Clinical Simulation in Nursing (2011) 7, S3-S7

www.elsevier.com/locate/ecsn

Standards of Best Practice: Simulation

Standard I: Terminology
The INASCL Board of Directors*

Cite this article:

The INASCL Board of Directors (2011, August). Standard I: Terminology. Clinical Simulation in Nursing, 7(4S), s3-s7. doi:10.1016/
j.ecns.2011.05.005
Ó 2011 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.

Statement consistency in the development, implementation, evalua-

Consistent terminology provides guidance and clear com-
munication and reflects shared values in simulation expe-
riences, research, and publications.
Rationale
Standardized terminology enhances understanding and
communication among planners, participants, and others
involved in simulation experiences. It also promotes
tion, and publication of or about simulated clinical
experiences or research studies for use in education and
practice.
Outcome
Terminology is descriptive and consistent in a variety of
settings, written documents, and publications. Use of
standard terminology facilitates consistent experiences for
participants, regardless of the simulation environment.

*The Board of Directors is comprised of Colleen Meakim, MSN, RN Criteria

(Lead); Teri Boese, MSN, RN; Jimmie Borum, MSN, RN; Sharon Decker,
PhD, ACNS-BC, RN, ANEF; Jana Faragher, ND, CNS, RN; Cheryl Feken, The criterion for this Standard is to include definitions for
MSN, RN; Teresa Gore, DNP, APRN; Kim Leighton, PhD, CNE, RN; Meg
Meccariello, MS, RN; Patty Ravert, PhD, CNE, RN; Leland (Rocky)
all terms used in the Standards of Best Practice in Patient
Rockstraw, PhD, RN; Carol Sando, PhD, CNE, RN; Marianne Schubert, Simulation.
MSN-Ed, CEN, MICP, RN; Renee Schnieder, MSN, RN, Janis Childs,
RN, PhD; Valerie Howard, EdD, RN; Beverly Hewett, PhD, RN; Nicole
Harder, RN, MPA, PhD. Terms
Disclosure/Conflict of Interest Statement. K. Leighton is an indepen-
dent contractor for Medical Education Technologies, Inc., and Assessment Andragogy: Expands on pedagogy and refers to active,
Technologies, Inc., and is on the advisory committee of McGraw-Hill
Publishing. T. Gore, C. Feken and C. Sando are independent contractors
learner-focused education for people of all ages. It is
for Pearson Publishing. C. Meakim is an independent contractor for As- based on learning principles that involve problem solv-
sessment Technologies, Inc., and McGraw-Hill Publishing and a consultant ing that is relevant to the learner’s everyday experiences.
for the York College of PA and Neumann College, PA. R. Schnieder is an Clinical Judgment: The art of making a series of decisions
independent contractor for Elsevier Publishing and McGraw-Hill Publish- in situations, based on various types of knowledge, in
ing. P. Ravert and N. Harder are independent contractors and adjunct fac-
ulty at Medical Education Technologies, Inc. The following board
a way that allows the individual to recognize salient as-
members have no disclosures: M. Meccariello, L. Rockstraw, J. Faragher, pects of or changes in a clinical situation, interpret their
J. Borum, M. Schubert, T. Boese, B. Hewitt, S. Decker, and J. Childs. meaning, respond appropriately, and reflect on the

1876-1399/$ - see front matter Ó 2011 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ecns.2011.05.005
Standard I: Terminology S4

