1:2 Simulation Rule WAC 246–840–5341
Washington State Board of Nursing (WABON) approved organizations for endorsement, accreditation, certification.
The nursing education program must obtain and maintain endorsement or accreditation from a board-approved organization that provides endorsement or accreditation in health care simulation.
A nursing education program offering simulation at a 1:2 ratio must obtain board-approved certification or endorsement by June 30, 2029. As of July 1, 2029, a nursing education program must obtain board-approved endorsement or accreditation before offering simulation-based learning experiences to students at a 1:2 ratio.
New nursing education programs receiving full board approval must obtain board-approved endorsement or accreditation within four years of receiving full board approval.
The organizations approved by WABON are:
The simulation program must be managed by an individual with all the academic and experiential qualifications required of nursing faculty. The simulation program manager must also hold a Certified Healthcare Simulation Educator (CHSE) certification, Certified Healthcare Simulation Educator-Advanced certification (CHSE-A), or other board-approved certification in simulation by June 30, 2029.
As of July 1, 2029, the simulation program manager must have and maintain board-approved health care simulation educator certification before initiating simulation program management duties SSH (CHSE, or CHSE-A)
The board may grant an exception to the requirements that the simulation program manager and at least 10 percent of nursing faculty who facilitate simulation-based learning experiences must hold a board-approved certification if the following conditions are met:
- (a) The program has a written plan for the simulation faculty and simulation program manager to obtain CHSE, CHSE-A certification, or other board-approved certification, within three years of application for exception;
- (b) The simulation program manager and simulation faculty participate in professional development under subsection (15) of this section;
- (c) Evidence of orientation, mentorship, and evaluation of the simulation faculty and the simulation program manager is maintained and available to the board for review upon request
Frequently Asked Questions
- Why was WAC 246-840-5341 adopted?
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WAC 246-840-534, adopted in 2016, describes the use of simulation-based learning experiences using a 1:1 ratio where one (1) hour of simulation counts for one (1) hour of required clinical and direct patient care experience. WAC 246-840-5341, effective October 24, 2024, was adopted in response to Engrossed 2nd Substitute Senate Bill 5582 which directed the WABON to adopt rules that allow one (1) hour of simulation to count for two (2) hours of required clinical and direct patient care experiences. Simulation-based learning experience hours may not exceed 50 percent of clinical hours for a particular course.
In holding to the Washington State Board of Nursing (WABON) mission to protect the public by overseeing nursing education, WABON reviewed the best available evidence-based research and standards of best practices related to clinical simulation and relied on the data around high-quality and high-fidelity simulation when drafting WAC 246-840-5341. WAC 246-840-5341 reflects the best available evidence for supporting high-quality simulation-based learning experiences.
- Is it now mandatory for a nursing education program to offer simulation-based learning experiences at a 1:2 ratio?
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No. WAC 246-840-5341 does not make using a 1:2 ratio mandatory. A nursing education program can choose to offer simulation-based learning experiences using a 1:1 (see WAC 246-840-534) or 1:2 ratio (See WAC 246-840-5341). WAC 246-840-5341 only addresses simulation-based learning experience hours at a 1:2 ratio. Given that a nursing program’s implementation of a 1:2 ratio will result in students receiving fewer clinical and direct patient experience hours, WAC 246-840-5341 is intended to ensure that simulation-based learning experiences provided at a 1:2 ratio meet simulation evidence-based and best practice standards.
- Does a nursing education program have to obtain WABON approval before offering simulation-based learning experiences at a 1:2 ratio under WAC 246-840-5341?
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No, a nursing education program does not need to seek WABON approval before offering simulation-based learning experiences at a 1:2 ratio. While no prior approval is required, the program must comply with WAC 246-840-5341 and will have compliance reviewed during site visits.
- Under what circumstances is a nursing program unable to substitute 1 hour of simulation for 2 hours of clinical or direct care experiences?
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A nursing education program cannot use a 1:2 ratio unless it meets the requirements of WAC 246-840-5341.
