Clinical Simulation in Nursing (2009) 5, e17-e21

www.elsevier.com/locate/ecsn

Featured Article

Nursing Leadership and Management Simulation Creating

Complexity
Clinta Che’ Reed, MSN, RN, Rebecca R. Lancaster, PhD, APN, Donna Bridgman
Musser, PhD, RN

University of Central Arkansas, Conway, AR 72035, USA

KEYWORDS Abstract: Clinical simulation is receiving additional emphasis as nursing programs face shrinking
Simulation; clinical placement sites and faculty seek new teaching strategies to produce competent clinicians. Fac-
leadership; ulty members teaching a senior level Nursing Leadership and Resource Management course reviewed
management; the current simulation literature and were unable to find any examples to replicate the complex, chang-
nursing; ing environment faced by nurses in leadership roles. Strategies already developed for creating success-
senior students ful scenarios were modified to develop a simulation experience that would mimic the challenges faced
by a charge nurse working with the nursing care team as well as a group of patients and family mem-
bers on a hospital nursing unit. This article describes the development, implementation, and evaluation
of a simulation leadership and management scenario.

Cite this article:

Reed, C. C., Lancaster, R. R., & Musser, D. B. (2009, January). Nursing Leadership and Management
Simulation: Creating Complexity. Clinical Simulation in Nursing, 5(1). doi:10.1016/j.ecns.2008.09.006.

Ó 2009 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier
Inc. All rights reserved.

Clinical simulation is a viable, efficient, and effective
instructional technique enabling nursing students to partici-
pate in intense learning experiences while gaining confi-
dence in their ability to care for patients and practice
clinical decision making (Issenberg & Scalese, 2008). Al-
though simulation scenarios developed by nursing faculty
are available for medicalesurgical nursing, maternity, pedi-
atrics, and critical care, there is a need for simulation sce-
narios in senior-level courses such as nursing leadership
and management. A simulation experience of this type is
especially important because nursing students are rarely
able to practice the leadership role in clinical settings.
As the Nursing Leadership and Resource Management
(NLRM) course faculty began discussing the development of
E-mail address: CReed@uca.edu (C. Che’ Reed).
a simulation scenario, several issues and challenges drove the
process: first, the simulation scenario should reflect course
and clinical objectives; second, the level of fidelity and use of
technology should be limited to the on-campus-laboratory
setting; third, the complexity of the scenario should reflect
the knowledge level of the students; and fourth, the
simulation experience should increase the confidence and
decision-making skills of the students. This article outlines
the process used to develop and implement the leadership and
management simulation experience.
Review of Literature
Jeffries’ (2007) framework served as the theoretical guide
for this simulation experience. The theoretical framework

