Teachers Stress: A Narrative Inquiry during COVID-19 Pandemic

This study aimed to explore the teacher's stress among public and private colleges brought by the COVID-19 Pandemic which was identified in China last December 2019 and has spread around the world. The participants of the research consisted of 11 teachers in the public and 11 teachers in private schools. The data were analyzed using a qualitative content analysis method and divided into themes, sub-themes, and codes. Revealed in the study was that teachers in the public and private tertiary schools experience stress from the different demands at work, specifically on workload in terms of number of classes online per day, the number of students in the Google classroom for large classes, number of hours spent online in correcting students activities and outputs. The fact that teachers need a strong support system now more than ever and it is important to stay positive and reflect on what the teachers can learn during this time about instructional innovation and transformation. Besides, recommendations have been put forward that online teaching will be effectively implemented shortly along with teachers’ significant training. Teachers have had to deal with symptoms and causes of psychological issues from the start of the pandemic. The lockdown and the travel restrictions changed the dimensions of the teaching profession, as schools had to close to deal with the threat of the pandemic. The teaching situation, therefore, has been grim over the years with less focus on how it affects the teachers. This study, therefore, used a sample of 22 teachers from public and private schools to select teachers from all sides of the teaching sector. They were given a questionnaire, which helped to determine and measure anxiety, stress, and depression. The outcome and discussion proved that teachers have indeed suffered from the pandemic and show a high percentage of stress and depression. There are however other variables such as job stability, which formed the basis for including both private and public college teachers, age, and gender of the teachers. This paper advocate for the protection and safeguarding of the teachers' mental welfare and helps maintain the standards and quality of teaching for the benefit of the students and the teachers.

Introduction
During the first months of 2020, the Covid-19 pandemic has affected school activities all over the world, including the Philippines. Thus, CHED called for an urgent need to explore other innovative learning modalities that will facilitate migration from traditional to flexible teaching and learning options. Experts say that the sudden shift, forced adoption of technology-delivered instruction will affect the well-being of faculty and students alike [1]. With this, teachers with no experience working online abruptly shifted all the teaching-learning to the new modality causes stress as confirmed in the previous study that both teaching and managing are already in the category of occupations reporting the highest stress levels [2]. Stress in a distance-learning course can be minimized by course design and by appropriate adaptation to present situations. There is little, however, in the literature on distance learning, that deals with perceived stress in teachers. Simpson [3] is one of the few writers who discussed stress concerning distance learning-but only does so in the general discussion of stress management, rather than the investigation of teachers stress that the present researcher aimed to examine qualitatively the college teachers stress and seek to understand how their experiences influence and impacts the commitment of teaching.
In the advent of the modern world, the teacher is engaged with the continuous change of curriculum and educational reforms, updating of teaching methodology, the rapid unfolding of technology, and the increased of social aggressiveness which made the role of a teacher more complex and diverse. Teaching has been described as one of the most stressful, exhausting, and difficult of all occupations [4,5] and emotionally demanding, [6], with the hazards of heavy workloads and performance demands which can impair one's physical and psychological well-being [7]. This results in the teacher's stress.
The coronavirus pandemic has altered the world as we knew it. The new restrictions have changed the way people interact especially in the education sector and social relationships. The result of these changes has been feelings of loneliness and isolation. The high rate of transmission has had significant economic, social, psychological, and health effects that have affected the whole globe. The closure of schools was an immediate outcome of the pandemic and the struggle to resume normalcy is still a challenge for most countries. Certain countries are working on the return of students to the classrooms and the teachers are expected to be responsible for this process and make the transition as smooth as possible. Research on the negative effects of significant disruptions in society on the well-being of educators. There is a high likelihood of significant effects on the teachers as the effects of Covid-19 rage on. Even though such a major event has not been experienced by humanity in recent times, there is a need to understand how it affects people in the education sector. There also remains a significant threat, as there are more strains of the various springing from various regions in the world and therefore warranting the need for a study on how the effects on teachers can be controlled. The aim of this paper is to identify the exact elements of the teacher experience during the pandemic and the nature of the impacts on the teachers.
Moreover, meta-analytical research on teacher burnout encompassed fifteen years of published and unpublished studies from January 2000 to January 2015 whose participants were from the rural or urban elementary, middle and secondary schools. The result indicated a positive relationship between emotional exhaustion and work overload, role conflict, role ambiguity, and student behavior [8].
The issue of stress and burnout has been an alarming phenomenon globally. It is assumed that the 21 st century gave birth to the emergence of educational transformation; as such, schools set new goals, broadened the curriculum to compete globally to suit diverse learners and skills. Today, students live in a modern society that is interconnected in preparing them to be more competitive.
To this change, classrooms should be healthy, safe, engaged, and supported. School administrators, parents, educators, and community members, must have the ability to meet challenges and share strengths.
In terms of responsibility towards student's welfare and well-being, teaching is a unique profession. It is regarded as one of the world's top ten most stressful professions [9]. Teachers encountered various stressors, such as workload, role overload, insufficient salary, students discipline; however, the main problem occurs when teachers' capacities are not sufficient in fulfilling the workplace demands, such that these stressors may eventually lead to job burnout. Studies have shown that teaching is a stressful task and almost one-fourth of teachers have stress during teaching. Western countries and the east of Europe had about 10 to 40 percentages of teachers who were exposed to stress and burnout. These percentages reached 50 to 70 percent in countries like Iran, Japan, and Taiwan [10].
Thornqvist [11] says burnout does not happen all of a sudden but from a long pattern. The cascade of the little annoyances in work gathers into momentum and one may become a fallen prey to stress. There is a feeling of self-neglect, slow disintegration that eventually erodes passion and compassion [12]. The stressful events to a typical contact professional such as a teacher may create anxiety, anger, and frustration resulting from any aspect of work.
Kassen et. al. [13] look at the teaching-related stress from two culturally western and eastern nations specifically: Canada, Britain, Hongkong, and Thailand. The results recommend that the teachers' self-viability changes how work stress impacts the commitment to continue teaching. In reality, Sadeghi et al. [10] discover out that within the western nations and east of Europe, instructors have stress which influences self-well-being and execution. From an organizational point of view, stress can translate an ineffective behavior [14], such as estrangement, unresponsiveness, and truancy.
McCormick and Bernett [15] hypothesize comparative to the study of Proulx [16] the connections between stress and burnout dimensions to arbitrarily chosen high schools in New South Wales, Australia utilizing established instruments of Maslach Burnout Inventory. The discoveries see that stress and burnout as an overwhelmingly psychological phenomenon.
Researchers carried out with people and animals show that long-term stress causes cognitive, emotional, and behavioral problems [17]. In addition to stress resources, teachers and schools also affect stress situations seriously. According to Jones [18], the stress level of children and adolescents depends on the time, which students spend at school and academic activities. Educational stress is also called academic stress and is defined as discomfort and anxiety that is caused by different troubles of the academic learning experience [19]. Verma and Gupta [20] stated that academic stress is a disappointment about academic failure and mental distress that is characterized by a fear of being unsuccessful. Academic stress causes substance use, unhealthy nutrition, and depression; and affects self-care skills negatively [21,22]. According to the study of the American Health Association that was carried out with 97.357 students in 2006, 32 percent of students consider educational stress as a reason for low grades and dropout [23]. High expectations, information overload, academic pressure, unrealistic ambitions, limited opportunities, and high competition are the most common causes of academic stress [24].
Recent studies show that the earliest effects of the pandemic on the teachers were sleep disturbance, stress anxiety because they had to use the internet as a medium of teaching. Other studies also show that there are cases of anxiety related to the use of ICT in work and the completion of jobs. It leads to decreased job satisfaction and fatigue among the users especially at a time when it is the only tool available for instructors. There are also other highlighted variables such as age, which determine how the pandemic affected the teachers. Teachers who had children were also identified as more vulnerable to the increased stress of having to work from home. The studies show that the teachers who were the most affected were young female teachers with children and people with chronic illnesses.
Educational stress decreases performance, poses a threat to student's well-being, and causes mental and physical health problems [25]. Lack of self-confidence, somatization disorders, suicide ideation, the negative sense of self are the situations that are derived from educational stress [26]. Perceived stress differs according to variables such as gender, cultural differences, and socioeconomic status. Researchers indicate that male students experience less educational stress than female students [27]. This finding typically can be because female students pay more attention to school performance and they are more worried about academic failure [28]. Students, who have a disadvantaged history as compared to their peers, experience more educational stress [29].
The researcher has observed signs of stress among teachers like irritability towards work and other tasks, loss of enthusiasm, and decreased participation to whatever causes that may be detrimental to an underlying commitment to the Commission on Higher Education-Quality Education. The present phenomenon could be associated with the teaching and task-related demands of the school that teachers are engaged with.
To minimize the impact of demands among teachers, this present study aimed to explore the teacher's stress during COVID 19 pandemic. The study looks into the experience of stress by teachers during the COVID 19 pandemic and other significant events that may occur in the course of their journey. The outcome of this study may serve as the basis for addressing the phenomenon being explored.