Additionally, a nursing education program cannot use a 1:2 ratio if:
(a) The program is on conditional approval from the board;
(b) The program is on conditional or probationary status from a nursing accrediting body;
(c) The program’s first-time NCLEX pass rates are below 80% for two consecutive years; or
(d) The program is on a plan of correction for a deficiency related to providing simulation-based learning experiences at either a 1:1 ratio under WAC 246-840-534 or a 1:2 ratio under WAC 246-840-5341.
- Can nursing programs use screen-based simulation?
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Yes. However, screen-based simulations may not be used when offering simulation as a substitute for clinical hours at the 1:2 ratio. WAC 246-840-534 allows for the use of screen-based simulation when offering simulation as a substitute for clinical hours at the 1:1 ratio. Screen-based simulation may also be used as a teaching and learning tool that does not replace required clinical hours, such as during skills labs.
“Screen-based simulation” means a simulation presented on a computer screen using graphical images and text, similar to the popular gaming format, where the learner interacts with the interface using a keyboard, mouse, joystick, or other input device.
- Can immersive augmented reality or virtual reality be used for simulation at the 1:2 ratio?
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Yes, programs may use immersive augmented reality or virtual reality at the 1:2 ratio, however, it must be synchronously facilitated and align with the requirements of WAC 246-840-5341.
- What if a nursing education program cannot locate clinical placement for a “particular curriculum content area”?
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Under WAC 246-840-5341(3), the WABON may grant an exception to a nursing education program demonstrating difficulty in locating clinical placement for a particular curriculum content area required by WAC 246-840-539 and WAC 246-840-541, or WAC 246-840-542.
Please reach out if you have questions on this issue and visit the WABON Education website to access an exception form.
- What is meant by a "particular course"?
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The rule requires that simulation-based learning experience hours may not exceed fifty percent of clinical hours for a particular course. Examples of a particular course or content area include Pediatrics, Obstetrics, Mental Health, Medical-Surgical, and Population/Community. Although there are not required hours in each content area, clinical experiences across the lifespan help to inform student’s education.
See WAC 246-840-5341(3) and WAC 246-840-539, WAC 246-840-541, or WAC 246-840-542.
- How many students can participate in a simulated-based learning experience at one time?
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It depends. Data indicates that active engagement of participants is a key element in student learning when utilizing simulation. Active engagement occurs when each student maintains a level of engagement conducive to the student’s achievement of learning objectives. WAC 246-840-5341 defines “active engagement,” “active participant,” and “active observer.”
At a maximum, one faculty member may facilitate a simulation-based learning experience for a group of up to ten students under certain conditions.
While a 1:10 ratio may be utilized, the rules require that group size be limited to the number of students who can be actively engaged in a simulation-based learning experience such that it is conducive to learning. The best available evidence supports limiting group sizes to 4-6 students; however, strategies exist, including the utilization of an observer engagement tool and/or non-faculty support, which may enable the effective implementation of a 1:10 faculty-to-student ratio.
Here is an example of what a simulation observation document (PDF) may look like.
To support the learning of all students, each student shall participate in a hands-on nurse role in each simulation-based learning experience.
When not an active participant in a hands-on nurse role, a student should be involved in structured activities designed for learner engagement as an active observer in the simulation exercise. For example, a student who is observing/monitoring the simulation for identified learning objectives and taking notes during the clinical scenario could be considered an active observer.
- What should a program do to demonstrate a plan that students are actively engaged in the simulation-based learning experience?
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A program should use program data to demonstrate the simulation-based learning experience ensures active engagement of all students in the hands-on nurse role, active participant role, and active observer role. Programs may decide how they wish to document this and may wish to use a written plan for the simulation-based experience, agenda of the day, and/or an observer engagement tool.
Programs are also required to document the use of learner assessments of engagement and achievement of learning objectives while in the hands-on nurse, active participant, and active observer roles in each simulation-based learning experience. Among other things, this evaluative data will help guide group size and is a best practice required for INACSL endorsement or SSH accreditation.
Here is an example of what a simulation observation document (PDF) may look like.
- What endorsement or accreditation is required for nursing education programs to offer simulation-based learning experiences at a 1:2 ratio?
