Simulation in Nursing Education: Types, High-Fidelity Evidence, Advantages, Disadvantages and Examples

Published · By VMS, Alehundred Studios

Simulation in nursing education is guided clinical practice on a manikin, a trained actor, a task trainer or a virtual patient, followed by a debriefing, so students can make real-time decisions with no risk to patients. The strongest evidence, from NCSBN, shows that high-quality simulation can replace up to half of traditional clinical hours with comparable outcomes.

Below are the types, what "high-fidelity" means, the real advantages and disadvantages, examples by course and the standards that govern it. For headsets specifically, see our guide to VR nursing simulation.

What is simulation in nursing education?

Nursing simulation is a teaching method that recreates clinical situations so students can practice assessment, decisions and skills before and alongside real patient care. The NCSBN Simulation Guidelines define simulation as "A technique, not a technology, to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner."

The National League for Nursing describes the purpose in its vision statement on teaching with simulation: "Simulation provides a rich learning opportunity for students to integrate theory with practice while making real-time clinical decisions in an environment that poses no risk to patients."

Whatever the equipment, a simulation session follows the same three parts:

  1. Prebriefing: objectives, the patient's background and the ground rules.
  2. The scenario: the student assesses the patient, recognizes the problem and acts.
  3. Debriefing: a guided discussion of what happened, why, and what to do next time.

What are the types of simulation in nursing education?

The main types are low-fidelity methods, task trainers, manikins, standardized patients, computer-based and virtual simulation, and hybrid simulation. The Healthcare Simulation Dictionary, published by the Society for Simulation in Healthcare with AHRQ, defines each one:

What is high-fidelity simulation in nursing education?

High-fidelity simulation is realistic and interactive enough that the student responds as if the patient were real, and it is not limited to expensive manikins. The SSH dictionary defines it as "experiences that are extremely realistic and provide a high level of interactivity and realism for the learner," and adds: "It can apply to any mode or method of simulation; for example: human, manikin, task trainer, or virtual reality."

Fidelity is also about coherence. In the same dictionary, conceptual fidelity "ensures that all elements of the scenario or case realistically relate to each other so that the patient makes sense as a whole to the learner(s) (e.g., vital signs are consistent with the diagnosis)." Findings that fit together are what teach clinical reasoning.

What does the research show? A systematic review and meta-analysis in BMJ Open pooled 33 studies of high-fidelity patient simulation built on life-threatening scenarios. Compared with any other teaching method, it showed "significantly larger effects sizes for knowledge (d=0.49, 95%CI [0.17 to 0.81]) and performance (d=0.50, 95%CI [0.19 to 0.81])." Most sessions used cardio-circulatory scenarios (54.5%), followed by respiratory scenarios (29.1%). The same review found no significant differences for satisfaction, self-confidence or self-efficacy, and reported "Significant heterogeneity among studies," so the gains are clearest for what students know and do.

Why is simulation important in nursing education?

It matters because it gives every student practice with critical situations that clinical placements cannot guarantee, without putting patients at risk. The NLN points to "the increasing complexity of patient care, and the growing lack of clinical placements for students," and notes that "Simulation can standardize clinical experiences in this time of unpredictable and often unequal clinical learning opportunities."

It also has regulatory weight. In the NCSBN National Simulation Study, students from 10 prelicensure programs were randomized to a control group (up to 10% of clinical hours in simulation) or to groups that replaced 25% or 50% of clinical hours with simulation, and 666 completed the study. At graduation there were no statistically significant differences in clinical competency (p = 0.688), comprehensive nursing knowledge (p = 0.478) or NCLEX pass rates (p = 0.737). The authors concluded that the results "provide substantial evidence that substituting high-quality simulation experiences for up to half of traditional clinical hours produces comparable end-of-program educational outcomes and new graduates that are ready for clinical practice." NCSBN's proposed model rule followed: a program "may use simulation as a substitute for traditional clinical experiences, not to exceed fifty percent (50%) of its clinical hours." Each state board decides its own rule; the INACSL Simulation Regulation Map "includes the state Board of Nursing regulations for pre-licensure nursing programs."

