Several years have passed since the National Council of State Boards of Nursing (NCSBN) approved simulation as a replacement for up to 50 percent of clinical time when simulation guidelines are met by schools of nursing (Alexander et al., 2015). For simulation to be effective, schools must meet NCSBN guidelines, but unfortunately, many nurse educators still lack foundational simulation knowledge (Fey & Jenkins, 2015). Simulation, in place of traditional clinical, allows schools of nursing to compensate for the loss in clinical sites, allows more nursing graduates to meet the demands of the predicted nursing shortage, and improves students' clinical judgment skills. Competing clinical sites, increased acuity of patients, and questions related to clinical effectiveness are reasons why regulations are needed (Hayden et al., 2014). However, many institutions of higher learning are still trying to develop regulations sanctioning simulation as a clinical support activity.
Recent literature on faculty development supports statewide simulation efforts to prepare faculty members (Beroz et al., 2020; Lemoine et al., 2015). However, there is limited support to assess the current state of faculty readiness for simulation or how a state might identify faculty simulation needs. The Maryland Clinical Simulation Resource Consortium created a statewide simulation curriculum to train the trainer across three levels: novice, competent, and expert (Beroz et al., 2020). The Simulation Medical Training and Education Council of Louisiana created a similar initiative (Lemoine et al., 2015). The Mississippi Academy for Simulation Training (MAST), sponsored by the Hearin Foundation in 2017, trained faculty to meet the NCSBN simulation guidelines.
This article reports the findings from a statewide simulation assessment study and describes one innovative program (MAST) to increase the number of simulation educators in prelicensure nursing programs. The research questions guiding this study were as follows: 1) What are the four greatest barriers and four greatest benefits to the use of simulation? 2) What percentage of simulation is being substituted for hospital-based clinical experience? 3) What infrastructures are in place to sustain the use of simulation? 4) What simulation inventory exists to support simulation? 5) What NCSBN simulation guidelines were being met in Phase 1 and Phase 2 of curriculum integration (Jeffries, 2012)? 6) What International Nursing Association for Clinical Simulation and Learning (INACSL) standards of best practice are least frequently utilized in simulation? 7) What are the areas for faculty development?
METHOD
This study used a descriptive mixed-method design and was deemed exempt by the institutional review board. To identify faculty participants for the study, the deans at 23 schools of nursing were contacted by email to request permission to assess their simulation program. The dean identified the faculty person with the most simulation knowledge and provided contact information. An email was sent providing details on the study, including the purpose, survey questions, and time required to complete the survey. Participants who elected to participate emailed the researcher, and a day/time was negotiated for the researcher to conduct a face-to-face or telephone interview.
The Program Assessment Survey for Simulation (PASS) was used to assess the current state of simulation education (Beroz, 2017). The PASS tool is an 86-item questionnaire developed from the NCSBN Simulation Guidelines for Prelicensure Nursing Programs (Alexander et al., 2015) and the INACSL standards of best practice (INACSL Standards Committee, 2016). Data were screened using exploratory data analysis methods to identify anomalies. Descriptive analyses were used to examine the data; categorical factors were described using frequencies and percentages. Participant responses to the open-ended questions were read, and traditional thematic analysis techniques were applied individually by the author and then by a second individual. The themes were reviewed by both, and consensus was achieved.
RESULTS
Twenty-two schools of nursing participated in the assessment: 14 community colleges and 8 universities. The schools enrolled a total of 4,671 nursing students (M = 212, ranging from 26 to 478) and reported a total of 511 full-time faculty (ranging from 6 to 58). The top four barriers to implementing simulation identified in the statewide assessment were time (32 percent), faculty buy-in (23 percent), space (23 percent), and money (18 percent). The top three benefits to implementation were as follows: replaces clinical hours with simulation hours (41 percent), provides a safe learning environment (36 percent), and increases student critical thinking (23 percent).
Eighteen percent of schools replaced 0 to 5 percent of hospital clinical hours with simulation, 36 percent replaced 6 to 10 percent, 32 percent of schools replaced 11 to 15 percent, and 14 percent replaced 16 to 25 percent of hospital clinical hours with simulation. Schools reported not having appropriate facilities (45 percent), supplies (41 percent), and faculty (73 percent) to conduct simulation. Many did not have a strategy to orient simulation faculty to their roles (82 percent). Twenty-three percent of schools had zero to one high-fidelity manikin; 32 percent had two to three manikins; 14 percent had three to four manikins; and 32 percent had five or more manikins.
