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Simulation as a Nursing Education Disrupter

Waxman, KT DNP, MBA, RN, CNL, CENP, CHSE, FSSH, FAAN; Bowler, Fara DNP, ANP-C, CHSE; Forneris, Susan Gross PhD, RN, CNE, CHSE-A; Kardong-Edgren, Suzie PhD, RN, ANEF, CHSE, FSSH, FAAN; Rizzolo, Mary Anne EdD, RN, FAAN, ANEF, FSSH

doi: 10.1097/NAQ.0000000000000369
Original Articles

Simulation as an evidence-based pedagogy began emerging at a time when many constraints were being imposed on clinical experiences for nursing students. As research illuminated the advantages of simulation and standards were developed, educators began to recognize the limitations of the clinical setting, such as the inability to provide experiences in teamwork and delegation, and a focus on tasks. Simulations are crafted to provide an experience that matches content that is being taught in class, and debriefing techniques guide learners in a reflective process that promotes the development of clinical reasoning and judgment. The National Council of State Boards of Nursing study concluded that simulation could be substituted for 50% of clinical hours. Simulation-exposed gaps in the curriculum and its pedagogical principles are now extending to adaptations of its use in the classroom and in clinical postconferences. They are also shaping teacher-student conversations in the office and the hallways. Use of simulation for assessment is beginning to evolve. In a little more than 10 years, it has started a revolution that will continue to have a major impact on all aspects of nursing education in the future.

School of Nursing and Health Professions, University of San Francisco, California (Dr Waxman); College of Nursing, University of Colorado Denver, Aurora (Dr Bowler); National League for Nursing, Washington, District of Columbia (Drs Forneris and Rizzolo); and Adjunct Faculty, Center for Medical Simulation, Boston, Massachusetts (Dr Kardong-Edgren).

Correspondence: KT Waxman, DNP, MBA, RN, CNL, CENP, CHSE, FSSH, FAAN, School of Nursing and Health Professions, University of San Francisco, 2130 Fulton St, San Francisco, CA 94117 (

The authors declare no conflicts of interest.

DISRUPTERS are becoming more and more common in the rapidly changing health care industry. Companies such as Amazon, big retail pharmacy chains, and walk-in clinics are examples of recent disrupters in health care.1 Over the last 10 years, nursing education has also had a disrupter: clinical simulation. Simulation has been something of a “Trojan Horse” in that it has forced us to question many long-held assumptions in nursing education, such as the previously unchallenged primacy of clinical experience for teaching nursing students.

Initially, many schools implemented simulation because clinical placements for students were difficult to find. Recognition that simulation is effective at recreating essential clinical encounters in a safe educational setting where no harm can come to patients soon followed.2 Frameworks3,4 for designing, implementing, and evaluating simulation emerged, and one has evolved into a middle-range theory5 fueled by an explosion of research in the field. More recently, a variety of general educational frameworks that shape simulation pedagogy have been raised in the literature to link learning with practice. Examples include sociocultural frameworks, such as communities of practice6 sociomaterial perspectives,7 and the concept of informal learning.8,9

Standards have been developed by the International Nursing Association for Clinical Simulation and Learning (INACSL). The first set of Standards was published in 2011, and the organization has continued to develop new Standards as evidence has become available, and to revise older versions as evidence is refined. Templates, processes, and tools emerged as well. All this work has encouraged faculty to look at what actually happens in clinical education through a different lens and to reevaluate the clinical experience.

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The renewed focus on what occurs in the 21st century clinical setting has encouraged new reflection and evaluation of this heretofore “gold standard.” In clinical setting, faculty often move rapidly from floor to floor, room to room, and student to student. They focus on tasks, with little time devoted to helping students develop clinical judgment.10,11 Furthermore, it is often difficult to find patients with conditions that reflect curricular content the students are learning. Increased concerns about liability often prevent students from performing key tasks; they can often only observe others. The ability to practice delegation, communication with other health care professionals, and teamwork are rarely, if ever, available. Additionally, caring for multiple patients in order to prepare students for transitioning to the practice environment cannot take place due to student-to-faculty ratios, high patient acuity, and patient safety considerations.

Shadadi and colleagues12 performed a systematic review of the literature and uncovered additional obstacles in nursing clinical education. They grouped these into 4 dimensions: individual obstacles, such as lack of motivation among students, instructors not assessing students based on objectives, and uncooperative personnel; management dimensions, such as large numbers of students and inadequate time; facilities barriers, such as limited patients available; and other, which reflected the culture of the workplace.

