Abstract
Keywords
Standard
Prebriefing is a process which involves preparation and briefing. Prebriefing ensures that simulation learners are prepared for the educational content and are aware of the ground rules for the simulation-based experience. Prior to the development of this standard, the preparation phase of prebriefing was part of the INACSL Standards of Best PracticeSM: Simulation Design and remains a crucial component of simulation design. According to the most current literature review, prebriefing is referred to as both preparation activities and briefing activities.
3.
, 4.
, 5.
,6.
,- Page-Cutrara K.
Prebriefing in nursing simulation: A concept analysis.
Clinical Simulation in Nursing. 2015; 11 (http://dx.doi.org/): 335-340https://doi.org/10.1016/j.ecns.2015.05.001
12.
,19.
,29.
,31.
,- McDermott D.S.
Prebriefing: A historical perspective and evolution of a model and strategy (Know: Do: Teach).
Clinical Simulation in Nursing. 2020; 49 (https://doi.org/): 40-49https://doi.org/10.1016/j.ecns.2020.05.005
32.
For the purposes of this prebriefing standard, prebriefing will refer to the activities PRIOR to the start of the simulation including the preparation and briefing aspects of the simulation-based experience. Guidelines for this standard will be provided that apply to both preparation and briefing and then each of those components will have their own guidelines to ensure they are met.- Ludlow J.
Prebriefing: A principle-based concept analysis.
Clinical Simulation in Nursing. 2020; X (https://doi.org/): 1-8https://doi.org/10.1016/j.ecns.2020.11.003
Background
Prebriefing information prior to simulation-based experiences is vital for learner success and may enhance debriefing and reflection.
4.
, 5.
, 6.
Deliberately designed preparation and prebriefing can balance the cognitive load demands of the learner and increase the effectiveness of the simulation-based experience.- Page-Cutrara K.
Prebriefing in nursing simulation: A concept analysis.
Clinical Simulation in Nursing. 2015; 11 (http://dx.doi.org/): 335-340https://doi.org/10.1016/j.ecns.2015.05.001
1.
, 2.
, 3.
High quality simulation requires simulationists and educators who are knowledgeable in the pedagogy, including the prebriefing phase.4.
, 5.
, 6.
- Page-Cutrara K.
Prebriefing in nursing simulation: A concept analysis.
Clinical Simulation in Nursing. 2015; 11 (http://dx.doi.org/): 335-340https://doi.org/10.1016/j.ecns.2015.05.001
Historically, prebriefing has been difficult to define due to variations in terminology regarding preparation, briefing, and prebriefing, which occur “prior to the simulation-based experience.”
7.
There are a variety of terms used in the literature to represent activities before the simulation scenario that are meant to prepare learners to meet scenario objectives, establish psychological safety, and provide an overall orientation to the simulation process.5.
,6.
,- Page-Cutrara K.
Prebriefing in nursing simulation: A concept analysis.
Clinical Simulation in Nursing. 2015; 11 (http://dx.doi.org/): 335-340https://doi.org/10.1016/j.ecns.2015.05.001
12.
,14.
,19.
,21.
,23.
,29.
,31.
,- McDermott D.S.
Prebriefing: A historical perspective and evolution of a model and strategy (Know: Do: Teach).
Clinical Simulation in Nursing. 2020; 49 (https://doi.org/): 40-49https://doi.org/10.1016/j.ecns.2020.05.005
32.
Examples of these different terms include: “Prescenario learning activities”- Ludlow J.
Prebriefing: A principle-based concept analysis.
Clinical Simulation in Nursing. 2020; X (https://doi.org/): 1-8https://doi.org/10.1016/j.ecns.2020.11.003
8.
“pre-planning sessions,”- Waxman K.T.
The development of evidence-based clinical simulation scenarios: Guidelines for nurse educators.
Journal of Nursing Education. 2010; 49 (http://dx.doi.org/): 29-35https://doi.org/10.3928/01484834-20090916-07
9.
“briefing,”10.
“preparation,”11.
“presimulation preparation”- Gantt L.T.
The effect of preparation on anxiety and performance in summative simulations.
Clinical Simulation in Nursing. 2013; 9 (http://dx.doi.org/): e25-e33https://doi.org/10.1016/j.ecns.2011.07.004
21.
“prebriefing, briefing, presimulation,”12.