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To offer simulation at the 1:2 ratio, a nursing program must obtain endorsement or accreditation from a board-approved organization. The current board-approved endorsement and accreditation programs are:
- What is INACSL Endorsement?
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INACSL endorsement recognizes healthcare institutions that have demonstrated excellence in applying the simulation standards from the Healthcare Simulation Standards of Best Practice (HSSOBPTM) in their educational simulation programs:
Programs may obtain INACSL Conditional Endorsement, which is acceptable until July 1, 2029. On July 1, 2029, all programs must have a full endorsement to use the 1:2 simulation ratio under WAC 246-840-5341.
- Always check the INACSL website for the most current updates.
Click the links to see more about INACSL Endorsement.
- What is the SSH Accreditation?
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SSH Full Accreditation is for programs that have demonstrated compliance with the SSH Accreditation Core and Area-Specific Standards and have a minimum of two years of experience in simulation.
Programs may obtain SSH Provisional Accreditation, which is acceptable until July 1, 2029. On July 1, 2029, all programs must have full accreditation to use the 1:2 simulation ratio under WAC 246-840-5341.
- Always check the SSH website for the most current updates.
Click the links to see more about SSH Full Accreditation and Provisional Accreditation.
- When must full endorsement or accreditation be achieved?
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A nursing education program offering simulation using the 1:2 ratio on or after the effective date - October 24, 2024 of this rule must obtain board-approved endorsement or accreditation before July 1, 2029.
As of July 1, 2029, new nursing education programs approved by the WABON will have four (4) years from the date of full board approval to achieve endorsement or accreditation.
See WAC 246-840-5341(8) - What happens if a nursing education program does not obtain/maintain board-approved endorsement or accreditation?
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A nursing education program offering simulation using the 1:2 ratio on or after the effective date of this rule must obtain board-approved endorsement or accreditation before July 1, 2029.
As of July 1, 2029, new nursing education programs approved by the WABON will have four (4) years from the date of full board approval to achieve endorsement or accreditation.
See WAC 246-840-5341(8) - What happens if a nursing education program does not obtain/maintain board-approved endorsement or accreditation?
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If a nursing education program is offering simulation at a 1:2 ratio and does not obtain/maintain board-approved endorsement or accreditation, WABON may take action against a nursing education program as identified in WAC 246-840-558.
See WAC 246-840-558 for more information on actions the WABON is authorized to take.
See WAC 246-840-5341(20) - What qualifications does an individual who manages a simulation program need to have?
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The simulation program must be managed by an individual who holds a Certified Healthcare Simulation Educator (CHSE) certification, Certified Healthcare Simulation Educator-Advanced certification (CHSE-A), or other board-approved certification. This individual may or may not have a nursing faculty title but must have all the academic and experiential qualifications required of nursing faculty.
The manager must obtain certification by June 30, 2029.
Visit the Society for Simulation in Healthcare Certified Healthcare Simulation Education (CHSE) website for more information on CHSE and CHSE-A.
- Is there an exception to the requirement that the individual who manages the simulation program uses the 1:2 ratio?
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Yes. Under WAC 246-840-5341(12), WABON may grant an exception to the requirement that a simulation program manager must hold an approved certification if the following conditions are met:
- The program documents a plan for the simulation program manager to obtain and the manager obtains CHSE, CHSE-A certification, or other board-approved certification, within three years of applying for an exception;
- The simulation program manager’s professional development is maintained according to WAC 246-840-5341(15);
- Evidence of orientation, mentorship, and evaluation of the simulation program manager is maintained and available to the WABON for review upon request.
The simulation program manager is not required to have a nursing faculty title but must have all the qualifications of a nursing faculty.
See Healthcare Simulation Standards of Best PracticeTM Facilitation Criterion 1-5
- How many faculty facilitating simulation need certification?
- By June 30, 2029, for programs providing simulation-based learning experiences at the 1:2 ratio under WAC 246-840-5341, at least ten (10) percent of nursing faculty who facilitate simulation learning experiences must hold a CHSE or CHSE-A certification, or other board-approved certification in simulation.
