Running Head: SIMULATION IN NURSING EDUCATION

Simulation in Nursing Education: Bridging the Preparation Practice Gap

Jean A. O’Connor

State University of New York Polytechnic Institute

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Simulation in Nursing Education: Bridging the Preparation Gap

The paucity of graduate nurses ability to function at the professional level is

known as the preparation practice gap. This gap has been identified as a serious challenge

facing graduate nurses since 1974 (Marlene Kramer, 1974). Preparation-practice gaps are

seen as a failure of nursing curricula to adequately prepare their graduates to transition

from academia to the clinical environment (Hickerson et al., 2016; Institute of Medicine,

2011, Robert Wood Johnson Foundation, 2014).

Nursing education is content laden, but clinical experience, and observations

assist nursing students to improve clinical competencies needed to practice safely in the

clinical environment (Benner, Sutphen, Leonard, & Day, 2010). One initiative to assist

student competency and improve readiness to practice is the implementation, and

utilization of simulation in nursing education (Berkow et al., 2008; Wall, Andrus &

Morrison, 2014; Hope, Garsied, & Prescott, 2010; Powers et al., 2018; Rossler, 2019;

Forcina, Woodley, & Goodwin, 2018).

Simulation in Nursing Education

Simulation in nursing education is a pedagogical strategy that combines theory

with practice to provide a conceptual learning environment focused on critical thinking,

and clinical reasoning. Nursing simulation dates back as far as 1847 where it was noted in

The Handbook for Hospital Sisters requirements for “every nursing school to have a

mechanical dummy, models of legs and arms to learn bandaging, a jointed skeleton, a

black drawing board, and drawings, books, and models (Hayden, Smiley, Alexander,

Kardong-Edgren, & Jeffries, 2014). The first simulation mannequin was built in 1911,

named Mrs. Chase, and was used to train nurses in basic skills (Aebersold, 2018). Nurses
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were trained in learning environments known then as demonstration rooms, the skills

laboratory, or the nursing laboratory (Aebersold, 2018). By the early 1990s simulation

had dramatically evolved with the development of high fidelity simulators. Nursing

students today are provided with a high fidelity simulation experience in a state of the art

simulation lab that incorporates high fidelity mannequins as well as simulated patients

portrayed by qualified actors.

Simulation education in nursing is a learner-centered approach that engages

students in scenarios designed to meet learning objectives (Aebersold, 2018). Simulation

is grounded in learning theories based on constructivism (Aebersold, 2018). Kolb’s

experiential learning theory, in particular, relates to simulation education. Kolb states

“Learning is the process whereby knowledge is created through the transformation of

experience (Kolb, 1984, p. 38). This experience is formed on a learning cycle that

includes: concrete experience, reflective observation, abstract conceptualization, and

active experimentation. Kolb’s theory is defined by four distinct learning styles:

diverging, assimilating, converging, and accommodating (McLeod, 2017). It is in Kolb’s

theory that one can see the process of simulation evolve through the learners experience

followed by a reflective discussion during debrief. Abstract conceptualization occurs with

the facilitation of knowledge gleaned from the experience, and active experimentation

occurs when the learner is able to transfer that knowledge into practice (Aebersold,

2018).

Significance of Simulation in Nursing Education

Nursing education is experiencing a significant shift in the way curricula are

preparing future nursing students. Content laden curricula are being replaced by concept-
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based curricula that focus on moving from critical thinking, to clinical reasoning (Benner

et al., 2010). Simulation in nursing education is at the forefront of this shift, and is

imperative to fill the gap as available nursing faculty and available clinical sites decline

(Aebersold, 2018; Nehring & Lashley, 2009). Simulation in nursing education is seen as a

bridge that links theoretical learning with practical application, and provides a safe

environment for students to learn in (Wall, Andrus, & Morrison, 2014).

Relevance of Simulation in Nursing Education

Simulation in nursing education is relevant to meeting specific student learning

objectives. In the clinical environment, students may not have the chance for hands on

experiences due to a lack of opportunity, or restrictions in practice by the clinical site.

Clinical experiences can often be more observational than immersive. Simulation

facilitates the development of clinical skills in a safe and structured environment (Wall,

Andrus, & Morrison, 2014). Simulation integrates Bloom’s taxonomy of psychomotor,

and affective skills at the higher levels of taxonomy to ensure graduate readiness to

practice.

