Clinical Simulation in Nursing (2021) 50, 107-111

www.elsevier.com/locate/ecsn Innovations in Simulation

Overcoming Resistance: Implementation of

100% Simulation for First Semester Nursing
Students
Angela Mulcahy, PhD, RN, CMSRN, CHSEa,*, Darla Gruben, RN, MSN, CHSE,
CNEb, Elizabeth Wells-Beede, PhD, RN, C-EFM, CHSEb
a
Clinical Assistant Professor, Prelicensure Program Coordinator, Texas A&M University Health Science Center, College
of Nursing, Round Rock, TX, USA
b
Clinical Assistant Professor, Texas A&M University College of Nursing, Round Rock, TX, USA

KEYWORDS and highlighted simulation as an alternative to traditional

Simulation;
Clinical reasoning; Clinical education; Clinical simulation; Nursing
education
Abstract: Clinical learning in the first semester of nursing school is
often challenging and difficult for students to assimilate multiple
subjects while applying clinical skills. One college of nursing
created a first semester simulation experience that helped
students to enhance clinical reasoning by aligning content in
multiple courses, allowing for application of information, and linked
clinical skills learned each week to the concept of total patient
care. The resulting change to course structure com bined basic
physical assessment and fundamental nursing care to one course
allowing students to un derstand the application of assessment to
nursing practice and skill.
Cite this article:
Mulcahy, A., Gruben, D., & Wells-Beede, E. (2021, January).
Overcoming resistance: Implementation of 100% simulation for
first semester nursing students. Clinical Simulation in Nursing,
50(C), 107-111. https://doi.org/10.1016/j.ecns.2020.09.003.
2020 International Nursing Association for Clinical Simulation and
Learning. Published by Elsevier Inc. All rights reserved.
The 2014 National Council of State Boards of Nursing
National Simulation Study identified the growing difficulty
in clinical placements for prelicensure nursing students
clinical experiences (Hayden, Smiley, Alexander, Kardon
Egren, & Jeffries, 2014). The increasing acuity of
patients in the hospital setting adds an increased
complexity unfit for the first semester undergraduate
nursing student. In addition to increased acuity, nursing
programs have grown to meet the demand for more
registered nurses in the
Funding: This innovation in simulation received funding from the
Texas Higher Education Board.
* Corresponding author: mulcahy@tamu.edu (A. Mulcahy).
workforce, increasing the demand for clinical learning
placements.
A large southwestern university was awarded funding
from the Texas Higher Education Coordinating Board to
transition the entire first semester of clinical learning for
the bachelor of science in nursing program from direct
patient care to simulated patient care activities. This
program’s state board of nursing does not have a
required total for the number of clinical hours completed
in a direct care setting; simulation experiences may
account for 50% of total clinical hours. The
Fundamentals of Nursing Course introduces the
prelicensure nursing student to the foundational skills in
nursing as well as the nursing process. Under the
previous curriculum, students in the fundamen tals
course experienced four simulated experiences during a

1876-1399/$ - see front matter 2020 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ecns.2020.09.003
100% Simulation First Semester 108