1876-1399/09/$ - see front matter Ó 2009 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved.
doi:10.1016/j.ecns.2008.09.006
Nursing Leadership and Management Simulation Creating Complexity
for simulation design provides a model for developing, im-
plementing, and evaluating simulations across nursing cur-
ricula. Framework components include teacher factors,
student factors, educational practices used, simulation de-
sign characteristics, and outcomes. Educational practices
used for the simulation experience included active learn-
ing, feedback, studentefaculty interaction, collaboration,
high expectations, incorporation of diverse learning styles,
and the time spent on tasks. Development of simulation
was based on the following simulation design characteris-
tics: objectives, fidelity, problem solving, student support,
and reflective thinking or debriefing. Each component,
practice, and design characteristic is considered during
the development of the simulation scenario to maintain
consistency and accurately assess effectiveness of the ex-
perience (Jeffries, 2007).
Jeffries (2005) suggested that objectives of simulated
clinical experiences should reflect course and clinical ob-
jectives; promote active learning strategies; and increase
student, faculty, and group interactions, resulting in in-
creased student self-confidence, satisfaction, and critical
thinking capacity. A review of available literature suggested
that the key to creating a substantive simulation experience
is the strategic planning and development of the scenario
(Curl, Smith, Chisholm, Hamilton, & McGee, 2007;
Gaba, 2004; Jeffries, 2005, 2007; Reznek, 2004).
Gaba (2004), Reznek (2004), and Jeffries (2005, 2007)
emphasized the importance of a high level of fidelity in the
laboratory setting to maximize the effectiveness of the expe-
rience. Conversely, Curl et al. (2007) suggested that the use of
high-fidelity patient simulators is not required to create
a role-playing experience that is complex and that allows
student nurses to act and react in clinical situations.
Larew, Lessans, Spunt, Foster, and Covington’s (2006)
simulation protocols proceed in a linear sequence in which
the studentefaculty interaction and the scenario progression
depend on the student’s proficiency in identifying, assessing,
and intervening in the clinical scenario. As the scenario
progresses, cues or prompts provided by the clinical facili-
tator are on a continuum from vague to specific in response to
the student’s questions and actions. Cues to guide the
participant toward the desired learning experience are
carefully scripted so that the clinical scenario unfolds as
planned and the student recognizes and responds to appro-
priate cues. Larew et al. (2006) also found that the clinical
complexity of the simulation scenario should correspond to
the student’s knowledge base. Exposing novice nursing stu-
dents to complex scenarios resulted in the students’ feeling
overwhelmed and anxious. In addition, time limits incorpo-
rated into scenarios should be comparable to those experi-
enced in real life, allowing students to recognize time
constraints inherent in practice (Larew et al., 2006).
Providing a debriefing session after completion of the
scenario encourages students to reflect on their experience
and to critically examine how they spent their time working
through the scenario (Jeffries, 2005). Integrating feedback,
pp e17-e21  Clinical Simulation in Nursing  Volume 5  Issue 1
e18
debriefing, and guided reflection into the simulation facili-
tates the learner’s ability to link theory to practice, synthe-
size knowledge, and develop insight (Decker, Sportsman,
Puetz, & Billings, 2008; Jeffries, 2007).
Scenario Development
The NLRM course faculty identified the need for senior-level
students to gain experience in prioritization and delegation of
patient care in acute care settings that were often not
available in clinical experiences because of staffing and
time pressures. Using the principles and suggestions found in
the literature, NLRM faculty developed a clinical simulation
scenario to offer the expected and unexpected challenges of
managing a nursing unit. The experience included practice of
critical skills required to manage time pressures, prioritize
and delegate patient care appropriately, interact with families
and physicians, and provide quality care. Course and clinical
objectives were merged to form the simulation lab objectives
used to guide the development and implementation of the
simulation experience.
Students enrolled in the course were in their final semester
prior to graduation and had completed all theory and clinical
specialty area course content. They synthesized knowledge
from previous courses with theoretical content from the
NLRM course to successfully complete the simulation lab
experience. Students experienced clinical simulation in at
least three prior clinical courses, but none of those experi-
ences involved the complexity required to simulate manag-
ing an entire nursing unit.
The simulation experience occurred in the final 6 weeks
of the semester. The majority of course content related to
delegation, prioritization, and care modalities had been
presented didactically. Students had also been in the clinical
setting for 4 to 6 weeks prior to the simulation experience.
Students received only the simulation lab objectives prior to
participating in the simulation lab experience. Because this
was the first simulation of this kind, and because of the time
required to develop and prepare the leadership simulation,
the same scenario was used for all students in the course.
Consequently, students were asked to keep the content of
the scenario confidential until all students completed the
experience.
Jeffries’ (2007) simulation design template provided the
structure for development of this simulation scenario. The
setting for the simulation consisted of eight beds in the
on-campus laboratory to simulate a medicalesurgical nurs-
ing unit. The simulation area contained four quadrants with
a central area for the nurses’ station, crash cart, and medi-
cation station. Each quadrant contained two beds with bed-
side tables, a nightstand, curtains, a sink, and a linen closet.
The nurses’ station included a desk and a telephone. The
crash cart was next to the nurses’ station, and the medica-
tion station was a designated place with a counter for stu-
dents to simulate preparing medication.
Nursing Leadership and Management Simulation Creating Complexity
Assigned student roles included the charge nurse, one
