Factors Influencing the Use of Simulation in Nursing Programs

By: Gail Auten, Jane Gannon, and Tammy Schwaab

The International Nursing Association for Clinical Simulation and Learning (INACSL) published eight standards to guide educators to appropriately integrate simulation into curricula (INACSL, 2016). The “Simulation Design” standard addresses steps needed to optimize the achievement of expected outcomes associated with simulation integration. However, a specific decision-making process to identify when simulation would be a better strategy than others is lacking. This gap formed the basis of our NLN Simulation Leader group project: to identify the decision-making process used for selecting simulation over other strategies. Our focus was the decision-making process involved in curricular integration of simulation. Our methodology consisted of one-on-one, semi-structured interviews with experienced simulation educators in three separate states.

Criteria I of the INACSL Simulation Design Standard describes a needs assessment process to determine evidence for a simulation scenario topic. It does not describe how to decide when to use simulation over other teaching/learning strategies. To begin our project, we  conducted a literature review on simulation integration using the Science Direct, CINAHL, and ProQuest databases. Our search used the following terms: simulation integration, simulation integration process, simulation nursing curriculum, simulation process, simulation decision-making, and simulation need determination.

Most of the studies we found focused on how to adopt simulation into curricula as opposed to identifying a decision-making process, but a study by Lee and associates (2018) found the need for more attention to the decision-making process. Some authors described specific needs assessment questions to guide simulation selection (Bultas, 2011; Cook, 2015), while others focused on matching learning objectives to the simulation activity (Hodge et al, 2008; Khamis et al, 2016). Many described a process, but these were inconsistent. The most common themes included the need to secure resources, train faculty, find a “fit” between objectives and simulations, and integrate the simulation(s) into the curriculum (Bultas, 2011; Conrad et al., 2011; Cook, 2015; Hodge et al, 2008; Howard, 2011; Irwin, 2011; Kleinheksel & Ritzhaupt, 2017; Taplay et al., 2015; Wolfgram & Quinn, 2012). There was no consistent, evidence-based decision-making process identified in the nursing literature.

In the medical literature, Kern’s model, a six-step approach to curriculum development, identified a needs assessment as a first step in the process (Khamis et al., 2016). Part of that process is to identify the educational goal, develop objectives, and then select the educational strategy. But the chasm between those last two steps –– identifying congruence between learning objectives and method of instruction  –– is where guidance is needed.

Following IRB approval, we conducted and recorded 30- to 45-minute semi-structured interviews of simulation educators within Florida, North Carolina, and Maryland to explore the question. Study aims were to assess the design limitations of the structured interview tool (see appendix), assess the utility of the interview process, and determine if themes emerged from the data that would aid decision-making around simulation use. We utilized a qualitative approach, expecting themes to arise from the transcribed data as opposed to starting off with a set of themes a priori. Analysis goals included a search for commonalities (themes), contrasts or opportunities for comparisons, and reduction of data as necessary through coding of those themes.

The structured interview questions were able to be answered within the anticipated time frame. Clarification was needed for all items, with interviewees asking an average of eight questions. From a utility perspective, data were sufficient for thematic analysis despite having fewer qualifying respondents than anticipated: 7 versus 12.

We identified predominant themes from responses to each of the six questions we asked. For instance, when asked to describe the decision-making process they used, the interviewees brought up themes of objective assessment, faculty interest, and retrospective assessment. For the question about seeking a rationale for simulation use in the classroom, facilitation and control arose as major themes (e.g., facilitation of critical thinking, retention and application, and control of content). When asked how the simulation leader assisted faculty members to use simulation, vague processes such as thoughtful, natural, faculty-directed, and mentored were described.

We concluded that no definitive process exists for determining why simulation is selected over other strategies. This may be due to the variety of educational approaches used in nursing curricula, or to the limited number of interviews conducted. However, this exploration did reveal themes that will provide a starting point to pursue the design of a quantitative survey and reach a wider audience of simulation experts. We anticipate that a quantitative survey will facilitate information gathering to help generate structured guidance on when to select simulation over other teaching strategies as a component of the larger simulation integration process


Buitas, M.W. (2011). Enhancing the pediatric undergraduate nursing curriculum through simulation. Journal of Pediatric Nursing, 26(3), 224-229. https://doi.org/10.1016/j.pedn.2010.06.012

Cook, S. (2015). Full integration of simulation in an ADN program. Teaching and Learning in Nursing, 10, 19-24. https://doi.org/10.1016/j.teln.2014.07.004

Conrad, M. A., Guhde, J., Brown, D., Chronister, C., & Ross-Alaolmolki, K. (2011). Transformational leadership: Instituting a nursing simulation program. Clinical Simulation in Nursing, 7(5), e189-e195. https://doi.org/10.1016/j.ecns.2010.02.007

Hodge, M., Martin, C., Tavernier, D., Perea-Ryan, M., & Alcala-Van Houten, L. (2008). Integrating simulation across the curriculum. Nurse Educator, 33(5), 210-214.

Howard, V.M., Englert, N., Kameg, K., & Perozzi, K. (2011). Integration of simulation across the undergraduate curriculum: Student and faculty perspectives. Medicine, 7(1), e1-e10. http://dx.doi.org/10.1016/j.ecns.2009.10.002

INACSL Standards Committee (2016, December). INACSL standards of best practice: Simulation Design. Clinical Simulation in Nursing, 12(S), S5-S12. http://dx.doi.org/10.1016.j.ecns.2016.09.005

Irwin, R. (2011). The diffusion of human patient simulation into an associate degree in nursing curriculum. Teaching and Learning in Nursing, 6(4), 153-158. https://doi.org/10.1016/j.teln.2011.02.004

Khamis, N.N., Satava, R.M., Alnassar, S.A., Kern, D.E., 2016. A stepwise model for simulation-based curriculum development for clinical skills, a modification of the six-step approach. Surgical Endoscopy, 30(1), 279–287. https://doi.org/10.1007/s00464-015-4206-x

Kleinheksel, A.J. & Ritzhaupt, A. (2017). Measuring the adoption and integration of virtual patient simulations in nursing education: an exploratory factor anaylsis. Computers and Education, 108, 11-29. https://doi.org/10.1016/j.compedu.2017.01.005

Lee, J., Lee, S., & Kim. J. (2018). A review of the curriculum development process of simulation-based educational intervention studies in Korea. Nurse Education Today, 64, 42-48. https://doi.org/10.1016/j.nedt.2018.01.029

Taplay, K., Jack, S.M., Baxter, P., Eva, K., & Martin, L. (2015). The process of adopting and incorporating simulation into undergraduate nursing curricula: A grounded theory study. Journal of Professional Nursing, 31(1), 26-36. https://doi.org/10.1016/j.profnurs.2014.05.005  

Wolfgram, L., & Quinn, A. (2012). Integrating simulation innovatively: Evidence in teaching in nursing education. Clinical Simulation in Nursing, 8(5), e169-e175. https://doi.org/10.1016/j.ecns.2010.09.002


Semi-Structured Interview Questions

  1. I would like to talk about the process you go through with faculty when designing a simulation for your students. How do you get started?
  2. Thinking about your work with faculty who are interested in integrating simulation into their courses, is there a defined process or similar experience you go through?
  3. How do you help faculty determine when and where to use simulation as a teaching strategy?
  4. More specifically, what questions do you ask to determine if simulation is the right strategy to teach particular content?
  5. Do you use simulation as a teaching strategy in the classroom? If so, describe the rationale for that.
  6. How about as a clinical substitution? At what percentage do you substitute clinical time with simulation? Is this course-dependent?

Leave a Reply