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Using Simulation to Create the Competencies You Want

Nursing's New Norm

Hospitals today are looking for a broader range of talents in new nurse hires. At the top of the list are leadership skills.

Rather than just completing tasks assigned by a physician, nurses today make critical and life-saving decisions. Take it from Rosanne Greenan, RN, CEN, of Northern Westchester Hospital:


Nurses are no longer caretakers to the healthcare team, carrying out tasks ordered by physicians. Now we are leaders of the team as well as patient advocates and educators. In the ED where I work, nurses are the first to assess patients and often establish the goals for their hospital stay. Physicians view us as colleagues who make concrete observations and offer valuable suggestions.”1


A nurse graduate who lacks leadership skills can be at a disadvantage in today’s new environment. The same holds true for an experienced nurse whose skills are not kept current and reinforced. The prerequisites to meeting today’s nurse expectations are not only hard skills, but soft skills, like teamwork and problem-solving. This is much different than what was expected of nurses 25 years ago.

To meet these increasing expectations, nurse educators are continually turning to simulation. We now know that up to 50% of clinical time can be replaced with simulation, according to the National Council of State Boards of Nursing (NCSBN).2 But, not all simulation is equal. Just as nursing has changed, so too has simulation.

Clinical simulation used to be synonymous with “task training.” Now, simulation is about creating a real-life rehearsal in an environment where task training is only one small part.

Nursing has settled into a new norm. In this article, we discuss how nursing has changed in the past 25 years, and how increasing your simulation fidelity can help you impart the necessary skills in today’s nursing environment.



1. Patient-Centered Care Is Under a Microscope

Nursing has always been at the core of patient-centered care. What has changed is the transparency associated with that care and the assessment of key performance indicators.

Hospitals today are held to strict government standards regarding patient satisfaction and safety measures. In addition, hospitals operate under an unprecedented influence from major patient safety advocacy groups – and with a bold transparency to the public. Nurses are the largest staff element that can influence the results.

Safe, effective delivery of patient care requires that nursing students understand the complexity of healthcare systems, the limits of human factors, safety design principles, characteristics of high reliability organizations, and patient safety resources. These components are critical to the preparation of safe clinicians and essential for 21st Century healthcare delivery.

Dr. Jane Barnsteiner, Professor of Pediatric Nursing, University of Pennsylvania*

Nurse employers are seeking nurses who have a sense for how human factors, system factors, and attitudes can impact patient-centered care. What this means for your simulation program is that fidelity counts. Offering a higher level of realism can better prepare your learners for real-life situations.

At Laerdal, we maintain that simulation is not about the simulator - it’s about the learning experience. When you’re trying to impart both hard and soft skills in a real-world context, however, the simulator remains foundational.

Knowing your circumstances, goals and desired outcomes are great building blocks on which to base the level of realism you need. Stick to those building blocks, and avoid compromising in areas that could detract from the experience your participants need to learn.

2. A New Importance Placed on Diagnosis & Assessment

There is a general expectation – within nursing and among patients – that nurses can give an accurate, detailed patient analysis and make recommendations to other members of the care team. And, while a nurse’s scope of practice has clear limits in the context of assessment and diagnosis, the limits are not what they were 25 years ago. 

Now, we have measurable competencies. Expectations are enormous and much more transparent. That’s a lot of pressure.

Deborah Suda, RN, BSN, MSN, Perinatal Unit Director, Ronald Reagan UCLA Medical Center**

Each year in the U.S., an estimated 12 million people experience diagnostic errors.3 This number equates to 1 in 20 adults per year, and it is typically common diseases that are missed.

This is another case where fidelity counts. To achieve diagnostic fidelity, choose a simulator that can present realistic vital signs, can show signs of consciousness, and has correct anatomy and key landmarks.

You should also consider features like:

  • Correct auscultation sites
  • Realistic limb articulation
  • The ability to perform fundamental therapeutic procedures

These features will be critical to your learner’s initial patient assessment, and will provide an opportunity to conduct physiological monitoring. During a high-fidelity simulation, learners can truly grasp the reality of their actions.

When coupled with validated scenarios, a high-fidelity simulator allows for evidence-based decision-making, followed by clinical interventions with “real” human reactions. This becomes especially important when training for low-frequency, high-acuity emergencies as part of a team.

Diagnosis is the foundation of medicine; without the right diagnosis, patients don’t receive the right treatment.

Dr. Hardeep Singh, Researcher, Baylor College of Medicine***

Simulation in this context helps to promote an environment for nurses to focus on critical thinking, clinical reasoning, and clinical judgment skills – in addition to acquiring knowledge.