Simulation provides the opportunity to develop objectives that align with hospital

workforce expectations. For example, when one university’s graduates faced barriers

getting entry-level positions because they lacked ACLS certification required for hire at

their partner facility, the university revised their curriculum to provide ACLS training

through simulation. Senior nurses were eligible to sit for ACLS certification prior to

graduating, and hiring facilities were impressed with their qualifications (Powers et al.,

2019). Simulation is relevant to bridging the preparation practice gap when student-

learning outcomes are able to align with hospital workforce expectations.

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Literature Review

Research in the field of simulation in nursing education is steadily increasing as

the use of simulation is increasing. Nehring and Lashley (2009) published a 40-year

review of nursing simulation. From mannequins, to task trainers, role playing, games, and

CAI, to simulated patients, and high-fidelity mannequins, these tools have been part of

the evolutionary process of nursing simulation, guided by theoretical frameworks like

Patricia Benner’s novice to expert, Kolb’s experiential learning, Jeffries and Rogers

nursing education simulation framework, and Nehring and Lashley critical incident

nursing management (Nehring & Lashley, 2009). Simulation has a role in both nursing

education, and nursing practice, and the future of simulation in nursing has boundless

potential (Nehring & Lashley, 2009). Guimaraes dos Santos Almeida et al.’s (2018)

literature review also concluded that scientific evidence supports the use of simulation in

nursing education as they sought to determine how researchers had been using nursing

simulation as a teaching-learning strategy.

In order for teaching to be effective, simulation must be structured, and based on

objectives, fidelity, problem solving student support, and debriefing (Guimaraes dos

Santos Almeida et al., 2018). The use of simulation in nursing education is imperative as

nursing shortages increase, and available faculty decrease. Abersold (2018) highlights the

need to incorporate simulation, not merely as an add on, but integrated into the

curriculum. Due to the relatively new research published in the area of simulation, there

have been questions as to whether or not simulation can or should replace nursing

students clinical experience. This is a concern in particular because of the already

existing presence of the preparation gap. However in a landmark longitudinal,

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randomized, controlled study by Hayden et al. (2014), it was concluded that nursing

students could substitute up to 50% simulation in lieu of traditional clinical experience

without sacrificing NCLEX exam pass rates, clinical competency, or readiness to

practice. This research helps to affirm the use of simulation in nursing education as a

teaching pedagogy, but more importantly allows for changes to policy guided by boards

of nursing.

Understanding that clinical experiences may not provide students with the

necessary skills to practice due to lack of opportunities in the partnering facilities,

increasing simulation experiences will both increase nursing students exposure to

developing necessary competencies while preparing them to practice after graduation.

Preparing students readiness to practice can be achieved through the effective use of

simulation in nursing education (Hope, Garside, & Prescott, 2010; Powers et al., 2018;

Rossler, 2019; Robinson & Dearmon, 2013; Labrague, McEnroe-Petitte, Bowling,

Nwafor, & Tsaras, 2018; Forcina Hill, Woodley, & Goodwin, 2018).

Benefits of Simulation in Nursing Education

In 2003 the Institute of Medicine (IOM) put out a report titled Health Professions

Education: A Bridge to Quality, which emphasized the need to improve patient safety

through reforming health professional education. Ensuring nursing students are prepared

to transition into practice safely is just one area of focus in the IOM report (Greiner, &

Knebel, 2003). It is ultimately up to the institutions of higher learning to implement

teaching-learning strategies that provide students with opportunities to become competent

safe practitioners, that are not only able to critically think, but reason clinically. Evidence

has shown that simulation can be substituted for 50% of clinical time without changes to
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measureable outcomes such as NCLEX pass rates, clinical competence, and readiness to

practice (Hayeden, 2014). Providing students with increased simulation scenarios in

nursing education allows for learning opportunities in a safe, and controlled environment

(Labrague et al., 2019). All stakeholders including: nursing students, faculty, institutions,

patients, and the community, benefit from simulation when nurses training is safe,

competent, and at the highest level to practice.

Ultimately it is the nursing student, upon graduation, who has to face the

challenges during the transition from graduate nurse, to practicing nurse. It is during this

transition period that increased mistakes are often made. New nurses are responsible for

75% of medication errors, and 40% of patient falls (Hickerson, Taylor, & Terbaar, 2016).

