Various teaching methods have been used in nursing education to develop those individuals who aspire toward leadership positions. Although the use of simulation has been seamlessly added into the curricula of undergraduate and clinically based graduate nursing programs, the ongoing use of simulated learning experiences for those who aspire toward the nursing leadership role has been less seamless (Sharpnack, Goliat, & Rogers, 2013; Waxman & Delucas, 2014). Identified by the National League for Nursing (NLN, 2015) to provide students with a low-risk, transformational clinical learning experience, simulation as a teaching methodology has become a critical component of nursing education.

Nursing leadership and administration is a specialty area within the nursing profession for which the needed skills, competencies, and developmental trainings have been historically overlooked. In the past, leadership roles were quickly filled by clinicians with astute psychomotor and critical thinking skills (Waxman & Delucas, 2014), without recognizing whether or not the individual had the qualities needed to successfully perform the role. Thus, the acquisition of leadership skills and experiences commonly occurred after one was already employed or by having solicited discussions for advice with mentors that may or may not be located on site. Sharpnack et al. (2013) described teaching leadership skills via case studies or similar pedagogies but did not address the complex clinical environment in which the skills would ultimately be implemented.

With an estimated 75 percent of the current nursing leadership planning to leave the workforce by 2020 (Hader, Saver, & Steltzer, 2006), succession planning and the acquisition of future nurse leaders with previously developed leadership skills has become more crucial. Individuals currently holding these roles must commit time and energy to the identification and proper vetting of future nurse leaders (Bulmer, 2013). With 88 million members, the millennial generation is expected to be the largest workforce group for the next two decades (Christmas, 2008) and will be best positioned to acquire the tasks of nursing leadership. With the future of nursing leadership in these hands, the education of tomorrow's leaders must include learning opportunities that address the areas of coaching, mentoring, evaluation, providing difficult feedback, teambuilding, patient and staff safety, quality outcomes, and effective financial and human resource management (Holtschneider, 2015; Sharpnack et al., 2013; Waxman & Delucas, 2014).

ROOT CAUSE ANALYSIS

Simulation was used in a master's-level nurse administration course to address content objectives and introduce the concept of root cause analysis (RCA). The simulated learning experience allowed graduate nurse administration students (GNAS) to acquire hands-on exposure to clinical situations that could potentially lead to a sentinel event. The GNAS were expected to walk through each step of the RCA and identify organizational issues or processes that needed to be addressed. This assignment introduced the concept and procedures needed to conduct an RCA while using simulation to foster the development of leadership competencies. Proficiency in organizational skills, prioritization, and better communication, which encompass skills of seeing, hearing, listening, and analyzing, were evident throughout the simulation encounter.

Overall, the experience required students to drill down to the five "whys" of an RCA, from beginning to end. The GNAS consulted with one another to review and ask why or what led to poor patient outcomes at a minimum of five intervals throughout the treatment plan. Although this experience exposed GNAS to leadership concepts and processes needed to execute a successful RCA, the methods of observing and providing undergraduate generic nursing students (UGNS) with a form of clinical coaching, mentoring, and evaluative feedback were also beneficial. The outcome of the experience provided UGNS with the expertise of nurses in practice while providing GNAS with opportunities to develop and implement communication skills needed for future nurse leadership positions.

EVALUATION AND DEBRIEFING

The scarcity of simulation champions led to the implementation of this innovative collaboration interaction. GNAS attended a simulation experience in which undergraduates executed an obstetrics scenario that would ultimately involve a laboring woman enduring an umbilical cord prolapse. UGNS were expected to recognize the medical emergency and take appropriate steps needed to avoid negative outcomes. The GNAS were given the option to observe UGNS behaviors, competencies, and decision-making skills or to interact within the scenario as nursing supervisors. Initially, the nurse administration students chose to observe and make notations in areas of mastery and deficiency and eventually joined the simulated experience as the nursing supervisor(s) on duty when UGNS called for help.

Immediately after completing the obstetrics scenario, all students and nursing faculty participated in a roundtable debriefing discussion focused on the student's initial thoughts and feelings. After hearing introductory feedback provided by undergraduate and graduate faculty, GNAS shared evaluative critiques of the skills and actions observed during simulation. They added to faculty critiques by providing undergraduates with positive and negative feedback different from that introduced by faculty. Debriefing sessions for UGNS and GNAS were held separately to ensure that course objectives were met. In the UGNS debriefing, faculty concentrated on merging didactic information and theory behind the application of the skills performed by students. The GNAS debriefing focused on feedback regarding the prioritization of clinical issues observed and the evaluative critiques given to UGNS. At the conclusion of this phase, GNAS were expected to use information acquired during the simulation to move through the RCA process and develop a presentation to be delivered during a future class meeting.

A postsimulation evaluation indicated that graduate and undergraduate students viewed the simulation training as a positive learning experience. Using simulation across nursing programs provided UGNS with the benefit of faculty guidance as well as feedback and advice from RNs currently practicing in various clinical roles. Graduate students were supported by faculty and UGNS in learning the RCA concept; they received the benefit of being able to critique the skills and behaviors of undergraduates while also being exposed to content needed to devise a presentation that incorporated steps to complete an RCA. The simulation provided a realistic clinical environment that afforded opportunities to demonstrate the use of effective communication skills in providing individual feedback and evaluation. Students and faculty alike verbalized an interest in future collaborative simulation activities.

DISCUSSION

According to Waxman and Delucas (2014), observations and simulation should be incorporated into courses whose outcome objectives lead to the development of nurse leaders. An element of team teaching and the use of simulation across programs speak to the faculty's innovative use of resources. Objectives for both nursing programs were met with creativity, learning, and collegiality among colleagues, students, and professional peers. UGNS received clinical insight, practice, and motivation, whereas GNAS demonstrated various leadership competencies and participated in the hands-on experience of formulating a realistic scenario and clinical case. Per the NLN (2015), collaborative practice learning environments work together in providing quality patient care that remains safe and competent. This intraprofessional learning opportunity cultivated a rich learning environment instrumental in presenting several concepts that included the introduction of clinical and leadership skills and competencies, critical thinking, coaching, mentoring, and communication. Feedback from faculty and students revealed a learning experience permeated with opportunities needed for leadership development.

It is imperative that proper vetting be applied to the development of future nurse leaders (Bulmer, 2013). Investing in the future of those with leadership aspirations will help ensure viability of the nursing profession. Essential leadership skills, competencies, and developmental training must be included in nursing programs whose purpose is to produce the future nursing workforce. Although simulation has been effectively used to deliver the basic theoretical competencies and psychomotor skills in several other areas of nursing, the same strategy should be utilized more effectively when introducing concepts essential for those aspiring to fill positions of leadership.

This multilevel simulation with peer-to-peer interaction and feedback differentiates this teaching strategy from other like methods. Although the use of simulation in this encounter failed to address the prioritization in the management of complex patient assignments, the training served to enhance collaboration, communication, and competency among students at a college of nursing. The overall outcome enhances the understanding of delineated roles and scopes of practice among students, colleagues, and peers.

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