Good morning!

Simulation, whether virtual or in-person has immense potential for the development of nursing skills and confidence (Koetting & Freed, 2017). Simulations may be digital or not, graded or not, and used in conjunction with gamification (Wiggins, 2016). A lot of discussion around simulation is focused on hand-on high fidelity simulation, but simulation can happen in a variety of ways. The degree of fidelity that is needed depends on what is being taught. Some studies suggest that online simulation may even be better than in-person simulation due to accessibility and learner safety (Duff, Miller, & Bruce, 2016). I think a combination of approaches is best.

Thumbs up Bitmoji

To maximize the potential of simulations, there are two really critical things I think teachers need to do: create a safe environment for learning and debrief! Of course there are other important things (like being prepared). However, these two are absolutely critical for learning and easy to forget.

Safe Learning Enviornment

First year students in particular are likely to be quite nervous entering a simulation, especially when it is their first time. The facilitator’s job is to make them feel safe. The outcomes need to be realistic. Time needs to be taken to orient them to the structure of the simulation. Orientation has been found to decrease anxiety and improve confidence for learners (Bommer et al., 2018). Researchers have also found that students will become more relaxed as the simulation progresses (Al-Ghareeb, McKenna, & Cooper, 2019). While simulation may be stressful, there is evidence to suggest that it decreases anxiety for subsequent assessments in the clinical setting (Stunden, Halcomb, & Jefferies, 2015). The ultimate goal of simulation is to help students get more learning from their clinical experience.

Safe! Bitmoji


Reflection is a critical component of the debrief that needs to be structured (previous blog). An integrative literature review captured some essential considerations for debriefing in simulation-based education (Hall & Tori, 2017). They found that:

  • Video or facilitator assisted debriefing can be effective.
  • Debriefing after the simulation is over is more effective than throughout the simulation. It is important to do the debrief immediately after the simulation is over.
  • Clear rules of conduct help to decrease anxiety. Confidentiality should be respected. Constructive, respectful and honest feedback should be used. Several authors suggest having a confidentiality agreement to help learners feel safe.
  • The person facilitating the debrief should be focused on closing gaps between the practice they see and what should happen.
  • It takes training and skill to effectively lead a debriefing session with students.
  • Poor debriefing can harm learner performance. As facilitators it is important to critically reflect on hoe debriefing is impacting the learner.
  • Focus debriefing on the learning outcomes of that simulation. The learning objectives are set before the experience and helps learners know what they need to accomplish.
  • Several approaches to debriefing are outlined in the article. A common thread is the need for structure and positive comments. A simple one to remember is the Plus Delta – ask students what went well, what did not go well, and how they would change their practice in the future.

The Bottom Line

Have some empathy for your learners. Simulation can be overwhelming for students. Have some structure in mind to promote reflection for the learners, but be flexible enough to meet them where they are. Above all, be positive and constructive. Make sure to comment on anything that they should not do with a client with rationale, but be empathetic about it. Say something like “I found it difficult to remember to raise the bed when I was in first year, but it really helps to protect my back and there are so many nurses I have heard of with back injuries.”  Remember to make them feel safe. Aim to build their confidence.

Thank you!


Many Thanks! Bitmoji

The Facilitator Innovation  

One of the innovative things we are doing in Nursing is placing year three students who are taking a course about teaching in the role of facilitator. They are facilitating an entry-level simulation for year one students. We hope that year three students are able to be empathetic and encouraging to the year one students. They have been reviewing theory in class about the importance of learning objectives, how to teach, and the need to be constructive. We look forward to seeing the outcome of this strategy.

Bitmoji with “Thoughts?” written beside it.


Al-Ghareeb, A., McKenna, L., & Cooper, S. (2019). The influence of anxiety on student nurse performance in a simulated clinical setting: A mixed methods design. International Journal of Nursing Studies, 98, 57–66.

Bommer, C., Sullivan, S., Campbell, K., Ahola, Z., Agarwal, S., O’Rourke, A., … Liepert, A. E. (2018). Pre-simulation orientation for medical trainees: An approach to decrease anxiety and improve confidence and performance. The American Journal of Surgery, 215(2), 266–271.

Duff, E., Miller, L., & Bruce, J. (2016). Online virtual simulation and diagnostic reasoning: A scoping review. Clinical Simulation in Nursing, 12(9), 377–384.

Hall, K., & Tori, K. (2017). Best practice recommendations for debriefing in simulation-based education for Australian undergraduate nursing students: An integrative review. Clinical Simulation in Nursing, 13(1), 39–50.

Koetting, C., & Freed, P. (2017). Educating undergraduate psychiatric mental health nursing students in screening, brief intervention, referral to treatment (SBIRT) using an online, interactive simulation. Archives of Psychiatric Nursing, 31(3), 241–247.

Stunden, A., Halcomb, E., & Jefferies, D. (2015). Tools to reduce first year nursing students’ anxiety levels prior to undergoing objective structured clinical assessment (OSCA) and how this impacts on the student’s experience of their first clinical placement. Nurse Education Today, 35(9), 987–991.

Wiggins, B. E. (2016). An overview and study on the use of games, simulations, and gamification in higher education. International Journal of Game-Based Learning, 6(1). Retrieved from

More on simulation:


Laura Killam is an experienced nursing educator from Northern Ontario with a keen interest in improving student learning through innovation. For more information please visit


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