Healthcare Simulation Week 2020! Reflections of a simulationist.

When I discovered simulation, I was first intrigued by the technology, l’ll admit. And the overall coolness of it… but it led me on a path that transformed what teaching means to me… and to the learner.

I went into teaching at first… I thought… because I like to hear myself talk. OK, not exactly but, you know, I wanted to share all my knowledge. Translate information, facts and the skills of being a nurse through me and to students. I envisioned myself as the wise, honored teacher. The Sage on the Stage… those were the teachers I learned from in my life, those I respected and emulated.

But then, I discovered simulation.  I was first intrigued by the technology, l’ll admit. And the overall coolness of it… but it led me on a path that transformed what teaching means to me… and to the learner.

My first simulation experience was as an observer… I actually- literally stumbled onto it… I was at the training center for Madigan Army Medical Center (now known as the Charles A. Andersen Simulation Center) earning my ACLS instructor certification. I was working as a floor nurse at MAMC at the time, and just beginning to nurture the teacher within.

My first exposure to simulation- I stumbled into a room with this going on!

While I was in class, I was distracted by loud noises from another room… shouting, moaning,  explosions. I slipped out of my classroom and wandered the halls until I found the source of the commotion. A dimly lit room, camo nets hanging from the ceiling, darkness punctuated by strobe light flashes, the sound of mortar explosions and someone groaning in pain. I look down to see a man on the ground, covered in blood, the source of the groans. It took a minute for me to realize he wasn’t real… that I’d stumbled into a well crafted battle injury scenario training space.

I thought to myself, “wow! What a way to learn”… to be immersed in the reality of a situation (to learn later that’s fidelity) in a place where mistakes and  learning have no risk and cause no harm (to learn later that’s psychological safety) with the opportunity to reflect on actions taken and how to improve (to learn later that’s debriefing).  I was hooked!

I went back to my ACLS class and inadvertently created and ran my very first sim scenario. I had to teach the asystole algorithm.  So I created a scenario with a witnessed asystole patient, who the learners go on to discover was DNR after they initiated resuscitation… it was fun to see the progression of the scenario (I got to use a Sim Man too!). And have a meaningful discussion about the challenges of this algorithm and the ethics of resuscitation. 

Fast forward many years from that day. I’ve run hundreds of simulations, in a variety of fidelity levels, in all sorts of settings, with the complete gamut of technologies and I have taught hundreds of nurses and health care providers.

And I no longer want to be that Sage on the Stage. I will admit, I am finding myself doing a lot of webinars and other types of presentations still have me up there, speaking and sharing ideas. But still, my goal is to awaken knowledge in others, not pour my vast amount of wisdom unto their heads. As a simulationist, I guide learners through experiences that allow them to determine their own learning. There’s a whole host of learning theories and teaching methods this approach supports from constructivism to heutogogy. But what reinforces it to me is seeing the results. Seeing learners gain insight and awareness during a robust and learner-focused debriefing.  I have come to realize my skill as a sim facilitator and debriefer is critical to guiding them to creation of knowledge and hitting those crucial levels in learning taxonomy through experiential learning.

Bloom’s Taxonomy AND Vygotsky’s Zone of Proximal Development to explain the importance of preparation for simulation. How nerdy is that?!

I now am privileged to be in a leadership position and supporting a program that provides simulation experiences to learners. I am also training up the next generation of simulationists. Simulation is still fun to me, though. I love creating real life scenarios,  making the environment realistic, helping learners suspend disbelief and seeing them get caught up in the excitement of a challenging patient care situation, a communication challenge, a team based intervention or disaster scenario.  When I see the wheels turning in their heads, the self-reflection turned on and,  in that psychologically safe environment, the ability to learn from doing things right AND making mistakes, I am inspired by them!

Me, presenting a webinar about how we are bringing students back to the Simulation Center during the pandemic.

I became a nurse, like many have before me, to “help” others. That extended to my teaching, to “teach” others. I have learned, though, we help others the best by not doing for them or “to” them… but doing with them. The path to healing belongs to the patient and the path to learning, to the learner. As a nurse I have had the honor to walk alongside folks on their path to wellness,  and now, as a teacher,  I am privileged to guide learners through immersion experiences from which they emerge as safe, competent healthcare providers.

Beginnings of a concept analysis

This principle-based concept analysis aims to examine prebriefing, a component of simulation in nursing education.

