Monday December 18th 2017

New validation for simulation education

Lori Lioce

Technology and improved teaching and learning strategies are changing education as we knew it. A 2013 review conducted by David Cook of more than 1,000 individual studies with more than 50,000 participants revealed that “technology-enhanced simulation is consistently associated with large, statistically significant benefits in the areas of knowledge, skills and behaviors.” And “for direct patient effects, such as major complications, mortality, or length of stay, the benefits are smaller but still significant.” These findings, published by the Agency for Healthcare Research and Quality, underscore what many nursing educators and students have experienced firsthand.

The ability to provide students with standardized clinical experiences on demand is a radical change in clinical education that allows the participant to assess, intervene in and re-evaluate a simulated patient’s condition and response to treatment. When health care simulation is combined with a theoretical framework, specific objectives developed and a briefing strategy identified, it can yield a unique and positive immersive learning opportunity. More impressive is that an overwhelming majority of today’s technically savvy students react positively to the experience when skilled facilitators set expectations before simulation and establish a trusting environment.

Using a neonatal simulator, Lioce facilitated pediatric assessment with undergraduate students from The University of Alabama in Huntsville.

Health care simulation is used in a variety of settings for student and employee orientation, physiologic assessment, deliberate practice, on-demand clinical experiences, reflective exploration, competency validation, communication and teamwork development, remediation, and high-stakes testing. The beauty of simulation-enhanced learning is that it uniquely and deliberately allows participants to make mistakes at the bedside in a controlled environment with no risk to a patient. Health care simulation shouldn’t replace all clinical experiences. However, specific and purposeful integration of simulation can be an incredible process to witness. Further, the subsequent debriefing, whether at the bedside or in a formal debriefing room, allows participants and peers to safely discuss competent practice, rehearse peer-to-peer communication, identify and correct errors and explore the implications for patients, apply clinical practice protocols, and examine clinical reasoning with a knowledgeable facilitator. Personally, I enjoy seeing the “light go on” in the face of the participants when they really “get it.” The rapid discussion of how they made the connection from their reading or didactic education to clinical application is the key. They are excited, and it is contagious. That’s when I know we have had a positive experience.

Keys to successful simulation training experiences

Successful simulation requires planning and practice. A programmatic framework with specific steps is essential to support successful repeatable outcomes. The process may include a theoretical framework, orientation to the simulator, an explanation of the facilitator and participant roles and expectations, and preselection of specific achievable and measurable objectives. Participants should understand this process. The participant should lead and be empowered through pre- and post-briefing to achieve true change in practice through discovery learning.

Often administrators, staff, novice facilitators, course managers, clinicians and even participants may underestimate the preparation needed. In the educational environment, where you may have multiple groups repeating the same simulation, I am an advocate for a simulation expert and facilitator-led “dry run” of all simulations before implementation with participants. The dry run without participants allows the facilitator to see the experience from the participants’ perspective and ensures selection of a pre- and post-simulation process, especially when there are different facilitators within a course for each clinical group. This deliberate planning provides a vital opportunity for selection of learning preparation assignments, didactic coordination, review of and emphasis on objectives, coordination of vital equipment and medications, altering of the scenario, and agreement on a scenario stopping point. Most important, it verifies the presence of all physical and verbal cues that enable the participants to follow the clinical reasoning. Without these, simulation may not be aspirational or improve patient outcomes. Several vital components of a successful simulation learning program are dedicated simulation staff, effective coordination and scheduling, and an experienced debriefer — one who can guide the participants in discovery learning and not steal the “aha” moment. In fact, once a facilitator sees that light come on for the participants, he or she may never want to lecture again.

National and state regulation

Be aware that rules and regulations are being considered in various states regarding the use of simulation. In fact, in June 2013, the National Council of State Boards of Nursing (NCSBN) completed data collection for a three-year multisite study on the use of simulation in prelicensure programs. The results are being released Aug. 13 at the NCSBN annual meeting in Chicago. I encourage you to periodically check with your state boards for specific updates.

Looking forward

As a simulation advocate, I am inspired by what the future of education holds and envision increased implementation into advanced practice with further development of advanced practice simulations, development of simulators that will allow more specific incorporation of advanced skills, and more independent interaction along with increased applications for development of products that will enable participant-led exploration of treatment interventions. While we have come a long way in the ability to provide on-demand clinical experiences, there is more to come. The future of simulation education is limited only by our collaboration with other disciplines, time for innovation and our imaginations. I truly believe advancements in health care simulation will continue to positively influence patient safety, increase competent practice, bring to life clinical education and encourage lifelong learning.

— Lori Lioce is a clinical associate professor at The University of Alabama in the Huntsville College of Nursing, where she serves as simulation coordinator.  She is vice president of operations for INACSL and is an Alabama State Nurses Association member.

Standards for best practice

With the rapid expansion in the field of health care simulation, standards for best practice have become increasingly important for quality, consistency, outcomes, and improvement of simulation programs and learning strategies.

In 2011, the International Nursing Association for Clinical Simulation and Learning (INACSL) published the seminal work Standards of Best Practice: Simulation. This document includes seven standards, and each standard includes specific criteria, outcomes and rationales. The standards provide a vital framework for decreasing clinical variability, planning strategically, initiating research and providing faculty development.

Four new standards, identified in 2013, are currently being prepared for publication in 2015 to address simulation design, research, standardized patients and interprofessional education.

In 2013, the standards were updated and guidelines were added to assist implementation of the standards. These standards and guidelines are providing a framework for developing institutional policies and procedures. They are crucial to aid advancement of simulation programs, support the science of clinical simulation and standardize terminology while sharing evidence-based best practices.

As health care education moves toward higher-stakes testing with simulation and health care facilities increase implementation of this teaching methodology to improve teamwork and decrease medical errors, the Standards of Best Practice: Simulation will continue to be a vital component of success.


Agency for Healthcare Research and Quality WebM&M site:

To order a copy of the Standards of Best Practice: Simulation, go to

Additional reading:
OJIN: Simulation in Nursing Practice:

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