Enriching Clinical Nursing Education through Simulation


By: Peter Miskin

clinical simulation

Practical clinical experiences are the central feature of nursing education.  They are an essential part of students’ professional growth and development, and a unique forum for educators to evaluate students’ ability to deliver safe care in accordance with the professional and quality standards. This is also the most sensitive portion of nursing education because it takes place in environments where the actual care is delivered.  As such, it requires balancing the needs of nursing education, with the needs of clinical agencies and health care consumers. 

However, significant changes in the delivery of healthcare services over the last two decades have made the provision of the practical portion of nursing education increasingly difficult. Nursing schools have been struggling with the shortage of adequate clinical sites for clinical practicums.  Consequently, even though there is a general consensus that professional nursing education should maintain a strong practice focus, nursing programs have been forced to reduce the number of clinical hours. One of the most frequently mentioned solutions to this problem in literature is a greater use of clinical simulation (Bakken, John, & Currie, 2008; Hermann, 2006; Rothgeb, 2008; Zurmehly & Leadingham, 2008).

The purpose of clinical simulation is to provide students with a practical learning experience focused on clinical skills and critical thinking abilities in a safe and secure environment. According to Hovancsek (2007, p. 3.), the goal of simulation is to ‘replicate some or nearly all of the essential aspects of a clinical situation so that the situation may be more readily understood and managed when it occurs for real in clinical practice’.  As such, clinical simulation can be an effective complement to practical clinical experiences, particularly when the clinical placements are inadequate or when they are not available.

Multiple studies have confirmed the effectiveness of this approach in nursing education. Cant and Cooper (2010) conducted a systematic review of the studies that explored the outcomes and effectiveness of clinical simulation in nursing programs. The review evaluated 12 studies, all of which compared the outcomes of traditional teaching methods with the outcomes of simulation based educational activities.  Based on the findings of the reviewed studies, the authors concluded that simulation is an effective teaching and learning method, particularly when the best practice guidelines are followed. Moreover, all the reviewed studies agree that simulation may have significant advantages over other teaching methods, depending on the context and subject matter. Possibly the most significant finding of the review is that simulation has a capacity to enhance the students’ abilities to develop, synthesize and apply their knowledge in a replica of real experience. This proves that this approach to teaching has a great potential to enhance the overall quality of nursing education, particularly when it comes to the issues of safety and quality of care in the practical portion of nursing education.

clinical simulation

Health care employers are continuously raising the bar when it comes to the competency requirements and expectation from the new graduates of nursing schools. Nowadays, healthcare industry expects nursing graduates to have the capability to think critically and to make sound decisions in a clinical setting from day one (National League of Nursing, [NLN], 2002).  Both clinical agencies and health care consumers expect them to be able to deliver safe and competent care to acutely ill patients in a variety of settings. However, research studies indicate that new graduates are not confident in their ability to meet the performance expectations they face in the workplace (Gerrish, 2000; Kilstoff & Rochester, 2004). According to Bowles and Candela (2005), up to 50% of new graduates may leave their first job within one year of employment due to patient care issues. A study by Sinclair and Ferguson (2009) evaluated the impact of the integration of clinical simulations into nursing courses on students’ perceptions of self-efficacy using Bandura’s theory of self-efficacy. The findings of the study suggest that the use of simulation as a method of teaching can improve the students’ sense of confidence when it comes to their ability to provide nursing care in real clinical situations and settings. In addition, the study participants reported higher levels of satisfaction, effectiveness and consistency with their learning style when exposed to the combination of lecture and simulation than their counterpart who were not exposed to clinical simulation. 

A systemic review conducted by Leigh (2008) supports these findings.  According to this review, learners and educators in the reviewed studies almost unanimously reported that that they felt that simulation significantly improved their clinical performance. Unfortunately, none of these studies explored if the learners’ perception of self-efficacy was in any way dependent on the extent and type of technology used in simulation.

A review by Goodman and Lamers (2010) may answer that question. These authors compared the findings of the studies that evaluated the outcomes of medium fidelity simulation with the findings of the studies that looked into the outcomes of high fidelity simulation. Although the focus of the review was on the methodological challenges of such comparisons, the authors developed a strong case for a high fidelity approach, clearly indicating that the skillful use of advanced technologies can improve the outcomes of clinical simulation. 

clinical simulation

Nursing literature strongly supports the use of simulation in nursing education, especially when it comes to the provision of practical experiences.  It is important to note that none of the authors imply that simulation should fully replace the experience of direct patient care. Rather, the general suggestion is that it should be used to provide students and educators with a medium to explore the practical application of nursing arts and sciences in a variety of situations that would normally be out of their reach.  As such, simulation is a valid and exceptionally effective method to facilitate practical experiences in nursing education.

About the Author: Peter Miskin, MSN, RN, CCRN is an assistant professor at Samuel Merritt University, San Mateo, CA. He is also a regular guest speaker at Kaiser Permanente where he teaches critical care courses. His scholarly interests include geriatrics, critical care, global health and sociology of health.


Miskin, P, Enriching Clinical Nursing Education through Simulation, Nurse Together.  

      Retrieved from http://www.nursetogether.com/Education/Education-


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