Finding the Value: Researching Simulation in Graduate Nursing Programs

UNLV Ph.D. graduate and Marian University assistant professor Christina Pepin 

May. 28, 2020

By Joseph Gaccione 

High fidelity clinical simulations are a vital piece of teaching young nurses about life on the frontlines. By simulating real-life scenarios, procedures, and face-to face interactions with patients in safe environments, students get a hands-on approach to improving their technical skills, communication, and critical thinking. The Clinical Simulation Center of Las Vegas is a prime local example of educating future nursing and medical leaders using this type of training. But while the practicality of simulations is visible in undergraduate programs, the opposite is true for graduate courses. 

If high-fidelity simulation is considered a valuable education tool, why isn’t it used more being used more for graduate programs? What are the barriers or limitations? UNLV Ph.D. graduate and Marian University assistant professor Christina Pepin (Ph.D., RN, CNE) decided to find out. 


Pepin’s Ph.D. dissertation specifically focused on the prevalence and use of high-fidelity simulation in Family Nurse Practitioner programs during the 2017-2018 academic year. She notes although NP programs grew 60% between 2012 and 2016, there was a shortage of appropriate clinical sites. The lack of growth for clinical sites prompted some programs to be moved to supplement clinical with high-fidelity simulation. While undergraduate programs can count simulation toward required clinical hours, graduate programs cannot because the accrediting and regulating bodies determined there was not enough evidence-based rationale to suggest simulation was effective in nursing instruction. 

To figure out why, Pepin had to start with what was out there regarding graduate-level simulations. The problem was, she says there was no specific literature out there as to what family nurse practitioner programs are doing in simulation. She says, "There are about 45 articles out there that are FNP programs or generic nurse practitioner programs saying how they're using simulation or, implementation of a hot topic item, such as breaking bad news or implementing tele-health into their curriculum and simulation surrounding that. But nothing about prevalence.” She added one challenge in studying simulation prevalence in NP programs is trying to study the specific impacts on various tracks like FNP, acute care, mental health, and pediatrics. 

“Those are all different graduate programs. They all have different needs”, says Pepin. “A family nurse practitioner is not likely to use a mannequin as a simulator device, because that's usually in a room that looks like a hospital room. Family nurse practitioners do not work in a hospital setting unless they work in the ER. It's just a different environment and different needs for family nurse practitioners comparatively to the other nurse practitioner realms.” Another factor is how different states regulate graduate programs. She says some states don’t have oversight of graduate programming; they just look at undergraduate content. Others will only consider accreditation from an outside agency. 


For her study, Pepin surveyed 377 FNP programs across the U.S. about their high-fidelity simulation practices, using a descriptive survey-research methodology. Her survey was modeled on a similar study from the National Council of State Boards of Nursing (NCSBN) on undergraduate programs. She received complete feedback from 119 programs, the majority of which reported using simulation (compared to 19 who said they did not). Among Pepin’s findings, the majority of responses (71.8%) called for more simulation. They cited limitations that included lack of staffing and difficulty scheduling lab time. Her research also called for asking these programs about the positive returns of high-fidelity simulation. The overall message was encouraging, from comments about effective teaching to facilitating role transition to reduced preceptor burdens. 

One of the biggest benefits of simulations is filling in the education gaps a student could face by the time they graduate. Nurse practitioners are required to have at least 500 clinical hours by the time they graduate. Unlike some practitioners, FNPs specifically have to be proficient across the lifespan of a patient (from pre-birth to death), so they need to learn a wide variety of clinical competencies with each lifespan phase. This is where Pepin argues simulation is a valuable resource to pair with clinicals, especially ones that don’t offer those opportunities. “A lot of FNPs, once they graduate, many don’t see the whole lifespan unless they’re working in an emergency room or urgent care clinic, or someplace where anybody can walk through the door. [This] is where simulation can come in, that the patient mix can be defined. Good simulation activities can address those deficits where programs might be having difficulty locating preceptors.” Furthermore, Pepin also found the majority of respondents would substitute up to 25% of clinical hours with simulation, but no one said they would substitute 80-100%. 


Pepin recognizes not all students enthusiastically support simulation; some find it very stressful. “They’re worried they’re being evaluated by a faculty member. People see clinical preceptors as protective. You can ask them a question, and they don’t make you feel dumb. Not every preceptor is like that. But they see it as more of a safe environment to ask a question than the person who has control over their grade”. Part of the difficulty in accurately assessing a simulation’s effectiveness is determining its purpose. In Pepin’s survey, most respondents said they use simulation to help students practice their abilities. Other programs reported they use simulation as a high-stakes summative assessment, which could exacerbate a student’s stress. 

It’s the communication that becomes imperative to let participants know whether they’re taking a test that could make or break their education career, or if it’s just training. She says when it comes to managing student stress with simulations as opposed to clinicals, it really depends on the program and the people involved. She encourages longer pre-briefings and appropriate simulation techniques to follow national standards. Pepin elaborated on the importance of strong pre-briefings, saying it’s vital to explain to a student ahead of time what their role is. “Even though I am familiar with simulation and run plenty of simulations as a faculty member, it’s a different role [for students]. Programs really have to look at how we orient students to the environment, to the expectations, to decrease some of that anxiety”. She recommends low stakes mini-simulations to help ease a student in for strictly practice purposes before throwing them into higher stake assessments. 


Pepin presented her findings on April 4th, but going forward, she would like to see the NCSBN study replicated, either by her or someone one else. She also wants to focus on the barriers of high-fidelity simulation in graduate levels , particularly sim options for online programs, tool development and, how faculty are trained. “A lot of programs just assume you can jump in and do it”, Pepin says. “Or they put the onus on the person who runs a simulation lab.” Another extension of Pepin’s work that she wants to explore is integrating more telehealth into simulation, a timely research due to the coronavirus outbreak and heavier emphasis on virtual medicine and remote education. 

Pushing for more instructional advances comes natural for Pepin. She chose UNLV’s Ph.D. in Nursing program because of her passion for nursing education (as well as an asynchronous online course load for her work schedule). She says evaluating a student’s technological capabilities is imperative, whether it’s simulation -related or studying remotely generally. “There’s a widening body of literature out there about how we assume all young persons know how to use any sort of technology we can throw at them. [Study authors] found a lot of college students didn’t even own computers. They had their phones, but if they couldn’t do it on their phone, they didn’t know how to do it or didn’t do it .”