The use of high- and medium-fidelity simulators has been

Use of Simulation in Nursing Education: National Survey Results Jennifer Hayden, MSN, RN While simulation use in nursing programs continues to increase, it is important to understand the prevalence of this new technology in nursing education, how this technology is utilized, and how educators are preparing to teach with this educational tool. This article reports on the results of a survey conducted by National Council of State Boards of Nursing of 1,060 pre-licensure nursing programs in the United States as a means of describing use of simulation. The use of high- and medium-fidelity simulators has been much discussed among nursing faculty, deans, and state boards of nursing (BONs). Reasons for adding simulation to the nursing curriculum as a teaching strategy are well cited in the literature. More and more nursing programs are using simulation, and the publications related to simulation have increased tremendously in the last 5 years. However, few publications report findings of simulation use in nursing education. Nehring and Lashley (2004) first reported on the prevalence of simulation use by surveying nursing programs and simulation centers regarding how simulation was used and what amount of time was spent with a human patient simulator. Adamson (2010) reported on a survey of associate-degree programs in one western state, emphasizing faculty barriers and facilitators to integrating simulation into the nursing curriculum. Katz, Peifer, and Armstrong (2010) reported the results of a survey sent to baccalaureate programs accredited by the National League for Nursing (NLN). This survey focused on courses using simulation, courses using simulation for competency assessments, and the question of whether clinical hours were being replaced by simulation. These reports made important contributions to the literature of nursing simulation; however, all three used a subset of the nursing education community. Because simulation is being used increasingly in all types of nursing educational settings, a thorough description of the current prevalence and practices is needed. The purpose of this survey, conducted by the National Council of State Boards of Nursing, was to assess the prevalence and practices of simulation in pre-licensure nursing programs in the United States. Data Collection Surveys were mailed to all pre-licensure registered nurse (RN) programs in January 2010. A reminder postcard was sent to all institutions included in the initial mailing. A second survey was mailed to nonresponders in February 2010. Results Respondents The initial mailing included 1,729 surveys sent to pre-licensure RN nursing programs in the United States. Overall, 1,060 surveys were used in the analysis, reflecting a 62% response rate. Survey responses were received from pre-licensure nursing programs from every state and the District of Columbia. Many respondents indicated that their institution offered more than one type of pre-licensure nursing program, for example, an associate degree and a baccalaureate degree. Most respondents described their academic institution as a college/ university setting or a community college/technical school. The number of respondents from metropolitan areas and the number from rural areas were nearly equal (see Table 1). Use of Simulation For the purposes of this study, simulation was defined according to level of fidelity of the manikin or scenario. The following definitions (adapted from Debra Spunt [2007, p. 113]) were included in the survey: High-fidelity simulation. Patient-care scenario that uses a standardized patient or a full-body patient simulator that can be programmed to respond to affective and psychomotor changes, such as breathing chest action. Examples of high-fidelity manikins include SimMan, METIman, and Noelle with Newborn Hal. Medium-fidelity simulation. Patient-care scenario that uses a full-body simulator with installed human qualities such as breath sounds without chest rise. An example of a mediumfidelity manikin is VitalSim. 52 Journal of Nursing Regulation

