Taking a Peek at State Simulation Regulations

By: Beth Hallmark, PhD, RN, MSN, CHSE, ANEF, Belmont University and Reba Moyer Childress, MSN, RN-BC, FAANP, Virginia State Simulation Alliance President

Over the last two decades health care simulation has grown dramatically. Variability in the use of simulation led the International Nursing Association for Clinical Simulation and Learning (INACSL) to establish standards to ensure consistency and quality in the use of this valuable teaching methodology (INACSL, 2016).  In 2014. as simulation became a visible part of direct patient care hours, the National Council of State Boards of Nursing (NCSBN) recognized the need to regulate simulation in academic settings (Hayden et al., 2014).

In 2019, the INACSL Regulations Committee conducted a review of the use of simulation nationally. The results led to the creation of an interactive map that links users to state directives surrounding the use of simulation (https://www.inacsl.org/simulation-regulations/). States either provided guidance or regulated the use of simulation, especially in relation to direct clinical hours.

With the advent of COVID, in-person simulations were challenged. Thus, the INACSL Regulations Committee is again surveying each state board of nursing (BON) on any revised simulation regulations. The updates will be published, and the map will be revised.

It is important to note that state boards of nursing are not necessarily prescriptive with regard to simulation usage for academic programs. The regulations are there to make sure simulations are of high quality and adhere to programmatic requirements. For example, BON recommendations and regulations may emphasize that simulation incorporate objectives, prebriefing, debriefing, and professional development for faculty and staff who facilitate simulation.

With the emergence of COVID-19, already limited clinical opportunities in nursing education were further impacted as learners were not allowed to enter patient care settings. To ensure safety of learners and educators, academic settings transitioned clinical experiences from actual patient care settings to simulation centers.  This rapid change led many schools to develop virtual simulations that would substitute for clinical hours.

Simulationists sought guidance from state boards and other professional organizations to ensure that virtual learning would adhere to academic and regulating body requirements. States varied on their response, from providing no guidance or no response to allowing an increase in the percentage of clinical that can be replaced with simulation (INASCL, 2020).  For example, pre-COVID, California and Virginia allowed 25 percent of clinical hours to be replaced by simulation; in March 2020, both states increased the percentage to 50 percent. The Tennessee Board of Nursing had previously supported the use of up to 50 percent of clinical being replaced by simulation and made no statements or changes during the pandemic. In the state of Maine, the BON had previously approved substituting up to 50 percent of clinical with simulation, and in late March 2020, it stated that if the percentage increased during the pandemic, the institution should report the change to the board. It further stipulated that if virtual simulation/instruction was used, the school should also report these adaptations.

As is readily apparent, state recommendations are diverse, leading to the question Should the NCSBN have more oversight over the use of simulation? Would this include tracking how schools use simulation, and how simulation in place of clinical hours is counted, how faculty are trained, and how schools adhere to standards?

There is much to consider with regard to how simulation is used to replace clinical, whether virtual or face to face. We hope this peek will encourage you to explore the INACSL map and find out what your regulatory body says about this matter. 

Additional Ideas

  1. Guidelines on the use of virtual simulation for clinical hours may be addressed with updates from the INACSL Regulations Committee.
  2. The NCSBN provides a document on its website that outlines t nursing regulatory bodies’ responses to COVID (https://www.ncsbn.org/Education-Requirement-Changes_COVID-19.pdf ).


Bradley, C. S., Johnson, B. K., Dreifuerst, K. T.., White, P., Conde, S. K., Meakim, C. H., Curry-Lourenco, K., & Childress, R. M. (2019).  Regulation of simulation use in United States prelicensure nursing programs. Clinical Simulation in Nursing, 33, 17-25. https://doi.org/10.1016/j.ecns.2019.04.004.

Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014).  The NCSBN National Simulation Study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in pre-licensure nursing education. National Council of State Boards of Nursing, Vol5, Issue 2.

International Nursing Association for Clinical Simulation and Learning. (2016).

INACSL Standards of Best Practice: Simulation℠


International Nursing Association for Clinical Simulation and Learning. (2020, June 6). Changes in education requirements for nursing programs during COVID-19. https://www.ncsbn.org/Education-Requirement-Changes_COVID-19.pdf

Leave a Reply