-Upper-Limb Coordination than the Agility group. Importantly, children with DCD improved comparably with TD peers in virtual and real-world games. CONCLUSION: Independent of training protocol, both children with DCD and TD children performed better on trained and non-trained ball, balance and agility tasks after 10 weeks of training.

A gamified augmented reality vocational training program for adults with intellectual and developmental disabilities: A pilot study on acceptability and effectiveness.

Objectives: The Augmented Reality Games to Enhance Vocational Ability of Patients (REAP) was an augmented reality vocational training program that provided skills training in the context of a psychiatric rehabilitation program. It was implemented over 10 weeks and consisted of gamified augmented reality café training scenarios and bridging group activities to facilitate transfer of learning to the work context. This pilot study aimed to explore the acceptability and effectiveness of the REAP program when carried out with adults with intellectual and developmental disabilities attending work therapy. Its objectives were: (1) to obtain feedback from participants and trainers on their experiences and acceptability of the REAP program and (2) to measure changes in vocational and cognitive skills of participants in the REAP program. Materials and methods: This was a pretest-posttest mixed methods study. 15 adults with intellectual and developmental disabilities attending work therapy in a non-profit organization participated in the REAP program and their vocational trainers were involved in assisting in this program. Feasibility Evaluation Checklist (FEC) and the Neurobehavioral Cognitive Status Exam (Cognistat) were administered at baseline, post-training and eight weeks after training. The participants and their trainers also provided user feedback via semi-structured interviews. Results: Majority of the participants and trainers found the REAP program to be useful and interesting. They also found that the augmented reality games were user-friendly and provided a unique opportunity to acquire new skills. Participants who engaged in this program showed a significant improvement in vocational skills and aspects of cognitive skills, which were maintained eight weeks after training. Conclusion: The gamified augmented reality vocational training was feasible and accepted by both adults with intellectual and developmental disabilities and their trainers. When integrated with bridging sessions to facilitate transfer of learning to existing work therapy, participants on the REAP program showed significant improvements in vocational skills and aspects of cognitive skills. Future experimental studies with larger sample size could provide stronger evidence on its effectiveness in improving vocational outcomes.

Use of core concepts of physiology can facilitate student transfer of learning.

Students often fail to utilize what they know about one topic (e.g., hemodynamics) when attempting to master another topic involving a similar phenomenon (e.g., airflow in airways). What accounts for this difficulty that students have? And how can students be assisted in doing a better job of applying what they already know to new topics? The phenomenon described above is an example of a failure of transfer of learning. However, much is known about the conditions that foster or promote transfer of learning. Applying this emerging knowledge and focusing on the core concepts of physiology can make learning physiology easier and provide students with tools to support lifelong learning.NEW & NOTEWORTHY Students often fail to utilize knowledge from prerequisite courses while learning physiology. They also fail to use what they know about one physiology topic when attempting to learn another topic. Much is known about the conditions that foster or promote transfer of learning. Applying this emerging knowledge and focusing on the core concepts of physiology can making learning physiology easier and provide students with tools to support lifelong learning.

The effects of testing the relationships among relational concepts.

Many concepts are defined by their relationships to one another. However, instructors might teach these concepts individually, neglecting their interconnections. For instance, students learning about statistical power might learn how to define alpha and beta, but not how they are related. We report two experiments that examine whether there is a benefit to training subjects on relations among concepts. In Experiment 1, all subjects studied material on statistical hypothesis testing, half were subsequently quizzed on relationships among these concepts, and the other half were quizzed on their individual definitions; quizzing was used to highlight the information that was being trained in each condition (i.e., relations or definitions). Experiment 2 also included a mixed training condition that quizzed both relations and definitions, and a control condition that only included study. Subjects were then tested on both types of questions and on three conceptually related question types. In Experiment 1, subjects trained on relations performed numerically better on relational test questions than subjects trained on definitions (nonsignificant trend), whereas definitional test questions showed the reverse pattern; no performance differences were found between the groups on the other question types. In Experiment 2, relational training benefitted performance on relational test questions and on some question types that were not quizzed, whereas definitional training only benefited performance on test questions on the trained definitions. In contrast, mixed training did not aid learning above and beyond studying. Relational training thus seems to facilitate transfer of learning, whereas definitional training seems to produce training specificity effects.