effectiveness of the intervention. Clinical judgment is

influenced by the individual’s overall experiences that
have helped to develop problem-solving, critical-think-
ing, and clinical-reasoning abilities (del Bueno, 1994;
Dillard, Sideras, Carlton, Lasater, & Siktberg, 2009;
Jackson, Ignatavicius, & Case, 2004; Lasater, 2007;
Tanner, 2006). See Figure 1.
Clinical Reasoning: The ability to gather and comprehend
data while recalling knowledge, skills (technical and
nontechnical), and attitudes about a situation as it un-
folds. After analysis, information is put together into
a meaningful whole when applying the information to
new situations (Alfaro-LeFever, 1995; Benner,
Sutphen, Leonard, & Day, 2010).
Clinical Scenario: The plan of an expected and potential
course of events for a simulated clinical experience.
The clinical scenario provides the context for the simu-
lation and can vary in length and complexity, depending
on the objectives.
Designing the clinical scenario should include the
following:
 Participant preparation. Figure 1 Nursing Skill Development and Clinical Judgment
ModelÓ. This model, developed by the INACSL, reflects the com-
 Prebriefing: objectives, questions, and/or material.
plexity of skill development necessary to progress from more ba-
 Patient information describing the situation to be sic skills to the higher-level clinical judgment and reasoning
managed. ability used in decision making for safe, effective nursing practice.
 Student learning objectives. All levels of development are inter-related, affect each other, and
 Environmental conditions, including manikin or stan- are interactive with each other.
dardized patient preparation.
 Related equipment, props, and tools and/or resources
for assessing and managing the simulated experience Confederate: A term sometimes used to describe an em-
to increase the realism. bedded actor (see Embedded Actor).
 Roles, expectations, and/or limitations of each role to Confidence: Belief in oneself and one’s abilities.
be played by participants. Confidence Interval: Margin of error.
 A progression outline including a beginning and an Confidence Level: A percentage that represents how
ending. certain one can be that a test measures what it intends
 Debriefing process. to.
 Evaluation criteria (Jeffries, 2007). Critical Thinking: A disciplined process that requires val-
Coaching: A method of directing or instructing a person or idation of data, including any assumptions that may
group of people in order to achieve a goal or goals, de- influence thoughts and actions; and then careful reflec-
velop a specific skill or skills, or develop a competency tion on the entire process while evaluating the effective-
or competencies. ness of what has been determined as the necessary
Competence: Standardized requirement for an individual action(s) to take. This process entails purposeful, goal-
to properly perform a specific role. It encompasses directed thinking and is based on scientific principles
a combination of discrete and measureable knowledge, and methods (evidence) rather than assumptions and/or
skills, and attitudes that are essential for patient safety conjecture (Alfaro-LeFever, 1995; Benner, 2004;
and quality patient care (National League for Nursing, Jackson et al., 2004).
2010). Cuing: Information provided that helps the participant
Computer-Assisted Instruction: A teaching process that progress through the clinical scenario to achieve stated
uses a computer in the presentation of instructional ma- objectives (NLN-SIRC, 2010).
terials. The participant may be asked a question or pre- Debriefing: An activity that follows a simulation experi-
sented with a problem. The participant inputs ence and that is led by a facilitator. Participant reflective
a response and receives feedback (sometimes immedi- thinking is encouraged, and feedback is provided regard-
ate) about the answer. This process is used to teach, ing the participants’ performance while various aspects
provide feedback, and evaluate clinical judgment and of the completed simulation are discussed. Participants
critical thinking. are encouraged to explore emotions, question, reflect,