Significant changes to the way nurses are educated and transitioned into practice should

be a priority in the academic community in order to reduce new graduate stress, reduce

medical errors that grossly affect patient safety, reduce overall costs to hospitals related to

turnover and poor patient outcomes, and improve new graduate readiness to practice

safely and effectively. Simulation provides the opportunity for nursing students to

improve their readiness to practice skills (Robinson & Dearmon, 2013).

Recommendations

It is recommended that simulation in nursing education should be integrated into

the nursing curriculum. Simulation frameworks should be grounded in learning theories

such as Patricia Benner’s theory describing the stages of novice to expert, or Kolb’s

theory of experiential learning, or Jeffries and Rogers’s theory of Nursing Education

Simulation Framework. Simulation ought to focus on both nursing education and nursing

practice (Nehring & Lashley, 2009). Nursing schools that have limited access to clinical
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sites, or insufficient adjunct faculty should consider increasing hours associated with

simulation learning to meet clinical objectives as evidence supports the safety and

effectiveness of increased simulation time compared to clinical hours (Hayden, et al.,

2014). Nurse educators should familiarize themselves with graduate readiness to practice

standards, and ensure that simulation, as a pedagogical strategy is an effective means to

improve the preparation-practice gap.

The Future of Nursing Education

Nursing education is a dynamic, fluid, ever evolving resource responsible for

producing graduate nurses that are safe, confident, and prepared practitioners. In order to

create a vision for the future of nursing, there must be a comprehensive understanding of

nursing’s past, and present. The state of nursing is at a crossroads. Nurses are faced with

an increasing shortage of nursing staff, nursing faculty, and clinical site availability

(Hayden et al., 2014; Nehring & Lashley, 2009). Nursing curricula have been heavily

burdened by content laden, didactic instruction in the classroom, supplemented by

traditional clinical experiences with partnering health care facilities. Past evidence

collected through the Nursing Executive Center surveyed nurse educators and senior

nurse administrators using the New Graduate Nurse Performance Survey which found

that nearly 90% of academic leaders believed their nursing students were fully prepared

to practice safely and effectively, compared to 10% of hospital nurse executives (Berkow,

Virkstis, Stewary, & Conway, 2008). This dichotomy is something nurse educators should

reflect on.

The 2010 Carnegie Foundation report “Educating Nurses: A Call for Radical

Transformation” Benner, Sutphen, Leonard, and Day (2010) called for improving the
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nursing education competencies by replacing abstract knowledge with concrete,

deliberate thought processes that allow for students to think contextually where patients

needs are concerned, integrate classroom education with clinical experience, and shift

from critical thinking to clinical reasoning (Hansen, 2014). The IOM called for a major

overhaul in education for health professions (Greiner, & Knebel, 2003). As past research

beckons changes to future education, nurse educators will undoubtedly feel the burden,

and responsibility to implement these changes through curricula reform. Integrating

simulation as a learning pedagogy into the curriculum is one way nurse educators can

improve student learning outcomes, provide high quality clinical related experiences, and

improve student confidence, safety, and clinical reasoning skills, in order to improve

nurse graduate readiness to practice.

Conclusion

The state of nursing education is facing challenges due to faculty shortages, limited

clinical site availability, or limited opportunity for students to practice within their

clinical sites due to restrictive hospital policies. As undergraduate nursing programs grow,

opportunities for clinical placement shrink (Hayden et al., 2014). Simulation in nursing

education is an effective pedagogical strategy that provides nursing students with quality

clinical like experiences in a safe, controlled environment. Evidence supports simulation

in nursing education as replacement of up to 50% of clinical site hours (Hayden, et al.,

2014). Simulation education prepares nursing students to transition from graduate nurse

to practicing nurse, and increases confidence, safety, and marketability when skills

obtained in simulation education align with hospital workforce expectations (Robinson &

Dearmon, 2013; Powers, et al., 2018).

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References

Aebersold, M. (2018). Simulatio-based learning: no longer a novelty in undergraduate

education. Online Journal of Issues in Nursing 23(2),

Benner P., Sutphen M., Leonard V., Day L. (2010). Educating nurses: A call for radical

transformation. Stanford, CA: The Carnegie Foundation for the Advancement of

Teaching.

