Ready for Practice! Virtual Simulation in Critical Care and Emergency Nursing Education

Abstract

Traditional orientations for nurses transitioning to critical care, critical care transport (CCT) and emergency department (ED) practice areas have relied on classroom lectures, apprenticeships and preceptored clinicals. Increasing patient acuity, workforce shortages, and limited clinical placement opportunities have challenged these traditional models. In the early 2000’s, simulation began to emerge as a strategy to accelerate readiness for transitioning into the practice area, enhancing clinical judgement, building confidence, and fostering interprofessional team competencies.

Simulation based learning experiences have been shown to increase confidence and competence among nurses, specifically in relation to performing focused patient assessments and emergency intervention skills (Hardenberg et al., 2019). There are several modalities for delivering simulation including in person and virtual simulations. This paper explores the use of virtual simulation as an evolving tool to prepare nurses for high-acuity practice. A review of current literature and educator experiences was conducted to identify best practices, benefits, and practical considerations for implementation. Findings suggest that structured debriefing, scenario realism, and integration into orientation programs enhance learner engagement and skill transfer.

The aim of this paper is to explore the benefits and provide practical tips for the use of virtual simulation with critical care and emergency nurses. Best practices in simulation are discussed. Practical tips and open-access resources are provided to support nurse educators in designing effective virtual simulations. Virtual simulation can provide an additional strategy for nurse educators to consider for developing orientations, ongoing professional development for staff and interprofessional team learning opportunities.

Introduction

Traditional orientations for nurses transitioning to critical care and emergency practice areas have relied on classroom lectures, apprenticeships and preceptored clinicals. In the early 2000’s, simulation began to emerge as a strategy to accelerate readiness for transitioning into the practice area, enhancing clinical judgement, building confidence, and fostering interprofessional team competencies.

As healthcare technology rapidly advances and clinical learning opportunities become increasingly limited, there is a growing need to reimagine how we orient ED, ICU (intensive care unit), and CCT nurses. Traditional models relying heavily on bedside exposure no longer provide consistent or comprehensive preparation and lack the ability to tailor scenarios to emphasize the translation from theory to practice (Claunch, 2024). Instead, orientation programs must integrate a variety of high and low fidelity simulation, virtual platforms, and structured competency-based learning to ensure nurses develop the technical proficiency, critical thinking, and adaptability required to manage complex patient care in today’s technology-driven environments (Stavropoulou et al., 2025).

Almabade et al., (2024) found that simulation-based training effectively prepares emergency nurses for clinical practice by providing a safe, realistic environment to develop critical thinking, technical skills, teamwork, and confidence needed to manage high-acuity, unpredictable situations. Simulation prepares novice emergency nurses for clinical practice by providing a safe, controlled environment to practice critical skills, decision-making, and teamwork, helping build confidence and competence before managing real emergencies (Meagher et al., 2022; Roncallo et al. 2020.) and can set the stage for high stakes, low frequency skills (Singleton, Allen, Li, McNerney, Naber & Braga, 2018). Simulation has also been recognized by the Commission on Accreditation of Medical Transport Services (CAMTS) as an alternative for clinical practice in terms of preparing the critical care transport nurse for entry to practice (CAMTS, 2022). It is found to replicate the challenging conditions of air medical environments, allowing them to safely develop advanced clinical, communication, and decision-making skills needed for high-risk patient care (Alfes et al, 2015). There are also benefits beyond orientation to improving safety in all high acuity practice environments with interprofessional simulation. Sung & Hsu (2025) describe the role of simulation-based interprofessional education helps prepare critical care nurses for clinical practice by strengthening collaboration and clinical skills, while highlighting the need for continued focus on communication, leadership, and situational awareness in high-stakes environments.

In a Canadian study, a high-fidelity in-person simulation intervention was shown to significantly increase the critical care nurse’ intent to stay in the ICU and in the nursing profession (Goldsworthy, 2021). Since ICU and ER have some of the highest turnover rates among all nursing units, simulation as a professional development and orientation strategy are an important consideration. Furthermore, research has shown that nurses new to critical care have a 18-60% chance of leaving the unit if they are not feeling comfortable with their transition into ICU (Blackmon et al., 2023).

The aim of this paper will be to explore practical implications for virtual simulation in preparation of critical care and emergency nurses. In person simulation will be contrasted with the nuances of virtual computer-based simulation. In addition, practical tips will be provided for the use of virtual simulation along with resources that are freely available to nurse educators.