What are the advantages and disadvantages of simulation in nursing education?

The main advantages are safety, consistency and repetition, and the main disadvantages are cost, faculty time and the conditions needed to make it work.

Advantages:

  1. No risk to patients. Mistakes become lessons, not harm.
  2. Every student gets the key cases. Critical events are scheduled, not left to chance.
  3. Repetition. The NLN notes that "simulation-based education with deliberate practice is effective in achieving specific clinical goals related to patient safety."
  4. Structured feedback. Every session ends in debriefing.
  5. Measurable gains. Comparable outcomes in the NCSBN study, and larger effects on knowledge and performance in the BMJ Open meta-analysis.
  6. Flexible formats. A 2024 meta-analysis in Frontiers in Medicine found a large effect of virtual reality simulation on nursing competency (Hedge's g = 0.88) and notes the advantage of "enabling safe and repetitive training without time and space constraints."

Disadvantages, and how programs handle them:

  1. Equipment cost and access. A trial in the Nagoya Journal of Medical Science lists the limits of physical simulators: "the cost of purchase and maintenance, the limited number of people who can use them at any one time, and the need to have skilled instructors." Programs answer with a mix: manikins for team scenarios, screen-based cases for individual volume.
  2. Faculty preparation. The NLN states that "simulation requires specialized faculty development resources." NCSBN expects a "Budgetary plan for sustainability and ongoing faculty training."
  3. Results depend on conditions. The NCSBN study's results hold under conditions that "include faculty members who are formally trained in simulation pedagogy, an adequate number of faculty members to support the student learners, subject matter experts who conduct theory-based debriefing, and equipment and supplies to create a realistic environment." NCSBN advises programs "to begin slowly and steadily increase the amount of simulation as they acquire expertise in this pedagogy."
  4. A single session is not enough. The Nagoya authors note that "the limited number of training sessions does not significantly improve the students' lung auscultation skills." Simulation pays off with repetition.
  5. Not every outcome moves. In the BMJ Open review, confidence and satisfaction did not differ significantly from other methods; knowledge and performance did.

What are examples of clinical simulation in nursing?

Clinical simulation in nursing covers every core course. The NCSBN study randomized students in its core courses: Fundamentals of Nursing, Medical-Surgical Nursing, Advanced Medical-Surgical Nursing, Maternal-Newborn Nursing, Pediatric Nursing, Mental Health Nursing and Community/Public Health Nursing. Typical scenarios by course look like this:

  1. Fundamentals: a head-to-toe assessment and vital signs on a newly admitted patient, with hand hygiene and patient identification.
  2. Medical-surgical: a postoperative patient whose blood pressure falls and heart rate rises, testing recognition and escalation.
  3. Advanced medical-surgical: a patient with worsening shortness of breath and crackles at both bases.
  4. Maternal-newborn: a postpartum assessment that reveals heavy bleeding.
  5. Pediatrics: a child with wheezing and increased work of breathing.
  6. Mental health: a therapeutic conversation with a standardized patient in crisis.
  7. Community health: a home visit focused on medication safety.

For the assessment itself, see our head-to-toe assessment nursing guide.

Which standards guide nursing simulation?

The INACSL Healthcare Simulation Standards of Best Practice are the reference, and NCSBN builds them into its checklists. The INACSL standards, with a fourth edition of the core standards revised in 2025, cover professional development, prebriefing, simulation design, facilitation, the debriefing process, operations, outcomes and objectives, professional integrity, simulation-enhanced interprofessional education, and evaluation of learning and performance.

Two of them apply to every session. "Prebriefing ensures that simulation learners are prepared for the educational content and are aware of the ground rules for the simulation-based experience." And "All simulation-based educational (SBE) activities must include a planned debriefing process." NCSBN's faculty checklist expects that "The faculty are prepared by following the INACSL Standards of Best Practice: Simulation," and the SSH dictionary gives programs a shared vocabulary for all of it.

Where does VMS fit in?

