This document discusses the role of simulation in nursing education from a regulatory perspective. It begins by outlining the goals of comparing simulation types, identifying advantages over clinical experiences, and using simulation for evaluation. It then defines simulation and discusses trends in nursing education that support its use. The document reviews different simulation types and their strengths/limitations. It addresses using simulation as a teaching strategy and evaluation tool. Several studies on the use of simulation in nursing education are summarized, focusing on its role compared to clinical experiences and regulatory views. The conclusion is that simulation is an important teaching approach and competency assessment tool that can be integrated with clinical learning along a continuum of nursing education.

1. The Role of Simulation in
Nursing Education:
A Regulatory Perspective
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2. Goals
• Compare and contrast different types
of simulation
• Identify potential
advantages/disadvantages of
simulation as a teaching strategy over
actual clinical experience
• Discuss the use of simulation as an
evaluation tool
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3. Simulation
• Simulation:
– “… as a strategy – not a technology – to
mirror, anticipate, or amplify real situations
with guided experiences in a fully interactive
way.”
• Simulator:
– “…replicates a task environment with
sufficient realism to serve a desired
purpose”
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4. The Role of Simulation
• A teaching strategy
• An evaluation tool
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5. Trends in Nursing Education
• Providing more experiential learning
opportunity than instruction
• Increased use of learning technology
• More emphasis on outcome-based then
process-based education
• More evidence-based education
strategies and curriculum Brought to you by

6. NCSBN Supports
“…the inclusion of innovative teaching
strategies that complement clinical
experiences for entry into practice
competency.”
– NCSBN position paper on clinical education, 2005
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7. Rationale
• To ensure patient safety
• To promote better preparation of new
nurses
• To support innovative teaching strategies
• To overcome faculty and preceptor
shortages and lack of clinical sites
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8. Types Of Simulation
• Screen-based/PC-based simulation
• Virtual patients
• Partial task trainers
• Human patient simulator
• Standardized patients
• Integrated models
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9. Principles of Selecting Type of
Simulation to Use
• Should be driven by the educational
goal/objective
• Should match the level of the student
• The higher the realism, the more
effective it is in engaging the student
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10. Strengths and Limitations of
Different Types of Simulation
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11. 1. PC-Based Simulation
Strengths
• Easy, flexible and unlimited access
• Useful for knowledge acquisition and critical thinking
• Accommodating to individual pace of learning
• Good for lower/entry level students
• Relatively low cost
Limitations
• No physical interactivity
• Low fidelity
• No experiential learning Brought to you by

12. 2. Virtual Patient Simulation
Strengths
• Easy access
• Economic for teaching multidisciplinary care
• Accommodating to individual pace of learning
• Good for lower level of students
Limitations
• Limited physical interactivity
• Low fidelity
• Limited experiential learning
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13. 3. Task Trainers
Strengths
• Low cost
• Good for procedural practice
Limitations
• Low fidelity
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14. 4. Human Patient Simulation
Strengths
• High fidelity
• Interactive experience
• Animating theoretical knowledge within the context of clinical
reality
• Using emotional and sensory components of learning
• Good for critical thinking, decision-making and delegation
• Good for knowledge integration and higher levels of students
Limitations
• Costly
• Limited access
• Dependent on availability of human instructors/operators
• Limited realistic human interactions Brought to you by