Purpose of the Study
This study aimed to analyze the teachers' stress among public and private colleges brought by the COVID-19 Pandemic.

Research Questions
1. What are the effects of the pandemic on teachers? 2. What factors contribute to the rise in stress among teachers during the pandemic? 3. How are teachers coping to keep up with the demands and stresses of online teaching?

Research Design
This study, which examined the stress creators is a qualitative research based on the narrative inquiry. This study utilized a narrative inquiry design. A Narrative inquiry is the study of experience understood narratively. It is a way of thinking about and studying, experience. Narrative inquirers think narratively about the experience throughout inquiry [30]. The narrative inquiry was used to gain access to the public and private college teachers' stress during the pandemic. According to the definition of [30], the story is a selective reconstruction of the autobiographical past and narrative anticipation of the imagined future that serves to explain, for the self and others, how the person came to be and where his/her life may be going.

Research Participants and Sampling
The sample of this research was determined by using purposive sampling as the method of recruiting participants. The population of the research consisted of 11 teachers in the public and 11 teachers in private tertiary schools, the academic year 2020-21. Inclusion criteria of the sample size may include factors such as gender, ages between 23-65 years old, type of school, job status, and home location. The difference by teachers in public and private schools is used due to the difference in infrastructure by the institutions and variability in job stability.

Data Gathering Procedure
The narratives were collected through interview forms. Semi-structured forms allow for fast coding and analysis of data, ease of measurement, and then allow comparisons with the scope of the research [31].
Informed consent was presented and signed by the participants about the general aim of the research, the anonymity of responses, and the voluntary nature of participation and signed informed consent. No incentive was given. The identity of the participants would be kept confidential and their answers would only be used for scientific purposes. Pet names were used instead of the real names of the participants. Accordingly, teachers were coded as private teacher 1(PrT1), private teacher 2 (PrT2) public teacher 1 (PuT1) and, public teacher 2 (PuT2).

Data Analysis
The research data obtained were analyzed by the content analysis method, which is frequently used in qualitative research methods. Content analysis is a method that is effective in classification, edition, and comparison of texts to make theoretical inferences [32]. The data required for content analysis was analyzed with Google Sheets. The answers were evaluated in detail by the researchers and codes reflecting the experiences of the participants were created. Then, related codes were grouped and themes and sub-themes were created. Finally, the process was concluded by interpreting the themes and codes associated with each other.

Measures to Ensure Rigor
Büyüköztürk et al. [31] suggest that data should be examined by more than one person to increase the validity of qualitative research and member checking should be performed for reliability. Member checking, also known as participant or respondent validation, is a technique for exploring the credibility of results. Data or results were returned to participants to check for accuracy and resonance with their experiences. For this reason, two researchers to ensure the validity of the research examined the data. Besides, the analyses were supported by the direct experiences of the participants.

Results and Discussions
The purpose of this study was to examine the effects of the pandemic on the mental health of teachers. It focuses on the role of stressors and identifies these factors in relation to teachers. It focuses on the results from the questionnaire to highlight how various factors affect the teachers. The paper proceeds to highlight the demands placed on teachers during the pandemic that may lead to stress. The effects of stress on the teachers are similarly highlighted to find how the teachers are having to cope with the pandemic. It continues to highlight how teachers find the motivations to ensure that they continue their work regardless of the state of things. The findings show that the teachers are affected by both issues in their personal lives for having to work from home and professional issues related to the demands and requirements of the profession. Teachers have had to shift from the traditional form of instruction to the modern technological method used during the pandemic.
The Instruction division is significantly influenced by the widespread. Numerous schools around the world have briefly closed to control the spread of the COVID- 19. The investigation appears that teachers' stress amid pandemics and online learning isn't isolated from each other. A few instructors are not fulfilled with the unused learning mode. The educator includes a large share in providing an intelligent environment for the students to get involved within the learning environment [33].
Emerged in the study are four major themes, with subthemes in some of them, that are reflective of the experiences of the participants. Discussed below are the emerged themes:

Theme 1. Stress Creators
The ongoing pandemic has created a great impact on people from all across the globe. Many have suffered and experienced changes in their day-to-day lives. Among these are the teachers in any learning institution. With this occurrence, the educational system was modified drastically in response to the need to continue educating the students using an alternative teaching-learning modality. With this, teachers have the burden of creating learning materials that will ensure effective facilitating the learning of students through alternative means. Some of the participants expressed their concerns on this matter as reflected in their responses below:

Sub-theme 1. Personal Family Issues
Participants' personal/family issues show that some teachers have financial constraints or limited family income. These teachers are dependent only on the teaching salary for daily needs because the husbands were laid-off in their job during the pandemic. The

Sub-theme 2. School Issues
The New normal way of teaching-learning, dependent on online technology and the use of technology identified by some participants as stress creators. The findings show that this school issue is associated with problems related to other codes like difficulty in connecting with students, students don't have suitable equipment like laptops, and computer inefficiency, and illiteracy of teachers and students. Due to a pandemic, this current educational structure is a complete alternative, but there is a problem with technical issues since teachers are not used to it. There are numerous studies within the literature appearing that there's a negative relationship between online instruction and resistance to online instruction [34]. According to Palloff and Pratt [35], technology alone isn't adequate in distance instruction.

Sub-theme 3. Environmental/School Issues
The research findings also include the environmental and social issues sub-theme which comprise nine codes. Eleven participants indicated that the following were stressful: unstable network in certain regions, intermittent signal, poor Internet connection, or fluctuation. Another group of participants does not have Internet access at home, the work environment is not conducive.
The PrT3 participant is residing in the hinterland and she said: "I am 15 years in service and not used to this system of teaching that's why I find it difficult adjusting, especially that I need to go to my relative's place in the downtown area for internet connectivity." The PuT17 states that she is afraid of COVID transmission, neighbors infected by the virus, and the socalled quarantine issues because this could hamper some of her daily tasks especially the demand of time in teaching.