registered nurse (RN), one licensed practical nurse (LPN),
and one unlicensed staff member. Two students were
designated observers. Descriptions of each staff member’s
experience, education, and temperament were included in
the scenario overview provided to all participants.
The charge nurse (primary student role) made patient
assignments based on patient acuity level, experience level
of staff, and rules and regulations of the state board of
nursing regarding scope of practice and delegation. In
addition, the student acting as charge nurse chose the nursing
care modality used in the simulation. Direct patient care and
communication with nursing care team members and
physicians were also included in this role.
The role description of the staff RN included direct
patient care. Additional duties included communicating
with other care team members, telephoning physicians,
assessing need for and administration of medication and
treatments, and working with patients’ family members.
The LPN was responsible for providing direct patient care,
giving medication, and communicating with nursing care
team members. The unlicensed staff member’s responsibil-
ities included basic patient care, direct venous lab draws,
and order entry. Students assigned as observers paid careful
attention to student decisions and behaviors in order to lead
the debriefing session at the conclusion of the scenario.
Three course faculty members led the simulation expe-
rience. One faculty member introduced the simulation
experience, acted as the physician, and called time changes.
Another gave morning report to the nursing care team
coming in to work for the day and acted as a family member.
A third faculty member acted as a family member and served
as a resource person to answer students’ questions when they
were unsure how to proceed during the scenario.
The scenario began with shift change at 7:00 a.m. and
ended at 12:30 p.m. The scenario did not progress in real
time. Faculty called out the time in 30-minute segments
during the shift. These 30-minute segments in reality
occurred in 5- to 10-minute intervals.
Faculty placed patient information sheets at the foot of
every patient bed. Each patient information sheet had a time
of day printed at the top. Students looked at each information
sheet as time was called and responded to the patient data
recorded on the page. For example, a patient information
sheet for 8:30 a.m. stated, ‘‘Your patient is complaining of
incision pain.’’ The student caring for that patient verbalized
the pain assessment and was given feedback by faculty
members. The student then simulated his or her chosen
intervention, resulting in a positive or negative change in the
patient’s condition.
A debriefing session was planned for the end of the
scenario. Students assigned the observer role led the session
using a list of debriefing questions developed by the faculty
and the students’ own observations. All students and faculty
participating in the scenario engaged in the debriefing session.
pp e17-e21  Clinical Simulation in Nursing  Volume 5  Issue 1
e19
Simulation Implementation
The simulation experience began with course faculty
welcoming students, going over simulation lab objectives,
orienting the students to the simulated nursing unit, and
explaining the way the simulation would progress. Students
were assigned nursing care team roles on a random basis.
All students were given a report sheet listing the patients on
the unit and their conditions. The students acting as the
nursing care team were given report by the faculty member
representing the night nurse. After report, the student acting
as charge nurse decided on the care model and made team
assignments.
The patient census was six at the beginning of the
scenario, with two pending admissions. The events of the
day began after report when the course faculty member
called time by stating, ‘‘It is now 7:30 a.m. You may assess
your patients and begin your day.’’ Students simulated
making rounds for their patients. After 5 minutes, the
faculty member stated, ‘‘It is now 8:00 a.m. Look at the
patient information sheets at the foot of your patients’ beds
and proceed accordingly.’’
As time was called, students turned over their patient
information sheets and proceeded according to what was
written on the page. The patient beds were empty, requiring
students to simulate patient care and interventions. The
students demonstrated remarkable ability to make adjust-
ments and to simulate critical thinking, prioritization,
patient care decisions, and delegation. Faculty rarely pro-
vided background information or cues in addition to those
already scripted.
Students could stop the action during the scenario and ask
for assistance from other participants or faculty. They faced
not only routine situations and tasks but also less routine
situations, such as a patient admitted from the emergency
room with a spider bite and whose condition was deteriorat-
ing; a patient from surgery who became oversedated;
a distraught family member screaming that her confused
sister, who was a patient, had fallen and was on the floor;
a dying patient whose vital signs became unstable; and
a diabetic patient who was found to have a stash of candy.
Students made decisions about when and whether to give
medication, call a physician, educate family members, and
delegate responsibilities.
All students participated in the debriefing session, led by
the students who had been the observers. These students were
given the list of debriefing questions at the beginning of the
simulation experience. Faculty facilitated the process by
adding their observations, pointing out critical decisions, and
reinforcing theoretical content. Evaluation criteria for the
simulation experience were based on the simulation lab
objectives in the initial implementation of the scenario. A
score was given to the students on the basis of their individual
fulfillment of each objective. Emphasis was placed on
additional criteria, including attendance, participation, role
Nursing Leadership and Management Simulation Creating Complexity
performance, and professionalism. A total of 50 points was
possible for the simulation experience.
The scenario portion of the simulation lasted approxi-
mately 1e1.5 hours (including the time required to orient
students to the experience), with debriefing lasting an
additional hour. One complete simulation took about
2e2.5 hours.
Simulation Evaluation and Refinement
The initiation of this simulation experience provided a great
deal of learning for all involved, and a number of simulation