As an assignment for my nursing theory class, we had to complete a principle-based concept analysis. I felt like I mostly had no idea what I was doing, but it did really help me understand my topic better and begin to see the gaps, conflicts and lay the foundation for my literature review. I have gotten feedback that implies this could be turned into something I could submit to a journal. So this should be considered only a draft version that I am sharing here. Please respect the ownership of my ideas. Thank you.


In 2004, Gaba described simulation as a “technique…to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner” (p. 12). This definition continues to be referenced as the most accurate description of simulation in health care (Alexander et al., 2015). Simulation is now considered to be an integral part of nursing education programs and has its own standards of best practice and a body of research evidence that supports its effectiveness (Jeffries, 2016; Lavoie & Clarke, 2017).
This principle-based concept analysis aims to examine prebriefing, a component of simulation in nursing education. Prebriefing is considered an essential element of simulation design (INACSL Standards Committee, 2016c). The International Nursing Association for Clinical Simulation and Learning (INACSL) Standards of Best Practice: Simulation SM define prebriefing broadly as “an information or orientation session immediately prior to the start of a Simulation Based Experience in which instructions or preparatory information is given to the participants.” (INACSL Standards Committee, 2016b, p. S43)
The definition also includes an emphasis on the role of prebriefing to provide a psychologically safe environment for learners (INACSL Standards Committee, 2016b). Despite this standard definition, prebriefing as a concept appears varied in the literature. Many educators will provide an orientation to the equipment and the space and process of simulation, but provide little information about the scenario itself, while other educators refer to preparation in the form of care planning, written assignments and role modeling as prebriefing (Page-cutrara, 2014a). There is also lack of consensus regarding how much information to provide to the participants about the simulation in this phase (Page-cutrara, 2014a). Unlike debriefing, which has a strong body of literature describing its best practices, theory, and framework, prebriefing is just beginning to appear as its own topic in the simulation literature. It lacks a well-defined framework and is considered a top priority research topic in nursing simulation (Fey & Chse, 2016; The International Nursing Association for Clinical Simulation and Learning, 2017).
This principle-based concept analysis is based on a review of the current state of the science of prebrief as reflected in the current literature. The “Search IT” function of Washington State University’s (WSU) Library searches the entire WSU library catalog in a variety of disciplines. This search tool found the following number of results for each term and combination of terms used: “prebrief” (102) “prebrief nursing simulation (34)”, “pre-brief, simulation (47) and “prebrief, nursing, simulation, education (232)”. Combinations of these terms, along with alternative terms such as “healthcare” provided similar results. Applying non-nursing and non- healthcare filters, yielded a small number of findings in the following disciplines: aircraft safety (8) and military (9), of which approximately half were duplicates. The most useful search strategy used the Boolean “AND” with the terms “prebrief”, “nursing”, “simulation”, “education” which yielded a total of 47 articles and dissertations. Of these, based on title and review of the abstract, about 13 were relevant to prebriefing in nursing education and simulation.
Searching the multidisciplinary literature in this way provides an expanded range of results, however, in this analysis prebriefing is a concept specific to simulation in nursing education. Since simulation is a specialized field in healthcare education, another approach used was to search the two peer reviewed journals that are dedicated to simulation in healthcare: Clinical Simulation in Nursing and Simulation in Healthcare. Focusing on these specific journals reduces the need to for additional terms such as “nursing education” or “healthcare education”. A search of the term “prebrief’ yielded 78 results and “pre-brief” yielded 387 results from Clinical Simulation in Nursing. Searching Simulation in Healthcare for “pre-brief” and “prebrief” only yielded 4 results, but the term “briefing” provided 80 results. These results were then narrowed down by title and abstract content and provided the published resources used in this analysis.
It is important to note that in 2016, two concept analyses of prebriefing were published. Neither author used the principle-based concept analysis approach, but both did acknowledge a gap in the literature regarding the standardization of prebriefing practices and the use of the term (Chamberlain, 2015; Page-Cutrara, 2014b). This principle based approach intends to explore the use of prebriefing in simulation literature from a different perspective by exploring it within four principles: epistemological, pragmatic, linguistic and logical (Penrod & Hupcey, 2005).
Epistemological Principle