15-week semester. The remainder of the clinical hours
were completed in a healthcare facility under faculty
direction. Clinical experiences in the healthcare facility
presented challenges and were inconsistent because of
patient census, faculty demand, faculty-to-student ratios,
and student inexperience with the hos
faculty to spend focused time with the students engaged
in deliberate practice to ensure skill acquisition and the
development of clinical judgment. The college of nursing
had an existing extensive simulation program at the time
that changes to clinical learning were proposed to the
fundamen tals course. The adult health courses in the
curriculum all
Key Points The Need for Change simulation.
Simulation is an effective method of
providing meaningful clinical learning ex Faculty identified a need to make a Innovation in Simulation
periences in first se mester nursing change in which clinical experiences
students. were designed to meet clinical Supported by the awarded grant
Alignment of content in the first objectives in the first semes funding, the curriculum was redesigned
semseter courses assisted learning and contained a simulation component in to allow students to participate in
applica tion of clinical reasoning when addition to the clinical requirements of clinical simulations consistent with
applied in simulated learning the course. Courses that used knowledge and skills normally acquired
experiences. simulation for clinical hours used in a traditional clinical setting. The
Faculty knowledge of simulation standardized patients in a simulated simulated-based learning experiences
teaching modalities was neces sary to clinical environment. In-situ simulation were designed to incorporate the
the success of simulated learning training and sched uled training nursing skills and competencies
experiences. sessions that followed the INACSL essential for fundamentals students to
pital setting. Scheduling is sues meant Standards in Best Practice℠ master before progressing in the
students completed direct patient care (INACSL, 2016a,b,c) were used to help nursing program. Examples include
clinical hours at different times during familiarize faculty with the standards led medication administration, basic patient
the semesters, leading to different by the team awarded grant funding. safety techniques, and physical
levels of knowl edge, skills, and comfort Beginning-level courses from the assessment. Guided by Experiential
for each group. All these factors led to a University of Washington Teaching with Learning Theory (Kolb, 2015), the
minimal ability to complete the clin ical Simulation modules (Zierler, Kardong- simulated
objectives necessary to advance to the Edgren, Pringle, Berg, & Patillo, 2020)
next course with a solid foundation in were also used for faculty new to
basic nursing care.
ter of the nursing program. These curricular changes administering medications independently. During the
were structured with the Quality and Safety Education for grant period, students in the Foundations course
Nurses competencies and knowledge, skills, and experienced 16 scenario-based ex periences over the
attitudes as a foundation (Cronenwett, et al., 2007). As a course of a 15-week semester with no traditional direct
result of growth within the program, the number of care clinical contact hours. An example of simulation
clinical sites available for clinical learning became limited experiences linked to theory and Quality and Safety
and could not accom modate all student clinical Education for Nurses knowledge, skills, and attitudes
experiences. First semester fac ulty saw a need to can be found in Table 1.
implement creative strategies for students to gain clinical In addition, students were exposed to innovative peda
experience in a systematic way while setting the gogical instruction to facilitate skill development and
foundation for basic nursing care. Simula tion was preparation for subsequent areas of study. All simulation
identified as the modality for meeting clinical ob jectives experiences were standardized to maintain consistency
and enhancing clinical learning, and a need existed to throughout the curriculum and to provide each student
increase and improve the utilization of simulation for with a holistic set of experiences at the foundational
student learning. The International Nursing Association level. The equipment acquired through the grant
for Clinical Simulation and Learning (INACSL) Standards included elec tronic stethoscopes, cameras, interactive
in Best Practice℠ were used to construct stimulations, whiteboards, lap tops, and rolling computer carts. All
fac ulty development, and training in the areas of items purchased were used to enhance the learning
Simulation Design, Objectives & Outcomes, Facilitation, experience.
and Debrief ing (INACSL, 2016a,b,c).

Simulation Within Our Program Innovation in First Semester Course Design

The simulated environment is a safe learning The magnitude of planning to create a meaningful experi
environment for learning new nursing skills and ence for the learners to meet all their clinical objectives
establishing compe tencies. This environment provides a was
unique opportunity for
learning experiences allowed the students to make
judgments about patient care along with preparing and pp 107-111 Clinical Simulation in Nursing Volume 50
100% Simulation First Semester 109

Table 1 Example of Simulation Experiences Related to Didactic Content

Theory Courses KSA Learning Labs Simulation
Example 1
Pathophysiology Anti-inflammatory Asepsis
Health and Disease Anti-allergic Safety
Immunity and Immunologic Vital Signs
Inflammation Example 2
Pathophysiology
Pharmacology Foundations Respiratory Illnesses
Pharmacology Precautions Activity Clinical on Campus
Respiratory Medications with 30-minute scenario with a
Metered Dose Inhalers and Standardized Patient. Patient history of
Nebulizers chronic
Foundations obstructive pulmonary disease, shortness
Oxygenation of breath, oxygen saturations 82%, thick
Thorax and Lung yellow sputum, infection control
Deliberate Practice
Assessment
Oxygen Devices
Example 3
Assessment Practice
Deliberate Practice
Hand Hygiene
Sterile Gloving
Vital Signs Practice
Environmental Safety Clinical Judgment/Nursing
Assessment Clinical Process Practice
Judgment/Nursing Hyperventilation Case Study
Process Practice Patient Care Clinical
Personal Protective 1.5-hour scenario. Students are the
Equipment and nurses and the patients to practice vital
Transmission signs, hand hygiene, and environmental
safety