“presimulation briefing,”13.
and “ presimulation assignments.”- Rudolph J.W.
- Raemer D.B.
- Simon R.
Establishing a safe container for learning in simulation. The role of the presimulation briefing.
Simulation in Healthcare. 2014; 9 (http://dx.doi.org/): 339-349https://doi.org/10.1097/SIH.0000000000000047
14.
In addition, simulation educators often design demonstration-based preparation activities that occur prior to the simulation-based scenario but may not consistently be referred to as part of prebriefing. These preparation activities may include “role modeling”
15.
,- Aronson B.
- Glynn B.
- Squires T.
Effectiveness of a role-modeling intervention on student nurse simulation competency.
Clinical Simulation in Nursing. 2013; 9 (http://dx.doi.org/): e121-e126https://doi.org/10.1016/j.ecns.2011.11.005
16.
“instructor modeled learning”- Johnson E.A.
- Lasater K.
- Hodson-Carlton K.
- Siktberg L.
- Sideras S.
- Dillard N.
Geriatrics in simulation: Role modeling and clinical judgment effect.
Nursing Education Perspectives. 2012; 33 (http://dx.doi.org/): 176-180https://doi.org/10.5480/1536-5026-33.3.176
17.
and “expert modeling.”18.
The lack of a common language regarding the activities which should be considered preparation, briefing, and/or prebriefing create confusion for those designing simulation-based experiences. As a result, this standard and the term “prebriefing” will be divided into two distinct components (preparation and briefing) and refer to all activities that occur before the simulation scenario. Therefore, there is a single term, which has a broader use.
6.
- Page-Cutrara K.
Prebriefing in nursing simulation: A concept analysis.
Clinical Simulation in Nursing. 2015; 11 (http://dx.doi.org/): 335-340https://doi.org/10.1016/j.ecns.2015.05.001
Prebriefing activities are intended to establish a psychologically safe learning environment by:
- 1)Situating the learners into a common mental model and preparing learners for the educational content of the simulation-based experience (preparation).
- 2)Conveying important ground rules for the simulation-based experience (briefing).
Because this standard addresses all aspects of pre-simulation activities, the criteria have been separated into categories with required elements: general criteria necessary for all aspects of the standard, criteria to meet the preparation aspect, and criteria to meet the briefing aspect of the standard.
General Criteria Necessary to Meet Every Aspect of this Standard
- 1The simulationist should be knowledgeable about the scenario and competent in concepts related to prebriefing.
- 2Prebriefing should be developed according to the purpose and learning objectives of the simulation-based experience.
- 3The experience and knowledge level of the simulation learner should be considered when planning the prebriefing.
General Criterion 1: The simulationist should be knowledgeable about the scenario and competent in concepts related to prebriefing. (Follow the Healthcare Simulation Standards of Best PracticeTM (HSSOBPTM) Facilitation for more information)
Required Elements:
- •Demonstrate competency in prebriefing through incorporation of the HSSOBPTM.
- •Maintain professional development through formal coursework, ongoing training, and education, or with targeted work in prebriefing.
- •Conduct a planned prebriefing session that is tied to the simulation objectives and serves to prepare learners for the simulation-based experience and the debriefing which follows.
- •Follow the HSSOBPTM Professional Development.
General Criterion 2: Prebriefing should be developed according to the purpose and learning objectives of the simulation-based experience.
5.
,6.
- Page-Cutrara K.
Prebriefing in nursing simulation: A concept analysis.
Clinical Simulation in Nursing. 2015; 11 (http://dx.doi.org/): 335-340https://doi.org/10.1016/j.ecns.2015.05.001
Required Elements:
For all simulation-based experiences:
- •Plan prebriefing as a structured part of the simulation experience.
- •Incorporate requirements for learner preparation and briefing during simulation design.5.,6.,
- Page-Cutrara K.
Prebriefing in nursing simulation: A concept analysis.Clinical Simulation in Nursing. 2015; 11 (http://dx.doi.org/): 335-340https://doi.org/10.1016/j.ecns.2015.05.00119. - •Preparation and briefing requirements may vary, depending on the overall purpose and objectives of the simulation-based experience.5.
For summative/high stakes simulation-based experiences:
- •Set the stage in supporting learner success with appropriate preparation and briefing.20.
