PART OF BECOMING a working professional always involves applying knowledge and practicing skills in carefully controlled and monitored settings to get constructive feedback. For many years, nurses have practiced taking BP readings on each other, learned to provide certain kinds of physical care on manikins, and rehearsed giving injections with oranges. With advances in technology, learning labs in nursing schools now include standardized patients (actors), various kinds of lifelike anatomical models, and full-scale simulators (manikins that manifest signs and respond to treatment decisions and other actions). The use of simulation in nursing education is now a common element in the preparation for practice. We review what you should know about simulation and how it's shaping the education of nursing students and graduate nurses.

Safe realism

In its most general sense, simulation is the replication of real-world scenarios, allowing trainees to perform skills and learn actively. One common way of talking about simulation relates to fidelity, or how closely a simulation experience reflects or mimics reality. Today, many options are available for simulation equipment, from low-fidelity anatomical models used by students to practice injections and other skills, to high-fidelity manikins that reproduce physiologic functions and are programmed to respond to interventions in real time. Audio-video recording devices enable learners to review their performance, and medical supplies and equipment enhance the realism and authenticity of simulation. Virtual reality applications offer new possibilities for developing immersive clinical experiences; many software packages that run on various platforms are available.

Simulation presents opportunities to reproduce both rare and frequent clinical events in a realistic manner as often as needed. Nurses can hone their abilities and skills-and commit every possible error-without harming real patients. Simulation has long been utilized to train nurses and other providers in CPR; it's now used in most nursing specialties for various other purposes, including physical assessment, communication, and collaboration.

Many clinicians, educators, and leaders believe simulation promotes patient safety and raises the quality of patient care when used for both the basic education of nurses and continuing education.1 Not surprisingly, given the challenges many nursing programs experience with finding clinical placements, some have begun thinking of simulation as a lifesaver.2 A few years ago, research appeared suggesting that up to 50% of clinical hours in a prelicensure RN program may be replaced by simulated experiences without negative impacts on learning outcomes.3

Clearly, students can build clinical skills and knowledge in settings other than live clinical placements. However, many factors must be kept in mind when deciding how to make the best use of simulation.

Finding the best approach

Simulation isn't always cheaper than traditional clinical placements. Considerable faculty time is needed to develop a simulation. Although students don't necessarily require the same intensity of faculty-student contact required for placements in practice settings, it can turn out to be the same. If equipment and technology are used, expenses build quickly. The costs of setting up a simulation environment can swiftly reach hundreds of thousands of dollars.

Sparse data are available about what types of simulation equipment support student learning at the most reasonable costs, and studies have sometimes reached contradictory conclusions about methods and approaches. To date, no compelling evidence shows that investing in the highest-end simulation equipment produces better learning outcomes. In fact, some evidence favors cheaper solutions.4 Similarly, video recording hasn't been shown to produce noticeably better learning.5,6 Although future studies may produce different results, schools and programs need to choose equipment based on their student learning goals and not assume that greater expenditures will pay off.

Above all, simulation is just one of many educational tools. As such, it's important to consider what kind of learning it's expected to produce. Research has shown that students often view simulation favorably and that they feel it improves their self-confidence, knowledge, and skills.7,8 However, simulation is both a learning and an evaluation tool. Not surprisingly, anecdotal evidence suggests students prefer simulations that are low-risk learning opportunities to those that are high-stakes tests. Participating in a simulation where there are no penalties for making mistakes is quite different than having clinical skills evaluated in a simulation. Even when simulations are designed for skills development rather than testing, students may experience performance anxiety and feel like they need to achieve near-perfect execution. So, any simulation environment can be stressful or intimidating, especially when the educator's purpose and expectations aren't clear from the outset. It's crucial that students become familiar with the simulation environment and have opportunities to practice skills under conditions similar to the ones they'll face in their evaluations.

Nonetheless, despite tremendous enthusiasm from students and many faculty members and community leaders, much is still unknown about how learning carries over from simulation to clinical practice. It's also unclear how much simulation is needed to produce learning outcomes and high-level performance in real practice, and how long learning through simulation persists.

Many questions about the best way to use simulation are still being addressed. Experts agree that it's essential to provide learners with a safe, trustworthy, and supportive learning environment in which they feel at ease to engage fully.9 Simulation must start with a clear definition of learning goals and be designed to help students to meet them.

It's notable that whereas much effort must be placed on the simulation's content, providing students with feedback after a stimulation event and giving them time to review and reflect on their performance (also known as debriefing) require as much, if not more, attention. Research suggests that debriefing is essential to simulation-based learning and should be closely tied to the expected outcomes of a particular simulation.10

If you're a manager interested in simulation as a tool for staff development, identifying clear learning goals, creating a safe learning space, and ensuring carefully planned debriefing apply equally to simulations used for orientation, competency assessment, and continuing education. Other tools and strategies, such as problem-based learning, case studies, and concept mapping, may be more appropriate for some purposes.

Taking its rightful place

Simulation can be extremely engaging and "wow" many in the community; however, everyone involved, including the clinical agencies receiving students in the placement phase of their education and at graduation, needs to understand how resource-intensive it can be. In the end, simulation is but one approach to nursing education-its wider use is neither a panacea nor a disaster in the making. Simulation will continue to be discussed as it finds its rightful place in educating students and experienced clinicians alike about essential nursing skills.

Bonus content

Head to http://www.nursing2017.com for more on the use of simulation in nursing education.

Preparing nurses to respond to in-house emergencies as a teamhttp://journals.lww.com/nursing/Fulltext/2016/10000/Preparing_nurses_to_respond_

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