15. 5. Standardized Patient (SP)
Strengths
• Higher realism in the interpersonal and
emotional responses
• Good for communication skills and
interpersonal relationships training
• Good for evaluation
Limitations
• Signs do not match symptoms
• Inversed power dynamic
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16. Principles should stay consistent
but strategies flexible.
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17. Factors Facilitating Teaching with
High-Fidelity Simulation
• Feedback
• Repetitive practice
• Curriculum integration
• Range of difficulty level
• Multiple learning strategies
• Capture clinical variation
• Controlled environment
• Individualized learning
• Defined outcomes or benchmarks
• Simulator validity Issenberg et al, 2005
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18. Simulation Fidelity
• The physical, contextual, and emotional
realism that allows persons to
experience a simulation as if they were
operating in an actual healthcare
activity.
- 2007 SSH summit
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19. A Question for Regulation
• What is the role of simulation in nursing
education in relation to clinical
education?
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20. Potential Advantages of Simulation
Over Actual Clinical Experience
• Reduces training variability and increases
standardization
• Guarantees experience for every students
• Can be customized for individualized learning
• Is more accurate reflective learning especially
with HPS
• Is student-centered learning
• Allows independent critical-thinking and
decision-making, and delegation
• Allows Immediate feedback
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21. • Offers opportunity to practice rare and critical
events
• Can be designed and manipulated
• Allows calibration and update
• Can be reproduced
• Occurs on schedule
• Offers opportunities to make and learn from
mistakes
• Is safe and respectful for patients
• Allows deliberative practice
• Also uses the concept of experiential learning
Potential Advantages of Simulation
Over Actual Clinical Experience (cont.)
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22. “ Tell me, and I will forget. Show me, and
I may remember. Involve me, and I will
understand.”
- Confucius, 450 BC
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23. Limitations of Simulation Compared to
Actual Clinical Experience
• Not real
• Limited realistic human interaction
• Students may not take it seriously
• No/incomplete physiological symptoms
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24. Vision for the Future:
Continuum of Learning
Class → Simulation → Clinical→ Real world
• Integrated into mainstream healthcare
education
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25. Simulation as a Teaching
Strategy: Challenges
• Initial capital expenditures
• High financial cost
• Faculty development
• Ongoing faculty/administrative/technical
support
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26. Research on Simulation:
Kirkpatrick Criteria (1998)
• Reaction
• Learning
• Behavior
• Results
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27. Future Research:
Simulation as a teaching strategy
• Impact on competence
• Impact on patient care
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28. • Goal: To explore the role of high fidelity
simulation in basic nursing education in
relation to real clinical experience
NCSBN’s Research Initiative
on Simulation
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29. The Question
• Can high fidelity simulation experience
be counted as real bed-side clinical
experience?
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30. Specific Objective
• Compare and contrast the effects of
simulation alone and in combination with
clinical experience on knowledge
acquisition/retention, self-confidence, and
clinical performance
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31. Design
• A randomized controlled study with
repeated measures pre- and post-
simulation/clinical to compare the effect
of simulation alone and in combination
with clinical on knowledge
acquisition/retention, self-confidence,
and clinical performance.
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32. Figure 1. Study Scheme
Front-load didactic instruction
Baseline assessment
Randomization
Simulation alone Simulation+clinical Clinical alone
Outcome measures
1. Knowledge acquisition/retention
2. Self-confidence
3. Clinical performance via standardized patient
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33. Groups
1. Simulation without clinical (30 hours of
simulation)
2. Simulation + clinical (15 hours of
simulation and 15 hours of clinical)
3. Clinical without simulation (30 hrs of
clinical)
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34. Outcome Measures
• Knowledge acquisition/retention
• Confidence
• Clinical performance
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35. Knowledge acquisition/retention
• Assessed with written examinations
before (after didactic instruction, which
is frontloaded) and after
clinical/simulation experiences.
• The examinations were equivalent in
content.
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36. Confidence
• Assessed with a Likert-type self-
confidence scale which consisted of 12
items.
• Reflect the student’s confidence in
assessing, intervening and evaluating
pts with critical illness.
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37. Performance Evaluation with SPs
• Three stations
• Each station provided one scenario
• 10-15 min each scenario
• Focused on symptom recognition, assessment
and intervention
• Performance evaluated by a faculty member
on-site and videotaped for further analysis by
two additional faculty members
• Staff: 6 faculty and 6 SPs Brought to you by

38. Format
• All students enrolled in the course
• Occur over 2 days
• Rush CON labs
• Each student – 3 scenarios using SPs
• One hour commitment for each
students
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39. Each Station
• Has the chart outside the pt room
• The chart has info on pt hx, meds etc
• Each pt room has essential equipment
• Faculty member acts as evaluator and
MDs if needed
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40. Three Scenarios
• A pt with CP (hx of knee replacement)
• A pt with sudden onset of SOB (hx of
abdominal surgery)
• A pt with a change of LOC (hx of fall at
night)
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41. • Purpose: examine the status of
regulation changes concerning the use
of simulation in nursing programs and if
no regulation changes, the presence of
approval for use of simulation
• 44 states plus the District of Columbia,
and Puerto Rico participated
A Survey of Boards of Nursing
Nehring, 2006
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42. A Survey of Boards of Nursing
(cont.)
• Five states and Puerto Rico have
changed nursing regulations to allow a
percentage of clinical time with the
simulators (Nehring, 2006)
• One state specified a percentage of
10% of clinical time to be replaced by
simulation experience (Nehring, 2006)
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43. • While no changes in regulation, 16
states give permission for schools to
use a percentage of their clinical time
with the simulation experience (Nehring,
2006)
• The percentage is determined on a
case-by-case basis (Nehring, 2006)
A Survey of Boards of Nursing
(cont.)
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44. The Role of Simulation
• A teaching strategy
• A competence assessment tool
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45. Competency Assessment:
Miller’s Pyramid (1990)
DoesDoes
Shows howShows how
Knows howKnows how
KnowsKnows Brought to you by

46. Common Assessment Methods
• Written exam (MCQ)
• Checklist evaluation
• Portfolios/Record review (e.g., skill’s
checklist)
• Simulations (Standardized patients and
models)
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47. Common Assessment Model
with Simulation
Combined
Criteria
Checklist Global rating Checklist Global rating
Process measure Outcome measure
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48. Types of Simulation Models for
Competency Assessment
• OSCE
• Computer-based simulation
• Computerized mannequin
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49. Potential Advantages of Using
Simulation for Assessment
• Able to measure more than knowledge
level
• Performance-based
• Standardized (same conditions for all
test takers)
• Measures integrated KSA
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50. Challenges of Using Simulation
as an Assessment Tool
• Measurement issues
–Reliability
–Validity
• Cost
• Feasibility
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51. Future Research:
Simulation as an Assessment Tool
• Establish valid content, structure and
scoring metrics
• Cost-effectiveness compared to other
tools
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52. The Future
Integrated models for both teaching and
assessment using simulation
Setting standards and guidelines for
various kinds of learning and
assessment
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