VMS, the Virtual Medical Simulator, is a screen-based and VR virtual patient simulator, one of the computer-based types described above. It runs on PC (mouse and keyboard) and VR (laser pointer), and is coming to Steam and Meta Quest. Nursing students pick the Nursing program (RN, PN or NP), and each case shows the exam content areas it trains, including the 2026 NCLEX-RN and PN Test Plans.

Every case runs as an OSCE station: one virtual patient, a step-by-step checklist and a score from 0 to 100%. You introduce yourself, gain consent, wash your hands or put on gloves, examine the patient with your hands (palpate, auscultate, take a pulse) and with tools such as the stethoscope, and close the encounter. Teach and Train modes guide and repeat; the OSCE exam button starts a random patient from your program in Test mode, with no hints and a time limit. Attempts are saved to your account, educators set up cases on the web and see results per student, and a class can play together in multiplayer, with an educator running the room as an option.

FAQ

What are the main types of simulation in nursing education?

Low-fidelity methods (case studies, role play), task trainers, manikins at medium or high fidelity, standardized patients, computer-based and virtual simulation (including VR), and hybrid simulation that combines two or more of them.

What is high-fidelity simulation in nursing education?

Simulation that is extremely realistic and highly interactive for the learner. It can use a manikin, a standardized patient, a task trainer or virtual reality; what makes it high-fidelity is realism and interactivity, with findings that make sense together.

What are the disadvantages of simulation in nursing education?

Equipment cost and maintenance, limited access when many students share one simulator, the need for trained faculty, and the fact that one session is rarely enough. Programs offset them with budgets, faculty training and a mix of manikin and screen-based simulation.

Why is simulation important in nursing education?

It guarantees every student practice with critical situations that clinical placements cannot promise, with no risk to patients, and the NCSBN National Simulation Study found comparable outcomes when high-quality simulation replaced up to half of clinical hours.

What is an example of clinical simulation in nursing?

A postoperative patient whose blood pressure falls and heart rate rises: the student assesses, recognizes the deterioration, escalates and then reviews every decision in debriefing.

Is there nursing simulation online for free?

Yes. VMS comes with 3 free cases, so you can try the whole workflow without paying. A subscription unlocks every case, and a subscriber can share their cases with friends or classmates in multiplayer, as long as the subscriber hosts the session and stays connected.

Where can I find scholarly articles on simulation in nursing education?

Start with the NCSBN National Simulation Study in the Journal of Nursing Regulation, the INACSL standards, and systematic reviews such as the BMJ Open meta-analysis on high-fidelity simulation and the Frontiers in Medicine meta-analysis on virtual reality simulation, all listed below.

Sources

  1. Hayden JK, Smiley RA, Alexander M, Kardong-Edgren S, Jeffries PR. The NCSBN National Simulation Study: A Longitudinal, Randomized, Controlled Study Replacing Clinical Hours with Simulation in Prelicensure Nursing Education. Journal of Nursing Regulation, 2014.
  2. National Council of State Boards of Nursing. NCSBN Simulation Guidelines for Prelicensure Nursing Education Programs. NCSBN, 2016.
  3. International Nursing Association for Clinical Simulation and Learning. Healthcare Simulation Standards of Best Practice. INACSL, 2025.
  4. International Nursing Association for Clinical Simulation and Learning. Simulation Regulation Map. INACSL, 2025.
  5. Lioce L, ed. Healthcare Simulation Dictionary, Third Edition. Society for Simulation in Healthcare and Agency for Healthcare Research and Quality, 2025.
  6. National League for Nursing. A Vision for Teaching with Simulation. NLN Board of Governors, 2015.
  7. La Cerra C, Dante A, Caponnetto V, et al. Effects of high-fidelity simulation based on life-threatening clinical condition scenarios on learning outcomes of undergraduate and postgraduate nursing students: a systematic review and meta-analysis. BMJ Open, 2019.
  8. Cho MK, Kim MY. Enhancing nursing competency through virtual reality simulation among nursing students: a systematic review and meta-analysis. Frontiers in Medicine, 2024.
  9. Higashiyama S, Tamakoshi K, Yamauchi T. Effectiveness of a new interactive web teaching material for improving lung auscultation skills: randomized controlled trial for clinical nurses. Nagoya Journal of Medical Science, 2022.