Simulation the answer to relieve pressured nurses?

December 2014 Vol 14 (6)

Can you halve the time student nurses spend on the ward or with a nurse in the community and still train a clinically competent nurse? A major US study has proven you can by replacing half the traditional clinical placement hours with quality simulation scenarios. 

Kathy HollowayWith a nursing shortage looming, FIONA CASSIE finds out whether New Zealand sees simulation as one way of training student nurses without placing more demands on busy working nurses.

It's always been a bit of a Catch-22. Busy nurses finding the time to train a new generation of nurses so – hopefully – they are less busy.

With the Nursing Council and Health Workforce New Zealand predicting a need to start training more nurses very soon to meet a shortage* hitting from 2020 onwards – when baby boomer nurses start to retire in greater numbers – the pressure for clinical training placements will only increase. (*Of course this predicted shortage is cold comfort to the already increasing cohorts of new graduates right now struggling to find jobs.)

Is one answer for nursing students to spend less time on the ward, or on the road with community nurses, and more time in high-tech simulation laboratories?

A major longitudinal study funded by the National Council of State Boards of Nursing (the NCSBN is the closest US equivalent to our Nursing Council) found no difference in the clinical competence of nursing graduates trained traditionally and those trained by replacing up to 50 per cent of traditional clinical placement time with high quality simulation scenarios (see sidebar one for details of study).

New Zealand currently allows no simulation training hours to be included in the minimum 1100 clinical experience hours required to become a registered nurse – though some simulation hours can count towards the enrolled nurse diploma and may shortly be allowed in the midwifery degree (see sidebar two for details and definitions).


Something's got to give

With traditional clinical placements in hospitals and other settings already stretched, something's got to give if New Zealand is to train more nurses.

Steps are underway for standardised and quality simulation scenarios like those used in the US study to be part of the solution.

"What we (nursing schools) are very clear about is that we can't increase the numbers coming through nursing programmes without a change in our clinical learning model," says Kathy Holloway, national chair of nurse educators group NETS.

This is the conclusion schools came to at an education workshop in 2013 that also discussed a simulation collaboration project (led by CPIT's Karen Edgecombe and funded by tertiary teaching agency Ako Aotearoa) that came up with teaching and learning guidelines for effective clinical simulation in undergraduate nursing training.

Holloway says moving towards the recognition of clinical simulation hours is just part of changing the clinical learning model, which also includes using dedicated education units (DEUs) and other ways of ensuring clinical learning experiences are quality learning experiences.

Of course, clinical simulation is already very much part of nursing training in New Zealand. It has come a long way from just repetitive technical skills training to detail scripted and researched simulation scenarios using high- fidelity mannequins or role-playing 'patients', followed by very sophisticated debriefing processes to maximise the learning.

If New Zealand is going to eventually replace some of the traditional hours on the ward with clinical simulation hours, there needs to be standards and consistency across the country in what counts as a clinical simulation experience.

Holloway says NETS has stepped in to fill that gap by developing some standard simulation scenario resources. First, nursing has to agree what should and could be taught by simulation.

This year, NETS has been working on just that by asking a group of 37 nursing school and clinical practice leaders to come to a consensus on the key learning outcomes it wants students to demonstrate in simulation scenarios.

It has now come up with ten learning outcomes, with the two coming out top being demonstrating clinical reasoning in assessing and managing nursing care and demonstrating clinical judgement.

The next step is to develop a set of standardised simulation scenarios drawing on scenarios that nursing simulation experts across the country have already created so, as Holloway puts it, they are not reinventing the wheel, just retreading it.


Time with real patients is very important

Denise Kivell, chair of nurse executives group NENZ, says simulation is a great tool for learning new skills but the quality of the simulation is critical.

"It does not represent a complete substitute for practice hours in undergraduate training."

She says Kathy Holloway has spoken to NENZ, which was aware that NETS was working on simulation standards. The Nursing Council had also indicated it was involved in the work around developing simulation standards.

"There are many very well constructed research-based programmes that we would support," says Kivell.

She adds that simulation is no longer just about "resus Annie" on the floor and clinical simulation experiences need to be as real as possible and include high quality feedback from the ‘patient’.

Kivell, who is director of nursing for Counties-Manukau District Health Board, says there also needs to be a balance between simulation and hands-on clinical time.

“The value of learning and developing how to have an effective therapeutic relationship with the ‘real' individual patient is so important, especially now with the decreased contact time and length of stay in many of the settings."

Kivell says, looking to the future, the increased nursing student intakes necessary will need to be accommodated using both clinical training methods.

"It is so important we all work together to ensure the simulation standards for the RN programme, and development of the simulation units and associated teaching methodologies, have robust quality measures that result in quality clinical learning."

She adds it would be prudent for NENZ members as directors of nursing and nurse leaders to work closely with nursing schools to ensure that the outcomes are acceptable.

"Simulation is not just about machines that go ‘ping’ and ECGs that go flat," agrees Holloway. She says it is replicating real life situations and giving students the opportunity and time to practice and test their skills in a safe environment and to debrief afterwards and learn from the experience.

Jane O'Malley, the Ministry of Health chief nurse, points out that the supply of New Zealand-educated nursing graduates is already increasing, having risen from around 1300 a year in 2010 to around 1800 in 2013. A major focus for her office is ensuring that as many of those nurses as possible are employed when they graduate.