Miller's Pyramid13 is commonly used to rank clinical competence, both in educational settings and in the workplace. Sullivan et al14 found that students spent more time performing at the higher levels of Miller's Pyramid (at the application and analysis level) in simulation rather than the lower levels of knowledge and does with assistance in clinical rotations. Higher levels of performance also occurred in much less time in simulation, by the very nature of the planning associated with simulation. In simulation, all 4 levels of the pyramid can be addressed: knows, knows how, shows how, and does.

Simulation can guarantee a robust standardized clinical experience in a safe, open, nonthreatening environment with dedicated trained simulation faculty, while circumventing many of the obstacles identified in traditional clinical education. It is an organized teaching/learning method that is carried out in distinct phases, beginning with prework and prebriefing, followed by a hands-on immersive experience, and culminating with a debriefing.15

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Postconference at the end of a clinical day is faculty driven, and is usually little more than a review of student experiences throughout the day. Debriefing, on the other hand, is a key concept in simulation that enables educators to connect with learners in an organized and powerful way. There are specific standards and an ever-growing body of knowledge associated with debriefing. Skilled debriefers guide learners through a reflective process that is based on sound evidence-based educational theories.16–18 Debriefing principles can be used in postconferences and other settings, and are endorsed by organizations such as the INACSL and the National League of Nursing (NLN).19 Socratic questioning, which is at the core of debriefing, is only slowly being adopted and used in other environments. Faculty facilitate learning by encouraging students to discover and construct knowledge and meaning (eg, active learning approaches). Three core concepts provide a foundation for understanding the nature of debriefing: conceptualizing learning as meaning-making; the cognitive strategy of being critical (ie, critical theory); and engaging learners through purposeful learning conversations.20,21 Rather than teaching moments, the focus is shifted to learning moments. It takes time and training for educators to develop skill in debriefing. However, once they do, they begin to encourage learners to self-reflect. They spend less time teaching, and more time using Socratic questioning techniques to draw out student understanding. This helps learners expand their critical thinking and clinical judgment.

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The landmark large-scale, randomized, controlled study conducted by the National Council of State Boards of Nursing in 2014 determined that simulation is as effective, if not better than, traditional methods of preparing prelicensure students.22 The study concluded that up to 50% of the clinical hours required in prelicensure schools could be substituted with simulation, as long as high-quality simulations were used and facilitated by dedicated, trained simulation faculty; the INACSL Standards were followed; and a theory-based debriefing method was used. The results of this study provide substantial evidence that substituting high-quality simulation experiences for up to half of traditional clinical hours produces comparable end-of-program educational outcomes and new graduates that are ready for clinical practice.22 A follow-up article by NCSBN23 provided guidelines for schools to use, including 2 checklists: 1 for faculty preparation and 1 for program evaluation.

Many state boards of nursing have traditionally remained silent on teaching methods or required number of clinical hours in the prelicensure curriculum. Of those that do address these topics, as of the submission of this article, 28 states have established simulation regulations.24 According to the INACSL Simulation Regulation Map,24 17 states now allow schools of nursing to utilize 50% simulation as a substitute for the required clinical hours, with the remaining 11 states ranging from 25% to 35% of clinical hours. Simulation has forced states to relook at the entire clinical experience and its effectiveness.

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Simulation was initially used only for formative assessment of learners. As simulation pedagogy evolved, faculty began to consider using it for summative evaluation as well. The ability to set up a controlled environment has many advantages over trying to assess learners in the chaotic and constantly changing clinical practice arena. In 2010, the NLN began a project that explored the use of simulation for high-stakes assessment.25 The study illuminated many issues that require further research and development before implementation on a large scale.26,27 The most important challenges related to training of raters and other studies are underway to refine the process. However, summative evaluations using simulation that contribute to part of a grade may certainly supply an additional dimension to a fair testing practice for students.