Berkow, S., Conway, L., Stewart, J., & Virkstis, K. (2008). Assessing new graduate nurse

performance. The Journal of Nursing Administration 38(11), 468-474.

Forcina Hill, J.M., Woodley, L., & Goodwin, M. (2018). Simulation to prepare graduate

nursing students for clinical faculty role. Nursing Education Perspectives 39(5),

319-321.

Guimaraes dos Santos Almeida, R., Jorge, B.M., Souza-Junior, M.J., Mazzo, A., Martins,

J.C.A., Negri, E.C., Mendes, I.A.C. Trends in research on simulation in the

teaching of nursing an integrative review. Nursing Education Perspectives 39(3),

E7-E10.

Greiner, A.C., Knebel, E. (2003). Health professions education: a bridge to quality.

Committee on the Health Porfessions Education Summit Board of Health Care

Services Institute of Medicine. Retrieved from

https://www.nap.edu/read/10681/chapter/1

Hansen, J. (2014). Nurse Residency Programs: Why now? Journal for Nurses in

Professional Development 30(1), 47-48. Retrieved from

https://www.nursingcenter.com/journalarticle?

Article_ID=1655516&Journal_ID=54029&Issue_ID=1655091
THE EFFICACY OF SIMULATION IN NURSING EDUCATION
11
Hayden, J.K., Smiley, R.A., Alexander, M., Dardong-Edgren, S., & Jeffries, P.R. (2014).

The NCSBN national simulation study: a longitudinal, randomized, controlled

study replacing clinical hours with simulation in prelicensure nursing education.

Journal of Nursing Regulation 5(2), supplement, S1-S41. Retrieved from

https://www.ncsbn.org/JNR_Simulation_Supplement.pdf

Hickerson, K.A., Taylor, L.A., & Terhaar, M.F. (2016). The preparation-practice gap: an

integrative literature review. The Journal of Continuing Education in Nursing

47(1), 17-23.

Hope, A., Garside, J., Prescott, S. (2010). Rethinking theory and practice: pre-

registrations student nurses experiences of simulation teaching and learning in the

acquisition of clinical skills in preparation for practice. Nurse Education Today

31(2011), 711-715.

Institute of Medicine. (2011). The future of nursing leading change, advancing health.

Retrieved from https://www.nap.edu/read/12956/chapter/1

Kramer, M. (1974). Reality shock; why nurses leave nursing. Saint Louis: C.V. Mosby

Co.

Labrague, L.J., McEnroe-Petitte, D.M., Bowling, A.M., Nwafor, C.E., Tsaras, K. (2019).

High-fidelity simulation and nursing students’ anxiety and self-confidence: a

systematic review. Nursing Forum, 1-11. DOI: 10.1111/nuf.12337

McLeod, S. (2017). Kolb’s learning styles and experiential learning cycle. Retrieved from

https://www.simplypsychology.org/learning-kolb.html

Nehring, W.M., & Lashley, F.R. (2009). Nursing simulation: a review of the past 40

years. Simulation & Gaming 40(4), 528-552.

THE EFFICACY OF SIMULATION IN NURSING EDUCATION
12
Powers, S., Claus, N., Jones, A.R., Lovelace, M.R., Weaver, K., Watts, P. (2018).

Improving transition to practice: integration of advanced cardiac life support into

a baccalaureate-nursing program. Journal of Nursing Education 58(3), 182-184.

Robert Wood Johnson Foundation. (2014). Nearly one in five new nurses leaves first job

within a year, according to survey of newly-licensed registered nurses. Retrieved

from https://www.rwjf.org/en/library/articles-and-news/2014/09/nearly-one-in-

five-new-nurses-leave-first-job-within-a-year--acc.html

Robinson, B.K., Dearmon, V. (2013). Evidence-based nursing education effective use of

instructional design and simulated learning environments to enhance knowledge

transfer in undergraduate nursing students. Journal of Professional Nursing 29(4),

203-209.

Rossler, K.L. (2019). Peer-assisted learning with simulation for examination and

transition success. Journal of Continuing Education Nursing 50(3), 115-120.

Wall, P., Andrus, P.M., Morrison, P. (2014). Bridging the theory practice gap through

clinical simulations in a nursing undergraduate degree program in Australia.

International Journal of Learning, Teaching and Educational Research 8(1), 127-

135.