- •Provide information to learners regarding the type of scenario and method of evaluation In advance of the simulation-based experience.20.
- •Develop preparation materials based on the simulation objectives and the descriptors in the assessment tool/rubric.21.
- •Use a consistent, preplanned, standardized, written briefing script including orientation to the simulation-based experience, environment and resources to enhance reliability of instructions to learners in preparation for the simulation-based experience.22.
General Criterion 3: The experience and knowledge level of the simulation learner should be considered when planning the prebriefing.
Required Elements:
- •The amount and type of prebriefing may be inversely proportional to the level of the simulation learner. For example: novices to simulation-based learning and to the clinical setting may require more preparation, briefing, and orientation than experienced simulation learners or clinical experts.
- •The simulation designer and facilitator are responsible for ensuring that preparatory and briefing activities address the knowledge, skills, attitudes, and behaviors that will be expected of the learners during the simulation-based experience.
PREPARATION CRITERIA
Preparation: Criterion 4: Based on needs assessment and purpose of the experience, preparation materials are developed to assure that learners are prepared for the experience and can meet the scenario objectives.
Required Elements:
- •Use adult learning theory principles to prepare prebriefing materials that are designed to decrease cognitive load and equip learners to practice “at the edge of their ability.”1.,13.
- Rudolph J.W.
- Raemer D.B.
- Simon R.
Establishing a safe container for learning in simulation. The role of the presimulation briefing.Simulation in Healthcare. 2014; 9 (http://dx.doi.org/): 339-349https://doi.org/10.1097/SIH.0000000000000047 - •Use organizational or regulatory requirements to develop preparation materials for the simulation-based experience.
- •Decrease learner anxiety9.and increase psychologically safety23.by providing preparation for scenario content. If prepared, learners are likely to feel comfortable to carry out scenario requirements and discuss scenario details during debriefing.6.,
- Page-Cutrara K.
Prebriefing in nursing simulation: A concept analysis.Clinical Simulation in Nursing. 2015; 11 (http://dx.doi.org/): 335-340https://doi.org/10.1016/j.ecns.2015.05.00123.,24.,25.,31.- McDermott D.S.
Prebriefing: A historical perspective and evolution of a model and strategy (Know: Do: Teach).Clinical Simulation in Nursing. 2020; 49 (https://doi.org/): 40-49https://doi.org/10.1016/j.ecns.2020.05.005
Preparation: Criterion 5: Preparation materials should be developed according to the purpose and learning objectives of the simulation-based experience.
Required Elements:
- •Use a variety of activities to ensure learner success in achieving the simulation learning outcomes.
- •Develop preparation activities and resources to support understanding of the concepts and content related to the simulation-based experience. These activities may include (but are not limited to), items such as:
- ○assigned readings or audiovisual materials
- ○concept mapping or care planning exercises
- ○review of patient health record/patient report
- ○case studies
- ○observation of a model of a simulated case
- ○completion of a pretest or quiz
- ○review of medications
- ○practice skills to be used in the simulation-based experience
- ○lecture or other didactic lesson
- ○clinical preparation sheet completion
- ○discussion of simulated patient
- ○virtual simulation activities
- ○
Guide learners to perceive “the meaning of the scenario information” and support learning based on learner level and scenario purpose.
6.
For example: a clinician may need limited information such as a patient report, but a novice learner may need assistance determining the salient aspects of the patient report.- Page-Cutrara K.
Prebriefing in nursing simulation: A concept analysis.
Clinical Simulation in Nursing. 2015; 11 (http://dx.doi.org/): 335-340https://doi.org/10.1016/j.ecns.2015.05.001
31.
- McDermott D.S.
Prebriefing: A historical perspective and evolution of a model and strategy (Know: Do: Teach).
Clinical Simulation in Nursing. 2020; 49 (https://doi.org/): 40-49https://doi.org/10.1016/j.ecns.2020.05.005
Preparation: Criterion 6: Plan the delivery of preparation materials both prior to and on the day of the simulation-based experience.
Required Elements
- •Augment learner's previous knowledge and previous experience with the simulation modality.
- •Allow for learners to complete preparation activities in advance of the simulation-based experience to reinforce previous learning and prepare learners for success.
- •Consider implementing a “ticket” to enter the experience once preparation activities have been completed to ensure learner readiness for simulation.5.,26.
