Regulation and Requirements in Simulation

Schools of nursing will be forced to bring their programs in line as simulation is defined by standardized best practices and regulatory requirements.

Description of the Issue

The use of simulation in nursing programs has evolved significantly in the last ten years and the research now supports it as a valid substitute for the traditional clinical learning experience (Jeffries, 2015). The National Council of State Boards of Nursing (NCSBN) national, multi-site, longitudinal simulation study found that substituting simulation for up to 50% of  students’ traditional clinical experience in pre-licensure nursing programs was as effective as traditional clinical learning and did not affect National Council Licensure Examination (NCLEX) pass rates or clinical practice (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). These findings led to the NCSBN recommendations for simulation programs, supported by The INACSL Standards of Best Practice: Simulation, and the NLN Vision Statement on Simulation in Nursing Education (Ackermann et al., 2013; Alexander et al., 2014; NLN Board of Governors, 2015). These publications are now being used by many state boards of nursing and other governing bodies as guidelines for best practices in simulation in schools of nursing (Hayden, Smiley, & Gross, 2014).

Clinical sites are difficult to secure and often lack opportunities for students to participate in much more than basic tasks (Ironside, McNelis, & Ebright, 2014). It is a challenge for students to get the rich learning experiences in these settings they require to become safe and competent nurses. In 2010, a national survey conducted by the National League for Nursing questioned over 2,300 nursing programs across the United States and found that a major barrier to clinical learning for nursing students is “lack of quality clinical sites” (Ironside & McNelis, 2010).  This situation has not improved much and increasingly nursing programs are looking to simulation as a way to provide students clinical experiences (Richardson & Claman, 2014).  The Guidelines established by the NCSBN study have great implications for nursing programs as programs will be required to be compliant with regulations of state boards of nursing and accrediting bodies in order to provide robust, evidence based simulation experiences to replace clinical learning.

Summary of the Literature

The most current data regarding national requirements by state boards of nursing comes from Hayden et al., (2014) in their descriptive survey of the current simulation regulatory environment.  They found that within the United States, 8 states do not allow registered nurse education programs to use simulation to replace clinical hours (Hayden, Smiley, & Gross, 2014). California, Vermont and Virginia specifically allow 25% of the clinical hours to be in simulation (Hayden, Smiley, & Gross, 2014). Florida recently increased its allowance to 50% (Rutherford-Hemming, Lioce, Kardong-Edgren, Jeffries, & Sittner, 2016).  The remaining U.S. states either have no specific amounts allowed or indicated they are planning to establish regulations (Hayden, Smiley, & Gross, 2014; Rutherford-Hemming et al., 2016).

In addition to guidance regarding amount of simulation, there are 14 U.S. Boards of Nursing have formal requirements or advisory statements for the use of simulation in registered nurse education programs. (Hayden, Smiley, & Gross, 2014).  Examples from states such as Virginia, Arizona and Washington provide specific advisory requirements which reflect both the INACSL standards and the NCSBN recommendations  (Arizona State Board of Nursing, 2015; Virginia Board of Nursing, 2013; Washington State Nursing Care Quality Assurance Commission, 2015).  For example, Arizona states, “Programs that use simulation in place of actual patient care need to do so using INACSL Standards” (Arizona State Board of Nursing, 2015). Virginia is less direct but does provide specific required components of simulation and faculty preparation that are similar to the INACSL Standards, such as clear objectives, pre-briefing/orientation and training requirements for the faculty facilitator conducting debriefing  (Ackermann et al., 2013; Virginia Board of Nursing, 2013).  The unpublished draft Washington State Administrative Code regarding simulation circulated via the CNEWS listserv lists criteria that are similar to the NCSBN recommended program and faculty preparation checklists (Alexander et al., 2014; Washington State Nursing Care Quality Assurance Commission, 2015).

Perspectives of the Issue from Education and Practice

The NCSBN guidelines were developed based on the requirements of the NCSBN study sites and, as Suzie Kardon-Egren recently stated, “Very few United States programs have the trained faculty and standardization to provide the same level of simulation used in the study” (Rutherford-Hemming et al., 2016, p. 3).  The challenge is that State Boards of Nursing are not telling programs how to meet the requirements. More states will be adopting similar requirements for simulation and nursing education program will have to carefully evaluate their plans to use simulation.  Reflecting on the NCSBN guidelines, the concern is how will programs and faculty obtain the financial and human resources necessary to meet these requirements.

