2022 Release
Virginia State Simulation Alliance (VASSA)
Recommendations for Use of 2:1 Simulation Ratio
Introduction
Simulation is recognized as an effective means to recreate essential clinical encounters while removing threats to patient safety. In 2014, the National Council for State Boards of Nursing Simulation Study determined that simulation could be substituted for traditional clinical hours with equivocal education outcomes in prelicensure nursing programs (Hayden, et al., 2014). Since the study was published, evidence to support the value of simulation has expanded and implementation of simulation-based education (SBE) as a robust replacement for clinical encounters has been adopted by many nursing programs (Waxman et al., 2019).
The impact of a well-designed simulation has been shown to expose students to diverse learning events in a more efficient manner than the direct care setting. Sullivan et al. (2019) compared traditional clinical and simulation settings by examining specific student learning activities using Miller’s Pyramid of clinical competence. Students who were immersed in simulation completed more activities in the higher levels of Miller’s Pyramid than students in traditional clinical settings. This evidence suggests that simulation is an intense learning activity in which the efficiency of the learning modality, depth of learning, and sustained independence supports an enhanced ratio of hours. It has otherwise been difficult to compare the relative effectiveness of simulation and traditional clinical experience because of an absence of research regarding student outcomes in clinical settings (Leighton et al., 2021).
Purpose
As an established organization for simulation users, the Virginia State Simulation Alliance (VASSA) promotes common interests through collaboration, mentorship, professional development, and improved utilization of simulation in healthcare education (VASSA, 2010). In accordance with this mission, the organization appointed a task force of expert members to examine this issue and develop standards for an enhanced ratio use. While regulations to address the implementation of simulation in nursing education have been established in Virginia, the hours used for simulation are stipulated by percentages of course-specific clinical time and cumulative program direct contact hours. The ratio of traditional clinical time to simulated clinical time has not been defined (Breymier et al., 2015; Bradley et a., 2019). These recommendations establish a consistent approach to simulation hour calculation, create suggested criteria for an enhanced ratio, and exist as an enhancement to the standards of best practice provided by INACSL (2021). The purpose of this recommendation is to provide guidance and consistency to statewide institutions that employ simulation as a pedagogy in healthcare clinical education for pre-licensure nurses.
Nursing educational programs that wish to provide simulation-based learning experiences in which the simulation scenario is calculated as double the clock-hours for traditional direct client care should meet best practice recommendations and state regulations. The International Nursing Association for Clinical Simulation and Learning offers evidence-based guidelines for development and implementation of a comprehensive standard of practice. These guidelines, The Healthcare Simulation Standards of Best Practice™(INACSL Standards Committee, 2021), are designed to advance the science of simulation and share best practices and are considered the foundational requirements from which simulation-based direct care experiences are developed. Additionally, the Virginia Board of Nursing establishes regulatory guidelines for nursing education programs (Commonwealth of Virginia Regulations for Nursing Education Programs, 2022) that encompass the use of simulation for direct contact hours. These regulations specifically address aspects of simulation-based learning experiences in terms of the types of learning experiences and qualifications of simulation faculty who facilitate this clinical encounter. These recommendations augment the regulations defined by the Board of Nursing.
In addition to best practice criteria and regulations that govern simulation in nursing educational programs in Virginia, these recommendations supported by VASSA provide standardization in the use of simulation for direct contact hours with an enhanced ratio and established the term, ‘high-intensity’ clinical learning experience, to identify qualified scenarios. Specifically, High-intensity Simulation Based Education (HiSBE) learning experiences have been developed to provide intensive learning encounters in which participation in the clinical event represents a compressed or accelerated timeline of the patient care trajectory.
Recommendations
The Virginia State Simulation Alliance (VASSA) supports the implementation of clinical learning experiences that are eligible for double the direct contact hour allocation when specific conditions have been met. These experiences will be distinguished by the term, High-intensity, simulation-based education (HiSBE) and must meet the following criteria:
- The HiSBE meets the criteria established by The Healthcare Simulation Standards of Best Practice™(INACSL Standards Committee, 2021) for professional development, simulation design, prebriefing, facilitation and debriefing, outcomes and objectives, and evaluation.