- •Consider establishing consequences for management of learners attending the simulation experience without having completed the preparation requirements.4.,27.
- •Consider additional preparatory activities on the day of the simulation-based experience such as a facilitated discussion or student planning session prior to beginning the simulation.4.,9.,28.,31.
- McDermott D.S.
Prebriefing: A historical perspective and evolution of a model and strategy (Know: Do: Teach).Clinical Simulation in Nursing. 2020; 49 (https://doi.org/): 40-49https://doi.org/10.1016/j.ecns.2020.05.005
BRIEFING Criteria
Briefing: Criterion 7: Prior to the simulation-based experience, the simulationist conveys important information to learners regarding expectations, the agenda, and the logistics for the experience.
5.
,6.
,- Page-Cutrara K.
Prebriefing in nursing simulation: A concept analysis.
Clinical Simulation in Nursing. 2015; 11 (http://dx.doi.org/): 335-340https://doi.org/10.1016/j.ecns.2015.05.001
13.
,- Rudolph J.W.
- Raemer D.B.
- Simon R.
Establishing a safe container for learning in simulation. The role of the presimulation briefing.
Simulation in Healthcare. 2014; 9 (http://dx.doi.org/): 339-349https://doi.org/10.1097/SIH.0000000000000047
19.
Required Elements
- •Set the expectations and tone for the upcoming scenario and debriefing and define expectations related to learners’ involvement and performance.
- •Discuss logistical factors such as: length of scenario(s), debriefing expectations, times for breaks, location of facilities, agenda or overview for the day.13.
- Rudolph J.W.
- Raemer D.B.
- Simon R.
Establishing a safe container for learning in simulation. The role of the presimulation briefing.Simulation in Healthcare. 2014; 9 (http://dx.doi.org/): 339-349https://doi.org/10.1097/SIH.0000000000000047 - •Consider use of a written or recorded prebriefing plan to standardize the process and content for each scenario/case.22.A written or recorded prebriefing plan should be required for simulation-based experiences when used for high-stakes or summative evaluations.22.,26.
- •Identify expectations and roles for the learner(s) and the simulationist(s). This includes establishment of ground rules and a fiction contract.
- •Discuss the fiction contract with learners. As an example: “Despite the attempts to create a realistic environment, not all aspects of a simulated experience may be totally realistic.” In order to achieve the objectives and learn from the experience, learners need to immerse themselves in the experience and should be aware of what can and cannot be simulated during the experience.13.,
- Rudolph J.W.
- Raemer D.B.
- Simon R.
Establishing a safe container for learning in simulation. The role of the presimulation briefing.Simulation in Healthcare. 2014; 9 (http://dx.doi.org/): 339-349https://doi.org/10.1097/SIH.000000000000004729.
Briefing: Criterion 8: Conduct a structured orientation to the simulation-based learning environment including the modality.
Required Elements:
- •Orient learners to roles and expectations.
- •Provide information related to the use of recording equipment and observations by others (peers, faculty, facilitators, staff, health professionals, administrators).
- •Review the evaluation methods being used for this experience and notify learners when they can expect to receive the measurement tools. (Follow the HSSOBPTM Evaluation of Learning and Performance)
- •Orient learners to all factors of the experience to help them achieve the objectives: objectives, scenario, equipment, manikins or other technology enhanced environment; embedded standardized personnel; scenario setting, and other environmental factors.5.,30.,
- Nielsen B.
- Harder N.
Causes of student anxiety during simulation: What the literature says.Clinical Simulation in Nursing. 2013; 9 (http://dx.doi.org/): e507-e512https://doi.org/10.1016/j.ecns.2013.03.00331.- McDermott D.S.
Prebriefing: A historical perspective and evolution of a model and strategy (Know: Do: Teach).Clinical Simulation in Nursing. 2020; 49 (https://doi.org/): 40-49https://doi.org/10.1016/j.ecns.2020.05.005- ○Orientation to the objectives should provide general information and context for the learners; however, simulationists may choose not to disclose the specific learner performance measures or critical actions if they are part of the simulation-based experience objectives.
- •Orient to all technology that will be used during the experience such as manikins, virtual learning environments, screen-based learning, or commercial learning products.
- •Provide learners with resources and guidance if they require technology assistance during the experience.
