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- Dana Vaughan⇑
- Mattie Brechbiel
- Lilianne Nelson
- Address for Correspondence: Dana Vaughan
, Grand Valley State University, vaughada{at}gvsu.edu
ABSTRACT
Simulation-based education has become a standard practice in health professions education. To provide students with realistic phlebotomy experience in a low-stakes environment, the Grand Valley State University Medical Laboratory Science (MLS) program incorporated a live simulation event into its MLS program curriculum. Using a pre- and posttest survey design, MLS students rated their perceived confidence in phlebotomy skills within 3 domains: patient interaction skills, phlebotomy skills, and safety skills. Results demonstrated a gain in perceived self-confidence across all 3 categories following the simulation. These findings suggest that simulation-based education may be an effective tool for increasing confidence in phlebotomy skills in MLS education.
- GVSU - Grand Valley State University
- MLS - medical laboratory science
- PEARLS - Promoting Excellence and Reflective Learning in Simulation
- SP - standardized patient
INTRODUCTION
Simulation-based education is a well-established component of health care training, supported by a substantial body of evidence demonstrating its value in building technical competencies and communication skills.1 Additionally, the use of simulation in health care education has the ability to increase student perceptions of self-confidence and readiness to perform clinical skills.2 Despite simulation-based education’s proven efficacy as a method of education across health care–based disciplines, it is underutilized and lacks compelling evidence in its use for medical laboratory science (MLS) students.3 As a result, the MLS profession may be overlooking a significant opportunity to advance educational development and more effectively prepare students for clinical practice.
A study of MLS students’ perceptions of their education showed that practicing clinical skills during didactic education helped to reduce stress and anxiety when encountering the same skills in a clinical environment.4 Additionally, the study demonstrated that practicing communication skills through roleplaying in preparation for clinicals positively impacted the learning experience of students. Another study of university students also suggests that perceived self-confidence in students positively correlates with willing participation, enjoyment of learning, and reduced anxiety.5 Building confidence in professional skills during didactic education is important in promoting resilience in students, which is a positive predictor of academic and professional success in health care.6
Educators within our program have consistently observed a high degree of anxiety among students related to the phlebotomy rotation of their clinical practicum, prompting the development of a live simulation event. Simulation-based education provides a low-risk environment where students can practice skills without the risk of adverse outcomes.1 By providing a simulated experience, our program sought to give MLS students the opportunity to practice both the interpersonal and technical skills required for phlebotomy before performing them in a clinical setting. This study aims to examine the perceived self-confidence of MLS students before and after a live phlebotomy simulation.
METHODS
Study Design
For this study, a quasi-experimental, single-group pretest–posttest design was employed to evaluate students’ self-perceived confidence in phlebotomy skills before and after a live simulation–based learning experience. Participants included a cohort of 22 MLS students who participated in a simulation event as part of the required coursework in the accredited MLS program at Grand Valley State University (GVSU) in Grand Rapids, Michigan. The simulation event took place in February of 2025, which marked the eighth week of a 15-week semester and this cohort’s first term in GVSU’s MLS program. Prior to the simulation, students received didactic education and skills practice in a classroom laboratory setting for a set of phlebotomy competencies. The simulation activity was used as a formative assessment of the students’ phlebotomy skills including venipuncture, patient interactions, and attention to safety.
Simulation-Based Learning Event
The simulation-based learning event took place in a simulated hospital suite designed to replicate an inpatient clinical environment. Standardized patients (SPs) were incorporated to provide students with practice in patient identification and interaction. According to the Association of Standardized Patient Educators, SPs are individuals trained to portray patients in realistic and reproducible ways.7 During the simulation, SPs were instructed to remain cooperative while portraying fatigue consistent with being awakened by laboratory personnel for blood collection. Technical phlebotomy skills were practiced on an upper-extremity venipuncture task trainer positioned beside the SP in the hospital bed.
