The State of Simulation in Nursing Education

Nursing simulation

The use of simulation in nursing education has dramatically increased in the last 15 years as the number of nursing programs has grown, competition for clinical sites has intensified, and simulation equipment and related products have become more sophisticated. This increase has been supported by the publication of additional research related to its effectiveness. For example, Lee and Oh (2015) found through a meta-analysis that the use of high-fidelity human simulation led to significant improvements in problem-solving, critical thinking, clinical judgment, and clinical competence.

In 2014, the National Council of State Boards of Nursing (NCSBN®) published a comprehensive, longitudinal, randomized trial using student nurses from across the country, to explore the effect of simulation on educational outcomes (Hayden, et al., 2014). Eight hundred and forty-seven students from ten diverse nursing schools (five ADN and five BSN) were chosen to participate in the study. Students in each school were randomly placed into three groups: A control group that had no more than 10 percent of their clinical time in simulation, the 25 percent group having one-fourth of their clinical time in simulation, and the 50 percent group, who spent half of their clinical time in simulations. Six hundred and sixty-six students completed all study components and graduated within two years. A number of reliable evaluation instruments were used to assess the identified outcome measures from the perspective of the clinical instructor, preceptor, and student. Results of this study demonstrated that high-quality simulation experiences could be substituted for up to 50 percent of traditional clinical hours across the pre-licensure nursing curriculum. The result of this study supports the increasing trend to use simulation to prepare nursing students in a low-risk environment. This allows faculty to ensure that students develop beginning competence in critical nursing scenarios, even if such situations are not available during the students’ traditional clinical experience (Hayden, et al., 2014).

The findings of the NCSBN simulation study that simulation can be used for up to 50 percent of traditional clinical hours across the curriculum, resulted in an increased interest in using simulation as a clinical strategy. Since state boards of nursing regulate various aspects of the nursing curriculum, faculty are particularly interested in their state board of nursing regulations regarding the substitution of simulation for clinical experience. In the 2016 state board reports to the NCSBN, less than half of the states reported regulations related to the maximum number of hours that students may spend in simulation as part of their clinical experience. Although there was a wide variety in the number of hours allowed by the reporting boards, with the majority requiring a maximum of 10 hours of simulation. However, since this is reported data, it may not reflect recent changes in board rules (Hooper, 2017).

The NCSBN has provided an additional tool to help nursing programs offer student-centric simulation experiences and to help state boards of nursing provide effective oversight. In 2016, an expert panel was convened to develop national guidelines that integrate evidence regarding simulation. The expert panel included representatives from the International Nursing Association for Clinical Simulation and Learning, the American Association for Colleges of Nursing, the National League for Nursing, the Society for Simulation in Healthcare, state boards of nursing, and the NCSBN. Box A outlines key research used to develop the guidelines.

Box A: References Used by the NCSBN Expert Panel

Hayden, J., Smiley, R., Alexander, M., Kardong-Edgren, S., and Jeffries, P. (2014). The NCSBN National Simulation Study: A longitudinal, randomized controlled study, replacing clinical hours with simulation. Journal of Nursing Regulation, 5(2), 1-64. Supplement.

Lapkin, Levett-Jones, Bellchambers, and Fernandez (2011). Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: A systematic review. Clinical Simulation in Nursing, 6(6), e207–e222. Retrieved from

Sportsman, Schumacker, and Hamilton, (2011). Evaluating the impact of scenario-based high-fidelity patient simulation on academic metrics of student success. Nursing Education Perspectives, 32(4), 259–265. Retrieved from

Foronda, Liu, and Bauman (2013). Evaluation of simulation in undergraduate nurse education: An integrative review. Clinical Simulation in Nursing, 9(10), e409–e416. Retrieved from

Fisher and King (2013). An integrative literature review on preparing nursing students through simulation to recognize and respond to the deteriorating patient. Journal of Advanced Nursing, 69(1), 2375–2388. doi:10.1111/jan.12174

Berndt (2014). Patient safety and simulation in pre-licensure nursing education: An integrative review. Teaching and Learning in Nursing, 9(1), 16–22. Retrieved from

After a review of the literature, the expert committee developed two checklists to be used to ensure evidenced-based simulation; one for the program and one for the faculty. Below is a synopsis of each checklist.

Program Checklist

  1. Adequate fiscal, human, and material resources
  2. Policies and procedures to ensure quality-consistent simulation experiences
  3. Adequate number of dedicated, trained simulation faculty members
  4. Job descriptions for simulation faculty/facilitators
  5. Plan for orienting simulation faculty/facilitators to their roles
  6. Use of a needs assessment to determine what scenarios should be used
  7. Subject matter expertise for each scenario debriefing
  8. Incorporation of INACSL Standards of Best Practice: Simulation
  9. Appropriate physical space for education, storage, and debriefing
  10. Use of evaluative feedback for quality improvement of the simulation program
  11. Long-range plan for the simulation program

Faculty Checklist

  1. Based on educational theories associated with simulation, such as experiential learning theory
  2. Preparation of faculty using the INACSL Standards of Best Practice: Simulation
  3. Evaluation plan reflecting INASCL Standards of Best Practice: Simulation Evaluation Methods
  4. Based upon clear objectives and expected outcomes communicated to students prior to each simulation activity
  5. A learning environment that encourages active learning, repetitive practice, and reflection; faculty provide appropriate support throughout each activity
  6. Preparation of faculty for use of facilitation methods congruent with simulation objectives/expected outcomes
  7. Use of a standardized method of debriefing using a Socratic methodology
  8. Development of a rubric to evaluate student acquisition of KSAs throughout the program
  9. Development of a method to share student performance with clinical faculty
  10. Collection and retention of evaluation data regarding the effectiveness of the facilitator
  11. Provides professional development (webinars, conferences, journal clubs, readings, and certifications such as certified health care simulation education) and participation in NLN Sim Leaders/Sigma Theta Tau International Nurse Faculty Leadership Academy (with a focus on simulation)

(Alexander, et al., 2015)

For more information about the guidelines established by the NCSBN expert panel, see the National Simulation Guidelines for Pre-Licensure Nursing Programs at

Simulation programs based on evidence continue to be an important component in developing nursing students’ clinical judgment and preparing them for practice. It is the responsibility of nurse faculty to stay up-to-date on the evidence. This article provides sources that should support excellence in simulation across the country.


Alexander, M., Durham, C., Hooper, J., Jeffries, P., Goldman, N., Kardong-Edren, S., Spector, N., Taglianieni, E., Radtke, B., and Filman, C. (2015). NCSBN Simulation Guidelines for Pre-Licensure Nursing Programs. Journal of Nursing Regulation, 6(3), October, 39-42.

Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., and Jeffries, P. R. (2014). The NCSBN National Simulation Study: A longitudinal, randomized controlled study replacing clinical hours with simulation in pre-licensure nursing education. Journal of Nursing Regulation, 5(2), S1–S64. Retrieved from

Hooper, J. (Personal Communication)

Lee, J., and Oh, P. (2015). Effects of the use of high-fidelity human simulation in nursing education: A meta-analysis. The Journal of Nursing Education, 54(9), 501-507.