The concept of prebriefing continues to mature epistemologically and develop its own distinction within the knowledge base of simulation (Penrod & Hupcey, 2005). The term was introduced and defined 2011, when INACSL published the first version of the Standards of Best Practice in Simulation (Sando, Faragher, Boese, & Decker, 2011). In those 2011 Standards, prebriefing was defined in Standard I: Terminology as an information session held before the simulation that provides instructions, preparatory information, and orientation to equipment (The INASCL Board of Directors, 2011).
In the next version of the Standards in 2013, prebriefing was defined similarly and was also included in Standard IV: Facilitation, under Criterion 1, as a facilitation method that occurs before the simulation and includes orientation to the equipment, ground rules to provide a psychologically safe environment, expectations, and background information on the scenario (Franklin et al., 2013) . In 2015, the Standards Committee added two additional standards. One of these was the Design Standard, which introduced prebriefing as “briefing” in Criterion 7 (Lioce et al., 2015). Participant preparation was delineated from the orientation aspects of briefing in Criterion 10: Participant Preparation (Lioce et al., 2015). This is the first mention of providing content-related activities to prepare the learner for the simulation in addition to the logistical orientation of (pre)briefing in the Standards.
In the most recent iteration, published in 2016, the Committee returned to the term “prebriefing”. Prebriefing and participant preparation are again addressed in two separate criterion of the INACSL Standards of Best Practice: SimulationSM Simulation Design Standard (the Standards Committee has removed the numbering of standards and now include a servicemark designation). Criterion 7 describes prebriefing as a required orientation phase of simulation, similar to its early definition (INACSL Standards Committee, 2016c). It is described as a structured and consistent element of simulation that includes orientation to equipment, space, time and other logistical aspects of the simulation (INACSL Standards Committee, 2016c). In addition, behavior expectations, establishing trust and ground rules, and a fiction contract are also part of the prebriefing. Criterion 10 addresses participant preparation, however it is not considered a phase in the simulation itself. It is discussed in the standard after the debrief and evaluation phases, as if an afterthought to the process. Its placement there is strategic, as the INACSL Standards of Best Practice: SimulationSM Simulation Design standard recommends that the preparatory materials are developed after the simulation is designed. Criterion 10 states that the preparatory materials aim to “address the knowledge, skills, attitudes, and behaviors that will be expected of the participants during the simulation-based experience” (INACSL Standards Committee, 2016c, p. S8). These materials should be completed prior to the prebriefing and may include didactic sessions, reading, concept maps, quizzes, and other activities that will enable the learner to be successful at meeting the simulation outcomes (Boese et al., 2013; INACSL Standards Committee, 2016c).
The 2016 version of the INACSL Standards of Best Practice: SimulationSM Facilitation brings preparation and prebriefing together in Criterion 3 (INACSL Standards Committee, 2016a). This Criterion is the most descriptive and proscriptive in regards to prebriefing and participant preparation thus far. In this Criterion there a directive to ensure participants have completed preparatory materials and an expansion of the content of prebriefing to include a minimum of six elements (INACSL Standards Committee, 2016a).
It would appear that, conceptually, prebriefing is a logistical part of the simulation based on these descriptions and represents a time to assure participants of their psychological safety; develop familiarity with the equipment; and clarify roles, rules, and expectations. Participant preparation for simulation, including assignments, reading, and didactic content, is considered a separate phase and aspect of simulation design and facilitation. However, this is reflected in the most recent literature. For example, in a 2017 study that looked at the impact of prebriefing on the performance of participants, the prebriefing was “… structured by concept mapping-type activities and guided reflection” (Page-Cutrara & Turk, 2017, p. 78). Another example is Chamberlain’s (2017) comparison of four different combinations of preparation for simulation, of which there were two preparation activities, both referred to as prebriefing: learning engagement and orientation. In their evaluation of the state of the science of anxiety in simulation, Shearer (2016) refers to the role of “preparation” in addressing the “Unknown” in simulation. The author states, “the use of standard practice in regard to preparation may assist the student to achieve the best possible outcome” (Shearer, 2016, p. 553), identifying a need for a standard preparation practice which is not specifically described as prebriefing. This lack of distinction between prebriefing and participant preparation is pervasive in the literature and demonstrates a lack of maturity in the concept.
Pragmatic Principle