Theme 2: Demands that Contribute to Stress
The theme of demands that contribute to stress is divided into two sub-themes: school tasks and requirements and students' and parents' concerns. Analysis of teachers' demands shows that school tasks and requirements are more demanding than the student's and parents' concerns.
As a result of the analyses, a total of 37 codes was identified, twenty-six in the school tasks and requirements and twelve in the students and parents concerns sub-theme.

Sub-theme 1: School Tasks and Requirements
Some of the teachers express their feelings as follows: PrT9 "It is very stressful that we urged to comply with hard copies of the requirements where we find difficulty in traveling due to some protocols to follow and harmful too for our health…", PuT13 "I'm tired of constantly monitoring students' submission online at any time because others are working for school expenses like loads, others are still searching for internet connectivity." Teachers went through difficult times in this process, both emotionally and psychologically.

Sub-theme 2: Students and Parents Concerns
The other demand that contributes to teachers' stress is the students' and parents' concerns. The parents' (of the students) complaints and when you extend an effort to reach out to your student yet they took it for granted according to some participants. The demands that contribute to the stress mentioned were evaluated by the participants from different perspectives. For example, PrT6 though it's tedious in contacting and monitoring students especially those who don't have an internet connection and gadget, there's a feeling of touching the heart of my students…" PrT17 it's so irritating to always repeat the guidelines and instructions to some parents who can't easily understand through short message service, personal message or even calls. PuT16" we are advised not to take students' attendance as long as students can comply with requirements". Attendance is an important factor for follow-up students' difficulties.

Theme 3: Effects of Stress
The theme of the effects of stress experienced by the teachers during the COVID-19 pandemic was observed. Teacher stress impacts teachers' health and Well-being. It is clear that most of the effects of stress on this theme, which consists of six codes in total, are related to health.
Codes obtained with this theme are teachers' poor performance, burnout, lack of engagement, and tiredness, students showed lower academic performance when teachers are highly stressed and others will resort to transfer to another kind of job or institution. In this regard, PrT20 stated that " I'm not ready for this present situation, its a 360 degree turn around and the reality is here like I'm not so capable of using computer-related activities or lack of technology skills, can't easily understand the technology training maybe because of my age, easily get tired of conducting the class. I still prefer the face-to-face classes." The case that teachers and students are physically absent limits interaction and lower the efficiency level. This online instruction will be a crucial show in the future, but a few instructors specified that this will be as viable as face-to-face instruction.

Theme 4. Motivations and Reasons that Influence the Teachers to Continue Teaching
The theme of motivations and reasons that Influence the teachers to continue teaching consists of forty-three codes.
Some teachers' motivations and reasons that influence them to continue teaching are their career or profession. Teaching is their chosen career, thus, they remain committed to serving the school in achieving its vision and mission. PrT20 said, "teaching is my bread and butter that motivates me to stay until this 20 th year now". PuT6 'Despite different challenges in this profession, I still remain positive because of my love for teaching. PuT3 expressed" that teaching is the most tiring profession, but enjoyable and rewarding." Considering the different themes mentioned in general, it is a remarkable finding that teachers are really stressed this time of the COVID -19 pandemic.

Conclusion/Recommendation
Teachers highlighted online teaching as more stressful. Teachers in the public and private tertiary schools experience stress from the different demands at work, specifically on workload in terms of number of classes online per day, number of students in the Google classroom for large classes, number of hours spent online in correcting students activities and outputs. This as well includes personal and family issues, school issues and environmental and social issues, and parents and administrative demand. Due to these demands, a decrease amount of time was experienced by the teachers to accomplish the teaching-related activity. This precipitates moderate exhaustion and fatigue among teachers. Teachers have a critical role in children's lives and teaching has become one of the most stressful occupations, with alarmingly high rates of job dissatisfaction.
In general, to overwork, the teachers with inadequate time and training for the new normal education system for compliance do not give the best output. Also, giving the assignment beyond the nature of their task makes them less efficient. The closure of schools and the disruption of the learning process have led to the teachers feeling confused and stressed. They are unaware of the direction and how long things will remain as they are currently. A major cause of the uncertainty and stress is the fact that the teachers have significantly lower knowledge of the new technology required to teach during the pandemic.
An intervention is made available to minimize the stress experienced by the public and private tertiary school teachers. Social support is called for from colleagues and administration making the intervention a success. Training can be carried out so that instructors can adjust to an internet framework more can be reinforced to dispense with technological issues.
Teachers' development plan of the school must include activities that will give a diversion to the stressful routine of the teachers. From the finding, it is critical to establish emotional support for teachers given the extent of the impact of the pandemic on their mental health. Teachers have had to cope with the pandemic by dealing with the stressors they face both at home at professionally. There are factors like age, gender, family status, and fears of job stability that also contribute to the stress of the teachers.
The paper proceeds to highlight the demands placed on teachers during the pandemic that may lead to stress. The effects of stress on the teachers are similarly highlighted to find how the teachers are having to cope with the pandemic. It continues to highlight how teachers find the motivations to ensure that they continue their work regardless of the state of things. The findings show that the teachers are affected by both issues in their personal lives for having to work from home and professional issues related to the demands and requirements of the profession. Teachers have had to shift from the traditional form of instruction to the modern technological method used during the pandemic.


s2fieldsofstudy: Education Medicine

text:
Evaluation of sleep quality among nursing faculty: Application of the Pittsburgh Sleep Quality Index—A descriptive correlational study

Abstract Aim The aim of this study was to describe the overall sleep quality, sleep patterns and severity of sleep difficulties among nursing faculty using the Pittsburgh Sleep Quality Index (PSQI). Design Cross‐sectional descriptive and correlational study. Methods A survey of faculty recruited from Texas Board of Nursing approved colleges/schools was used. A purposive, convenience sample of 105 faculty completed the PSQI, a reliable and valid instrument, in an online setting. Data was collected from January 2019 through April 2019. Results Nursing faculty reported sleep difficulty across all components, with more problems in sleep latency, sleep disturbances and subjective sleep quality. Overall, 70.5% of participants were reportedly “poor” sleepers, a salient finding. Faculty experienced poor sleep quality across all academic ranks and age groups. Sleep latency and subjective sleep quality were components that presented higher in severity for the youngest faculty.

| INTRODUC TI ON
Restorative sleep is a basic condition for enhanced wellbeing through the renewal of the body, mind and soul (Helvig et al., 2016). The Sleep Quality Consensus Panel agreed that sleep latency, number of awakenings >5 min, wake after sleep onset and sleep efficiency were appropriate indicators of sleep quality across the life-span (Ohayon et al., 2017) while Buxton et al. (2009) identified sufficient sleep duration and quality as key components of adequate sleep practices. Epidemiological and laboratory evidence has found that decreased sleep duration and poor sleep quality are associated with several negative health outcomes, such as obesity and chronic disease (Bowman et al., 2019;Chouchou et al., 2013;Zuraikat et al., 2020). Among health science students, healthcare workers and emergency personnel, poor sleep quality and sleep deficiencies have been linked to decreased work performance, poor decision-making, medical errors, personal health challenges and burnout (Greeson et al., 2015;Melnyk, 2020;Wolkow et al., 2015;Xu et al., 2016). There has been some research on sleep quality among nurses (Fang & Li, 2015) and nursing professors' quality of life (Cruz et al., 2015), but very little research about nursing faculty.