Briefing: Criterion 9: Establish a psychologically safe learning environment during the prebriefing.
13.
- Rudolph J.W.
- Raemer D.B.
- Simon R.
Establishing a safe container for learning in simulation. The role of the presimulation briefing.
Simulation in Healthcare. 2014; 9 (http://dx.doi.org/): 339-349https://doi.org/10.1097/SIH.0000000000000047
Required Elements:
- •Establish a psychologically safe environment to ensure the learners feel comfortable to express thoughts without feeling uncomfortable or fear negative consequences.23.
- •Incorporate activities that help establish an environment of integrity, trust, and respect.13.
- Rudolph J.W.
- Raemer D.B.
- Simon R.
Establishing a safe container for learning in simulation. The role of the presimulation briefing.Simulation in Healthcare. 2014; 9 (http://dx.doi.org/): 339-349https://doi.org/10.1097/SIH.0000000000000047 - •Discuss the procedure for confidentiality and professionalism.
- •Respond to questions and seek input from learners.23.,31.Simulationists create an atmosphere of trust by being accessible and approachable.
- McDermott D.S.
Prebriefing: A historical perspective and evolution of a model and strategy (Know: Do: Teach).Clinical Simulation in Nursing. 2020; 49 (https://doi.org/): 40-49https://doi.org/10.1016/j.ecns.2020.05.005 - •Prevent defensive behavior and support risk taking which supports learning and development of a professional identity.13.
- Rudolph J.W.
- Raemer D.B.
- Simon R.
Establishing a safe container for learning in simulation. The role of the presimulation briefing.Simulation in Healthcare. 2014; 9 (http://dx.doi.org/): 339-349https://doi.org/10.1097/SIH.0000000000000047
Following the prebriefing standard will create:
- •A psychologically safe learning environment.
- •Prepared and engaged simulation learners.
- •More effective debriefing.
About the International Nursing Association for Clinical Simulation and Learning (INACSL)
The International Nursing Association for Clinical Simulation and Learning (INACSL) is the global leader in transforming practice to improve patient safety through excellence in health care simulation. INACSL is a community of practice for simulation where members can network with simulation leaders, educators, researchers, and industry partners. INACSL also provided the original living documents INACSL Standards of Best Practice: SimulationSM, an evidence-based framework to guide simulation design, implementation, debriefing, evaluation, and research. The Healthcare Simulation Standards of Best PracticeTM are provided with the support and input of the international community and sponsored by INACSL.
References
- Cognitive load theory for the design of medical simulations.Simulation in Healthcare. 2015; 10: 295-307https://doi.org/10.1097/SIH.0000000000000097
- Cognitive load measurement, Worked-out modeling, and simulation.Clinical Simulation in Nursing. 2018; 23: 10-15https://doi.org/10.1016/j.ecns.2018.07.004
- Using cognitive load theory to inform simulation design and practice.Clinical Simulation in Nursing. 2015; 11: 355-360https://doi.org/10.1016/j.ecns.2015.05.004
- The impact of simulation prebriefing on perceptions of overall effectiveness, learning, and self-confidence in nursing students.Nursing Education Perspectives. 2017; 38: 119-125https://doi.org/10.1097/01.NEP.0000000000000135
- The prebriefing concept: A Delphi study of CHSE experts.Clinical Simulation in Nursing. 2016; 12: 219-227https://doi.org/10.1016/j.ecns.2016.02.001
- Prebriefing in nursing simulation: A concept analysis.Clinical Simulation in Nursing. 2015; 11 (http://dx.doi.org/): 335-340https://doi.org/10.1016/j.ecns.2015.05.001
- INACSL Standards of Best Practice: SimulationSM Simulation Glossary.Clinical Simulation in Nursing. 2016; 12: S39-S47https://doi.org/10.1016/j.ecns.2016.09.005
- The development of evidence-based clinical simulation scenarios: Guidelines for nurse educators.Journal of Nursing Education. 2010; 49 (http://dx.doi.org/): 29-35https://doi.org/10.3928/01484834-20090916-07
- The Case for group planning in human patient simulation.Nurse Education Perspectives. 2011; 30: 83-86https://doi.org/10.1043/1536-5026-030.002.0083