Task trainers. Part of a manikin designed for a specific psychomotor skill, for example, an arm for iv insertion practice. Using these definitions, respondents were asked whether their nursing programs used high- or medium-fidelity experiences. Overall, 87% indicated that students in their programs receive high- or medium-fidelity experiences. Pre-licensure MSN programs were mostly likely to use simulation (94%), and diploma programs were least likely to use it (73%). The majority of respondents (55%) use simulation in five or more courses. Because a typical nursing program has less than 10 clinical courses, these data indicate a trend toward integrating simulation throughout the curriculum. Overall, high-fidelity simulation is used most commonly in medical/surgical courses and obstetric nursing courses followed by pediatric nursing courses. Medium-fidelity simulators are used most commonly in foundations courses, medical/surgical courses, and obstetric nursing courses. Task trainers are used in most clinical courses, with the highest frequency of use in foundations courses (see Table 2). The median number of scenarios used throughout the curriculum was 13, with a range of 1 to 233. Scenarios tended to be used most often in foundations and medical/surgical nursing courses. Overall, simulation is used during lecture in less than 15% of programs, with the highest use in obstetric nursing, medical/surgical nursing, and advanced medical/surgical courses. Pre-licensure MSN and diploma programs are exceptions. Both use high rates of simulation during lecture in advanced medical/ surgical nursing courses; however, no diploma programs reported using simulation in gerontological or community health nursing lectures. Overall, mental health, capstone/role transition (a course that provides the opportunity to integrate knowledge, skills, and leadership before graduation), and community health courses incorporate simulation less frequently than other clinical courses, though associate-degree and diploma programs are using simulation in community health courses more often than baccalaureate and pre-licensure MSN programs. The majority of respondents use simulation scenarios that take between 15 and 30 minutes, but about 20% of the respondents indicate scenarios can last more than an hour. Many respondents selected more than one category for scenario length, indicating that within a program some scenarios may take longer than others. This would most likely depend on the objective of the scenario. Several respondents wrote that scenarios in capstone courses are evolving cases that take longer; for example, a scenario may start with a chronic health condition and evolve into a hospice scenario concluding with end-of-life issues. About 80% of programs using high-fidelity or mediumfidelity simulation are debriefing students for at least the same amount of time the scenario takes. However, a substantial number of programs are debriefing for shorter periods (42% overall), and 75 programs indicated they do not debrief students after the scenario. Most commonly, student performance is not graded. Table 1 Demographic Information N Type of Program Associate 614 Baccalaureate 433 Diploma 79 Pre-licensure MSN 42 Type of Institution Academic/Teaching Medical Center 39 University/College Setting 428 Hospital-based Nursing Program 41 Community College/Technical School 403 Geographic Setting Urban/Metropolitan Area 342 Suburban Area 244 Rural Area 316 When it is, the program most likely uses a pass/fail rating rather than assigning a score. When asked about the types of learning opportunities offered by their simulation laboratory, respondents listed assessment and psychomotor skills as the most frequently available, yet all learning opportunities listed on the survey are offered by most of the simulation labs (see Table 3). Other responses included communication, clinical make-up, clinical decision making/ critical thinking, skill competency validation, prioritization, delegation, interdisciplinary team training, open lab/tutoring, and practicing multiple patient loads. Respondents were asked to indicate types of simulation, other than manikin-based, used in their pre-licensure programs. Responses included role play, MicroSim and Virtual Clinical Excursions (computer-based case scenarios that involve clinical decision making), case studies, and electronic health records. Faculty Resources Though 67% of programs purchase scenarios, 78% have faculty members who write scenarios, even if their program purchases scenarios from a publisher. Perhaps the supply of commercially available scenarios is not sufficient to meet the demands of some programs. Or perhaps faculty members are trying to use simulation for courses that publishers have not yet addressed. Of those programs where faculty write their own scenarios, 30% stated that all educators who write scenarios have received training; 61% stated that some of their educators have received training; and 13% stated that none of their educators have received training to write scenarios. Faculty members who were trained to write scenarios learned from the manikin representative (81%), local or regional training (45%), a vendor workshop (43%), a conference (27%), and online training through the NLN Volume 1/Issue 3 October 2010 www.journalofnursingregulation.com 53