Prior to the event, students were provided with a video demonstration of the activity they were expected to perform. Participating students were placed into groups, each led by a faculty member who began the activity with a standardized discussion of expectations for the learning event, referred to as the prebrief. The prebrief established the simulation exercise as a formative experience within a safe space to promote psychological safety of the students. After the activity, faculty also led their assigned groups in a debrief using the Promoting Excellence and Reflective Learning in Simulation (PEARLS) Healthcare Debriefing Tool as a guiding framework.8 The PEARLS approach to debriefing aims to provide consistency and efficacy in simulation-based learning by using learner self-assessment, focused facilitation, and providing immediate and direct feedback to students.8
For the simulation experience, students were given 5 minutes outside their assigned SP’s room to prepare for their phlebotomy procedure. During this time, they were instructed to check labels and ensure the provided phlebotomy tray included all the required materials. After 5 minutes, students were instructed to enter the SP’s room to perform a single multitube collection via venipuncture. The venipuncture was performed on an upper-extremity venipuncture task trainer, situated next to the SP. A total of 10 minutes were given to complete the full procedure and exit the room. Students who were not actively participating in the exercise observed their peers on monitors. Faculty also observed students performing phlebotomy on monitors outside the simulated hospital rooms. Recordings were provided to each student to review and reflect on their own performance. Students received feedback from their assigned faculty and members of their peer group. Each student was expected to complete peer reviews and a personal reflection as part of the activity.
Data Collection and Analysis
This project was submitted to the GVSU’s internal review board, who determined the research to be exempt (25-226-H). All 22 students participating in the simulation were invited via email to complete voluntary and anonymous pre- and postevent surveys. Respondents were willing and gave their informed consent electronically prior to completing the surveys. The pre-event survey was sent 2 days prior to the start of the activity and closed at commencement of the activity. The postevent survey was sent after the conclusion of the activity and remained open for 2 days. Both surveys were created using Qualtrics XM (2025 version) software (Qualtrics) and distributed as an anonymous link. Each survey asked students to rate their confidence in performing skills using a Likert scale: 1, not at all confident; 2, somewhat confident; 3, moderately confident; 4, very confident; and 5, extremely confident. The pre- and postevent surveys presented the same set of skills to evaluate (Table 1). The skills evaluated in this section of the survey were derived from the competency checklist provided to students for the activity.
Survey questions as part of each domain for the pre- and postevent surveys
Pre- and postevent survey responses were analyzed using SAS statistical software version 9.4 through SAS Studio (SAS Institute Inc).9 Survey items were categorized into 3 domains: patient interaction skills, phlebotomy skills, and safety skills. Given the small sample size, a nonparametric approach was selected, and exact P values were calculated using Monte Carlo estimation. The Wilcoxon two-sample test was used because responses were not linked at the individual student level; therefore, pre- and postevent groups were treated as independent samples. Because this study was designed specifically to test improvement, a 1-sided significance test was selected. It was hypothesized that the simulation activity would increase student confidence scores compared with baseline, making it strictly directional.
RESULTS
A total of 22 MLS students participated in the live phlebotomy simulation event as part of their required coursework and were invited to participate in this study. The pre-event survey yielded 12 responses (54.5% response rate), and 10 responses were received for the postevent survey (45.4% response rate).
Survey items were identical between the pre- and postevent surveys. The skills evaluated fit into 1 of 3 categories: patient interaction skills, phlebotomy skills, or safety skills (Table 1). The responses within each domain were averaged for an overall perception of confidence in each category rather than each item. A gain in the mean perception of confidence was observed in all 3 domains after the simulation event (Figure 1).
Perceived student confidence pre- and postsimulation event. Given is a box-and-whisker plot of pre- and postsimulation survey responses in each domain. Data in the figure represent the mean of each item assessed in that domain.
Statistical significance was established at P <0.05. This threshold was met by all domains in the analysis (Table 2). Additionally, a Cronbach’s alpha cutoff of >0.70 was used to establish the internal consistency and reliability of the data; this standard was also met by both the pre-event and postevent surveys (Table 3).
Monte Carlo P value estimates for the exact test for data sets within each domain
Cronbach’s alpha and CIs for data sets within each domain
For patient interaction skills, the mean increased from 3.57 to 4.12, demonstrating an 11.0% average gain in confidence for the group. Phlebotomy skills saw the smallest gain in perceived confidence by respondents, with the mean increasing from 3.74 to 4.08, a gain of 6.8%. Phlebotomy skills were also the category with the highest perceived self-confidence prior to participation in the simulation event. For safety skills, the mean increased from 3.49 to 4.07, demonstrating a gain of 11.6% and the largest gain for the 3 categories.