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Standard I: Terminology
and provide feedback to each other. The purpose of de-
briefing is to move toward assimilation and accommoda-
tion in order to transfer learning to future situations
(Johnson-Russell & Bailey, 2010; NLN-SIRC, 2010).
Decision-Making Abilities: An outcome of mental pro-
cesses (cognitive process) leading to the selection of
a course of action from among several alternatives.
Embedded Actor (also known as Scenario Guide,
Scenario Role Player, or Confederate): A person
assigned a role in a simulation encounter to help guide
the scenario. The guidance may be influential as positive,
negative, or neutral or as a distracter, depending on the ob-
jective(s), the level of the participants and of the scenario.
Although the embedded actor’s role is part of the situation,
the underlying purpose of the embedded actor is not iden-
tified to the participants in the scenario or simulation.
Evaluation or Assessment:
Formative Assessment: Assessment wherein the facilita-
tor’s focus is on the participant’s progress toward goal
attainment; a process for an individual or group engaged
in a simulation activity for the purpose of providing con-
structive feedback for that individual or group to im-
prove (Billings & Halstead, 2009; NLN-SIRC, 2010).
Summative Evaluation: Evaluation at the end of a learn-
ing period, in which participants are provided with feed-
back about their achievement of outcome criteria;
a process for determining the competence of a participant
engaged in health care activity. The assessment of
achievement of outcome criteria may be associated
with an assigned grade (Billings & Halstead, 2009;
NLN-SIRC, 2010).
Facilitation Methods:
Facilitator Prompting Simulation: Simulation can be led
with prompting and guidance by the facilitator, keeping
the participant(s) focused by means of guidance and in-
struction throughout the decision-making process.
Prompting is provided in an effort to assist the partici-
pant(s) in prioritization of assessment, data collection,
implementation, and evaluation. This guidance allows
the participant(s) to progress toward completion of ob-
jectives (Nehring & Lashley, 2010).
Partial Facilitator Prompting Simulation: During the
simulation experience, participants carry out activities
without interruption. At the beginning, they enter the
room with a plan and execute the plan without interrup-
tion. This approach gives the participants time to carry
out the intended plan and offers them the opportunity
for self-correction. Group decisions and discussions are
employed. If participants venture off track, the simulated
experience is taken in a new direction. Redirection can be
introduced in the form of verbal cues by the ‘‘patient,’’
incoming lab results, health care provider phone calls,
or input from the facilitator (Nehring & Lashley, 2010).
No Facilitator Prompting Simulation: Participants pro-
vide care without any interruptions and continue the
simulation until the scenario is completed. Cuing may
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S5
be provided if needed to assist in redirecting the sce-
nario. At the completion of the scenario, the facilitator
engages the participants in the debriefing session
(Nehring & Lashley, 2010).
Facilitator: An individual who guides and supports partic-
ipants toward understanding and achieving objectives.
Feedback: One-way communication given to a participant
from a facilitator, simulator, or other participants in an
effort to improve performance.
Fidelity: Believability, or the degree to which a simulated
experience approaches reality; as fidelity increases, real-
ism increases. The level of fidelity is determined by the
environment, the tools and resources used, and many
factors associated with the participants. Fidelity can in-
volve a variety of dimensions, including (a) physical fac-
tors such as environment, equipment, and related tools;
(b) psychological factors such as emotions, beliefs,
and self-awareness of participants; (c) social factors
such as participant and instructor motivation and goals;
(d) culture of the group; and (e) degree of openness
and trust, as well as participants’ modes of thinking
(Dieckmann, Gaba, & Rall, 2007; NLN-SIRC, 2010).
Guided Reflection: Process used by the facilitator during
debriefing that reinforces the critical aspects of the expe-
rience and encourages insightful learning, allowing the
participant to assimilate theory, practice, and research
in order to influence future actions (NLN-SIRC, 2010).
Guidelines: Procedures or principles that are not manda-
tory but are used to assist in meeting standards. Guide-
lines are not necessarily comprehensive; they provide
a framework for developing policies and procedures.
High-Stakes Evaluation: An evaluation process associated
with a simulation activity and that has a major conse-
quence or is the basis for a major grading decision, in-
cluding passefail implications. High stakes refers to
the outcome or consequences of the process.
Knowledge: The awareness, understanding, and expertise
an individual acquires through experience or education.
Outcome: Results of the participants’ progress toward
meeting learning objectives.
Participant Objectives: Statement of cognitive (knowl-
edge), affective (attitude), and/or psychomotor (skills)
goal(s).
Pedagogy: The art or science of instructional methods. The
study of teaching methods, including goals of education
and the ways those goals can be achieved.
Prebriefing: An information session held prior to the start
of a simulation activity and in which instructions or pre-