Table 2 High-Fidelity, Medium-Fidelity, and Task Trainer Simulation Use in Nursing Courses Nursing Courses High-Fidelity Simulation Use Overall N = 917 Associate N = 523 Baccalaureate N = 379 Diploma N = 48 Pre-licensure MSN N = 31 Foundations 335 (43%) 182 (35%) 147 (38%) 18 (30%) 18 (45%) Health Assessment 190 (37%) 86 (16%) 104 (27%) 11 (18%) 11 (28%) Medical/Surgical Nursing 569 (71%) 320 (61%) 256 (66%) 30 (49%) 29 (73%) Advanced Medical/Surgical Nursing 560 (80%) 313 (59%) 248 (64%) 25 (41%) 21 (53%) Obstetric Nursing 419 (46%) 222 (42%) 196 (51%) 23 (38%) 25 (63%) Pediatric Nursing 383 (42%) 198 (38%) 194 (50%) 18 (30%) 23 (58%) Gerontological Nursing 92 (10%) 44 (8%) 44 (11%) 5 (8%) 6 (15%) Mental Health Nursing 116 (13%) 66 (13%) 48 (12%) 6 (10%) 7 (18%) Community/Public Health Nursing 51 (6%) 11 (2%) 39 (10%) 1 (2%) 1 (3%) Capstone/Role Transition 162 (18%) 74 (14%) 87 (23%) 10 (16%) 7 (18%) Medium-Fidelity Simulation Use Foundations 479 (61%) 275 (52%) 205 (53%) 39 (64%) 27 (68%) Health Assessment 326 (63%) 137 (26%) 190 (49%) 18 (30%) 20 (50%) Medical/Surgical Nursing 452 (56%) 271 (51%) 182 (47%) 35 (57%) 16 (40%) Advanced Medical/Surgical Nursing 302 (33%) 184 (35%) 120 (31%) 18 (30%) 12 (30%) Obstetric Nursing 351 (38%) 194 (37%) 163 (42%) 23 (38%) 16 (40%) Pediatric Nursing 325 (35%) 182 (35%) 148 (38%) 23 (38%) 14 (35%) Gerontological Nursing 67 (7%) 41 (8%) 27 (7%) 6 (10%) 3 (8%) Mental Health Nursing 56 (6%) 33 (6%) 23 (6%) 3 (5%) 1 (3%) Community/Public Health Nursing 34 (4%) 9 (2%) 26 (7%) 0 3 (8%) Capstone/Role Transition 73 (8%) 33 (6%) 36 (9%) 12 (20%) 5 (13%) Task Trainer Use Foundations 535 (68%) 294 (56%) 256 (66%) 30 (49%) 26 (65%) Health Assessment 276 (53%) 112 (21%) 167 (43%) 15 (25%) 19 (48%) Medical/Surgical Nursing 348 (44%) 187 (36%) 162 (42%) 19 (30%) 16 (40%) Advanced Medical/Surgical Nursing 250 (27%) 127 (24%) 121 (31%) 28 (46%) 12 (30%) Obstetric Nursing 279 (30%) 147 (28%) 132 (34%) 16 (26%) 12 (30%) Pediatric Nursing 240 (26%) 127 (24%) 114 (30%) 16 (26%) 14 (35%) Gerontological Nursing 70 (8%) 34 (6%) 34 (9%) 4 (7%) 1 (3%) Mental Health Nursing 92 (10%) 42 (8%) 54 (14%) 3 (5%) 3 (8%) Community/Public Health Nursing 53 (6%) 10 (2%) 41 (11%) 3 (5%) 3 (8%) Capstone/Role Transition 63 (7%) 27 (5%) 33 (9%) 6 (10%) 6 (15%) Simulation Innovation Resource Center (17%). The quality of the scenarios written by faculty is most often determined by student evaluation at the end of the simulation session, followed by faculty peers evaluations of the content and pilot testing. Among programs with educators who write scenarios, 40% share them with other pre-licensure programs. Pre-licensure MSN programs tend to have the most faculty training, use the most pilot testing, use the NLN Simulation Design Scale 54 Journal of Nursing Regulation

Table 3 Types of Learning Opportunities Offered by Simulation Lab Practice Procedures Practice Routine Assessments Practice Patient Scenarios Discussed in Class Practice Rare Patient Scenarios Unlikely to See in Clinical Practice High- Risk Scenarios Remediation of Skills Overall 851 (93%) 887 (97%) 683 (74%) 579 (63%) 704 (77%) 668 (73%) 92 (10%) Associate 477 (91%) 502 (96%) 395 (76%) 320 (61%) 385 (74%) 368 (70%) 44 (8%) Baccalaureate 364 (96%) 372 (98%) 277 (73%) 256 (68%) 313 (83%) 292 (77%) 45 (12%) Diploma 44 (92%) 47 (98%) 39 (81%) 34 (71%) 38 (79%) 35 (73%) 4 (8%) Pre-licensure MSN 31 (100%) 31 (100%) 25 (81%) 23 (74%) 27 (87%) 26 (84%) 7 (23%) Other methods to determine the quality of their scenarios more often, and share their scenarios with other programs. Respondents that use simulation were asked if they believed their programs should be using more or less simulation, or if they believed they were using the right amount. Overall, 18% (N = 164) thought they were using the right amount of simulation; 81% thought they should use more; and three respondents thought they should use less. Respondents who thought their program should use more simulation were asked to indicate barriers to doing so. Overall, the most common barrier was that more faculty members need training in facilitating simulation (see Table 4). Other reasons included cost, insufficient or broken equipment, insufficient lab space, scheduling difficulties, no one to run the lab, faculty resistance, faculty workloads, and issues within the curriculum. Replacing Clinical Time with Simulation When