As anyone in the field would surely attest, nursing is a career that is both incredibly rewarding while also fraught with significant demands and challenges. One area in particular that has been making strides in supporting nurses is the expanded and refined use of simulation—in order to practice the clinical skills necessary to ensure safe patient care.

Using life-like computerized mannequins to replicate the complex patient environment of the clinical setting, simulation offers nursing students the opportunity to practice in a safe atmosphere before beginning full-time work in a real clinical setting. Simulation benefits students, faculty, and health care providers, and also carries the power to transform the health care system through improvements in quality, safety, efficiency, and care outcomes.

At a number of nursing schools throughout the country today, simulation is integrated as part of the formal nursing curriculum, resulting in success for students and faculty alike. However, this wasn’t always the case. As with any new technology, simulation technologies are sophisticated systems that come with many advantages, but some challenges to manage as well. It took time—combined with a passion for nurse education and a persistence to get it right—for appropriate curriculums to be developed.

Overcoming the myth of simulation

Early uses of health care simulation date back to the 1960s and include the use of airway simulators for anesthesia training and CPR instruction, as well as for medication administration training. For instance the Institute of Medicine’s (IOM’s) 1999 report, “To Err Is Human: Building a Safer Healthcare System” highlights the promise of deliberate practice in curbing medical errors through improved communications, team performance, education, and training, all of which can be accomplished with the use of simulation.

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Motivated by early simulation success, in the early 2000s many provider organizations and schools of medicine and nursing purchased or received donations of high-fidelity simulators ranging in costs of $75,000–$100,000 each. While there were high expectations for immediate use and derived benefits of these simulation technologies in nursing, some people in the industry had the notion that nursing simulators would perform on their own with the simple click of a button—and that students would “magically” learn the content. With that idea, faculty members were left to fend for themselves in conducting simulation design, implementation, management, and monitoring.

In 2004, staff at Robert Morris University integrated these very life-like simulations into their nursing curriculum. That effort has led to today’s unprecedented and innovative template for nursing simulation curriculum at the Robert Morris University School of Nursing and Health Sciences.

Laying the foundation for curriculum development

Integrating simulation in nursing education requires an understanding of these high-fidelity mannequins, which are as true to life as one can imagine, with an advanced level of realism. They speak, they bleed, and they react. They respond to interventions with changes in heart rate, lung and heart sounds, and vital signs. As a result, some of the most effective uses of these simulators is to recreate what are known as low-occurrence, high-risk scenarios such as strokes, heart attacks, and other critical health situations. While these medical situations may not happen with regular frequency, when they do, they require an incredibly swift and accurate response from nurses. In other words, the ability to teach and practice responding to these situations, in the safe and controlled environment of the simulation lab, is invaluable.

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But implementing simulations in educational settings—universities, colleges, and career schools—has not been easy. To meet this challenge, an interdisciplinary team at Robert Morris University School of Nursing and Health Sciences, in Moon Township, Pennsylvania, took on the task of investigating barriers and roadblocks to simulation adoption, from understanding the technology behind the mannequins to curriculum writing and development of a well-planned educational experience, in addition to faculty development and pilot testing.

Among the issues under review were the following:

  • How prevalent is simulation in nursing education?  
  • How can nursing faculty design an effective simulation experience?
  • What constitutes a worthwhile simulation experience for nursing students?  
  • What’s the best way to measure learning outcomes, including knowledge and critical thinking?

Considering curriculums

After much research; hands-on experience; and feedback from students, teachers, and even system designers, RMU implemented its currently used Simulation Learning System (SLS) curriculum in 2009. At the heart of the program are the following three components:

Pre-scenario: Nurse faculty members receive guidance on a wide range of areas, including simulation set-up, features and functions, and anticipated possible student reactions. They are also advised to think about others—besides the students and mannequins—who should be involved with the SLS process to make it as real as possible (i.e., should there be parents or other family members?). Time parameters are also important. Each scenario can range from as little as 20–30 minutes, to 50 minutes or an hour. Reading materials and relevant background research are also suggested for the faculty. And finally there are pre-scenario learning activities, which prepare students with the tools necessary to be successful during the scenario, without giving away the details.