| BACKG ROU N D
There has been a significant amount of research on the impact of irregular work schedules, such as shiftwork, on sleep among nurses.
Several studies using the Pittsburgh Sleep Quality Index (PSQI) (Buysse et al., 1989) in nurses reported poor quality of sleep for shift workers in the USA (Colditz et al., 2016), Taiwan (Lee et al., 2015), Turkey (Baskent et al., 2017), Ankara (Karahan et al., 2020), and Italy (Giorgi et al., 2017). Poor sleep quality has been associated with insomnia and emotional disturbances (Huang & Zhu, 2020;Lee et al., 2015), and sleep deprivation, irregular sleep patterns and sleepiness were significant issues for shiftwork nurses (Debbia et al., 2021;Zhang et al., 2016). In a systematic review, longer shift patterns, such as consecutive night shifts, were associated with poor sleep quality and fatigue (Querstret et al., 2020). Melnyk's et al. (2018) study also reported poorer mental and physical health in nurses who work longer shifts. Research has also shown that shiftwork is associated with sleep deprivation and a decrease in psychomotor skills, attention, concentration, processing speed and quality of performance (Kaliyaperumal et al., 2017;Karahan et al., 2020).
Medical errors have been linked to sleep disturbances and fatigue (Karahan et al., 2020) and hypersomnolence, excessive daytime sleepiness, have been associated with increased risk of accidents (Garbarino et al., 2016).
The work of nursing faculty involves clinical practice, academic responsibilities and a heavy workload, all likely to impact their worklife balance and sleep (Fang & Li, 2015;Santos et al., 2019). Mintz-Binder and Sanders (2012) described the workload demands of 242 associate degree nursing program directors in the USA and their association with sleep problems, decreased overall physical health and burnout. A study of non-nursing university professors working full time found that females and faculty between ages 45 and 54 reported more frequent fatigue, inability to sleep and poor concentration than males and those 35-44 years old (Tacca Huamán & Tacca Huamán, 2019). These few studies indicate the need to examine sleep quality and the extent of sleep difficulties among nursing faculty. The significance of this study was to address this gap and contribute to building an evidence base that will guide future research and interventions to mitigate potential negative implications of sleep difficulties among nursing faculty. This study was conducted to be the foundational work in evaluating sleep quality among nursing faculty leading to a larger study with a more diverse population.

| Research question
The purpose of this study was to describe the overall sleep quality, sleep patterns and severity of sleep difficulties among nursing faculty using the PSQI and examine demographic factors. The study aims were to (a) describe the overall sleep quality and sleep patterns of nursing faculty using the component scores of the PSQI and (b) describe the severity of sleep difficulties in this sample (in terms of poor and good sleepers).

| Design
The study design was a cross-sectional descriptive and correlational study of sleep quality.

| Participants
A survey of nursing faculty recruited from Texas Board of Nursing approved colleges or schools of nursing was used to conduct a crosssectional descriptive and correlational study of sleep quality. The Institutional Review Board from the University approved the study, which was conducted between January and April of 2019. Inclusion criteria were the following: (a) nursing faculty who worked in a Texas Board of Nursing approved college or school of nursing, (b) 21 years of age or older and (c) able to read and understand English. Pregnant women were also eligible.
Recruitment to participate in the nursing faculty sleep quality study began with development of a purposive sampling of nursing faculty emails from accredited schools and colleges in Texas.
Processes in developing the list included email requests sent to deans and directors of accredited Texas Board of Nursing programs and direct email invitations to faculty. This procedure yielded 681 nursing faculty email addresses. A cover letter and consent were sent by the researcher via email to eligible faculty. Among the 681 targeted faculty, 126 accessed the survey using a Survey Monkey password protected account. Electronic consent had to be provided before the online survey would advance. Of the 126 respondents, 21 did not complete all components required for data inclusion, resulting in a final sample of 105 (15.42% response rate). This study was motivated by the lack of information surrounding sleep habits in nursing faculty to eventually study health consequences of nursing faculty. We had ample sample size to estimate response rates in this study and will be able to use results from this study to aid in designing a future hypothesis-driven study.

| Procedures and instruments
The study used Survey Monkey software to collect nursing faculty data on basic demographics and a validated measure of sleep quality. A secure, reliable and encrypted website was used to host the survey and collect the data. After consent was obtained, a greeting script from the researcher was presented which contained instructions for filling out the survey. The greeting script was followed by the Demographic Form, and PSQI survey. Each subject created their own five-digit self-assigned identification number, which appeared at the top of the demographic form. The study data were encrypted for added security. The survey allowed only one attempt.
A final page displayed a thank you message for completing the survey with an option for eligibility to receive one of eight $25 Visa gift cards upon completion. All survey questions had to be completed to be eligible for a gift card. Two-week and 3-day reminders were sent after the beginning of the study, and again at the 1-day mark for completion of the survey. Gift cards were not issued until the study was completed.

| Demographic form
Participants filled out basic demographic information including their gender, age range, race/ethnicity, employment status and academic rank.

| Pittsburgh Sleep Quality Index
The PSQI (Buysse et al., 1989) is a widely used self-report questionnaire that assesses overall sleep quality and sleep components along seven domains based on the past month: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication and daytime dysfunction. The PSQI consists of 19 items, most of them with a Likert response format. Items are combined to produce the component scores using authors' recommended formulas. Each derived component has a range from 0-3 whereby "0" indicates no sleep difficulties and "3" represents more severe sleep problems. For instance, the daytime dysfunction score is the sum score on two items (how often taking medication to help sleep; how often having trouble staying awake during daily activities such as driving and eating), coded on the 0-3 scale (0 = 0, 1-2 = 1, 3-4 = 2, and 5-6 = 3). The subjective sleep quality component (1 item) refers to the person's rating of their overall sleep quality on a scale of 0 (very good) to 3 (very bad). Sleep latency represents how long it takes for the person to go to sleep, whereas sleep duration refers to how many hours of sleep a person actually gets at night. Habitual sleep efficiency is calculated as a ratio of number of hours slept/number of hours spent in bed multiplied by 100, which translates into a percentage (˃85% indicates no sleep problems, scored as "0"; <65% indicates more severe sleep problems, scored as "3"). The sleep disturbances component is derived from the sum of eight item scores indicating how often the person had trouble sleeping (e.g., waking up during the night, having pain or feeling too cold/hot). The global PSQI score is the sum of the seven components and ranges from 0-21, with a total score above 5 indicating a "poor" sleeper. The PSQI also includes an open question on "other reasons" for having trouble sleeping. The original authors found a diagnostic sensitivity of 89.6% and specificity of 86.5% in differentiating poor and good sleepers; a sensitivity of 98% and specificity of 55% were found in the Chinese population (Tsai et al., 2005).
The PSQI has been used in numerous studies of adult populations internationally to assess sleep quality and its relation to a variety of outcomes (Bowman et al., 2019;Huang & Zhu, 2020;Karahan et al., 2020). For instance, the PSQI was used as part of the Midlife in the United States (MIDUS) study, which includes the general adult population. A higher global PSQI score was associated with a higher risk of depressive symptoms (Huang & Zhu, 2020). Baseline data for the American Heart Association (AHA) Go Red Women prospective cohort study (Zuraikat et al., 2020) also included the PSQI, and results indicated that poor sleep quality was associated with greater food intake and lower quality diet, which are risk factors for cardiovascular disease. The PSQI was also used in a large cross-sectional community-based study of the Korean Medicine Data Center which showed an association between sleep problems and digestive symptoms (Hyun et al., 2019). In academic populations, the PSQI has been primarily utilized in studies with students, including nursing students (Liu et al., 2021). A recent literature review of determinants of sleep quality in college students (Wang & Biro, 2021) found that physical activity and healthy social relations related to improved sleep quality, while caffeine intake, stress and irregular sleep-wake patterns were associated with decreased sleep quality.
A comprehensive meta-analysis of observational studies of sleep quality among medical students in four continents (Rao et al., 2020) found a pooled prevalence of poor sleep quality of 52.7% using the PSQI and a mean PSQI score of 6.1. Sleep quality was more prevalent in Europe and the Americas. Very few studies have examined sleep quality among university faculty using the PSQI. A few studies have been conducted in Brazil and Portugal, which investigated contributing factors to sleep quality among university professors and related poor sleep quality to physical and emotional symptoms (Crepaldi & Carvalhais, 2020;Santos et al., 2019;Silva et al., 2018;Sousa et al., 2018).