respondents already using simulation were asked if they would substitute it for clinical time if no rules, regulations, or limitations prevented them from doing so, only 20% said they would not. A full 77% said they either are substituting simulation for clinical time or would do so if permitted. Respondents would be most comfortable replacing about 25% of clinical time with simulation. When respondents were asked if the time their students spend in simulation scenarios counts toward clinical hours, 69% said it is counted or has been counted on occasion; 28% use simulation as a supplement to clinical time; and 26 programs did not answer the question. Among programs that do substitute simulation for clinical time, 83% use an equivalent rate of 1 hour of simulation to 1 hour of clinical time; 10% use a rate of less than 1 hour of simulation to 1 hour of clinical time; and 7% use a rate of more than 1 hour of simulation to 1 hour of clinical time. For each hour of clinical time, 32 programs substitute 0.5 hour of simulation, and 25 programs substitute 2 hours of simulation. Respondents stated that substitution of simulation for clinical time was most common in medical/surgical nursing courses. At least half of the programs that substitute simulation do so in medical/surgical nursing, obstetric nursing, and pediatrics courses. On average, health assessment and foundations courses had the greatest percentage of clinical time replaced with simulation time. When considering substitution of simulation as a percentage of clinical hours, one must know the current number of clinical hours in a program, so participants were asked to indicate how many clinical clock hours were associated with each clinical course in their program. Baccalaureate, diploma, and pre-licensure master s degree programs reported on average more clinical hours than associate-degree programs (733, 737, and 780, respectively, compared with 621). Limitations A limitation of this study is that some types of degrees are overrepresented. Many schools offer more than one type of degree that uses simulation and, in some cases, responses regarding which programs use more simulation were unclear. In these cases, responses were reported for both program categories, but the overall responses reflect one nursing program. This study may be underreporting programs that do not use simulation because they may not have responded to the survey despite a cover letter requesting participation from programs not using simulation. Discussion This survey examined the use of simulation in pre-licensure nursing programs in the United States. Of all responding programs, 87% use simulation, and 54% of those programs are using simulation in at least five clinical courses, indicating a continuing trend to use simulation throughout the nursing curriculum. Foundations and medical/surgical courses tend to be the highest users of simulation followed by obstetric and pediatric nursing courses (courses in which clinical placements can be dif- Volume 1/Issue 3 October 2010 www.journalofnursingregulation.com 55

Table 4 Barriers to Increasing Simulation Use in Nursing Program Overall N = 740 Associate N = 420 Baccalaureate N = 313 Diploma N = 31 Pre-licensure MSN N = 25 More faculty need to be trained in writing scenarios Faculty do not have enough time to write scenarios More faculty need to be trained in debriefing simulations More faculty need to be trained in facilitating simulations Not enough staff to run the simulation controls and oversee the students Difficult to schedule additional time in the simulation lab due to other groups using the lab 422 (57%) 238 (57%) 178 (57%) 26 (84%) 10 (40%) 393 (53%) 228 (54%) 163 (52%) 21 (68%) 10 (40%) 435 (59%) 240 (57%) 194 (62%) 23 (74%) 13 (52%) 562 (76%) 329 (78%) 229 (73%) 27 (87%) 16 (64%) 511 (69%) 301 (72%) 216 (69%) 20 (65%) 17 (68%) 362 (49%) 210 (50%) 153 (49%) 19 (61%) 14 (56%) State nurse practice act and/or rules/regulations 61 (8%) 36 (9%) 28 (9%) 2 (6%) 2 (8%) Other 171 (23%) 85 (20%) 82 (26%) 10 (32%) 9 (36%) ficult). Interestingly, mental health courses (also courses in which student clinical placements can be difficult) report low rates of simulation use. Perhaps the faculty time required to develop scenarios or the unavailability of patient actors has contributed to a low level of simulation use in mental health courses. Though increased simulation use in pre-licensure programs is spreading to more clinical courses, not all faculty members embrace this teaching tool. When programs were asked if all clinical instructors within a course use simulation, the highest