Simulation

What is simulation?

Simulation is a pedagogy that uses one or more modalities to promote, improve, or validate a participant’s progression from novice to expert (Lioce et al., 2023). Simulation based learning activities (SBLE) are “commonly reported to increase confidence, improve communication skills, develop reasoning and critical thinking, and facilitate readiness for professional placement…” (Squires et al., 2022, p.408). There are multiple modalities in simulation that can include: high-fidelity human simulators, simulated patients (actors), virtual computer-based simulation, virtual reality (VR) immersive simulation and augmented reality (AR). .

Simulation in Nursing Education

The use of simulation in nursing education has rapidly increased over the past 20 years. Recent advances in technology in the form of computer based virtual simulation, augmented reality (AR), and virtual reality (VR), have provided alternatives and/ or opportunities for the use of hybrid simulation (the use of one or more simulation modalities together) to accelerate learning. In addition, virtual computer-based simulation has provided increased accessibility to simulation for learners. In-person simulation for ICU, CCT and ED nurses can be provided in the simulation centre or on the unit and offer hands-on training in complex patient care scenarios. Many critical care nursing skills evolve through exposure to complex clinical situations that may not present themselves during the clinical portion of an orientation or be considered too complex or sensitive for a novice nurse to be involved with.  Simulation can be used to support mastery of these skills in a psychologically safe environment that promotes the bridging of theory to practice.  For example, Lindberg & Fridh (2021) found that providing a simulation experience on end-of-life (EOL), during clinical placement in a post-graduate specialty in ICU certificate, provided an opportunity for students to better prepare for end-of-life conversations.

Simulation (whether virtual or in-person) is designed to provide learning in a psychologically safe environment with educators experienced in briefing (prebriefing), enacting the scenario, debriefing and evaluation. The delivery of high-quality simulation must be completed with educators that have formal training and/or certification in simulation and adhere to international best practice standards in simulation (INACSL, 2025c).

Best practices and phases of simulation

Simulation in nursing education has evolved as a science and has defined phases including preparation, briefing (prebriefing), debriefing and evaluation. International best practices in simulation guide the delivery of simulation learning education (INACSL, 2025b)

In-Person High Fidelity Simulation

In-person simulation learning experiences for critical care and emergency nurses typically occur in a simulation centre or in situ (on the unit) with high-fidelity simulators. “High-fidelity human patient simulators with full body mannequin and advanced technology mimick human anatomy and physiological signs” (Kim et al., 2023, p. 569). Critical care and emergency nurses may have participated in advanced cardiac life support scenarios with high fidelity simulators; however, structured simulation learning experiences need to include all of the phases of simulation: preparation, briefing (or prebriefing), the enactment of the scenario, debriefing and reflection to be most effective . Debriefing needs to be conducted by experienced simulationists with formal training in simulation, utilizing a debriefing framework and guides learners in achievement of the learning outcomes (INACSL, 2025).

Virtual Computer-Based Simulation

There are multiple modalities that can be used in simulation education. Computer-based virtual simulations allow learners to ‘drive’ the simulation themselves versus in-person simulation where educators ‘drive’ the simulation scenario. Some of the benefits of virtual simulation include accessibility (learners complete at the time and location of their choice), it is pandemic proof, and it provides a method to introduce complex scenarios that can be repeated or paused for increased mastery of competencies (Al-Sharari et al., 2025). For nurses new to critical care, virtual simulations allow for the opportunity to experience high-risk, low-frequency skills as well as practice core critical care competencies in a psychologically safe learning environment.

Benefits of virtual simulation include accessibility, increased confidence while completing the scenario in their own location and ability to choose the timing to complete the scenario. In addition, learners can repeat the scenario as many times as they like to achieve mastery. For nurse educators, there are several options when facilitating virtual simulation. Learners can complete the scenario asynchronously, followed by a virtual (or in-person) synchronous debrief. Another advantage of virtual simulation is that learners can complete a self-debrief prior to coming to the virtual synchronous debriefing session and therefore enhance the reflection phase of simulation.

Combining simulation modalities or hybrid simulation is defined as; “the melding of simultaneous use of two or more methods of simulation” (Lopreiato & Sawyer, 2015, p. 137).  For instance, the nurse educator could have the learners participate in a virtual computer-based simulation initially and then offer an in-person simulation that mirrors the virtual simulation to enhance confidence and competence by repetition with a different simulation modality.

