Validating high-fidelity simulation for assessing procedural skills in nursing education: a kane framework approach in Ghana

Simulation-based assessments (SBAs) are increasingly embraced as reliable tools for evaluating procedural competence in nursing education. In Ghana, however, their formal adoption and validation remain limited. This study investigated the construct validity of high-fidelity simulation-based assessments (HFSAs) for nursing students using Kane's Validity Framework, which structures validation across four inferences: scoring, generalization, extrapolation, and implication. Using a quantitative, cross-sectional design, data were collected from 150 final-year students across three accredited nursing institutions in Ghana. For the scoring inference, inter-rater reliability was strong (ICC = 0.77-0.84), and internal consistency was high (Cronbach's alpha = 0.83), confirming that assessors applied the rubric consistently and that items reliably measured procedural competence. Generalization was supported by a moderate correlation between simulation and OSCE scores (r = 0.45, p < 0.01), indicating that both assessments capture related clinical skills. For extrapolation, multiple regression revealed that simulation scores significantly predicted clinical practicum performance (R² = 0.42, p < 0.01), suggesting that HFSA results meaningfully reflect real-world competence. Factor analysis further validated the unidimensionality of the simulation tool, and Multi-Trait Multi-Method (MTMM) analysis demonstrated strong convergent validity and minimal method bias. Regarding implication, Cohen's kappa coefficient (κ = 0.67, p < 0.01) showed substantial consistency between pass/fail decisions based on simulation and OSCE scores. These findings provide robust evidence that HFSAs are not only psychometrically sound but also practically defensible for evaluating clinical readiness in Ghanaian nursing education. The results support the integration of simulation into competency-based curricula, while highlighting the need for sustained investment in simulation infrastructure, assessor calibration, and equitable access across institutions.