This inconsistency between the standard-based description of the concept of prebriefing and its manifestations in the literature present a pragmatic challenge as the concept is identified by experts in a variety of ways (Penrod & Hupcey, 2005). In 2016, the same year the current INACSL Standards of Best Practice: SimulationSM were published, McDermott published a Delphi study that reviewed the concept of prebriefing with simulation experts. According to this study, clear consensus is still lacking as to what exactly prebriefing is; however, the experts described prebriefing as having three phases: planning, briefing, and facilitating (McDermott, 2016). The planning phase is when learning activities are provided to prepare the participant. To these experts, participant preparation is not considered a separate element of the simulation, but an early phase of prebriefing (McDermott, 2016).
Another example of a deviation from the standard definition of prebriefing as orientation only is the use of role-modeling as a prebriefing technique. Multiple studies have used forms of expert role modeling as simulation preparation: some refer to the intervention as part of the prebriefing, while others make no mention of prebriefing but include the role modeling intervention as part of the orientation phase of the simulation (Anderson, LeFlore, & Anderson, 2013; Aronson, Glynn, & Squires, 2013; Coram, 2016; Johnson et al., 2012; Stockert et al., 2015).
Linguistic Principle
The terms prebriefing, brief, pre-simulation preparation, pre-scenario work, preparatory activity and orientation appear in the literature referring to the preparatory activities that occur before a simulation experience (Chamberlain, 2015, 2017; Page-Cutrara, 2015; Tyerman, Luctkar-Flude, Graham, Coffey, & Olsen-Lynch, 2016). Of these terms, linguistically, prebriefing is consistently context bound to the activities that occur in the period preceding the simulation scenario (Penrod & Hupcey, 2005).
Many articles mention prebriefing when describing the activities that occur before the simulation scenario used in a study. In a study using a medication safety simulation, the authors state, “all students received standardized prebriefing, including objectives, case overview, and preparatory work. The preparation included readings and review questions. In addition, students were oriented to their surroundings and given the opportunity to ask questions” (Mariani, Ross, Paparella, & Allen, 2017, p. 213). Another example is less descriptive but placed the prebriefing before the scenario, “learners in both types of simulations received a standard prebriefing” (Luctkar-Flude, Wilson-Keates, Tyerman, Larocque, & Brown, 2017, p. 266). Some authors do separate the preparatory work from the prebriefing orientation in their descriptions, yet it still occurs in the context before the scenario. For example, in a study comparing the sequencing of simulation and hospital based experiences, the authors stated, “activities… included orientation to the simulation room and manikin, prebriefing, a prequiz, the patient care scenario, and debriefing” (Woda, Gruenke, Alt-Gehrman, & Hansen, 2016, p. 530). While there is a lack of consensus in the literature as to what specific components comprise prebriefing, conceptually it is a component of the activities occurring prior to the simulation scenario.
Logical Principle
Prebriefing is an element in many teaching and learning theories as they are applied, pedagogically, to simulation. Within these theories, prebriefing — whether it is orientation or other activities — remains clear as a concept of preparation (Penrod & Hupcey, 2005). Much like simulation in general as a pedagogical modality, prebriefing fits conceptually into many learning theories as such as Kolb’s Experiential Learning theory, adult learning theory, Bandura’s Social-Cognitive theory, situated cognition, cognitive load theory, brain-based education, and constructivist theories in the role of preparation to facilitate learning (Bethards, 2014; Cardoza, 2011; Clapper, 2015; Kaakinen & Arwood, 2009; Onda, 2012; Paige & Daley, 2009; Poore, Cullen, & Schaar, 2014; Zigmont, Kappus, & Sudikoff, 2011).
Cognitive load theory is an excellent example. In this theory, the concept of prebriefing is an essential element that can diminish the learner’s extraneous cognitive load, establish prerequisite knowledge and allow the learning experience of simulation to be committed to the learner’s working memory (Fraser, Ayres, & Sweller, 2015). Prebriefing provides orientation to the environment and equipment, establishes psychological safety, and increases the learning capacity of the participant by decreasing anxiety about the situation and distraction (Fraser et al., 2015; Hessler & Henderson, 2013; Janzen et al., 2016; Josephsen, 2015; Reedy, 2015; Rudolph, Raemer, & Simon, 2014). As a preparatory activity, prebriefing fits nicely into the framework of cognitive load theory.
This principle-based concept analysis shows that prebriefing is context bound to the time period preceding simulation scenarios and is clear as a concept in many learning theories; however, it is not yet a distinct concept in the literature, nor does it manifest itself consistently. References to prebriefing in the literature blur the line between prebriefing and participant preparation. The goal of future research on prebriefing should be to unify these elements and expand the concept of prebriefing beyond orientation and into a theory driven, structured process that takes into account the needs of the nursing student as a learner acting in the role of novice nurse in simulation. Adopting McDermott’s (2016) expert-generated idea of phases of prebriefing unites preparation with prebriefing and allows for the development of a phase-based, structured framework that would establish psychological safety, decrease anxiety and extraneous cognitive load, and increase learner engagement with prerequisite knowledge.