Students were also asked to rate their perception of preparedness to perform phlebotomy in a clinical setting in the following Likert scale: 1, not at all prepared; 2, somewhat prepared; 3, moderately prepared; 4, very prepared; and 5, extremely prepared. Average preparedness ratings improved from 2.42 to 2.90 (9.6%). Although this represents a slight gain following the event, the final mean suggests the group still perceives itself as slightly below the level of being moderately prepared. More notably, 16.7% (n = 2/12) felt “not at all prepared” to perform phlebotomy in a clinical setting prior to the simulation event, but no respondents (n = 0/10) responded “not at all prepared” afterwards. No respondents felt “extremely prepared” before or after the simulation event (Table 4).
Perceptions of preparedness for clinicals: responses to the prompt, “Please rate how prepared you feel to perform phlebotomy in a clinical setting,” normalized into the percentage of participants
DISCUSSION
The largest gain in self-perceived confidence (11.6% gain) was for safety skills. Safety skills also had the lowest average confidence rating in the pre-event survey at 3.49. This may be attributed to the fact that this domain assessed items that were specific to a hospital setting such as confirming a patient’s identity using a wristband and returning their bedrail to a locked position. Participating students had not encountered these experiences in the classroom setting prior to the simulation event. Conversely, phlebotomy skills had the highest average confidence rating in the pre-event survey at 3.74, and the smallest gain in confidence when assessed again in the postevent survey, a 6.8% gain. This may be explained by the fact that students had practiced all the items in the phlebotomy skills domain in the classroom, prior to the event. These results suggest that the simulation-based learning event was effective in increasing self-perceived confidence in the necessary components of performing phlebotomy for these participants.
Although the mean response regarding preparedness for clinical phlebotomy increased by 9.6%, the postevent mean of 2.9 indicates that participants generally felt less than “moderately prepared.” Notably, however, no respondents reported feeling “not at all prepared” following the intervention. Furthermore, the proportion of students who felt “very prepared” rose from 8.3% (n = 1/12) to 30% (n = 3/10), representing a 21.7% increase (Table 4). It is important to note that the absence of unique identifiers prevented paired-sample analysis, making it impossible to assess individual shifts in perception. Given the small sample size and inability to link pre- and postevent responses, these findings can only suggest that the simulation event increased confidence in clinical preparedness.
The inability to pair pre- and postevent survey data is a significant limitation of this study. Surveys were collected without any identifying information or unique identifiers; consequently, group means were assessed rather than individual growth in perceived self-confidence. Using paired data in future research would enhance the statistical power of the findings and provide a more granular view of the effect of simulation-based learning events on learner confidence. Furthermore, the absence of demographic data on participants constrains the generalizability of these findings. Future studies should incorporate the demographics of participating students, including prior experience in phlebotomy, to account for relevant variables.
Additional limitations include the small sample size (n = 12 pre-event and n = 10 postevent) and modest response rates (54.5% pre-event and 45.4% postevent), introducing the potential for nonresponse bias. Students were invited to participate in their eighth week of a 15-week semester, which coincided with a period of high academic workload. The midsemester timing, along with narrow response windows for the surveys (2 days), may have hindered participation in this study. To improve response rates, future studies should consider more flexible response windows for the surveys, offering in-class time to participate, or an incentive for participation.
CONCLUSION
The results of this study suggest that simulation-based education can increase students’ perceived confidence in their technical, safety, and interpersonal skills when performing phlebotomy. Although the generalizability and statistical strength of these findings are limited, participants of this study appeared to benefit from the simulation-based learning event, especially when encountering components of phlebotomy that cannot be practiced in the classroom. Although the results from this small study are encouraging, further research is needed to validate these results in larger cohorts. For greater impact, future studies should also explore how perceived confidence in a skill affects anxiety and performance related to that skill in a clinical environment.
- Received May 18, 2026.
- Accepted May 22, 2026.
American Society for Clinical Laboratory Science
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