1. Schoen, Denise MSN, RN, BC

Article Content


The use of patient simulation is a growing strategy used by educators to teach and assess the nurse's clinical knowledge, attitudes, and skills. Simulation is an interactive, multimedia patient scenario that allows real patient simulations to be replicated in a safe environment for practice and learning. Each specific patient scenario defines the appropriate assessments and interventions that the learner is to perform. The manikin responds according to the interventions chosen. Nurse educators have the challenge of developing and implementing simulation laboratories and experiences for staff. There are many considerations in implementing simulation. This article provides 10 tips from the time the nurse educator takes the simulation manikin out of the cardboard box to the time the nurse educator runs the first simulation experience. The following tips will provide a basic outline of what needs to be accomplished to be successful in implementing the simulation.



There are multiple resources that the educator should use: the company selling the simulation manikin; departments within the institution, such as information systems (IS), telecommunications, and environmental services; and the simulation experts in the area. Scheduling a site visit with the company's simulation representative is helpful in the initial planning. The company's representative will help with decisions such as finding the ideal area to perform simulation, determining how much space is needed to store equipment, and assessing computer and audiovisual needs. The educator should inquire about the technical support that is available from the company once the "boxes" arrive. Collaboration with the institutional IS representative is essential because of the sophistication of the simulation equipment requiring technical support. The IS representative can assist in areas such as determining computer requirements and the type of microphone and video recording devices needed to best fit the institution's budget and space. Support from telecommunications is important if installing telephones in the simulation area. Checking with the environmental department and other disciplines aids in gathering the necessary equipment to "mock up" the patient room. Successful simulation educators also network with other institutions. Learning from field trips to see how other educators have set up their simulation laboratories and how they run and build their scenarios is invaluable information.



A budget needs to be developed not only for the purchase and set up of the simulation laboratory but also for ongoing equipment, software upgrades, and supplies to maintain simulation. The time required to create, practice, and modify a simulation session can be burdensome and should be viewed by the educator as similar to writing a detailed lecture (Rauen, 2001). The simulation process demands thoughtful attention to staff costs. When exploring possible grants for purchase of necessary equipment, remember to seek funding for the education of the staff who will be performing simulation. Investigate if there would be cost savings if the institution were to purchase and set up its own computer, microphone, and recording/playback equipment versus buying these from the simulation company. Factors to consider in making this decision include the ability of the institution's IS staff to provide this support. To save money on supplies, nurse educators should arrange with the purchasing department/storeroom staff to use expired products and supplies for simulation.



Educators are more likely to perform simulation if there is a dedicated space for a mock patient room with all the equipment available and the simulation manikin set up. Dedicated space is needed because of the amount of time it takes to set up and break down the manikin and to support the monitoring equipment. Efficient simulation laboratories have designated areas such as the control room, patient's room, nursing station, a resource area to look up information, and an area for debriefing. Curtains or screens can be used to define these central areas. Having a room the same size as a patient's room is the ideal situation, yet it limits the number of participants in the room during simulation. If the budget allows, it is best to have a separate control room with one-way glass so the educators can see and hear the learners but the learners cannot see or hear the educators. This eliminates distractions and possible cues from the educator when documenting and implementing a change in the patient's status through the simulation software. Having a dedicated space works well with scheduled simulation times, such as with a new graduate program in which the new graduate may be scheduled to perform simulation for the day instead of orientation on the clinical unit. However, the educator should also consider purchasing a portable manikin so that simulation can be performed on the clinical units. It can be difficult for staff to leave their units to participate; having the ability to make the simulator portable can bring simulation to the staff. Mock medical emergencies are a great example of using simulation on the clinical unit, where staff perform in their own work environment and with their own equipment and resources.



Several areas need to be addressed when gathering equipment for simulation: technical equipment to run simulation, equipment to mock up a patient room, supplies to perform simulation, materials to store equipment, and documentation for each scenario. Depending on the budget and dedicated space, the educator will need to consider what audiovisual equipment (e.g., camcorder, DVD player, and sensitive microphone) is needed to record and play back the simulation scenario. Consider having two working telephones, each with a different telephone number. The telephones create a realistic environment for the learner to notify the physician of a patient's condition. This is the ideal because the simulation participant, using one telephone line, has the ability to call the educator in the simulation control room, who is answering on the second telephone line. To mock up a patient room, check on the ability to procure equipment such as a patient bed, nightstand, overbed table, call bell, and oxygen flow meter. If a functioning wall suction or oxygen cannot be provided, obtain a portable suction device and mock up an oxygen faceplate and meter. Check the feasibility of dedicating a computer laptop for accessing the institution's documentation system. For each simulation scenario, gather the equipment needed, such as a stethoscope, intravenous pump, identification band, dressing material, reference materials (e.g., drug, laboratory, and nursing skills books), and a chart setup. For storing equipment, it works well to have storage cabinets or shelves to hold all the equipment. Plastic bins help separate the equipment by categories such as respiratory, urinary, medication, and intravenous insertion supplies, or the supplies for each simulation scenario can be placed in a large plastic sealable bag. Lastly, assemble and mock up the institution's documentation records (e.g., unit-specific flow sheet, admission assessment, and medication administration record) specific to each simulation scenario.