3. "Transition Shock" Is a Growing Concern

“Transition shock”, the jump from nursing education to nursing practice, is credited as one of the major reasons for high turnover rates among new nurses.4 With new nurse attrition rates as high as 25% within the first year on the job, concern is mounting. 5

Managerial confidence in new nurses is also a concern within many hospitals. A survey shows that only 10% of nurse executives believe that new nurses are competent to perform their jobs.6 At the same time, the desire to minimize the time-to-floor and maximize new nurse productivity is on the average nurse executive’s mind.

All of this can lead to workforce stress, and it can manifest itself in a decrease in patient safety and patient satisfaction. One study showed that 75% of new nurses observed had been seen to commit medication errors.7

Often, institutions will seek to address this kind of issue through didactic training, counseling or a review of protocol and procedures. Measures like these rarely generate a level of engagement that proves effective.

High-fidelity simulation can have a major impact on these circumstances, not only as a form of training but as a form of intervention. Simulation engages learners, increases learner retention, and directly impacts patient care management. 9,10,11

Whether you represent a nursing school or a hospital, approaching simulation as an intervention can help you narrow your focus and impart the confidence and competence that nurses need in today’s nursing environment.



Simulate What Nurses Really Need to Achieve

The changes that the nursing field has seen within the past 25 years point to a need for more hands-on, inclusive, and immersive experience for nurses in training. With additional attention on teamwork, communication skills and safe care practices, nurses benefit from earlier and additional exposure to simulation-based training.

Research findings suggest that students who engage in simulations experience an increase in overall self-efficacy, develop confidence to assess vital signs, and provide an improved patient education.12

They think as the nurse. They are making decisions independently with the knowledge they have, and if they go down the wrong pathway, that’s OK, because it’s a safe learning environment. If they make a mistake, they’re not going to harm a patient.

Sandy Swoboda, Simulation Educator, Johns Hopkins University School of Nursing ****

Nursing now requires an extraordinary focus on patient safety, diagnosis, assessment, and clinical reasoning. At every level, nursing today involves a new level of leadership, and a new sense of ownership.

High-fidelity simulation can provide the necessary support for nurses to develop with competence, with compliance, and positioned to optimize patient care. If you would like to better prepare your nurses to meet the challenges in healthcare today, please contact us. We are here to help.


  1. (2013). Q & a: Now and then in nursing. Retrieved from  
  2. National Council of State Boards of Nursing. (2017). Simulation study. Retrieved from
  3. Baylor College of Medicine. (2017). Reducing misdiagnosis: Time for the next chapter in improving patient safety. Retrieved from
  4. Harwood, M. (2011). Transition shock -- hitting the ground running. Nuritinga, (10), 8-18. Retrieved from
  5. Twibell, R. & St. Pierre, J. (2012). Tripping over the welcome mat: Why new nurses don’t stay and what the evidence says we can do about it. American Nurse Today, 7(6).
  6. Ibid
  7. Ciocco, M. (2016). Fast facts for the nurse preceptor: Keys to providing a successful preceptorship in a nutshell. Springer Publishing.
  8. Pfaff, K.A., Baxter, P.E., Jack, S.M., & Ploeg, J. (2014). Exploring new graduate nurse confidence in interprofessional collaboration: A mixed methods study. International Journal of Nursing Studies, 51(8); 1142-1152. doi: 10.1016/j.ijnurstu.2014.01.001           
  9. Frengley, R., Weller, J., Torrie, J., Dzendrowskyj, P., Yee, B., Paul, A., et al. (2011). The effect of a simulation-based training intervention on the performance of established critical care unit teams. Critical Care Medicine, 39(12), 2605-2611. Doi 10.1097/CCM.0b013e3182282a98       
  10. Lateef, F. (2010). Simulation-based learning: Just like the real thing. Journal of Emergencies, Trauma, and Shock, 3(4), 348-352. Doi 10.4103/0974-2700.70743            
  11. Fowler Durham, C.F. & Alden, K.R. (2008). Patient safety and quality: An evidence-based handbook for nurses. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from         
  12. Bambini, D., Washburn, J. & Perkins, R. (2009). Outcomes of clinical simulation for novice nursing students: Communication, confidence, clinical judgment. Nursing Education Perspectives 30(2), 79-82.     


* Barnsteiner, J. (2011). Teaching the culture of safety. OJIN: The Online Journal of Issues in Nursing, 16(3). Doi 10.3912/OJIN. Vol16No03Man05  

 ** Waszak, D. (2017). Nursing then and now. Retrieved from

 *** Baylor College of Medicine. (2017). Reducing misdiagnosis: Time for the next chapter in improving patient safety. Retrieved from

**** Fink, J. (2014). Playing a bigger part. Retrieved from