Nursing simulations have been used for over 100 years to better prepare nursing students and equip them with the medical and social skills necessary to provide high quality patient care. The use of simulation in nursing programs has helped students better their clinical skills, increase their confidence with patients, and practice with rare and difficult medical and social scenarios. With states approving up to 50% replacement of clinical hours with simulation hours, many schools have taken this opportunity to provide their students with the technology. With the onset of the COVID pandemic, clinical placements were suspended, and nursing programs turned to virtual simulations. The California Board of Nursing (BON) increased their approval to 75% replacement of clinical hours (AB2288) and, based on the results of this study, the vast majority of California nursing programs increased their percent of simulation use by 100% on average. Simulation was used to replace a higher percent of clinical hours than ever before. This explanatory sequential mixed methods study included a survey, followed by an interview to understand how simulation use changed as a result of the COVID pandemic and explore ways in which simulation technology can impact nursing school admissions for the future. For the quantitative portion, surveys were sent to simulation leaders at 128 of the 149 nursing programs in California, and 43 completed the survey (a 34% response rate). The survey revealed that 90% of programs increased their simulation use overall during the pandemic, 92% of respondents stated that the increase was necessary to address a scarcity of clinical placements, and the percent of clinical hours replaced by simulation during the pandemic rose from an average of 16% to 40%. After the pandemic, 68% of respondents predicted that they would use more simulation than they did before the pandemic, which suggests that schools have increased their buy-in to the benefits of the technology. Lastly, 31% of respondents stated that they were able to increase admission offers in 2020 because of increased simulation use.
From the survey data collected, I interviewed simulation leaders of 5 nursing programs at which simulation impacted enrollment in the past, currently or had a predicted impact on future enrollment. Interviews were conducted virtually and further confirmed that increasing simulation use for the replacement of clinical hours could allow the enrollment of more students. If each student requires fewer clinical placement hours because a higher percent of these hours can be replaced by simulation, then the available clinical placement hours can be spread across more students. However, all interview respondents stated the next biggest barrier of increasing enrollment, insufficient number of faculty, would stifle any hopes of enrolling more students.
Program leaders reported highly positive perceptions of the effectiveness of simulation on student NCLEX scores as well as their clinical competence. Respondents noted that the top three motivators for increasing simulation use before the pandemic was to practice clinical skills, expose students to rare scenarios and assess students’ clinical skills. During the pandemic, the top three motivators shifted; an overwhelmingly high percent of respondents (92%) stated that the top reason for increasing simulation was to address the scarcity of clinical placements.
Although most nursing programs have increased their simulation substantially, there are still programs that are nowhere near the maximum allowable usage. The Diffusion of Innovation theory categorizes schools that have not fully integrated the innovation as being in the implementation stage. Applying the theory and understanding the history and current state of simulation use may help more California programs diffuse the technology, meet the maximum allowable replacement of clinical hours, and use the clinical placements that have opened to increase student admissions