Documents need to be developed in two areas. First, paperwork needs to be developed for the educator who will be building and conducting simulation. The educator will need instructions on initiating, operating, and shutting down the simulation laboratory; a worksheet for building simulation scenarios; and an evaluation tool of the learner. The educator will need to complete specific documentation for each scenario, such as a report sheet, flow sheet, and physician's order sheet. Second, documents need to be developed for the learner. A confidentiality statement, an information sheet, and an evaluation tool are basics. Consider developing a confidentiality statement in which a safe environment is created to critique behavior and thinking processes and to make mistakes. This statement needs to be signed by all parties involved in the simulation experience: the learners and the educators. The specifics of what happened during the simulation "stay in the room"; however, the learner must be informed that general patterns of progress, concerns, or both will be communicated to the clinical supervisor. Producing an information sheet is vital to educating the learner. It should contain the purpose, expectations, and process of simulation, as well as the capabilities of the simulation manikin. Lastly, developing an evaluation tool for the learner to evaluate the simulation experience provides the educators with valuable feedback for building future simulations.



To aid in building simulation scenarios, several sources such as the National Patient Safety Goals, the institution's identified core measures, the top diagnostic-related groups, quality indicators, and incident reports can be used to review to help identify what to develop. As the nurse educator develops the scenario, he or she needs to consider the target audience, whether the simulation is for education or a competency, and the time frame for implementing and debriefing the scenario. The nurse educator should anticipate all possible events that could emerge during the scenario and build in performance measures. Each scenario should have clearly defined objectives; be cautious as to the number of objectives identified. Ideally, there should be a limit of two or three objectives per scenario. A novice building scenarios can make the mistake of building a scenario that is too complex. The educator should start by building a simple trend that is triggered by an intervention. For example, when oxygen (the intervention) is given to the patient, it will increase the patient's SpO2 by five points (the trend). The rest of the scenario can be performed by manually changing the patient's response, such as vital signs and lung sounds, during the simulation. As the educator gains confidence, he or she can increase the complexity by adding more trends and building in the vital signs. It is important to keep the scenario simple and focused so as not to overwhelm the learners. If there are too many objectives or the scenario is trying to accomplish too much, the risk of intimidating and frustrating the learner will be increased. Limiting the objectives and writing a detailed scenario will decrease these risks.



Simulation is a relatively new technology. It is likely to be a new experience for both the educator and the learner. The educators must be comfortable with the clinical simulation experience and supportive to the learner. According to Rauen (2001), educator intimidation is a common reason for the simulation teaching aids becoming unused. There are two areas of focus that can be developed to aid in the comfort level of the educator and the learner. First, an educator workshop is vital to coach the staff to decrease anxiety and facilitate understanding of how to build a scenario as well as how to be competent in running the equipment during simulation. Second, an orientation for the learner should include a tour through the designated areas of the room, the manikin's capabilities, and the components of a simulation experience, such as receiving report on the patient, performing the simulation, and holding a debriefing session. Taking the time to educate both groups will build confidence and create more successful experiences.



The simulation manikin is a computerized manikin that cannot simulate all components of a human being; therefore, the nurse educator needs to be creative in producing the most realistic simulation experience possible. The educator can be creative and make the manikin more realistic by using a spray bottle to simulate sweat, using theater makeup to simulate bruising (pretest on a nonvisible area of the manikin or a spare part for staining), or laminating a picture of cellulitis to wrap around the manikin's leg. It is helpful to create role identification badges to assist in communicating to the learner what role the educator is playing, making the scenario more realistic. These are only a few examples of how to produce a more realistic patient and scenario; however, the educator can gather more creative ideas by networking with simulation experts in the area to learn what they have done. Being creative can be fun and exciting, and there is no limit to one's imagination.



It takes a lot of time and energy to implement simulation. Installing the simulation equipment, determining a budget, producing the paperwork, building the scenarios, and educating are all areas that hold measures for success. Taking time to congratulate and reward nurse educators helps to motivate them when they complete their first simulation experience. Implementing a safe learning environment that fosters the acquisition of psychomotor skills, critical thinking, and problem solving is a wonderful achievement. This environment also increases the confidence of learners as they react to a situation without having time to prepare. This is reason to celebrate.



Although a simulation scenario has been written and performed, the job is not done. Evaluations of both the simulation experiences and the learner need to be conducted. The educator will probably revisit the scenario to make it better and more realistic. As time progresses, the educator should assess the scenario to see if it reflects current best practice. The other key area to evaluate is the learner's ability to perform skills, think critically, and make effective decisions during the simulation experience. By embedding performance measures in the simulation scenarios, educators can provide feedback to learners, based not only on outcomes but also on progress (Merril & Barker, 1996). This feedback should be shared with the clinical supervisor as he or she conducts the learner's performance evaluation.



Patient simulation is rapidly becoming a standard teaching strategy for educators in healthcare institutions and nursing schools. The availability of controlled clinical learning situations through simulation in a risk-free environment can help meet the educational demands of learners. Simulation is an effective teaching strategy that can be individualized to the learners by providing them with exposure to certain high-risk patient populations and procedures. Simulation does, however, require significant resources in terms of staff and equipment. It should be viewed as an investment in future practice, care delivery, and risk management and a continuing commitment to multidisciplinary working practices (Barton, Davies, Graham, & Temlett, 2003). To be successful and to decrease the intimidation of becoming proficient with the simulator, the educator must understand how to use it and "make" it do whatever is needed to create the desired learning environment (Rauen, 2001). From getting the manikin out of the box to implementing those first simulation experiences, these 10 tips will set the stage for the innovation of simulation.




Barton, M., Davies, C., Graham, J., & Temlett, J. (2003). A new approach to training in intravenous drug therapy. Nursing Times, 99(43), 26-29. [Context Link]


Merril, G. L., & Barker, V. L. (1996). Virtual reality debuts in the teaching laboratory in nursing. Journal of Intravenous Nursing, 19(4), 182-187. [Context Link]


Rauen, C. A. (2001). Using simulation to teach critical thinking skills: You can't just throw the book at them. Critical Care Nursing Clinics of North America, 13(1), 93-103. [Context Link]