| Analysis
Overall sleep quality as measured by the global PSQI score was assessed numerically and nominally ("good" vs. "poor" sleeper) in terms of severity of sleep difficulties. Numerical data for PSQI and its component scores were presented as means (M), standard deviations (SD), and quartiles and ranges. Component scores (0-3) are ordinal categories; thus, quartiles, 25th, 50th (median) and 75th percentiles, and/or interquartile ranges (IQR = 75th percentile-25th percentiles) are appropriate to report measures of central tendency and spread.
Overall sleep quality was defined based on a cut-off of 5 on the global PSQI score (poor sleepers: >5; good sleepers: ≤5). Spearman correlation was used to assess the relationship between component scores and overall PSQI. From the demographic questionnaire, age was reported in six categorical ranges (under 25; 26-35; 36-45; 46-55; 56-65; and >66 years) and further collapsed into the following four age groups deemed meaningful for analysing sleep patterns in this population: ≤45; 46-55; 56-65, and ≥66 years. Among relevant demographic populations, Kruskal-Wallis test was used to evaluate PSQI scores (numerical) and Fisher's exact test was used to evaluate severity of sleep difficulties (nominal). Overall differences in severity of sleep difficulties among all nursing faculty were analysed using the binomial test of proportions. All statistical tests were conducted using an alpha level of 0.05. Statistical analysis was performed using Stata statistical software, version 14.0 (StataCorp., 2015). Buysse et al. (1989) report an internal consistency reliability (Cronbach's alpha) of 0.83 for the seven components. A recent study conducted among 923 Chinese nurses found a Cronbach's alpha reliability coefficient of 0.73 (Li et al., 2019). In the current sample of nursing faculty, the estimated Cronbach's alpha coefficient was 0.68, with domain by overall score correlations ranging from 0.446-0.736.

| Characteristics of sample
Nursing faculty demographics and characteristics are presented in Table 1. The majority of the nursing faculty was female (97%), white

| Overall sleep quality and patterns
The global PSQI score for sleep quality among nursing faculty was on average 8.14 (SD = 3.81) (range: 1-17), with a median score of 7 and IQR: six points (Table 2)  Global PSQI scores were lower among the middle age groups (46-55 and 56-65 year olds) and, on average, were worse among the youngest and oldest age groups (Table 3)

| Severity of sleep difficulties
Study results demonstrated that a large percentage (70.5%) of the nursing faculty reported as poor sleepers (total PSQI>5) (p < .05) ( Figure 2). No significant effects of age group were found to be associated with severity of sleep difficulties ("poor" vs. "good" sleepers; p = .835) as depicted in Figure 2. Severity of sleep difficulties did not significantly differ across gender, race, work status or academic rank (p > .05).

| D ISCUSS I ON
The aim of this study was to describe the overall sleep quality, sleep patterns and severity of sleep difficulties among nursing faculty using the PSQI. Our results showed that over 70.5% of nursing faculty reported poor sleep quality ("poor sleepers") as compared to     (Lee et al., 2017;Wolkow et al., 2015).
Therefore, our youngest faculty members may be at increased risk of cumulative effects harmful to their health. Finding the aetiologies and targeted interventions of the nursing faculty's poor sleep quality must be individualized. Melnyk (2020) (Wu et al., 2020). Some possible causes from the literature are irregular schedules, mental health issues, such as, anxiety and depression, chronic health conditions, such as, a respiratory condition, gastroesophageal reflux disease, or pain, and sleep apnea.  et al., 2018), the combination of objectively and subjectively assessed sleep being recommended (Bowman et al., 2019).

| Limitations
This study has limitations that may affect generalizability of findings including a homogenous sampling of white, females, working fulltime as faculty members, although it reflects the basic demographics of nursing faculty. There is possible selection bias with using a purposive sampling from schools of nursing in Texas and with invitations being forwarded by a person holding a position of authority, such as a Dean or Director of a nursing program. PSQI is a well-validated measure of sleep quality, but may be limited by retrospective selfreport biases. The response rate was low at 15% for the online survey which is slightly below the 20%-30% expected rate (Sauermann & Roach, 2013). Self-selection bias could also have inflated the results by respondents that were interested in reporting their sleep problems. No definitive conclusions can be drawn from this study without a larger sample of faculty with more diversity.

| CON CLUS ION
Nursing faculty in this study reported poor sleep quality, which is likely to compromise their health and well-being. Work-family conflict was identified by faculty as interfering with their sleep and is important factors to address in intervention development. Evidencebased interventions to balance personal and work life, as described by Melnyk (2020), are needed. Developing a culture of wellness in academia, which promotes self-care and sleep health, is essential to sustaining healthy nursing faculty and academic programs.

ACK N OWLED G M ENTS
This work was supported by a grant from the Phi Chi Chapter of Sigma. We wish to thank the Nursing faculty who participated in this study, Earline Moreland from the University of Houston College of Nursing who assisted with data management, Rachel Helbing and Stefanie Lapka with the University of Houston Libraries.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the authors.

AUTH O R CO NTR I B UTI O N S
SC involved in study design and acquisition of data; SC, JB, CB and TM took part in analysis and interpretation of data; SC, JB, CB and TM participated in drafting of the manuscript; SC, JB, CB and TM involved in critical revisions of the manuscript for important intellectual content. All authors read and approved the final manuscript.

E TH I C A L A PPROVA L
This study was reviewed and approved by the University's Institutional Review Board (IRB). The greeting script, demographic form, data collection procedures and questionnaire were approved by the IRB. The IRB identification number STUDY00001376 was approved. Participation in the study was voluntary. Each study participant self-selected their own participant identification number. There were no foreseeable risks related to the procedures conducted as part of this study. Data were encrypted for additional security.

DATA AVA I L A B I L I T Y S TAT E M E N T
Research data are not shared. The data are not publicly available due to privacy and compliance with the Institutional Review Board protocol approval.


Comparison of Learning Transfer Using Simulation Problem-Based Learning and Demonstration: An Application of Papanicolaou Smear Nursing Education

The purpose of this study was to compare the effects of simulation problem-based learning (S-PBL), a type of learning that reflects various clinical situations, and demonstration-based learning, a conventional type of learning that shows clinical skill performance, of Papanicolaou smear education on the self-confidence, learner satisfaction, and critical thinking of nursing students. A quasi-experimental control group pretest-posttest design was used. Nursing students who were classified as advanced beginners were randomly allocated to the control group (n = 53) or the experimental group (n = 52). Students in the control group participated in a conventional demonstration of a Papanicolaou smear, while students in the experimental group participated in S-PBL. The students’ self-confidence, learner satisfaction, and critical thinking were measured via a self-reported questionnaire. Compared with the control group, self-confidence, learner satisfaction, and critical thinking increase significantly more (p < 0.001) in the experimental group. S-PBL was found to be an effective strategy for improving learning transfer, applying learned nursing knowledge to simulated nursing situations. Thus, S-PBL is recommended to improve training in nursing education.

