1. Palmer, Janice L. PhD, RN, CNE
  2. McLaughlin, Dorcas E. PhD, RN
  3. Hankamer, Beth A. MSN, RN

Article Content

With difficulties in securing clinical practice sites and recent study findings1 concluding that up to 50% of clinical hours may be substituted with simulation-based education, the use of simulation teaching strategies in nursing education programs has increased exponentially. Concern exists that nursing programs are substituting clinical hours with simulation without providing adequate training in simulation best practices to faculty.2 Several examples of training in the use of simulation to improve clinical outcomes are cited in the literature. Lane and Mitchell3 described a 3-step train-the-trainer program for nurse educators in staff development roles. Simulation champions were identified, developed, and integrated into the role. Shellenbarger and Edwards4 implemented training in simulation in a graduate nursing program. Also, the Maryland Clinical Resource Consortium initiated a 3-day train-the-trainer program to increase knowledge of simulation pedagogy and to develop faculty members as simulation champions.5 Since Consortium program implementation, the number of clinical hours replaced with simulation hours has increased, several simulation experts have been identified to train others, and at least temporally related, participating programs have seen an increase in NCLEX pass rates.5


In this article, we describe a full-day simulation boot camp developed for master of science in nursing students preparing for the nurse educator role. A model for increasing knowledge and confidence in planning, running, debriefing, and evaluating simulation sessions was developed, implemented, and evaluated. The overarching goal of the boot camp was exposure to the complexity of the educator's role and best practices in high-fidelity simulation.



Design and Sample

After obtaining institutional review board approval, a convenience sample of 38 master's students consented to study participation and completed a pre-boot camp rating of confidence related to scenario development, simulator operation, simulation facilitation, and debriefing. Participants self-reported experience with simulation, including time as participants, before the boot camp: this ranged from 0 to 4 hours: n = 18; 5 to 15 hours: n = 9; and 16 to more than 20 hours: n = 7.


A 90- to 120-minute classroom session related to uses of simulation, best practices, and scenario development followed consent. Participants were instructed to (1) conduct an analysis of their clinical setting for gaps of knowledge/practice on which to develop a simulation scenario using the International Nursing Association for Clinical Simulation Standards of Practice,6 (2) write a scenario using Bambini's Step-By-Step Guide,7 and (3) consider methods for debriefing participants post simulation including the Debriefing for Meaningful Learning8 and the Promoting Excellence and Reflective Learning for Simulation9 approaches. Thirty-four participants returned for a 1-day simulation boot camp and completed post-boot camp ratings of confidence and change in knowledge and open-ended questions about the experience.



After the classroom session, participants worked in groups of 2 to 3 to develop a simulation scenario for use in the boot camp. Supplemental Digital Content, Table,, provides a partial list of scenarios developed by the participants. On the morning of the boot camp, the facilitator, a nurse educator with extensive simulation experience, outlined the day's activities and reviewed the learning outcomes.


After a review of debriefing best practices, the facilitator led the participants in debriefing role-play. Participants were divided into triads. Each person was given an index card describing the simulation scenario and his/her role in the debriefing session. One member of the triad assumed the role of facilitator, and the other 2 members played roles of participants in the debriefing session and manifested various emotions and challenging behaviors. For example, challenging behaviors might include participants overestimating their knowledge or skills, belittling others, monopolizing the group, manifesting distracting or disengaging behaviors, or becoming silent or tearful. Initially, participants approached the role-play activity hesitantly but soon engaged in the experience with enthusiasm.


In addition to the role-play activity, small groups of participants circulated among various stations to gain experience in the simulation instructor role. For example, at 1 station, participants practiced starting the manikin, computer, and monitor using a software program to run scenarios. At another station, participants were supplied materials and recipes for preparing wounds and body fluids. During the afternoon session, the groups ran their scenarios and discussed what went well, what did not go so well, and what could be done differently next time to improve the scenario. At the end of the day, the facilitator summarized the activities and reviewed the process of scenario development. To gain further insight into knowledge gained from the experience, participants identified 3 ways to integrate concepts from the boot camp into their practice.



A paired-samples t test was conducted to compare pre- and post-boot camp ratings of confidence. Statistically significant improvement in confidence was noted in all domains (Table). Also, participants self-rated change in knowledge from 1 (little or no increase in knowledge level), 2 (moderate increase), to 3 (definite increase). The mean score for increased knowledge in all areas approached 3, indicating that most participants perceived a moderate to definite increase in knowledge for all domains. When asked to identify 3 ways to integrate the concepts from the boot camp into their practice, primary themes were as follows: (1) use gap analysis in creating simulation scenarios and other educational activities (20 responses). One participant wrote, "Use of scenarios to educate to prevent misses or near misses"; (2) facilitate learning with simulation (20 responses). A participant wrote she will "use simulation in the workplace to help new grads better communicate up the chain of command"; and (3) implement best practice debriefing skills in academic and clinical practice settings (31 responses). A participant wrote, "The debriefing steps are very important to use in the ED (emergency department). I will even be able to use these after critical situations or codes/deaths."

Table Changes in Con... - Click to enlarge in new windowTable Changes in Confidence Pre-Post Boot Camp


Compared with didactic instruction, the boot camp provided a hands-on approach with role-playing in the educator role and the motor skills of simulation and is consistent with the practice of simulation. As expected, participation in the boot camp resulted in increased confidence and knowledge of simulation. Also, participants reported ways to incorporate debriefing skills in other areas of their practice, for example, when working with new nurses and after near misses and errors in care. For these reasons, we believe the boot camp could be replicated with nursing faculty and clinical nurse educators. Initially, encountered barriers to running the boot camp included identifying an experienced simulation facilitator who shared our vision and goals to coordinate the boot camp, scheduling a full-day camp outside of class time, and limiting the scope of the camp to the learning objectives.



The proliferation of simulation-based education in nursing programs demands that future nurse educators develop the knowledge and skills needed to effectively design, implement, and evaluate high-quality simulation experiences to meet desired student learning outcomes. Study participants reported increased knowledge in simulation pedagogy, enhanced debriefing skills, and improved confidence in implementing simulation-based teaching strategies. The boot camp was an efficient and effective instructional strategy that begins to address concerns about the preparation of the faculty workforce in simulation best practices.




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