Reflecting back since 2009, what immediately comes to mind is how far simulation pedagogy and research have progressed. The use of clinical simulations has evolved and exploded, from very embryonic stages a few years ago to what is now a valuable experiential teachinglearning intervention, used as a mechanism for testing and for facilitating interprofessional education and practice.
What began with sometimes grudging acceptance has progressed to the development of high quality simulations, the publication of robust research, and evidence of best practices, innovations, and futuristic ideas on the use of clinical simulation in education and practice. These concepts and more are discussed in two special issues of Nursing Education Perspectives - the one you are reading now (Vol. 36, No. 5) and the November/December issue (Vol. 36, No. 6). The evolution of clinical simulations in just over half a decade has been phenomenal, not only in nursing, but in all our health care professions.
The Past
A review of the 2009 special simulation issue tells us that contributions to the knowledge base at that time were primarily small studies with a focus on outcome measures such as student satisfaction and self-confidence. In addition, we were still learning how to develop and implement simulations in our nursing curricula. We questioned the educational value of simulations, whether we could substitute clinical simulation time for "real" clinical time, and whether or not simulation provided a sufficient return on the investment. There were only a few simulation champions here and there, with little integration of simulation within the nursing curriculum.
Much has been accomplished over the intervening six years. In August 2014, the National Council of State Boards of Nursing (NCSBN) revealed the results if its sentinel, national, multisite simulation study, the most rigorous educational study ever done in the history of nursing education. The results and implications of the study were revealed first to state boards of nursing and then disseminated regionally, nationally, and globally through various media.
The Present
With the publication of the NCSBN study, the global nursing community now has evidence that clinical simulations can be substituted for real clinical time up to 50 percent in pre-licensure nursing programs, with students getting their clinical education effectively and passing the NCLEX-RN(R) licensure exam with appropriate resources and faculty support. These findings are powerful and impactful. No longer do we need to ask, Do simulations work? We know that they do.
These two special issues of Nursing Education Perspectives document the current state of the science in clinical simulation. The evolution in only six years has been astronomical compared to other educational and clinical education changes we have experienced (or not) over decades of nursing education.
The article by Adamson on the state of the science of clinical simulation in this issue is a major contribution. It provides a systematic review of the NLN/Jeffries Simulation Framework, created more than a decade ago and used frequently by nurse scholars, researchers, and doctoral students in nursing as well as other health professions. Based on Adamson's review and the contributions of other nurse researchers, members of the International Nurses Association of Clinical Simulation Learning (INACSL) and the National League for Nursing (NLN), and with the guidance of Dr. Beth Rodgers, an expert on theory development, the NLN Jeffries Simulation Model has now been declared a midrange nursing theory.
Utilizing the systematic review while building on the attributes needed to declare a new theory, you will see how the original NLN Jeffries Simulation Framework evolved to become the simulation theory we are introducing today. Along with these two special issues of Nursing Education Perspectives, the NLN has published a monograph, The NLN Jeffries Simulation Theory, which details the evolution of simulation in nursing education and research and discusses implications and the NLN's strategic vision for clinical simulation in the future. In this issue, Sittner and colleagues outline the historical evaluation of INACSL's standards for best practices in the design, conduct, and evaluation of simulation activities.
Evaluation strategies, metrics, and validity/reliability of instruments measuring various outcomes of clinical simulations have also changed over the past six years. There is more work to do as we move simulation research forward in a rigorous, dynamic manner. In their article, Reising and colleagues focus on the psychometric testing of a rubric for measuring interprofessional communication. Leighton and colleagues focus on the psychometrics of the simulation effectiveness tool they created and are using in the simulation community. In their research, Forneris and colleagues seek to replicate the findings of enhanced clinical reasoning scores using a method of structured reflective debriefing developed by Dreifuerst, who authored a concept analysis on debriefing for the 2009 special issue.
Over the years, I have had the opportunity to experience and participate in growth areas focused on clinical simulation. In their featured article, Dr. Mary Anne Rizzolo and a team of simulation experts detail how they explored the feasibility of using high-fidelity simulations, delivered in the controlled environment of a simulation center, for high-stakes assessment of prelicensure students. Their findings and recommendations regarding the need for faculty to engage in deliberative conversations about expected behaviors of students are important if we wish to improve the reliability and validity of all student assessments.
Other advanced concepts in simulation that were not mentioned only a few years ago, but have escalated to the top, include the effectiveness of expert modeling intervention for novice nurses and the development of theory-based simulation educator resources. In the past few years, clinical simulations have been integrated across the entire nursing curriculum, with the result that the Research Briefs and Innovation Center articles in this issue focus on simulations for specialty nursing areas, including psychiatric mental health and chronic care management. An article on using Google Glass to improve medication safety behaviors in undergraduate nursing students directs us toward important areas that were not even on the radar six years ago.
These findings are powerful and impactful. No longer do we need to ask, Do simulations work? We know that they do.
The Future
It is hard to believe how far we have come in clinical education in the years since our last simulation special issue. Never before in nursing education have we seen an educational pedagogy evolve so quickly, from being defined and rigorously studied to exploding into the world of global health care.
As nurse educators/researchers/practitioners today, we live amidst numerous opportunities in the evolution of clinical education. We can envision the transformation of nursing education and the creation of safe, quality care environments as our new graduates make their transition to practice. Enjoy the journey - we have indeed come a long way, with research and innovation taking us all to a whole new level, and there is much more to do. I hope this issue of Nursing Education Perspectives will inspire you to conduct research, integrate simulations into nursing programs and residencies, and disseminate your research, scholarship, and innovations as we continue to contribute to nursing science, knowledge, and best practices in clinical simulation.