Implications for nurse education

Going forward, nursing education programs will have to either revise their current simulation practices or develop new ones that meet their state requirements. As Lori Lioce stated, “Implications from the NCSBN study support and require changes in daily operations and structure of health care simulation education programs”(Rutherford-Hemming et al., 2016). This effects a large number of programs, in 2010 87% of schools of nursing used simulation in their programs and that number has been steadily growing (Fey & Jenkins, 2015; Hayden, 2010).  Major areas for programs to address are based on the NCSBN Guidelines and focus on faculty and program preparation (Alexander et al., 2014).

Faculty Preparation

The lack of properly prepared educators is considered a barrier to the expansion of the use of simulation curriculum (McNeill, Parker, Nadeau, Pelayo, & Cook, 2012). Often the training faculty receive is focused on the technology, rather than the methodology and pedagogy of simulation (Waxman & Miller, 2014). Jeffries et al (2013) recommend the creation of a faculty development program that extends beyond a single session of training and includes hands on experiences with simulation along with continued professional development opportunities. Standardized training programs such as the NLN SIRC ( are now available in addition to certification as a Certified Healthcare Simulation Educator. These can be used by nursing programs to prepare their faculty and demonstrate their level of expertise (National League for Nursing, 2015; Society for Simulation in Healthcare, 2016).

Once properly trained, faculty need to meet the other requirements of the Guidelines, such as the use of standardized, theory-based debriefing (Fey & Jenkins, 2015). Faculty will also have to work together to develop or revise simulation programs that provide “active learning, repetitive practice, and reflection” and scenarios with clear objectives and outcomes (Alexander et al., 2014, p. 41). Faculty will also develop and implement a plan for evaluation of all aspects of the simulation program, including the effectiveness of the facilitators and the simulation experiences (Alexander et al., 2014).

Program Preparation

Administrators of schools of nursing need to be prepared to provide the resources necessary, including financial, human and material, to support the Guidelines (Alexander et al., 2014). The needs of faculty and the program must be provided by institutional resources, such as funding for training and time for the development of curriculum.

Programs need leadership that understand the need for long range planning that supports the growth of simulation at their institution (Alexander et al., 2014). Nursing programs often have the equipment (simulator) to run simulations, but it was obtained through non-sustained funding like grants and donations. Programs also need sustainable income to support staff salaries, training, and equipment upkeep plus the supplies necessary to simulate a “realistic patient environment” (Alexander et al., 2014).  This is a major issue for many programs. In an international study of simulation centers, dedicated funding and adequate staffing (specifically dedicated simulation technicians) are found to be top strengths and, when lacking, they are seen as barriers to growth (Qayumi et al., 2014).  One strategy is to pool resources through the development of state consortiums and interdisciplinary simulation centers (Jeffries et al., 2013; Lujan et al., 2011; The Forum of State Nursing Workforce Centers, 2012).

Potential research areas

It is necessary to continue to pursue rigorous research of the use of simulation in nursing programs in order to support the resources needed for high quality standardized simulation. Information regarding how schools of nursing respond to their Boards of Nursing simulation requirements, including strategies they are using to meet the requirements, can guide simulation program development. As most published standards require evaluation processes in simulation programs, research that explores how nursing programs evaluate their use of resources, faculty and student performance, and simulation effectiveness can also provide guidance. Research that compares learning in clinical and simulation environments more directly lends support to funding to state mandated requirements for simulation in nursing programs (Leighton, 2015).

Studies need to demonstrate the return on investment of simulation in ways such as improved patient outcomes and safety in order to support the resource demands of simulation (Rutherford-Hemming et al., 2016).  While there is already evidence that faculty preparation influences simulation effectiveness, continued research needs to expand and examine correlations between faculty qualifications and certifications, and the student outcomes, such as NCLEX pass rates and clinical performance in order to support the amount of resources necessary to adequately train faculty(Fey & Jenkins, 2015).


Schools of nursing will be forced to bring their programs in line as simulation is defined by standardized best practices and regulatory requirements. While the NCSBN Guidelines seem very reasonable, a deeper look reveals the challenges that programs will face implementing them. The need for institutions and administration to support faculty as they work to develop simulation programs that meet these requirements is crucial. Sustainable models that include maintained funding, continued professional development and embedded evaluation are no longer optional for schools that plan to use simulation to replace clinical hours. As one participant at the 2015 INACSL Conference NCSBN Study forum stated, “…the option to use simulation today will become a mandate for simulation in the future”, so will the use of best practices in simulation be a mandate for the future of nursing education (Rutherford-Hemming et al., 2016).


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