Developing Simulated Learning Experiences

Picture of Jennifer Storer
Simulation/Clinic Ratio
by Jennifer Storer - Wednesday, September 17, 2008, 4:59 PM

Currently, we are in the process of substituting a clinical day for a day in the simulation lab. I have heard many different trains of thought and rationale on this and I know that each institution has different standards regarding this topic. I'm wondering if anyone knows of any resources/documents that can shed any light on the recommended amount of time in simulation versus clinical? For example, I have heard many say they use a 3:1 or 2:1 ratio (3 hours of clinical=1 hour in the simulation lab (including debriefing)). I have heard of others having 4 simulations within a 6 hour clinical, and yet others stating that 1 hour of clinical equals 3 hours of simulation! Our state Board of Nursing has not yet made any guidelines on this. I'm just trying to figure out what will be best for our program and wondering if anyone can lend me some insight on this issue?

Thank you for your help!

Jennifer Storer
Assistant Professor of Nursing
Kirkwood Community College
Cedar Rapids, IA

Picture of Suzie Kardong-Edgren
Re: Simulation/Clinic Ratio
by Suzie Kardong-Edgren - Wednesday, September 17, 2008, 9:13 PM

Love this question. If you have run simulations with students, or listened to them as they debrief and evaluate a scenario, there is almost no student who doesn't say they learn more in simulation than in real clinical. (So, 2 hours of simulation =4 hours of "real" clinical) This is probably because things can be taken to their natural progression in a safe environment. Tanner or Oermann said, we need to stop focusing on hours in clinical and start focusing on what is happening in those hours. This would be a great dissertaion topic, using the work of Hodnett in labor and delivery several years ago. Is a student learning anything if they do the same thing every single day in clinical and nothing happens? We have almost no support for what we do now, except tradition. In fact what the data shows is that what we are currently doing does NOT prepare a student to practice well. (re" Del Bueno, multiple citations)

A smarter approach might be to say that in this semester or quarter, we will make sure that every student takes care of a diabetic crisis of some sort, an acute coronary syndrome, a pulmonary embolus, has the opportunity to recognize the need to call a code, start it, and act appropriately till the code team arrives, calls and gives a report to a doctor and uses SBAR appropriately, demonstrate the abilty to  recognize hypovolemic shock and act appropriately. Because I can guarantee you that most students will not get this opportunity while in clinical, but will be expected to do all of these things almost immediately upon graduation.

I know anecdotally from students coming to find me after summer jobs, that simulations the previous semester helped them recognize and act appropriatly when others did not know what was happening. One student actually told me, "I recognized what was happening, started to freak out and then said to myself, wait, I didn't do this well in simulation, but I KNOW what to do now". So she did.

Bottom line, simulation should be worth more than clinical hours. BUT, simulation does not replace all clinical hours. Perhaps students should do required simulated clinical hours prior to real hospital hours, so they get maximum bang for the buck while they are using this increasingly precious commodity of time on a clinical floor.

Picture of kathee  long
Re: Simulation/Clinic Ratio
by kathee long - Wednesday, February 20, 2013, 4:35 PM

My school is looking at the same topic. Our state has no regulations but our director thinks that the ratio should be 1:1. On the clinical side of things, we know that the ratio is not proportionate. I'd love to know what schools are doing now...almost 5 years after this post...has anything changed?

Picture of Crissy Hunter
Re: Simulation/Clinic Ratio
by Crissy Hunter - Thursday, February 21, 2013, 4:36 PM
we are in the same boat. Our program was doing it on a 1:2 basis for the last 2 years but are now moving in back to 1:1 due to administration. I think all the research states that simulation is a benefit to students, can be more intensive than regular clinicals, however until the NCSBN study comes out next year or so, we are all just in a stand still. Please feel free to email me if any more questions,
Crissy Hunter
Picture of Debbie Murphy
Re: Simulation/Clinic Ratio
by Debbie Murphy - Wednesday, February 27, 2013, 10:56 AM
Our state has not made a determination of how much clinical time can be substituted with simulation nor have they considered the ratio of substitution. They handle it on a case by case basis with the individual school submitting a request and receiving board approval. We currently substitute 1 hour of clinical time each week on a 1:1 ratio. We have every student in each of our 4 clinical courses come for 2 hours of simulation every other week. They come in groups of 7-8 and go through a simulation that is tied to what they are doing in theory. They go through 27 simulated experiences over the course of our ADN program. One of those however, is a multi-patient scenario with 4 patients. All of the patients have electronic medical records that I have entered into SimChart by Elsevier and they have iPads and a laptop on wheels in the simulation room with them to view and document in the medical record. Prior to SimChart they all had a paper chart. We think this has been extremely effective and are currently looking at increasing the amount of clinical time we substitute. Our only limitation at this time is faculty and space so that we can do more than one simulation at a time. I am enjoying this discussion to see how other schools approach simulation. Debbie