paratory information is given to participants. The
purpose of the prebriefing is to set the stage for a sce-
nario and assist participants in achieving scenario objec-
tives. Suggested activities in a prebriefing include an
orientation to the equipment, environment, manikin,
roles, time allotment, objectives, and patient situation.
Problem Solving: The skill used in managing the work
role, working in a team, and managing a health care
Standard I: Terminology
setting. Problem solving refers to the process of selec-
tively attending to information in the patient care set-
ting, using existing knowledge and collecting
pertinent data to formulate a solution. This complex
process requires different cognitive processes, including
methods of reasoning and strategizing, in order to man-
age a situation (Uys, Van Rhyn, Gwele, McInerney, &
Tanga, 2004).
Prompt: A cue given to a participant in a scenario.
Psychomotor Skill: The ability to carry out physical move-
ments efficiently and effectively, with speed and accu-
racy. Psychomotor skill is more than the ability to
perform; it includes the ability to perform proficiently,
smoothly, and consistently under varying conditions
and within appropriate time limits.
Questioning: The strategic process of seeking information
or knowledge, thoughts, feelings, and judgments of the
participant(s) before, during, and after a scenario.
Reflective Thinking: The engagement of self-monitoring
that occurs during or after a simulation experience. Con-
sidered an essential component of experiential learning, it
promotes the discovery of new knowledge with the intent
of applying this knowledge to future situations. Reflective
thinking is necessary for metacognitive skill acquisition
and clinical judgment and has the potential to decrease
the gap between theory and practice. Reflection requires
the creativity and conscious self-evaluation to deal with
unique patient situations (Decker, 2007a, 2007b;
Dewey, 1933; Kolb, 1984; Kuiper & Pesut, 2004;
Ruth-Sahd, 2003; Sch€ on, 1983, 1987).
Reliability: The consistency of a measurement, or the de-
gree to which an instrument measures in the same way
each time it is used under the same conditions with
the same participants. It is the repeatability of a measure-
ment. A measurement is considered reliable if a person’s
scores on the same test given twice are similar. Reliabil-
ity can be determined by a testeretest method or by test-
ing for internal consistency.
Role: A character assumed in a scenario or simulation.
Safe Learning Environment: The emotional climate that
facilitators create by the interaction between facilitators
and participants. In this positive emotional climate, par-
ticipants feel at ease taking risks, making mistakes, or
extending themselves beyond their comfort zone. Facil-
itators are thoroughly aware of the psychological aspects
of learning, aware of the effects of unintentional bias,
aware of cultural differences, and attentive to their
own state of mind in order to effectively create a safe
environment for learning (Readingtoparents.
org, 2005).
Safe Patient Care: Quality care provided by health care
practitioners with a focus on the prevention of harm to
patients.
Scenario: See Clinical Scenario.
Simulated Clinical Experience: The simulated clinical ex-
perience includes prebriefing, the clinical scenario, and
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S6
debriefing. It is the engagement part of a clinical
scenario.
Simulation: A pedagogy using one or more typologies to
promote, improve and/or validate a participant’s pro-
gression from novice to expert (Benner, 1984; Decker,
2007).
Simulation Experience: Term often used synonymously
with simulated clinical experience or scenario.
Simulation Learning and Testing Environments:
Simulation Learning Environment: An atmosphere that
is created by the facilitator to allow for sharing and dis-
cussion of participant experiences without fear of humil-
iation or punitive action. The goals of the simulation
learning environment are to promote trust and foster
learning.
Simulation Testing Environment: An atmosphere that
is created by the facilitator to allow for formative or
summative evaluation to occur. The goals of the sim-
ulation testing environment are to create an equiva-
lent activity for all participants in order to test
their knowledge, skills, and abilities in a simulated
setting.
Skill Acquisition (Skill Attainment): After instruction, the
ability to integrate the knowledge, skills (technical and
nontechnical), and attitudes necessary to provide safe
patient care. The individual progresses through five
stages of proficiency: novice, advanced beginner, com-
petent, proficient, and expert (Benner, 1984; Benner,
Tanner & Chesla, 1996).
Skill Development: The progress along a continuum of
growth in knowledge, skills, and attitudes as a result
of educational or other experiences.
Standardized Patient: A person trained to consistently
portray a patient or other individual in a scripted sce-
nario for the purposes of instruction, practice, or
evaluation (Robinson-Smith, Bradley, & Meakim,
2009).
Typology: Classification of types. In simulation it refers to
the classification of different educational methods and/or
equipment used to provide a simulated experience. For
example, simulation methodologies may include written
simulation cases, 3-dimensional models, computer soft-
ware, standardized patients, partial task trainers, or high-
fidelity patient simulators.
Validity: The degree to which a test measures what it is
supposed to measure.
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