response was that 47% of programs have all foundations faculty members using simulation. Adamson (2010). found faculty barriers to high-fidelity simulation include lack of time, lack of administrative and technical support, and lack of appropriate equipment. Programs interested in increasing simulation use will likely need to overcome these barriers. A looming issue for nursing programs and BONs is the substitution of simulation experiences for clinical experiences. Nehring and Lashley (2004) found that 20 of 35 programs (57%) counted time with manikins as clinical time. Their study also reported the amount of time simulation was used per course, but a rate of substitution cannot be inferred from these data. Katz et al. (2010) reported 18 of 78 baccalaureate programs (23%) were replacing clinical time with simulation. In this survey, 69% of respondents said they substitute simulation regularly or occasionally. This study reports only the current practices of pre-licensure programs regarding the replacement of clinical hours with simulation hours in terms of the courses that replace clinical time and the amount of time replaced. The literature is beginning to see reports of educational outcomes when traditional clinical time is replaced with simulation. Lambton (2008) reported qualitative results when simulation was substituted for 25% of pediatric clinical time with faculty and student perceptions of student improvement in performing assessments. A study comparing traditional clinical time with simulation alone or a combination of simulation and clinical time during a clinical elective course found significantly increased student reports of self-confidence in the two simulation groups; however, clinical performance findings were inconclusive (Hicks, Coke, & Li, 2009). Another study found significantly fewer actual and potential medication errors made by secondyear baccalaureate students during clinical rotation when some clinical time was replaced with simulation compared with their control group peers (Sears, Goldsworthy, & Goodman, 2010). The early reports of educational outcomes of simulation use are encouraging. As programs are increasing the integration of simulation throughout the pre-licensure curricula and substituting simulation for clinical time, the effect of this technology on student outcomes is an area for much needed additional research. References Adamson, K. (2010). Integrating human patient simulation into associate degree nursing curricula faculty experiences, barriers, and facilitators. Clinical Simulation in Nursing, 6(3), e75 e81. Hicks, F. D., Coke, L., & Li, S. (2009). Report of findings from the effect of high-fidelity simulation on nursing students knowledge and performance: A pilot study. Chicago, IL: National Council of State Boards of Nursing. 56 Journal of Nursing Regulation

Katz, G. B., Peifer, K. L., & Armstrong, G. (2010). Assessment of patient simulation use in selected baccalaureate nursing programs in the United States. Simulation in Healthcare, 5(1), 46 51. Lambton, J. (2008). Integrating simulation into a pediatric nursing curriculum: A 25% solution? Simulation in Healthcare, 3(1), 53 57. Nehring, W. M., & Lashley, F. R. (2004). Current use and opinions regarding human patient simulators in nursing education: An international survey. Nursing Education Perspectives, 25(5), 244 248. Sears, K., Goldsworthy, S., & Goodman, W. M. (2010). The relationship between simulation in nursing education and medication safety. Journal of Nursing Education, 49(1), 52 55. Spunt, D. (2007). Setting up a simulation laboratory. In P. R. Jeffries (Ed.), Simulation in nursing education: From conceptualization to evaluation (pp. 105-122). New York, NY: National League for Nursing. Jennifer Hayden, MSN, RN, is an associate in the Research Department at the National Council of State Boards of Nursing (NCSBN) in Chicago, Illinois. Many thanks to Suzan Kardong-Edgren, PhD, RN (Washington State University) and Kevin Kenward, PhD, MA, (NCSBN) for survey design and manuscript review and to Pam Jeffries, PhD, RN, FAAN, ANEF (Johns Hopkins University) and Nancy Spector (NCSBN) for assistance with designing the survey. Additional thanks to Catherine Maney, MS, APN, CNS (Northern Illinois University), Donna Semar, PhD, RN (University of Arizona), Fred Brown, DNP, RN, ONC (Rush University), Jeanne Cleary, BSN, MA, RN (Ridgewater College), and Christine Thomas, PhD, RN (West Chester University) for piloting the survey and to Richard Smiley, MS, MA, for assistance with database management. Volume 1/Issue 3 October 2010 www.journalofnursingregulation.com 57