Turmoil in the economy, looming health care reform, and the convergence of a shortage of nursing professionals accompanied by the demand for improving patient safety and decreasing medical errors with limited resources has created an environment likened to the perfect storm. As nurses make up the single largest component of the health care system, it is imperative that nurses achieve and maintain the highest level of competency. The Institute of Medicine's report on the future of nursing identified simulation as a key technological component in facilitating nurses in acquiring and maintaining competencies. This article will review the evidence supporting simulation, define the core elements of health care simulation, describe the bodies that regulate advanced practice nursing, identify the principle areas in which neonatal nurse practitioners (NNPs) must maintain proficiency and expertise, and illustrate how simulation is utilized in acquisition, maintenance and competency evaluation for NNPs in 1 of the largest NICUs in the country.