Pathophysiology Deliberate Practice Clinical on Campus

Genitourinary and Abdominal Assessment OSCE (end of semester)
Gastrointestinal Diseases Indwelling Urinary 30-minute scenario with a standardized
Insertion Practice patient status post abdominal wound
Nasogastric insertion Safety abscess, colostomy, medication
Assessment Practice administration, environmental safety, ten
Pharmacology Clinical Judgment/Nursing Process Practice minute bedside assessment
Genitourinary and Gastrointestinal Constipation and
Medications Diarrhea Case Study
Three-hour scenario with a standardized
perioperative patient. Indwelling urinary
catheter insertion, morning care, vital signs,
Foundations
environmental safety, medication
Elimination (Bowel and Urinary) Nutrition
administration

Note. KSA ¼ knowledge, skills, and attitudes; OSCE ¼ Objective Structured Clinical Examination.

a three-year journey. Semester after semester, the
Funda mentals course made improvements based on
outcomes, faculty input, and student evaluations. Once
100% of
clinical experiences in simulation was implemented, it
became clear to faculty that control over the introduction
and exposure of content was obtainable. Therefore,
through
pp 107-111 Clinical Simulation in Nursing Volume 50

100% Simulation First Semester 110

Pulmonary Pulmonary Assessment
Pathophysiology
Figure 1 Week of content structure.
a collaborative effort, faculty began alignment of the
content in the first semester core courses, including
Health Assessment, Pharmacology, Pathophysiology,
and Fundamentals.
The content in the first semester courses was
structured differently for each course. Content
organization followed different methods of organization.
For example, the Health Assessment course delivered
content in a Head to Toe body system approach,
Pathophysiology and Pharmacology were organized by
the sequencing of the textbooks, and the Fundamentals
course was structured by Maslow’s Hierar chy of Needs
(Maslow, 1968). A need existed to align first semester
content to provide instruction and clinical patient
experiences that linked theory to practice. Therefore, the
first semester core courses were restructured to align all
content in an organized systems approach. As part of
course alignment, it was proposed the content and skills
for the Fundamentals and Health Assessment courses
were com bined into one clinical course (Mulcahy &
Gruben, 2019). The resulting course, Foundations of
Nursing Prac tice, combined the content and clinical
components of both the Health Assessment and the
Fundamentals courses with five credit hours of theory
and three credit hours of clinical. The learners
experience 100% clinical contact time in simulation (135
hours) during the first semester. The clin ical hours
distribution are as follows: 76 hours of deliberate skills
and assessment practice, 48 hours of clinical simula
tions with formative evaluations using standardized pa
tients, nine hours of skill check-offs for competency,
ending the semester with a two-hour Objective
Structured Clinical Examination summative assessment
with a stan dardized patient. The process of course
content alignment and restructuring developed over
three semesters with ongoing collaboration and
commitment by faculty.
Week of Content Structure
A typical class week starts with a lecture in the
Pathophys iology class with instruction about the
disease process of respiratory illnesses, and in the
afternoon, students learn the assessment techniques of
the thorax and lungs. The next day, students learn the
pulmonary pharmacological treat ments followed by
spending the afternoon incorporating the nursing
process, adding oxygenation interventions/skills, and
discussing the learning of the week. On the third day,
Pulmonary Pharmacology Pulmonary Nursing Skills
students arrive in the simulation laboratory prepared for
deliberate practice of skills, including the assessment of
the thorax and lungs, administration of oxygen devices,
nasopharyngeal suctioning, and teaching their patients
breathing and coughing techniques.
Included in the skills laboratory day is a case study
activity where students work in groups with faculty over
sight to create a care plan using the nursing process and
clinical judgment models engaging the content from the
week. On the fourth day, students complete a simulated
clinical experience with a standardized patient who is
experiencing shortness of breath with a history of respira
tory illness. This simulation is designed as a formative
assessment with students receiving one-on-one
feedback from faculty using advocacy inquiry followed by
a small clinical group debrief (Figure 1).
Discussion and Addressing Challenges
With a large undertaking, there were many challenges
experienced in the implementation of 100% simulation to
replace clinical contact hours in the first semester. With
the increase in simulation, there were faculty not as
familiar with simulation as a pedagogy. Experienced
simulation faculty only comprised half of the course
faculty during the implementation period. Simulation
education and training were provided during the grant
period, including the certification of eight experienced
faculty as certified healthcare simulation experts.
In addition, faculty assigned to the course and faculty
teaching in subsequent semester clinical courses
verbalized concerns regarding student preparation and
readiness for traditional clinical experiences with all the
traditional clinical hours in the first semester spent in
simulation. Faculty were concerned students would not
be properly prepared, and nursing skills could not be
applied in a simulated setting; traditional patient
experiences were required for the acquisition of
knowledge. Course planning huddles occurred at each
phase of implementation and as faculty rotated in and
out of the course. Discussions were also held with
faculty in courses after the first semester to explain the
course outline and reassure faculty that students would
be prepared to move forward.
Students also expressed concern that they would not
be participating in traditional clinical experiences in their
first
pp 107-111 Clinical Simulation in Nursing Volume 50
 100% Simulation First Semester 111