Example:
In the nursing program, there are 30 nursing faculty that work in simulation. At least three faculty must hold board-approved healthcare simulation educator certification prior to initiating simulation facilitation duties using the 1:2 ratio.
In a nursing program, there are 2 nursing faculty that work in simulation. At least one faculty must hold board-approved healthcare simulation educator certification prior to initiating simulation facilitation duties using the 1:2 ratio.
Adjunct faculty may be counted in calculating the 10% of faculty.
- Is there an exception to the requirement that 10% of nursing faculty must hold a CHSE or CHSE-A certification, or other board-approved certification in simulation?
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Yes. Under WAC 246-840-5341(12), the WABON may grant an exception to the requirement that 10% of simulation faculty must hold an approved certification if the following conditions are met:
- The program has a written plan for faculty to obtain and the faculty obtains CHSE, CHSE-A certification, or other board-approved certification, within three years of application for exception;
- Faculty professional development is maintained according to WAC 246-840-5341(15);
- Evidence of orientation, mentorship, and evaluation of the simulation faculty is maintained and available to the WABON for review upon request.
For example, if only 8% of simulation program faculty are certified through CHSE, CHSE-A, or other board-approved certification, then the program must maintain evidence of the above three points for the remaining 2% of faculty.
Please see the WABON website for the exception form.
- What information does a nursing education program need to maintain regarding nursing faculty who facilitate simulation?
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Programs providing simulation-based learning experiences at the 1:2 ratio under WAC 246-840-5341 shall ensure that simulation faculty are academically and experientially qualified and that all faculty demonstrate competency in the use of simulation. This can be done by maintaining documentation that:
- The faculty have specific knowledge and skills in simulation pedagogy;
- The faculty’s facilitative approach is appropriate to the level of learning, experience, and competency of the students;
- Facilitation occurs throughout the simulation-based learning experience aiming to support students in achieving expected outcomes. The facilitation methods need to include briefing to prepare students for the simulation and a synchronously facilitated debriefing.
It is important to note that documentation of the above is also required for INACSL endorsement or SSH accreditation. Also, proof of simulation nursing faculty’s current CHSE, CHSE-A, or other board-approved certification may be used as proof of compliance with the first two bullet points above.
This documentation should be maintained for the WABON review during a site visit and does not need to be submitted to the WABON separately.
To ensure compliance with the requirement that nursing faculty has specific knowledge and a facilitative approach is appropriate to meet program outcomes, a program can typically maintain simulation faculty/staff portfolios, resumes, completed curriculum education credits (conferences/workshops), and/or curriculum vitae.
To ensure compliance with the requirement that facilitation occurs throughout the simulation-based learning experience, a program can use the INACSL endorsement criteria or the SSH accreditation criteria, which require that facilitation occurs during a briefing session, the scenario itself, and during a debrief session.For more information on INACSL Endorsement criteria please see the INACSL Endorsement Program FAQ
For more information on SSH Accreditation criteria, please see the Society for Simulation Healthcare FAQ website
See Healthcare Simulation Standards of Best PracticeTM Facilitation Criterion 1-5
See Healthcare Simulation Standards of Best PracticeTM Debriefing Criterion 2
- Can faculty who facilitate a simulation-based learning experience using the 1:2 ratio have operational responsibilities?
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No. A faculty member who is facilitating a simulation-based learning experience cannot have operational responsibilities.
A faculty member who operates a simulation-based learning experience cannot be counted in the faculty-to-student ratio.
Here is an example of how a program could count faculty for the 1:2 ratio if the person operating the simulation manikin is faculty: Faculty one is operating a manikin computer and faculty two is facilitating. Faculty one does not count toward the 1:10 student-to-faculty ratio as are directly participating in the simulation experience.
- What sort of documentation does a nursing education program need to maintain to comply with WAC 246-840-5341?
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Generally, a nursing education program does not need to maintain or create documentation that is supplemental to what would already be required by an endorsing, accrediting, or certifying body, such as INACSL, SSH, or CHSE.