Introduction
Cervical cancer is one of the most prevalent malignancies of the female reproductive tract, and infection with human papillomavirus (HPV) is considered to be the primary cause [1]. Globally, it is the second most commonly diagnosed carcinoma in women; 569,847 new cases and 311,400 deaths were reported in 2018 [2]. In South Korea, the number of patients diagnosed with cervical cancer has gradually increased from 59,910 in 2017 to 62,071 in 2018 and 63,051 in 2019 [3]. The incidence of cervical cancer has not been decreased dramatically considering the development of improved research tools and test methods. Accordingly, the National Cancer Screening Project in South Korea has promoted the Papanicolaou smear (Pap smear) as a screening method for cervical dysplasia and carcinoma among women over the age of 20 [4].
A Pap smear, introduced by George Papanikolaou in 1943, is a simple, quick, and inexpensive screening procedure for cervical cancer [5]. A Pap smear can be performed in an obstetrics and gynecology outpatient clinic at a medical institution that conducts national cancer screening [1], and in most cases, hospitalization is not required. Therefore, nursing students have limited opportunities to observe Pap smears in maternal nursing practice, which are mainly held in the delivery room and obstetrics and gynecology wards.
In recent years, the demand for professional knowledge and clinical skill performance of nursing students has increased, while participatory observation and direct nursing experiences have become more restricted due to the reinforcement of patient privacy and safety measures. Therefore, simulation-based learning is increasingly being used as an alternative [6,7].
Simulation-based learning can effectively reproduce clinical nursing settings and improve nursing performance through lifelike nursing experiences [8,9]. In particular, simulation problem-based learning (S-PBL) is an educational method that enables nursing students to identify problems in given scenarios and repeatedly perform nursing procedures with a human patient simulator or human body model to improve their nursing competency [7,10].
Previous studies have evaluated simulation of maternal nursing situations, such as delivery or postpartum hemorrhage, and compared the effects of simulation-based learning and clinical nursing practice on clinical performance and learner satisfaction [11,12]. While previous studies have assessed the effects of simulation-based learning in obstetric care, there is a lack of studies on simulation-based learning for preventative screening in gynecological nursing, particularly in performing Pap smears.
Therefore, in this study, we developed Pap smear nursing scenarios based on Jeffries's simulation model and evaluated the effects on nursing education ( Figure 1) [13]. The model is based on constructivist learning theory, and it can be applied in various ways to nursing education as it presents components that can systematically explain nursing simulation education design [14]. Jeffries's simulation model presented a nursing simulation education design and explained that simulation experiences occur considering design and background in an overall context [13]. As dynamic teacher-student interactions are crucial, teachers need to apply proper simulations based on teacher-student clinical practice to induce educational outcomes. The main components of a simulation model are students, teachers, educational practice, intervention, and expected outcomes [13]. In this study, nursing students are students, faculty is teacher, maternal nursing educational practice is educational practice, S-PBL or demonstration is intervention, and self-confidence, learner satisfaction, and critical thinking are expected outcomes. A well-developed simulation intervention results in self-confidence, learner satisfaction, and clinical thinking according to Jeffries's simulation model [13]. A demonstration is a popular way to present skills for nursing students in South Korea. Simulation practice allows students to build their own knowledge system while experiencing virtual situations. As Bandura's self-efficacy theory [15] self-efficacy leads from knowledge to practice. Self-efficacy is required for students to apply the information they have acquired to the actual situation, and what kind of experience students have at this time is a major factor in determining their self-efficacy. Enactive attainment in simulation education is a major element leading to self-efficacy, and while vicarious experiences (e.g., demonstrations) also lead to self-efficacy, enactive attainment in simulation education is a more important element than vicarious experience.
Self-confidence and learner satisfaction are important aspects of simulation experiences. Such experiences can be offered to provide clinical nursing information for Pap smears. Nurses must identify complex situations and detect each patient's needs in the midst of substantial information during clinical practice. Thus, nursing students need to develop critical thinking skills to accurately make decisions in complex situations. In Jeffries's model, the outcome consists of self-confidence, learner satisfaction, critical thinking, and so on [13]. Those results correspond to the skills that the students need to gain from the education.

Aims
S-PBL for Pap smear education provides nursing students with opportunities for interaction and communication with patients, guardians, and medical staff through peer role-play. It promotes teamwork and allows students to think and cope with nursing scenarios by directly applying women's health nursing knowledge [10]. Therefore, this study implemented S-PBL to assess its effects on self-confidence, learner satisfaction, and critical thinking and compared them to the effects of conventional demonstrations to provide a basis for active learning transfer among nursing students.
More specifically, the objectives of this study were as follows: First, we assessed self-confidence, learner satisfaction, and critical thinking among nursing students. Next, we evaluated the relationship between self-confidence, learner satisfaction, and critical thinking. Finally, we compared the effects of S-PBL to those of conventional demonstrations.

Research Hypotheses
The hypotheses of this study are as follows.

Hypothesis 1:
The S-PBL group will show a higher increase in self-confidence than the control group after the intervention.

Hypothesis 2:
The S-PBL group will show a higher increase in learner satisfaction than the control group after the intervention.

Hypothesis 3:
The S-PBL group will show a higher increase in critical thinking than the control group.

Research Design
This study utilized a quasi-experimental control group pre-test-post-test design, which is shown in Figure 2. The experimental group engaged in S-PBL based on Pap smear knowledge and the control group participated in a Pap smear demonstration based on Pap smear knowledge, and the two groups' self-confidence, learner satisfaction, and critical thinking skills were then compared ( Figure 2).

Subjects and Setting
Third-year nursing students from a nursing college at a university located in S city (a metropolitan area) in South Korea who participated in a maternal nursing practice course were included in the study. All participants had completed a pre-requisite maternity nursing course and had basic knowledge related to women's health nursing before the study.
The minimum sample size was calculated using G*Power Software (G * Power 3.1.7, Heinrich-Heine-University, Düsseldorf, Germany) with a significance level of α = 0.05, a power of 0.95, and an effect size of 0.8 [16,17], and 84 subjects with 42 subjects each in the control and experimental groups were required. A total of 105 subjects were included to compensate for the dropout rate of about 20% in data collection. The subjects were assigned to the control group (n = 53) and experimental group (n = 52) through randomized blinded allocation. No subjects dropped out, and a total of 105 subjects were included in the final analysis, satisfying the minimal required sample size.

Preliminary Assessment
General characteristics and knowledge about Pap smears were assessed before the intervention for both the experimental and control groups. Knowledge about Pap smears was assessed using 10 items regarding intended targets, purpose, timing, procedures, cautions, and an overall understanding of the anatomical physiology of the female genitalia (i.e., the cervical cancer screening conducted by the National Health Insurance Service is recommended once every two years for women over the age of 20; one can have a Pap smear during menstruation; cervical dysplasia can be detected from the results of Pap smears, etc.). The items were evaluated using a "True or False" quiz format. This tool was developed by two professors with more than five years of experience in maternal nursing instruction, practical education, and clinical experience in maternal nursing. The total score ranged from 0 to 10, and a higher score indicated a higher level of knowledge.