Basic frequencies were used to analyze the quantitative data based on the NCSBN guidelines and the first two steps of curriculum integration of clinical simulation (Jeffries, 2012). The schools reported not meeting the following NCSBN guidelines: based on educational theory, 54 percent; conducts a needs assessment, 54 percent; has a simulation committee, 68 percent; has a policy/procedure manual, 77 percent; and has a new faculty simulation orientation, 82 percent. Using a 3-point Likert scale (A = always, B = sometimes, C = never), the participants considered if the INACSL standards of best practice were being met at their school (see Figure 1).
Respondents were asked on how the program provides faculty with simulation-related professional development. Forty-five percent reported faculty receive simulation training through conferences, 23 percent receive simulation training through workshops, 14 percent receive simulation training through formal in-house course offerings; 5 percent receive simulation training through vendors; and 9 percent do not receive any training. Seventy-seven percent reported needing foundational simulation knowledge and curriculum assistance, 73 percent needed beginning debriefing training; 86 percent needed training in simulation evaluations; 50 percent were interested in learning about simulation research; 86 percent reported the program needed more simulation interprofessional education knowledge; and 82 percent needed to learn more about standardized patients.
DISCUSSION
The PASS identified insufficiencies in prelicensure nursing simulation practices that mimic findings reported by Beroz et al. (2020). However, it is hard to compare these results on a national or international level because of lack of other statewide simulation assessments. The benefits of expanding nursing simulation education have been evident for some time, and schools have known for years that addressing faculty needs early in a systematized manner helps safeguard the success of the simulation center (Schaefer, 2004). As seen in this survey, funding at most institutions is limited for faculty development and simulation infrastructures, making it difficult to implement simulation activities.
The NCSBN survey created simulation guidelines in 2015, but faculty workloads have not been described, specifically related to simulation-based learning (Blodgett et al., 2018). Results from the study reveal faculty do not have adequate time or a designated percentage of their workload to develop and implement simulation activities. Although recent data clearly show learners complete more activities in less time and spend more time implementing higher critical reasoning during simulation (Sullivan et al., 2019), faculty time has not been designated to support simulation efforts. One possible reason is that many state nursing regulatory bodies have not yet applied emerging evidence and set specific standards in replacing clinical hours with simulation. This may also explain why only 14 percent of schools in the study replaced hospital-based clinical hours with simulation.
Schools do not have funding to have the adequate infrastructure that simulation requires. As evidence, over half of the schools surveyed in this study had fewer than three high-fidelity manikins. To sustain and grow a simulation program, a formalized planning process is necessary, with clear policies developed by a core group and approved by all stakeholders. This responsibility falls on a simulation committee that is instrumental in assisting in the adoption of an educational theory and the integration of simulation throughout the curriculum. Almost 70 percent of schools of nursing in this study did not have a simulation committee, and more than half had not been successful in these areas. It is apparent across this state's schools of nursing that many of the INACSL standards of best practice need to be further established, especially in utilizing terminology, design, debriefing, evaluation, and interprofessional education.
Based on the PASS results, only 14 percent of schools surveyed had formal simulation training for faculty. Because this state had mostly rural colleges and faculty with limited availability to attend in-person classes, the MAST director designed a free, online train-the-trainer simulation course to meet the state's simulation needs. This course consists of seven simulation modules: theory, design, facilitation, debriefing, interprofessional education, standardized patients, and evaluation. To accommodate all the programs, MAST allows one faculty member from every school to participate in the MAST simulation fundamentals course. To establish buy-in, faculty receive up to 25.5 continuing educational hours.
According to pre- and post- self-assessment surveys of MAST participants, the courses have been effective in increasing the use of simulation into the participants' curricula. After participation, 82 percent of participants planned to increase simulation in their curricula, in contrast to 8 percent prior to the course.
This study highlights how the barriers of utilizing simulation can inhibit schools of nursing in meeting simulation standards. To date, MAST has facilitated six cohorts of 123 nursing faculty members. Participant feedback supports a growth in understanding of simulation. Past participants plan to conduct needs assessments, pilot test simulations, and utilize simulation more overall. Furthermore, many course participants plan to lead their schools in creating new policies and procedures. Prior to the formation of MAST, the state had four Certified Healthcare Simulation Educators, and now there are a total of 11 faculty who have attained this designation. In addition, there was only one accredited simulation center in the state, and now there are three.
CONCLUSION
Simulation has quickly advanced as a successful teaching-learning strategy in nursing education and can replace up to 50 percent of hospital-based clinical hours with simulation (Hayden et al., 2014). Apprehensions have surfaced as prelicensure nursing programs substitute hospital-based clinical hours with simulation without adequate faculty development, business plans, or administration support (Alexander et al., 2015), and many states have not been successful in identifying the needs of faculty to address these issues. This article provides states with a model to assess and address simulation needs.
REFERENCES