A nursing program is only required to maintain documentation of the following:
A strategic plan for the simulation program; A plan to manage simulation space, equipment, and personnel resources for the simulation program; Policies and procedures to support and sustain the simulation program; Faculty who are academically and experientially qualified in simulation; Defined qualifications of simulation operation support personnel; Simulation-based learning experiences that are student-centered, evidence-based; have measurable student learning objectives, designed to include context and the appropriate level of fidelity; and supportive of the students’ psychological safety; A plan to orient, mentor, and evaluate nursing faculty who facilitate or manage simulation-based learning experiences; Document non-CHSE faculty participation in simulation-related professional development; and A plan for evaluation of the student, the simulation-based learning experience, and the simulation nursing faculty (facilitator).As noted, documentation of the above is also required for INACSL endorsement, SSH accreditation, and CHSE accreditation. This documentation should be maintained for review during a WABON site visit and does not need to be duplicative or submitted to the WABON separately.
A program will need to submit additional information or documentation to WABON when seeking exceptions beginning July 1, 2029.
See WAC 246-840-5341 (9), (13), (14), (15), (16), and (17)
See Healthcare Simulation Standards of Best PracticeTM Outcomes and Objectives Criterion 1, 3, and 4.
See Healthcare Simulation Standards of Best PracticeTM Operations Criterion 1, 2, 3, and 4.
- What are the defined qualifications of simulation operations support personnel?
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Simulation operations support personnel assist the faculty facilitator with the implementation and delivery of a simulation activity through the application of simulation technologies such as computers, audio-visual (AV), or networking technologies.
Simulation operations support personnel do not have primary responsibility for the simulation experience. Responsibilities may include but are not limited to preparing the environment, operating equipment and technology, and voicing roles. For example, the support personnel could be a simulation lab technician.
Please note that WAC 246-840-5341 does not require certification for simulation operations support personnel.
Recommended qualifications for individuals in the role of operations support personnel include:
- Experience in healthcare simulation in an operations role
- Demonstrated focused simulation expertise with learners in undergraduate, graduate, allied health, or healthcare settings
The program must maintain documentation of the operations support personnel qualifications for WABON review during a site visit and does not need to be separately submitted to WABON for review. A curriculum vitae or resume with the simulation operations support personnel’s qualifications may prove compliance.
The Certified Health Simulations Operations Specialist (CHSOS) website has helpful information on best practices for operations support personnel.
- What documentation is needed for the plan to orient, mentor, and evaluate nursing faculty who facilitate/manage simulation-based learning experiences?
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As stated in WAC 246-840-5341(14), the nursing education program shall document a plan to orient, mentor, and evaluate nursing faculty who facilitate or manage simulation-based learning experiences.
A nursing program may wish to utilize a checklist, timeline, assignment of mentor, mentor/mentee responsibilities, aggregated student evaluation of facilitation, professional development plan, and formal evaluation.
- What counts as simulation-related professional development?
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Faculty who hold CHSE certification are required by SSH to participate in simulation-related professional development to maintain certification. WAC 246-840-5341 requires that the nursing program provide the means/opportunities for nursing faculty who do not hold current CHSE or other board-approved certifications to participate in simulation-related professional development.
Simulation-related professional development consists of activities that reasonably contribute to the professional knowledge and development of faculty for the purposes of providing simulation-based learning experiences to students (CHSE Renewal Examples). This can include but is not limited to:
Seminars/Webinars/Conferences Course Development or redesign Professional Service Professional Speaking/Teaching Authoring/Publishing Poster Presentation Academic Coursework Simulation Fellowship Academic Course Development Mentoring Simulation Advocacy Simulation-Related Journal/Articles/BooksSee the CHSE Renewal Handbook Continuing Professional Development Units for more information.
See Healthcare Simulation Standards of Best PracticeTM Professional Development Criterion 1 and 2.
Exception Forms
Exception to 10% of Simulation Faculty Certification
Exception to Clinical Placement for WAC 246-840-5341
Exception for Simulation Program Manager Certification
Useful Links and Resources*
*Disclaimer: The WABON does not endorse any organization or business listed below. The following information is intended for reference purposes only.