semester and contacted the Dean of the college.
Therefore, an information session was held before the
start of the semester, and students were presented with
the evidence, the pedagogy, and overall plan for the
implementation of simulation as 100% of the clinical
hours in the first semester. Although many students
remained skeptical, fears were eased, and students
went into the semester optimistic for the experience.
Planning and preparation were key to the proper use
of space and multiple standardized patients. The
multiple patient simulations were logistically challenging
and required additional organization and resource
utilization. The use of simulation as clinical replacement
for 100% of the clinical hours in the first semester
coincided with an increase in enrollment with the college.
Although the change to the first semester clinical
learning aided in clinical placements, challenges with
scheduling and the cost of the increase in simulation
were not accounted for by grant funds.
INACSL Standards Committee. (2016b). INACSL standards of best
prac tice: SimulationSM debriefing. Clinical Simulation in Nursing,
12(S), S5-S12. https://doi.org/10.1016/j.ecns.2016.09.005
INACSL Standards Committee. (2016c). INACSL standards of best
prac tice: SimulationSM facilitation. Clinical Simulation in Nursing,
12(S), S5-S12. https://doi.org/10.1016/j.ecns.2016.09.005
Jeffries, P. R. (2008). Getting in S.T.E.P. with simulations: Simulations
take educator preparation. Nursing Education Perspectives, 29, 70-73.
Kolb, D. A. (2015). Experiential learning: Experience as the source of
learning and development (2nd ed.). Upper Saddle River, NJ: Pearson
Education Limited. Accessed October 21, 2020.
Maslow, A. (1968). Toward a psychology of being (2nd.ed.). New York:
Van Nostrand-Reinhold.
Mulcahy, A., & Gruben, D. (2019). From fundamentals to foundations:
The beginnings of nursing practice. Vail, Colorado: Podium
Presentation Presented at the Nurse Educator’s Conference in the
Rockies.
Zierler, B. K., Kardong-Edgren, S., Pringle, E., Burg, G., & Pattillo, R. E.
(2020). Teaching with Simulation Lessons. Center for Health
Sciences Interprofessional Education Research and Practice,
University of Wash ington. Retrieved from
https://collaborate.uw.edu/resources-and training/online-training-and-
toolkits/simulation/.

Conclusion

The utilization of simulated-based learning experiences

as a substitution for traditional clinical hours did not have
a negative impact on the learning or progression of the
student. Students were successful in subsequent
courses, faculty reported a difference in the students’
clinical judgment when entering the clinical setting, and
the program continued with a 100% pass rate on the
National Council Licensure ExaminationdRegistered
Nurse exam ination. Students went on to future
semesters not only prepared but are now shocked to
learn first semester clinical experiences historically took
place in a direct care setting. In addition, the ongoing
need for faculty expertise in the pedagogy of simulation
(Jeffries, 2008) was identified, and future funds were
sought to seek certification for faculty us ing simulation
and to support novice faculty in ongoing development. pp 107-111 Clinical Simulation in Nursing Volume 50
Acknowledgments

Texas Higher Education Coordinating Board Nursing

Inno vation in Simulation Grant funded this project. In
addition, the authors wish to thank the many faculty
involved in the simulations/restructuring of courses who
have tirelessly devoted their knowledge and skills to the
benefit of our students.

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