- Instructional problems in briefings: How to prepare nursing students for simulation-based cardiopulmonary resuscitation training.Clinical Simulation in Nursing. 2012; 8: e307-e318https://doi.org/10.1016/j.ecns.2010.12.002
- The effect of preparation on anxiety and performance in summative simulations.Clinical Simulation in Nursing. 2013; 9 (http://dx.doi.org/): e25-e33https://doi.org/10.1016/j.ecns.2011.07.004
- Use of prebriefing in nursing simulation : A literature review.Journal of Nursing Education. 2014; 53: 136-141https://doi.org/10.3928/01484834-20140211-07
- Establishing a safe container for learning in simulation. The role of the presimulation briefing.Simulation in Healthcare. 2014; 9 (http://dx.doi.org/): 339-349https://doi.org/10.1097/SIH.0000000000000047
- Setting learners up for success: Presimulation and prebriefing strategies.Teaching and Learning in Nursing. 2018; 13: 185-189https://doi.org/10.1016/j.teln.2018.03.004
- Effectiveness of a role-modeling intervention on student nurse simulation competency.Clinical Simulation in Nursing. 2013; 9 (http://dx.doi.org/): e121-e126https://doi.org/10.1016/j.ecns.2011.11.005
- Geriatrics in simulation: Role modeling and clinical judgment effect.Nursing Education Perspectives. 2012; 33 (http://dx.doi.org/): 176-180https://doi.org/10.5480/1536-5026-33.3.176
- Comparison of self-directed learning versus instructor-modeled learning during a simulated clinical experience.Simulation in Healthcare. 2007; 2: 170-177https://doi.org/10.1097/SIH.0b013e31812dfb46
- Comparison of expert modeling versus voice-over PowerPoint lecture and presimulation readings on novice nurses’ competence of providing care to multiple patients.Journal of Nursing Education. 2014; 53: 615-622https://doi.org/10.3928/01484834-20141023-01
- Prebriefing in nursing simulation: A concept analysis using Rodger's methodology.Clinical Simulation in Nursing. 2015; 11: 318-322https://doi.org/10.1016/j.ecns.2015.05.003
- Code of Fair Testing Fair Testing Practices.American Psychological Association, 2004: 1-12
- A systematic review of health care presimulation preparation and briefing effectiveness.Clinical Simulation in Nursing. 2019; 27: 12-25
- Authoring simulations for high-stakes student evaluation.Clinical Simulation in Nursing. 2014; 10: e177-e182https://doi.org/10.1016/j.ecns.2013.11.006
- Psychological safe environment: A concept analysis.Clinical Simulation in Nursing. 2018; 18: 47-55
- Prebriefing in simulation-based learning experiences.Nurse Educator. 2016; 41: 1https://doi.org/10.1097/NNE.0000000000000217
- Effects of prebriefing on psychological safety and learning outcomes.Clinical Simulation in Nursing. 2018; 25: 12-19https://doi.org/10.1016/J.ECNS.2018.10.001
- INACSL Standards of Best Practice: SimulationSM. Simulation Design.Clinical Simulation in Nursing. 2016; 12: S5-S12https://doi.org/10.1016/j.ecns.2016.09.005
- Effectiveness of simulation preparation on novice nurses’ competence and self-efficacy in a multiple-patient simulation.Nursing Education Perspectives. 2015; 36: 324-325https://doi.org/10.5480/14-1546
- Impact of prebriefing on competency performance, clinical judgment, and experience in simulation: An experimental study.Nurse Education Today. 2017; 48: 78-83
- Guidelines and essential elements for prebriefing.Simulation in Healthcare. 2019; 14: 409-414https://doi.org/10.1097/SIH.0000000000000403
- Causes of student anxiety during simulation: What the literature says.Clinical Simulation in Nursing. 2013; 9 (http://dx.doi.org/): e507-e512https://doi.org/10.1016/j.ecns.2013.03.003
- Prebriefing: A historical perspective and evolution of a model and strategy (Know: Do: Teach).Clinical Simulation in Nursing. 2020; 49 (https://doi.org/): 40-49https://doi.org/10.1016/j.ecns.2020.05.005
- Prebriefing: A principle-based concept analysis.Clinical Simulation in Nursing. 2020; X (https://doi.org/): 1-8https://doi.org/10.1016/j.ecns.2020.11.003
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© 2021 Published by Elsevier Inc. on behalf of International Nursing Association for Clinical Simulation and Learning.