Interventions: Simulation Problem-Based Learning (S-PBL) vs. Demonstration
The experimental group participated in S-PBL in the simulation room of the nursing college. Simulation scenarios were developed by the researchers based on the Korean Society of Obstetrics and Gynecology, literature on women's health nursing, and clinical cases of Pap smear nursing observed in obstetrics and gynecology departments. A professor with extensive experience in simulation-based maternal nursing was consulted. S-PBL was formatted as a small group activity, consisting of 3-4 students (each student played the role of one doctor, one or two nurse(s), or one guardian) who were randomly selected. According to Benner [18], Pap smear S-PBL is a practical form of education for advanced beginners who are at least second-year students. The difficulty level of the Pap smear S-PBL is Level II intermediate, which means that the students have to consider the individual characteristics of patients and provide nursing based on communication rather than show a mere replay of skills in a specific situation [7]. Pap smear S-PBL consisted of 60 min of prebriefing, 15-20 min of running time, and 60 min of debriefing, using a human body model with the anatomy of the female genitalia including the cervix ( Figure 3). The instructors provided sufficient time to review the knowledge and skills required for orientation and simulation in the pre-briefing session [19]. In the running time, the students performed Pap smear nursing duties, while the instructors who facilitated the simulation provided cues about the Pap smear nursing situation and patient information. In addition, the instructors measured subjects' Pap smear skill performance using a structured checklist that was developed by two professors who had more than five years of experience in maternal nursing teaching, practical education, and clinical experience in maternal nursing ( Table 1). The checklist consisted of 17 items, which were evaluated on a 3-point scale (1 = "not performed," 2 = "partially performed," and 3 = "well performed"). Pap smear skill performance score ranged from 17 points to 51 points. In the debriefing stage, subjects provided feedback and reflected on the small group activities.  The control group watched Pap smear demonstrations by the instructors for 15-20 min in groups of 3-4 students and asked questions at the end.

Outcome Assessment
After the intervention, self-confidence, learner satisfaction, and critical thinking were evaluated, using a structured questionnaire to measure learning transfer related to Pap smears, both for the experimental and control group. The 11-point Numeric Rating Scale (NRS), for which the question is "How much self-confidence do you have in Pap smear nursing?" was used to measure the participants' degree of self-confidence on a scale of 0-10 from "not at all" (0 points) to "very much" (10 points), and a higher score indicates higher self-confidence. The NRS, which is likely the most commonly used self-report tool in various disciplinary fields such as clinical, research, and so on, allows for quick mea-surement, and NRS has strong psychometric properties, thereby offering a valid approach to the self-assessment of confidence in examination skills by health care students [20,21]. Learning satisfaction was measured with 24 items developed by Yoo [22]. The items (i.e., "I became more interested in this field after taking this class," "The teaching method made it easy to understand," etc.) were evaluated on a 5-point Likert scale from "not at all" (1 point) to "very much" (5 points), and a higher score indicated higher learner satisfaction. The reliability of the tool, indicated by Cronbach's α, was 0.94 in the original paper and 0.94 in our study. Permission was granted by the original author to use the tool in this study [22]. Critical thinking referred to personal dispositions and habits used for problem solving and decision-making. In this study, critical thinking was evaluated using a tool developed by Yoon for nursing [23]. The tool consisted of 27 items (i.e., "When dealing with a complex problem, I judge and deal with the problem according to the criteria I set," "I withhold my judgment and ponder the matter until adequate and sufficient evidence is obtained," etc.) that were evaluated on a 5-point Likert scale from "not at all" (1 point) to "very much" (5 points). Items 4 and 14 were reverse-scored, and the total score of the tool ranged from 27 to 135. A higher score indicated better critical thinking. The reliability of the tool, which is indicated by Cronbach's α, was 0.84 in the original paper and 0.90 in our study [23]. Permission was granted by the original author to use the tool in this study.

Data Collection
This study was conducted from 19 October 2020, to 4 December 2020. The subjects were blinded to the group to which they belonged, and the control group and experimental group participated in the study at different times to prevent spillover effects between the two groups. The researcher provided a sufficient explanation of the research, intervention, and procedure for the research, distributed the questionnaire before and after each intervention, and collected the questionnaire separately from the consent form. Data were acquired using a structured questionnaire, which required approximately 10 min to complete for both the pretest and posttest, and the participants were provided with small compensation (school supplies worth 1000 KRW) for their participation.

Statistical Analysis
Statistical analysis was performed using IBM SPSS Statistics ver. 22.0 program (IBM Co., Armonk, NY, USA). Descriptive statistics were used to analyze the general characteristics of the subjects. Cronbach's α, Pearson correlation coefficient, and t-test were used to analyze the reliability of the evaluation tools, correlation analysis between the variables, and homogeneity test and comparison of intervention effects, respectively. The correlation between the factors was assessed using the correlation coefficient and a p-value < 0.05 was considered statistically significant.

Ethical Considerations
This study was approved by the Institutional Review Board of Eulji University (No. EUN20-041). The details of the study were sufficiently explained to the subjects, and written consent was acquired from those who voluntarily wished to participate. The subjects were allowed to withdraw from the study at any time and for any reason, and it was explained that there would be no disadvantages if they refused to participate, to relieve any unnecessary tensions in the study. The control group was provided with an opportunity to take part in S-PBL without data collection after the study was completed. Table 2 shows the general characteristics and homogeneity test of variables between the experimental and control groups. The mean age (standard deviation [SD]) of subjects in the experimental and control groups was 22.54 (2.84) and 22.08 (1.99), respectively. The experimental group consisted of 41 female students (78.8%) and 11 male students (21.2%), while the control group consisted of 44 female students (83.0%) and 9 male students (17.0%). Subjects generally make an independent choice to study nursing, with 32 (61.5%) and 23 (43.4%) in the experimental and control groups, respectively, and 37 (71.2%) and 40 (75.5%) students were very satisfied or satisfied with their major in the experimental and control groups, respectively. The number of students who were satisfied with clinical nursing practice was the greatest in both groups, with 23 (44.2%) and 28 (52.8%) in the experimental and control groups, respectively. The number of students who were moderately satisfied with academic achievement was the greatest, with 32 (61.5%) and 21 (39.6%) in the experimental group and control group, respectively, and 36 (69.3%) students in the experimental group and 31 (58.5%) students in the control group had high or very high academic stress. Preliminary assessment of Pap smear knowledge showed that there was no significant difference between the two groups, with a mean score (SD) of 6.75 (1.55) points and 6.62 (1.44) points in the experimental group and control group, respectively (t = 0.43, p = 0.127). Pre-test homogeneity tests between the two groups showed that the general characteristics, self-confidence (t = 0.51, p = 0.612), learner satisfaction (t = 0.72, p = 0.475), and critical thinking (t = 1.42, p = 0.158) were homogeneous (p > 0.05).

Correlation between Variables
Correlations between the variables are shown in Table 3. Self-confidence was positively correlated with learner satisfaction (r = 0.361, p < 0.001) and critical thinking (r = 0.208, p = 0.033), and learner satisfaction was positively correlated with critical thinking (r = 0.622, p < 0.001).

Mean (SD 3 )
Exp. 1  When the post-intervention effects were compared between the two groups, it was observed that self-confidence (t = 2.52, p = 0.013), learner satisfaction (t = 3.47, p = 0.001), and critical thinking (t = 2.07, p = 0.041) had improved significantly more in the experimental group than in the control group (Table 5). Therefore, hypothesis 1, "The S-PBL group will show a higher increase in self-confidence than the control group after the intervention," hypothesis 2, "The S-PBL group will show a higher increase in learner satisfaction than the control group after the intervention," and hypothesis 3, "The S-PBL group will show a higher increase in critical thinking than the control group," are all supported.

