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“No industry in which human lives depend on the skilled performance of responsible operators has waited for unequivocal proof of the benefits of simulation before embracing it.”

-David M. Gaba, MD


  • Describe the history of simulation and influential factors in its use.

  • Identify the philosophical framework for simulation.

  • Discuss adult learning principles that pertain to simulation-based activities.

  • Recognize the legal and ethical issues common to simulation-based activities.

  • Review published standards and guidelines for simulation-based activities.

  • Understand the code of ethics for simulationists.

Introduction to Simulation

Today's dynamic and complex healthcare environment requires healthcare providers to demonstrate evidence-based clinical judgment while providing safe, reliable, and effective care as a collaborative member of a healthcare team (Frankel, Haraden, Federico, & Lenoci-Edwards, 2017; Institute of Medicine [IOM], 2004a, 2011). National leaders, organizations, and accreditation agencies have challenged nurse educators to transform the current educational process to a learner-centered, active pedagogy.

In 2004, the IOM—renamed the National Academy of Medicine (NAM) in 2015—provided recommendations for evidence-based revisions in the clinical education of healthcare professionals. Multiple IOM/NAM reports (IOM, 2001, 2003, 2004a, 2011, 2015) have stressed the need for research in order to:

  • Understand how to apply adult learning principles to clinical education

  • Obtain empirical evidence to support the integration of new technologies, including simulation, into curricula

  • Explore the outcomes achieved by different types of teaching technologies

  • Understand the process of translating knowledge to clinical practice

  • Perfect the science of team-based care

Simulation combined with other technologies facilitates the development of skills, competencies, and clinical judgment needed to provide safe, quality patient care (Benner, Sutphen, Leonard, & Day, 2010; Gaba, 2004; IOM, 2004a, 2004b, 2011). For example, the IOM (2004b) report Keeping Patients Safe states that simulation is the most useful approach for developing skills related to unpredictable situations and crises. Similarly, Benner et al. (2010) support the development of clinical reasoning and interprofessional communication through new technologies such as simulation. Additionally, learning in a simulated environment is transferable to the clinical setting but enables educators to monitor learner progress without risk to patients (IOM, 2011). Simulation is a complement to—rather than a substitute for— actual patient care. It promotes a learner's ability to integrate theory into a patient-care situation in a safe and controlled environment (International Nursing Association for Clinical Simulation and Learning [INACSL] Standards Committee, 2016b).

Definition of Simulation

The definition of simulation has evolved over time:

  • In 2004, Gaba described simulation as “a ‘technique,’ not a technology, to replace or amplify real experiences with guided experiences, often immersive in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion” (p. i2).

  • Jeffries (2005) described simulation as ...

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