Video Game Play Does Not Improve Spatial Skills When Controlling for Speed-Accuracy Trade-Off: Evidence From Mental-Rotation and Mental-Folding Tasks.

Researchers have been divided on the efficacy of computerized cognitive training (CCT) for enhancing spatial abilities, transfer of training, and improving malleability of skills. In this study, we assessed the effects of puzzle video game training on subsequent mental rotation (MR) and mental folding (MF) performance among adults with no cognitive impairment. We assessed participants at baseline with the Shepard-Metzler MR test followed by the differential aptitude test: space relations MF test (i.e., far transfer). We ranked participants' skills on these pre-tests and used a matching technique to form two skill groups from which we then randomly assigned members of each skill group either to an experimental group or a wait-list control group. The experimental group played two puzzle video games closely related to two-dimensional and three-dimensional MR tasks during 4-week training sessions (total of 12 hour of video games). Post-training, participants completed the MR and MF tests again. Two months later, we re-assessed only the experimental group's spatial skills to explore the sustainability of the trained performance. In addition to response times (RT) and error scores (ES), reported separately, we combined these variables into rate correct scores (RCS) to form an integrated measure of potential speed-accuracy trade-offs (SAT). As a result, we did not find significant improvements in MR performance from CCT engagement, nor did participants show a transfer of skills obtained by practicing MR-related puzzle games to a MF task. Based on the current findings, we urge caution when proposing a game-based intervention as a training tool to enhance spatial abilities. We argue that separately interpreting individual test measures can be misleading, as they only partially represent performance. In contrast, composite scores illuminate underlying cognitive strategies and best determine whether an observed improvement is attributable to enhanced capacities or individual heuristics and learned cognitive shortcuts.

Metacognitive control, serial position effects, and effective transfer to self-paced study.

Serial position effects involve the differential recall of information based on its temporal order at encoding. Previous research indicates that learners may be aware of these effects under certain encoding conditions, but it is unclear whether metacognitive control is sensitive to serial position effects. The current study examined whether there are serial position effects in participants' study time and whether they can learn about serial position effects under fixed encoding conditions and then transfer what they have learned to self-paced study conditions. Specifically, participants were given lists of to-be-remembered words and studied each word for a fixed duration on initial lists, but self-paced their study time on later lists. Results revealed that self-paced study times oppositely mirrored serial position effects (i.e., briefer study times in the beginning and end of each list), and serial position effects were reduced in self-paced study conditions, particularly in participants initially studying under fixed conditions before self-pacing their study time. Specifically, participants may have monitored their output and, based on observations of forgetting middle items, transferred their learning of serial position effects from prior lists. Thus, participants may use forgetting and serial position information to guide encoding, indicating that fundamental properties of the memory system can be incorporated into the processes that guide metacognitive control.

Impact of palliative care simulation on nursing students' learning outcomes and reported use in hospital placement.

AIM: Nursing students report emotional distress and feelings of inadequacy to the complexity of palliative care. This study aimed to examine nursing students' attainment of learning outcomes in palliative care through simulation and hospital placement. DESIGN: A longitudinal, intervention study. METHODS: Fifty-five second-year bachelor nursing students participated. Three waves of assessments were performed: (1) pretest; (2) postsimulation test and (3) postplacement test after the completion of the placement. Non-parametric Wilcoxon's signed-rank test for paired samples was used to test for differences between assessments of knowledge, skills and competence before and after simulation, and between postsimulation and post hospital placement. RESULTS: The results showed positive differences between pre- and postsimulation, indicating that learning outcomes were attained through simulation. However, negative differences between the postplacement test and postsimulation test scores indicated that the participants had practiced learning outcome from the simulation to a small degree during placement.