Discussion
In this study, Pap smear nursing S-PBL was developed based on Jeffries' simulation model, and its effects on self-confidence, learner satisfaction, and critical thinking were assessed and compared to the effects of a conventional demonstration [13].
Self-confidence was found to have significantly increased in the experimental group than in the control group after the intervention. Accurate self-evaluation of a learner's nursing skill performance is a necessary step for professional nurses to understand their strengths and weaknesses and to promote their development [24]. Simulations provide nursing students with opportunities to practice decision-making and develop team skills in a non-threatening environment [25]. These findings are consistent with the results of previous studies [26]. Moreover, results of simulations of rapidly deteriorating clinical cases with medical students [27] and preoperative nursing skills simulations with nursing students are also consistent with the findings of our study [28].
In contrast, in a study by Brannan, White, and Bezanson [29], there was no significant difference in self-confidence after traditional classroom lectures and instructional methods using the human patient simulator as a tool for experiential learning. It is possible that differences in learning design, such as pre-briefing and debriefing time, and number of students per group affected the results. In particular, the current study was designed such that communication between nurse, doctor, and patient could be performed through peer role-play, to encourage appropriate nursing behaviors. In simulations, communication and emotion affect confidence [30]. Therefore, it is necessary to consider the effects of positive interactions and emotions on self-confidence in the experimental group who took part in S-PBL. In future studies, qualitative evaluation of communication and emotion in students, quantitative evaluation of the relationship between these factors, and confidence in the context of various educational methods, such as S-PBL and demonstrations, should be explored.
In our study, learner satisfaction increased significantly more in the experimental group than in the control group, and this finding was consistent with that of a previous study [31]. The S-PBL used in this study required the subjects to engage in appropriate communication beyond relaying disease-specific information, therefore their confidence, and thereby their satisfaction with the program, increased [32].
Pap smears are mainly performed in medical checkup centers, and obstetrics and gynecology outpatient departments, so it is difficult for nursing students, who are mainly placed in wards, operating rooms, and delivery rooms, to experience their administration in nursing practice. The program stimulated students' curiosity and motivated them to participate actively in the class by exposing them to scenarios and skills that they were unable to experience through clinical practice. Preliminary activities, such as orientation and question-and-answer sessions related to simulation, were included to induce active participation. Previous studies have shown that this learner-centered education strategy is useful for nursing students who need to acquire complex nursing knowledge and skills [29]. Therefore, it would be beneficial to stimulate the interest of students through S-PBL about frequently occurring clinical nursing cases that are difficult for nursing students to experience in order to maximize the learning transfer effects for knowledge, skills, and attitudes.
In our study, critical thinking increased significantly more in the experimental group than in the control group. This finding is consistent with the results of various other simulations that involve apnea in high-risk infants, rapport-building, febrile infant care, and delivery nursing [33,34]. The S-PBL was configured such that communication was facilitated by peer role-play and nursing skill practice was facilitated by the use of an anatomical structure model of the female genitalia. Our findings are consistent with previous studies that reported that critical thinking of nursing students was improved through peer role-play-based simulation education, which is widely used in nursing education [34,35]. However, multi-mode simulation with 'high-fidelity simulator and peer role-play' or 'standardized patient and peer role-play' have been shown to improve critical thinking, communication skills, self-efficacy, and level of understanding patient and guardian perspectives [34,35]. However, it is necessary to verify the effects of peer role-play-based simulation education with various research designs, because this type of education can be used in universities that are unable to use high-fidelity simulators due to high costs.
In this study, sufficient time was provided to the students during the pre-briefing session, which likely increased critical thinking. Pre-briefing time for S-PBL preparation plays a key role in inducing critical thinking and facilitating learning [36]. Thus, it is important to provide sufficient pre-briefing time during simulation practice to encourage students to solve problems on their own.
Significant differences were observed when we compared pre-and post-intervention self-confidence, learner satisfaction, and critical thinking in the two groups of this study. In our study, a question-and-answer session was held with both the control and experimental groups. Interaction of students with instructors and feedback improved learning transfer [37]. Therefore, it is necessary to promote learning transfer through appropriate question-and-answer sessions and feedback in conventional demonstrations in addition to S-PBL. Moreover, demonstrations of medical equipment are effective [19], so conventional demonstrations during pre-briefing sessions may further enhance understanding, decrease unnecessary tension among students, and maximize the learning transfer effects [10,19].
Finally, the results of this study suggest that S-PBL with peer role-play can be an effective alternative for nursing education environments where high-fidelity simulators or trained standardized patients are not accessible due to high costs [10]. In addition, the use of S-PBL is especially useful due to the coronavirus disease 2019 (COVID-19) situation because S-PBL enhances learning transfer, which has resulted in limited clinical practice for nursing students. Simulation learning allows students to take on the role that they will be expected to perform as practicing nurses [37]; therefore simulation level should be set according to learning objectives. Sufficient pre-briefing, demonstrations, and evaluation tools for learning transfer should be used to maximize the effects of S-PBL.

Limitations
In this study, the effects of short-term interventions for Pap smear education were assessed, and self-confidence, learner satisfaction, and critical thinking were evaluated through self-reported questionnaires to compare intervention effects. However, a crosssectional study has an inherent limitation, in that causality cannot be determined. The following limitations must be considered in the interpretation and generalization of the results. The learning interventions were based on a single Pap smear scenario using a human body model of the female genitalia. A comparison of the effects of various interventions (e.g., with a high-fidelity simulator or multi-mode simulation) using multiple Pap smear scenarios would provide additional insight about the most effective method of educating nursing students on how to perform Pap smears.

Conclusions
Systematic and integrated application of S-PBL that can provide learning experiences in various nursing scenarios that are necessary as an alternative to limited direct nursing during clinical practice. Therefore, in this study, a Pap smear S-PBL using a human body model of the female genitalia was developed and applied, and the effects were assessed. We suggest that S-PBL, which can increase self-confidence, learner satisfaction, and critical thinking more than can conventional demonstrations, is an effective alternative educational strategy to compensate for the limitations of clinical nursing practices. Furthermore, we recommend that S-PBL be utilized more frequently when developing nursing curricula. In addition, we provided basic data to maximize the effects of learning transfer. In particular, this study is significant in terms of theoretical implication in that it confirmed the concept of learning transfer and verified its effectiveness based on Jeffries's simulation model. As this theory is concise, clear, and easy to apply [14], it can be used as a basis for designing simulation education for other subjects. As shown in the results of this study, Jeffries's model has clinical significance as it can enhance the ability to actively cope with changes in the environment and circumstances, thereby improving the students' competence for solving patients' health problems. In terms of implications for practice in particular, the learning transfer effect of S-PBL when applied to various clinical cases will help nursing students provide specialized care in various situations as nurses in the future. Finally, in order to overcome the limitations of clinical practice in situations such as the COVID-19 pandemic, the results suggest that reproducing a realistic environment through a nursing simulation based on various cases can be useful as a teaching method that enables learners to have an authentic experience with active involvement.  Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The data presented in this study are available on request from the corresponding author. The data are not publicly available due to restrictions eg privacy or ethical.

Conflicts of Interest:
The authors declare no conflict of interest.