- The HiSBE meets the Virginia State Board of Nursing regulatory guidelines for the use of simulation for direct client care.
- The HiSBE is initially designed as a high-intensity activity in which the scenario represents an accelerated or unfolding episode(s) that portrays the ongoing trajectory of the client experience during different stages or settings within the continuum of care.
- The HiSBE is planned and scheduled to be implemented as a scenario that qualifies for a 2:1 ratio. A simulation scenario cannot be retrospectively designated as a HiSBE after students have completed the experience.
- The HiSBE must be directly administered by qualified faculty in the simulated clinical environment.
- The HiSBE is delivered onsite, face-to-face, and requires that students provide direct care through authentic, hands-on interaction with a simulation mannequin or standardized patient.
Definitions
SBE: Simulation-based Education (Lioce et al., 2020): “an array of structured activities that represent actual or potential situations in education and practice. These activities allow participants to develop or enhance their knowledge, skills, and attitudes, or to analyze and respond to realistic situations in a simulated environment.”
High-intensity SBE (HiSBE) or high-intensity simulation (HiS): a simulation designed to be implemented in an intensive simulated clinical environment in which participants are immersed in a fast-paced learning environment that represents a compressed or accelerated timeline of the patient care experience
References
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.
Breymier, T. L., Rutherford-Hemming, T., Horsley, T. L., Atz, T., Smith, L. G., Badowski, D., & Connor, K. (2015). Substitution of clinical experience with simulation in prelicensure nursing programs: A national survey in the United States. Clinical Simulation in Nursing, 11(11), 472-478. http://dx.doi.org/10.1016/j.ecns.2015.09.004.
Commonwealth of Virginia Regulations for Nursing Education Programs, Vir. Stat. § 18VAC90-27-60 (rev. 2022). https://www.dhp.virginia.gov/media/dhpweb/docs/nursing/leg/NursingEducation.pdf
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 prelicensure nursing education. Journal of Nursing Regulation, 5(2), S3-S44.
INACSL Standards Committee. (2021). Healthcare Simulation Standards of Best PracticeTM.. Clinical Simulation in Nursing, https://doi.org/10.1016/j.ecns.2021.08.018.
International Nursing Association for Clinical Simulation and Learning (INACSL) (2021). INACSL simulation regulation map [data set]. Retrieved from https://www.inacsl.org/simulation-regulation-map
Leighton, K., Kardong-Edgren, S., McNelis, A. M., Foisy-Doll, C., & Sullo, E. (2021). Traditional clinical outcomes in prelicensure nursing education: An empty systematic review. Journal of Nursing Education, 60(3), 136-142. https://doi.org/10.3928/01484834-20210222-03
Lioce, L., Lopreiato J.., Downin, D., Chang, T.P., Robertson, J.M., Anderson M., Diaz, D.A., Spain, A.E., & Terminology and Concepts Working Group (2020). Healthcare simulation dictionary (2nd ed.) (L. Lioce, Ed.). Agency for Healthcare Research and Quality; AHRQ Publication No. 20-0019. DOI: https://doi.org/10.23970/simulationv2
Sullivan, N., Swoboda, S. M., Breymier, T., Lucas, L., Sarasnick, J., Rutherford-Hemming, T., … & Kardong-Edgren, S. S. (2019). Emerging evidence toward a 2: 1 clinical to simulation ratio: A study comparing the traditional clinical and simulation settings. Clinical Simulation in Nursing, 30, 34-41.
Virginia State Simulation Alliance [VASSA] (2010). Philosophy, mission, and vision. Retrieved April 11, 2022 https://www.virginiasimulationallianceinc.org/wordpress/?page_id=109
Waxman, K.T., Bowler, B., Forneris, S.G., Kardong-Edgren, S., & Rizzilo, M.A. (2019). Simulation as a nursing education disrupter. Nursing Administrator Quarterly, 43(4), 300-305. Doi: 10.1097/NAQ.000000000000369