principles were reinforced. Jeffries’ (2007) evaluation plan
was used to systematically evaluate the design, implementa-
tion, and outcomes of the simulation experience.
The simulation design was evaluated on the basis of the
clarity of the objectives and information given to the students,
the amount of student support provided by the faculty, the
amount of problem solving and degree of complexity
embedded into the scenario, the fidelity of the experience,
and the quality of guided reflection and debriefing (Jeffries,
2007). According to Jeffries (2007), the presence of certain
educational practices and principles is critical to successful
implementation of the simulation scenario. These educa-
tional practices include active learning, incorporation of di-
verse ways of learning, high expectations for the students
participating, and collaboration among students and faculty.
During the debriefing session, outcomes such as increased
knowledge, enhanced skill performance, high learner satis-
faction, critical thinking, and increased self-confidence
were evaluated directly based on the student responses.
Based on Jeffries’ (2007) evaluation plan and this initial ex-
perience, the following recommendations are offered.
First, it is clear that faculty involved in leading a simula-
tion experience need to be familiar with basic simulation
principles. Second, all faculty should have some experience
with simulation even if it is merely observation of a simula-
tion. Third, it is critical that students experience a positive
simulation environment. Students at the point of graduation
and working as new nurses often experience anxiety and
a lack of confidence about their professional abilities. For this
reason, it is critical for faculty to recognize students’ need for
help quickly and offer timely support. Students should be
redirected in a supportive and encouraging manner if they
begin to stray from the experience objectives.
Recommendations for Future Simulations and
Research
Faculty observed several aspects of the simulation that need
to be refined for future simulation experiences. These
include having no patients in the beds and students’ having
the opportunity to experience only one role and one
scenario. One faculty suggestion for refinement was to
increase the number of students in the simulation lab at one
pp e17-e21  Clinical Simulation in Nursing  Volume 5  Issue 1
e20
time from 6 to 16 so that students could be patients in the
beds and then change roles to act as nursing care team
members in another scenario.
A further recommendation was to give the patient
information sheets at the foot of the bed to the students
acting as patients in the beds. That way, the student acting
as the patient could respond according to what was written
on the sheets, and students acting as the care team would be
responding to actions and behaviors of patients rather than
printed data. Some information, such as changes in vital
signs, would need to be written, but the students acting as
patients would present this information to students acting as
the care team when appropriate.
There is little doubt among nursing faculty that this type
of scenario needs to be investigated further to determine
how best to implement simulation across nursing curricula.
Significant strides are being made toward this goal. Nursing
leadership and management is a new addition to the arena
of simulation development and research.
The student acting as charge nurse was making decisions
related not only to the physiological condition of each
individual patient but also to the care team, the notification
of other health care professionals about current conditions, and
the management of six to eight patients and their families. The
students demonstrated awareness of their surroundings and the
ability to comprehend the situation, make decisions quickly,
and plan for potential complications. Studies to define the
development of awareness, comprehension, decision making,
and planning as they apply to simulation of nursing in
leadership roles are needed.
Conclusion
Faculty observed the ability of students to make good
decisions quickly in complex situations during this simu-
lation. The demonstration of this ability in such a complex
situation increased the confidence of the faculty that
leadership and management skills can be taught, practiced,
and evaluated in the on-campus laboratory environment.
The incorporation of simulation into clinical courses on
nursing leadership and management has the potential to
increase the confidence and ability of nurses entering a pro-
fession in need of effective leadership. New graduate nurses
are often given the responsibility of charge nurse within the
first year of practice rather than after several years of experi-
ence. Nurse educators, through the use of simulation, can offer
students the benefit of experience in a positive learning envi-
ronment to effectively increase the students’ clinical expertise,
clinical decision making, and confidence as new graduates.
References
Curl, E. D., Smith, S., Chisholm, L., Hamilton, J., & McGee, L. A. (2007).
Multidimensional approaches to extending nurse faculty resources without
testing faculty’s patience. Journal of Nursing Education, 46(4), 193-195.
Nursing Leadership and Management Simulation Creating Complexity
Decker, S., Sportsman, S., Puetz, L., & Billings, L. (2008). The evolution
of simulation and its contribution to competency. Journal of Continuing
Education in Nursing, 39(2), 74-80.
Gaba, D. M. (2004). The future vision of simulation in health care. Quality
and Safety in Health Care, 13(Suppl. 1), i2-i10.
Issenberg, S. B., & Scalese, R. J. (2008). Simulation in health care educa-
tion. Perspectives in Biology and Medicine, 51, 31-47.
Jeffries, P. R. (2005). A framework for designing, implementing, and eval-
uating simulations used as teaching strategies in nursing. Nursing Edu-
cation Perspectives, 26(2), 96-103.
pp e17-e21  Clinical Simulation in Nursing  Volume 5  Issue 1
e21
Jeffries, P. R. (2007). Simulation in nursing education: From conceptuali-
zation to evaluation. New York: National League for Nursing.
Larew, C., Lessans, S., Spunt, D., Foster, D., & Covington, B. G. (2006).
Innovations in clinical simulation: Application of Benner’s theory in an in-
teractive patient care simulation. Nursing Education Perspectives, 27(1),
16-21.
Reznek, M. A. (2004). Current status of simulation in education and
research. In G. E. Loyd, C. L. Lake, & R. Greenberg (Eds.), Prac-
tical health care simulations (pp. 27e47). Philadelphia: Elsevier
Mosby.