All resources listed below are freely accessible unless denoted by $.
Simulation Organizations
Association of SP Educators (ASPE)
Canadian Alliance for Nurse Educators using Simulation (Can-Sim)
INACSL- International Nursing Association of Clinical Simulation and Learning
NLN Center for Innovation in Education Excellence, Institute for Simulation and Technology
Sim Ghosts- The Gathering of Healthcare Simulation Technology Specialists
SSH- Society for Simulation in Healthcare
Accreditation and Endorsement
INACSL Endorsement: https://www.inacsl.org/endorsement-program
SSH Full Accreditation: https://www.ssih.org/Credentialing/Accreditation/Full-Accreditation
SSH Provisional Accreditation: https://www.ssih.org/Credentialing/Accreditation/Provisional-Accreditation
Healthcare Simulation Standards of Best Practice™ (HCSSOBP)
Professional Development
Healthcare Simulation Standards of Best PracticeTM Professional Development
Simulation Code of Ethics Website
CHSE-Certified Healthcare Simulation Education
Essentials in Clinical Simulation Across the Health Professions
California Simulation Alliance Courses $
Center for Medical Simulation – Gateway Debriefing Skills Workshop $
Center for Medical Simulation - Simulation Instructor Workshops $
INACSL Simulation Education Program (ISEP) $
INACSL Center for Learning-Cornerstones to Best Practice $
Healthy Simulation: https://learn.healthysimulation.com
Prebriefing
Healthcare Simulation Standards of Best PracticeTM Prebriefing: Preparation and Briefing
Basic Assumption from the Center for Medical Simulation at Harvard
Simulation Design/ Outcomes & Objectives
Healthcare Simulation Standards of Best PracticeTM Simulation Design
Healthcare Simulation Standards of Best PracticeTM Outcomes and Objectives
Needs Assessments
- Simulation Educator Needs Assessment Tool (SENAT)
- Simulation Operations Needs Assessment Tool- coming soon
Objectives
Fidelity
- Carey, J. M., & Rossler, K. (2020). The how when why of high fidelity simulation.
- Vital sign measurement across the lifespan, freely accessible
- About Moulage – Resources, Kits, Recipes & More
Standardized Patients
- The Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP)
- Actions, Communication, & Teaching in Simulation Tool (ACTS)
Virtual Simulation Resources
Facilitation
Healthcare Simulation Standards of Best PracticeTM Facilitation.
Simulation Observation Checklist Template (PDF)
Observer Engagement Tools
- Clinical Judgment Measurement Model (i.e., recognize cues, analyze cues, prioritize hypothesis, generate solutions, take action, and evaluate outcomes) can be used to organize notes during observation
The Debriefing Process
Healthcare Simulation Standards of Best PracticeTM The Debriefing Process
Healthcare Simulation Tools from HealthySimulation.com
Simulation Debriefing from HealthySimulation.com
Debriefing Tools
- Debriefing with Good Judgment
- Debriefing for Meaningful Learning
- Gather – Analyze – Summarize (GAS)
- Plus Delta
- PEARLS- Promoting Excellence and Reflective Learning in Simulation (Free training from the University of Miami)
- The 3D model of debriefing: defusing, discovering, and deepening
Operations
Healthcare Simulation Standards of Best PracticeTM Operations
CHSOS- Certified Health Simulations Operations Specialist
Evaluation of Learning and Performance
Healthcare Simulation Standards of Best PracticeTM Evaluation of Learning and Performance
Facilitator
- Facilitator Competency Rubric-Leighton et al, 2015
- Debriefing Assessment for Simulation in Healthcare© (DASH)
- Clinical Learning Environment Comparison Survey (CLECS & CLECS 2.0)
Learner
- Creighton Competency Evaluation Instrument (C-CEI)
- Quint Leveled Clinical Competency Tool (QLCCT)
- Mind the Gap! A Strategy to Bridge the Time Between Simulation and Debriefing Article on self-debriefing.
- Post Simulation Reflective Activity
Simulation Experience