Sequential simulation-based clinical ethics education for clerkship students: A mixed-methods pre-post study.
INTRODUCTION Clerkship students encounter ethically significant dilemmas but have limited opportunities to rehearse ethically grounded decision-making and difficult conversations in realistic clinical contexts. We evaluated an immersive, sequential simulation-based clinical ethics education program. METHODS We conducted an explanatory sequential mixed-methods pre-post study with clerkship students at Kaohsiung Medical University from September 1, 2022, to May 31, 2023. Participants completed a core e-learning curriculum (digital modules/videos) before a two-day immersive simulation. The simulation comprised six longitudinal standardized patient cases, each with four sequential scenarios. Quantitative outcomes included ethical knowledge, ethical sensitivity, vignette-based ethical decision-making, and confidence in managing clinical ethical dilemmas; satisfaction was measured post-intervention. Pre-post comparisons were made using Wilcoxon signed-rank tests. Focus groups were audio-recorded, transcribed verbatim, and analyzed using reflexive thematic analysis. Findings were integrated using a joint display. RESULTS Thirty-eight clerkship students participated. Post-intervention ethical knowledge showed gains across all seven assessed domains. Ethical sensitivity increased across three issues, and ethical decision-making improved across all six vignettes. Confidence increased in nine of 11 items, including dilemma awareness, clarifying ethical problems, ethical reasoning, communication to reach consensus, and confidence in ethical decision-making. Satisfaction with simulation education was high. Qualitative integration identified three themes explaining these gains: confidence through enactment, structured ethical decision-making, and voice and consensus under pressure. DISCUSSION The program was associated with short-term gains in ethics knowledge, ethical sensitivity, vignette-based decision-making, and confidence. Qualitative findings suggested that enactment, feedback, and reflection made ethics learning more practical and increased learners' perceived readiness for challenging clinical encounters. Sequential simulation may help clerkship students connect principle-based ethics teaching with real-time reasoning and communication demands. Controlled longitudinal studies are needed to examine durability, transfer, and workplace-based performance. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT05547893.