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Scenario: Faculty instructors receive tips on how to run the scenario, including making changes to the mannequin to best suit their needs, guiding students through the experience, and facilitating a debriefing where students view and reflect on their performance, answer critical-thinking questions, and link theory to practice.  

Post-simulation: This is the debriefing component and the chance to evaluate how the scenario went. Part of this phase is faculty administering post-exams, post-tests, and concept mapping to solidify what students have learned with the simulation. In addition, students have the ability to reinforce content with animated movie clips, which clarify concepts related to pathophysiology or procedural skills.

RMU also responded to common faculty recommendations for implementing high-fidelity human simulation (HFHS), including:

  • Appoint a dedicated coordinator or champion.
  • Offer technological support.
  • Provide adequate facilities.
  • Use standardized programming forms.
  • Arrange for adequate facilities.
  • Fund supplies that enhance realism.
  • Offer workload release time.

Next steps for RMU

With its new Regional Research and Innovation in Simulation Education (RISE) Center, RMU continues its commitment to simulation learning and advancement. Opened in 2009, the RISE Center features two high-fidelity treatment rooms, a critical-care room, two classrooms/debriefing areas, and a low-fidelity nursing skills practice lab.

With additional funding, RMU has hired both a simulation technician and simulation specialist, who integrated simulations, including approximately eight scenarios with over 100 students. Students who are about to graduate or transition also rely on simulations to prepare for the real-world nursing environment.

Thus far, more than 120 Robert Morris nursing students and five nursing faculty have participated in simulation experiences facilitated through the SLS. Post-evaluations reveal positive results from students on dimensions such as satisfaction, value, simulation realism, and applicability of the simulation to real-world clinical settings. In addition, students demonstrate improved SLS post-test scores following simulation experiences.

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An administrative software system allows RMU to track usage statistics; usage rates have increased exponentially, from four scenarios in 2008 to more than 20 in 2011, as have the types of simulations offered.

Additional simulation recommendations

Among the recommendations for an effective simulation experience are these:

  • Ensure adequate time and resources. Invite faculty to learn about simulations and underlying technologies, while creating a sense of anticipation about the simulation experience among students. 
  • Utilize standards and guidelines as much as possible. The first set of simulation standards was recently released by the International Association of Clinical Simulation and Learning (INACSL) and can serve as a guide for both novice and expert simulation educators.
  • Overcome faculty fears relating to lack of support, assistance, and time. 
  • Hire staff that can assist in implementing, managing, monitoring and evaluating the simulation program. Rely on a technician to handle technical glitches, video, and sound.
  • Solicit feedback from both faculty and students on issues such as usability, learning experience, and outcomes. 
  • Seek out other nursing schools with experience and expertise in using simulations.
  • Partner with providers, associations, and reputable vendors.
  • Consider simulation certification.
  • Rely on highly developed simulation learning systems that alleviate the pressure of simulation design, implementation, administration, pre- and post-testing, and tracking.  Especially important are competencies related to Quality and Safety Education for Nurses (QSEN, competencies, which should be integrated into every simulation experience. 

The next phase for simulation in nursing

As new developments occur, simulations within the nursing curriculum are likely to change and evolve somewhat rapidly. Among the new and emerging trends:

  • Team spirit: Team training will occur across disciplines and specialties. Team STEPPS,  ( is an evidence-based team training system developed by Department of Defense’s Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality (AHRQ.).
  • Research: Research on simulations will surge. Especially critical are issues related to the impact of simulation on patient outcomes and on provider effectiveness. Among the questions currently under investigation: How can simulation be used for high stakes testing situations? What are the knowledge and clinical competency outcomes of students when simulation technology is used for clinical experiences? (NCSBN study) 
  • Patient safety: Simulation will emerge as a patient safety strategy. Organizations will increasingly view simulation as a tool to promote patient safety, prevent medical errors, and curtail costly readmissions.
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