The National Simulation Study: A Longitudinal, Multi-Site, Randomized, Controlled Study Examining the Use of Simulation as a Substitute for Clinical Hours

Purpose: The purpose of this presentation is to discuss the findings from a multi-year, multi-site, randomized, controlled study of the educational outcomes when simulation is used to replace traditional clinical hours throughout the undergraduate nursing curriculum. Providing high quality clinical education experiences for nursing students is a challenge for nurse educators worldwide. An international nurse faculty shortage, along with competition for clinical sites, high patient acuity, and short hospital stays make it difficult for students to obtain consistently good educational experiences. Educators have turned to high fidelity patient simulation as one solution to the perennial challenges of traditional clinical education. Program administrators and faculty have witnessed the benefits of this teaching pedagogy and are interested in using simulation to replace a portion of their clinical hours with simulation, but the research literature has not addressed the end of program outcomes achieved when simulation is used as a clinical replacement throughout the curriculum.  This was the largest, most comprehensive study to date examining the use of high fidelity simulation in the undergraduate nursing curriculum. Educational outcomes of clinical competency, nursing knowledge and new graduate nurse readiness for practice will be discussed.

 Methods: The Fall 2011 student cohort from 10 nursing programs across the US were randomized to one of three study groups: traditional clinical (control group),  25% simulation in place of traditional clinical hours, or 50% simulation in place of traditional clinical hours. This randomization was maintained throughout the two years of clinical courses. In each clinical course, and at the end of the nursing program, students were assessed on clinical competency and tested on their nursing knowledge. The ATI Comprehensive Assessment Review Program was used to assess nursing knowledge throughout the study. The Creighton Competency Evaluation Instrument (CCEI) was used by clinical instructors to assess competency throughout each clinical course. End of Program determinations of clinical competency were made by the final clinical preceptor/instructor using the Critical Thinking Diagnostic and New Graduate Nurse Performance Survey.

The study cohort graduated in May 2013. A follow-up study of these new graduate nurses was conducted to evaluate their clinical abilities in the workplace. Nurse Managers completed surveys of the new graduates’ critical thinking, clinical competence and readiness for practice at 6 weeks, 3 months and 6 months after being hired for a clinical position.

Results: A total of 667 nursing students completed the study requirements at graduation. There were no differences between the study groups in nursing knowledge assessed by the ATI Comprehensive Predictor (p=0.48), New Graduate Nurse Performance Survey scales (p-values ranged from 0.43 to 0.85), the Critical Thinking Diagnostic scales (p-values ranged from 0.32 to 0.49), or the overall rating for clinical competence and readiness for practice (p=0.69). Course specific data showed some variability in the competency assessments, while the standardized nursing knowledge assessments revealed a trend of higher scores in the 50% group. National licensure examination results will also be presented.

At graduation, 587 new graduates consented to participate in the follow-up study. Once these new graduate nurses starting working in clinical positions, their managers provided ratings of clinical competency, critical thinking and readiness for practice using the New Graduate Nurse Performance Survey and Critical Thinking Diagnostic. These results will be reported for the 6 week, 3 month and 6 month follow-up periods.

Conclusion: We found no differences in end of program nursing knowledge, clinical competency or readiness for practice between the three study groups when up to half of the required clinical hours were replaced with simulated clinical experiences. These results indicate that using well trained simulation faculty to provide nursing students with simulated clinical experiences produce educational outcomes equivalent to traditional clinical education at the end of the nursing program. These results have significant policy implications for regulation and education in the US and other countries.

Leading nurse educators have been calling for a transformation to clinical education. Human patient simulation provides students the opportunity to learn while in the role of the nurse, rather than the nursing student. Educational opportunities can be standardized for all students; high morbidity and low frequency patient conditions can be practiced in a safe learning environment; interprofessional communication and safety standards can be incorporated in scenarios, and all students can debrief and reflect on the experience afterwards as a group.  When best practices are utilized, nursing students can be exposed to many patient conditions, practice critical behaviors and synthesize key concepts in the simulated environment, then work to solidify those concepts and behaviors in the traditional clinical environment.