Featured Article| Volume 30, P34-41, May 2019

Emerging Evidence Toward a 2:1 Clinical to Simulation Ratio: A Study Comparing the Traditional Clinical and Simulation Settings

Published:March 21, 2019DOI:


      • Students complete more activities in less time in simulation compared with the clinical setting.
      • Students spend more time in Miller's “knows how” (application) in simulation.
      • Students spend more time in Miller's “knows” (recall, not application) in the clinical setting.
      • Students spend more time in Miller's “does” (independent action) in simulation.
      • The efficient environment of simulation is emerging evidence toward a 2:1 clinical to simulation ratio.



      There is limited evidence comparing the clinical and simulation environments.


      This multicenter observational study compared traditional clinical to simulation on the type, number, and level of educational activities as determined by Miller's Pyramid.


      Forty-two students' experience revealed that skills, physical assessment, teaching, and critical thinking activities occurred more frequently in simulation, with safety interventions more common in clinical. In addition, in simulation, students performed a greater percentage of activities in higher levels of Millers Pyramid, “Knows How”; 12.8% as compared with 8.6% in clinical, and “Does”; 66.3% as compared with 46.2% in clinical. Notably, the activities in “Does” were completed in approximately 1/5 of the time in simulation; 440 minutes, as compared with clinical; 2,137 minutes.


      The intensity and efficiency of simulation was demonstrated through the completion of more activities in higher levels of Millers Pyramid in significantly less time than clinical providing emerging evidence toward a 2:1 clinical to simulation ratio.


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