References (Apologies: not properly formatted in any way)
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Appendix A
The following is a proposed theoretical framework based on this concept analysis integrates the three domains of learning into three phases of preparation:

The preparatory phase (cognitive domain) where learners prepare by learning about the content they will encounter in the simulation. They may review pathophysiology or medications, or develop concept maps or care plans for their simulated patients. They will be accountable for this prep work. This phase allows the learner to develop a foundation on which to build their learning in the scenario.

The orientation phase (psychomotor) which allows the learners to experiment hands-on with equipment or examine the space the simulation will occur and become familiar with it. In this phase, they may review skills that may be required in the simulation whether it is auscultation of the manikin or insertion of a foley catheter. This phase allows the learner to gain some comfort and eliminate distractions so they can focus on their higher-level actions and decisions in the scenario.

The prebriefing phase (affective) where the facilitators review the expectations, elements of psychological safety, fiction contract, the process of debriefing and other aspects that will provide a safe and respectful learning environment for the participants. This phase is intended to help alleviate the learner’s anxiety going into the simulation and give them a sense of self-efficacy.





Simulation in non-academic settings

Admittedly I have spent the last 7 years developing a simulation program in only one setting- academic. I have developed and implemented simulation for pre-licensure nurses in an ADN program. But in my years of learning and exploring, I have met with and learned from experts from all settings. Many in hospitals, at large universities with huge IPE programs, and even a few independent simulation companies. While my direct hands-on experience has been focused on students and their learning and application of new skills, I have been exposed to the many ways simulation can improve nursing, and not only nursing, but health care overall.  In fact, the certified healthcare simulation educator exam  is geared towards a variety of settings, and in my preparation for it, I had to open my mind to not only what works or is appropriate in my setting, but to also understand the universal “truths” of simulation in all settings.

Recently I endeavored to learn a little more about ways simulation is used in hospitals and healthcare systems. In my searches, I came across a very informative plenary speech from IMSH 2014 by Dr. Jennifer Arnold (link at the end of this post). At first I thought, she seems familiar- I remember seeing her at IMSH in 2016 and thinking then how I had seen her at other conferences (I notice the Sim Celebs at these things!) and that I’d seen her at other conferences. I don’t watch a lot of TV shows,  so I completely missed that she’s also a reality TV star! Once I found that out, I fell in total love with her- an  educated, eloquent and intelligent woman, representing simulation to the public was a great thing! Next time I see her at a conference, I plan to shake her hand and thank her!

That was my first time at IMSH- I’ve attended INACSL (very nursing focused) a few times and other nursing education focused NLN sponsored conferences, but this year was my first IMSH and it was amazing. It was a refreshing experience to interact and network with simulation experts from all sorts of disciplines and backgrounds.

Anyhow back to her speech- she explained the model they  developed at Texas Children’s Hospital to use simulation. It includes 5 areas that simulation can be applied:

  • Education
  • Competency and Assessment
  • Quality and Patient Safety Initiatives
  • Research and Development
  • Advocacy

In her speech she gives examples of each area and how they have developed simulations in response to a need presented to their center. Having a framework which the center’s mission is build upon is crucial. It keeps the simulation center focused on it’s mission, and creates criteria for appropriate use of resources and a structure for evaluation and program development.

In academia, we often find ourselves focused on specific learning outcomes and lose sight of the big picture of what those outcomes feed into. Our program is currently undergoing a curriculum revision and after the development of a new philosophy statement, we had to distill out program/educational outcomes for “what our students should look like” when they complete the program. That was a challenging but intriguing endeavor that produced 5 solid  outcomes that we can build our curriculum around. I think as the simulation “person”, I need to now integrate those outcomes into my simulation center mission (I am working on a policy and procedure manual for our newly renamed “Clinical Performance and Simulation Center”) so that the resources are used in a mindful fashion with program outcomes/goals in mind.  I think I might also develop a framework similiar to this.

I am using the SSIH Accreditation Standards to build the policy and procedure manual as they give a good framework for essential elements in a high functioning sim center. I plan to integrate the following standards into a mission/framework, along with the program philosophy and education outcomes:

Here is Dr. Arnold’s great speech:


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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