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Simulation has exposed gaps in how nursing curricula are operationalized, moving educators from conceptualizing the classroom as a series of lectures delivering content, to thoughtful consideration of how classroom can be a contextual learning encounter. In thinking who the learners are, why they learn, what they learn, and how they learn, a schematic design for each course can be developed to determine how content (nursing knowledge) can be thoughtfully linked to context (nursing encounter) both inside the classroom (virtual simulation) and in the simulation laboratory (manikin simulation). Simulation, as individual learning encounters, is guided by learning outcomes that drive the direction of the learning experience. Good teaching and learning is driven ultimately by learning outcomes, and likewise teaching and learning in the classroom. Nonetheless, the focus of many of our classroom experiences in nursing education becomes an opportunity to dump and run nursing content, hoping the learner will magically apply this content in clinical practice.28,29 Benner and colleagues30 again raised this question, emphasizing that experiential learning allows for situated cognition—or learning in context—a concept at the forefront of contemporary educational reform. Situated cognition embraces context. Context can enrich the classroom experience by guiding thinking; using reflection; and engaging learner perspectives to reflect and reframe understanding. When making a shift in approach from a focus on teaching to a focus on learning, learning outcomes serve as the framework for the development of specific learning activities.21 Thoughtful design of simulation scenario encounters is guided by learning outcomes resulting from a curriculum needs assessment and analysis. Thoughtful integration of simulation into the curriculum considers the intricacies of the curriculum and how the specific courses intersect with each other. Examining specific course content and the clinical site placements gives a broad overview of the types of experiences learners are exposed to and how objectives are met. The challenge is to incorporate thoughtful integration and use of simulation in the classroom to engage active learning. Simulation experiences have moved beyond simply teaching and practicing psychomotor skills. It is an evidence-based contextual learning teaching strategy that facilitates experiential learning and fosters critical thinking and clinical reasoning.16,31 Effective facilitation of classroom experiences using techniques grounded in theory-based debriefing provides an opportunity for educators to be meaning makers. The challenge with debriefing as a classroom conversation is to shift the emphasis from delivering content to guiding the use of content through a process of thinking. It is a conversation that moves from “let me show you and tell you” to “tell me how you understand this.” The classroom dialogue involves moving beyond the simple application of facts and rules to a process of sense-making. Nurse educators are recognizing the importance of creating and implementing teaching methodologies that replace inactive, traditional classroom learning environments. Debriefing has paved the way for educators to guide their classroom conversations and role-model their thinking, which ultimately demonstrates to learners how an expert nurse would think through the content. Debriefing in the classroom becomes an opportunity for learners to share in this dialogue while uncovering their gaps in knowledge and explaining their rationale and thinking.20,21

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Simulation is a method of active learning pedagogy; it is an educational technique. Incorporating simulation into our classrooms in both schools of nursing and hospitals is necessary for the future. According to the Nursing Executive Center, The Advisory Board Company's CNO/Dean survey,32 Chief Nursing Officers do not feel that new graduates are prepared to work in their clinical settings, while Deans feel that schools do prepare their graduates for practice, but that the hospital staff do not adequately support them. Blame is placed on both sides. Forming strong academic/service partnerships is critical to the future of nursing education. Rather than operating in silos, we need to think and learn together, and collaborate on curriculum. It would be shortsighted to think that simulation can replace all clinical encounters. Human connections and emotions are valuable learning tools that are difficult to capture through simulation. However, as clinical sites continue to decline, we need to look along the continuum for adequate learning opportunities for the next generation of nurses. Using simulation centers as “clinical sites” is the future. These centers, with trained faculty, as well as ample space and equipment, can provide guaranteed clinical experiences to our learners that are of comparable, and in some circumstances, higher quality than the hospital. As simulation modalities continue to evolve, using immersive technologies like virtual reality, artificial reality and mixed reality, the possibilities for creating new learning environments are endless.

As the only health care profession without a formal residency program embedded in the curriculum, nurse residency programs/transition to practice programs are prevalent but not yet mandatory. During these residency programs, simulation should be incorporated to provide our new graduates the opportunity to experience real-life events before they begin to work on the nursing units. Nursing is the only health care profession that does not have a practice component for licensure. Could high-stakes testing with simulation be in nursing education's future?

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The INACSL Standards of Best Practice: SimulationSM4 provides a detailed process for evaluating and improving simulation operating procedures and delivery methods that would benefit every simulation team. Many schools and states, such as Colorado, Arizona, and Florida, have adopted the standards as part of their regulatory requirements. The standards provide a framework for schools to incorporate simulation. We can also learn from the simulation standards and apply them to other teaching/learning settings.

Simulation has proven to be an effective innovative methodology that arrived at the right time to solve new constraints developing in our traditional clinical environments. Well-executed simulation allows educators to provide learners with a safe, nonthreatening environment where a standardized high-quality clinical experience can be guaranteed. It has already disrupted nursing education on many levels, and will continue to do so, as new technologies emerge. Research and internal computers will collect data, analyze learners and their learning style, and then design the next simulation that can advance the user to a more challenging problem or provide remediation. That disruption of the future is not far away.

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clinical experience; disruption; nursing education; simulation

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