She says her office is aware of the NCSBN simulation study and the work that NETS and the Nursing Council are doing around it.

"There is a push to improve the quality of nurses' clinical learning experience and a recognition that simulation is a part of that," says O'Malley.

She adds that clinical experience hour requirements are primarily an issue for the Nursing Council. Her office and Health Workforce
New Zealand were working with the National Nursing Organisations' group (of which NETS and NENZ are a part) on a broader workforce programme to address the workforce and predicted shortage issues identified by the Ministry and the sector.


Where to next?

So how close is New Zealand to including any clinical simulation hours towards the required clinical experience hours, let alone 50 per cent?

"We're still at the beginning of the process," says Holloway.

For some simulation hours to be counted as clinical experience hours, the Nursing Council has to change the current education standards for registered nurses.

Last year, Nursing Council chief executive Carolyn Reed said the council was working with NETS on looking at simulation standards for undergraduate RN programmes and was awaiting with interest the NCSBN simulation study findings. As Nursing Review went to press, she was unprepared to comment on the simulation study and its implications for New Zealand, as the council was due to further discuss the topic and study findings in 2015.

Holloway says she has been keeping the Council and sector briefed with NETS progress in developing simulation standards.

"In order for the Council to be confident that there is a standard that is shared across the sector in terms of simulation, we need to do this work."

The NETS report is due to be signed off and published in 2015 and will then be presented to Council. The steps beyond that are not known, but Holloway believes it will take time to bring some nursing colleagues onside so is not pushing for a tight timetable. NETS is aiming to have its first standardised simulation scenarios completed by the end of 2015 – possibly just concentrating on scenarios for first-year students – so it would be at least 2016 or 2017 before nursing schools would be ready to look at offering some standardised clinical simulation hours.

Maybe it won’t be that far away when the nurse beside you has developed and proven their clinical competence and confidence by caring for both real and virtual patients?


New Zealand clinical experience training requirements

Registered nurse

Nursing schools must provide a minimum of 1100 clinical experience hours for all students and all students are entitled to up to 1500 clinical experience hours to prove competence. Simulation hours cannot be included in clinical experience hours (Nursing Council of New Zealand).


Enrolled nurse

Students are required to complete 900 clinical experience hours during the programme, which can include up to 200 hours of simulation
(Nursing Council of New Zealand).



Currently analysing feedback on new education standards that include a proposal to allow 10 per cent (i.e. 240 hours) of simulated practice to count towards the 2400 midwifery practice hours required. A decision will be made in the New Year and the earliest the new standards may be introduced is 2016. Currently some clinical skills – childbirth emergencies like undiagnosed breech and neonatal resuscitation – can be assessed through simulation (Midwifery Council of New Zealand).


Nursing Council definition of simulation:

Activities that mimic the reality of a clinical environment and are designed to demonstrate procedures, decision-making and critical thinking through techniques such as role-playing and the use of devices such as interactive videos or mannequins. A simulation may be very detailed and closely simulate reality, or it can be a grouping of components that are combined to provide some semblance of reality.

Definition from US nursing academic Pamela Jeffries


Midwifery Council definition of simulation:

Simulation is a technique for practice and learning that can be applied to many different disciplines and types of training. It is a technique (not a technology) to replace and amplify real experiences with guided ones, often ‘immersive’ in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion. ‘Immersive’ here implies that participants are immersed in a task or setting as if it were the real world.


US study on replacing up to half of traditional clinical experience with simulation


  • Control: No more than 10% of clinical hours spent in simulation
  • 25% group: 25% of traditional clinical hours replaced by simulation
  • 50% group: 50% of traditional clinical hours replaced by simulation



  • A standardised simulation curriculum was developed and provided to the 10 selected nursing schools to ensure that quality simulation scenarios were used at all study sites.
  • The study team staff members from each school were required to attend three mandatory training sessions in the NLN/Jeffries Simulation Framework and were taught the Debriefing for Meaningful Learning method.
  • Simulation scenarios involved: medium or high-fidelity manikins, standardised patients, role-playing, skills stations, and computer-based critical thinking simulations.
  • Students were assigned roles during the simulation scenarios, including Nurse 1, Nurse 2, family member, and observer. Clinical instructors stayed with the remaining students in the clinical group to observe the scenario. All students in the simulation group participated in the debriefing.
  • Examples of simulation scenarios worked through in a clinical practice day could include, in bed one, a paracetamol overdose patient with depression, and in bed two, an appendectomy patient one day post-surgery with pain, nausea, and vomiting.


At graduation:

A total of 666 students graduated from the 10 selected nursing schools. Clinical preceptors and instructors reported no statistically significant differences in clinical competency, nursing knowledge, or pass rates between the three groups.

Six months into first job:

The new graduates' managers at their first jobs reported on overall clinical competency and readiness for practice at six weeks, three months, and six months and found no difference between the traditional and simulation trained graduates.


"The results of this study provide substantial evidence that substituting high-quality simulation experiences for up to half of traditional clinical hours produces comparable end-of-program educational outcomes and new graduates that are ready for clinical practice."

Reference: HAYDEN J, SMILEY R, ALEXANDER M, KARDONG-EDGREN S & JEFFRIES P (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) July 2014 supplement.

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