Briefing (Prebriefing)Virtual Simulations

After providing preparation to the learners (i.e. readings, mini lectures, an orientation to the virtual simulation learning platform), the prebriefing phase in simulation occurs and is aimed at creating a safe learning environment for learners (INACSL, 2025b). Key points to include in your prebrief are confidentiality, fiction contract (have learners treat the scenario as an actual case), learning objectives, rules of engagement and the logistics of the scenario (timing, evaluation methods).

Debriefing Virtual Simulations

The debriefing phase is a critical component of the simulation learning environment to allow for performance gaps to be addressed and reflection to occur. Debriefing of a simulation should be completed by an educator that is experienced in debriefing, and a debriefing framework is used to guide the experience (Decker et al., 2025).

There are several nuances within the virtual environment to consider when facilitating a computer-based virtual simulation that differ from in-person simulations. When a learner is online for a virtual synchronous debriefing session, the nurse educator can promote a psychologically safe learning environment by providing options to learners that can make them feel more comfortable in the debrief and more willing to engage in the discussion. For example, the educator could offer options such as using their video or using the chat function. In addition, learners can use the ‘raise hand’ function, type into the chat or speak into their microphone (Goldsworthy & Verkuyl, 2021). Setting up learners well with clear expectations in the prebrief will enhance discussion in the debrief phase.

Practical Tips for Using Virtual Simulation

Virtual simulation can provide another teaching strategy to help orientate nurses new to critical care and emergency. In addition, virtual simulation can provide an accessible way to deliver ongoing professional development to the whole critical care and emergency team. There are a few practical tips to consider when introducing virtual simulation to your team (adapted from Verkuyl & Atack, 2024(a), Verkuyl et al.,2024(b) :

1. Ensure the virtual sim is for the right time and right level of learner
2. Prepare faculty/facilitators and support champions
3. Consider virtual sim for learner assessment or remedial practice
4. Provide preparation for learners (i.e. readings, best practice guidelines, a case study)
5. Prebrief the virtual simulation using best practices.
6. Debrief the virtual simulation using best practices with experienced debriefers and use a debriefing framework to ensure consistency for all learners (consider co-debriefing with another experienced educator)
7. Ensure technology runs smoothly and that learners have a thorough orientation to the platform. Make sure you are familiar with the simulation and have completed it.
8. Collaborate with other teams- consider using interprofessional simulations.
9. Evaluate the virtual simulation experience (the simulation, the learners feedback, debriefer feedback).

Resources for educators

There are several comprehensive open access resources available for educators to use. The first is a virtual simulation toolkit for educators that can be found at: Virtual Simulation: An Educator’s Toolkit – Simple Book Publishing. Another fulsome resource is the Simulation Canada simulation repository that offers open resource peer reviewed virtual simulations and can be found at: SIM Scenario Exchange – Simulation Canada.

Implications for Nursing (managers, clinical educators)

Virtual simulation can offer an alternative to traditional orientations and professional development for critical care and emergency nurses. In addition, the provision of simulation for critical care nurses aligns with the World Federation of Critical Care Nurses (WFCCN) Position Statement: the Provision of Critical Care Nurse Education: “ Preparation of critical care nurse education must be accessible, evidence-based and include a sufficient experiential component (e.g. high-fidelity simulation and preceptorship in the critical care unit.” (Goldsworthy et al., 2020, p.2) There are open access resources and formal training available for nurse educators to develop their skill in facilitating simulation. Virtual simulation is accessible, increases confidence and competence and can accelerate transition of new nurses into critical care and emergency practice areas. Virtual simulation also provides a pathway for interprofessional education and can aid in fostering team competencies in the critical care and emergency area for teams.

Summary

In this paper, virtual simulation has been explored as a potential innovative strategy to assist in the orientation of new nurses, the provision of ongoing professional development, and as a method to increase team competencies. Benefits of virtual simulation include accessibility, increased confidence, and the ability to work toward mastery of core critical care and emergency skills as well as enhancing those competencies that are high-risk/low-frequency.

Author Notes:

Sandra Goldsworthy PhD, RN, CNCC(C), CMSN(C), CCSNE, Mount Royal University, Calgary, Alberta, Canada^.

Joan Harris, MHSc, RN, Mount Royal University, Calgary, Alberta, Canada.

Heather McLellan MEd, BN, RN, CEN, CFRN, FAASTN, Mount Royal University, Calgary, Alberta, Canada.

Holly Feist, MN, RN, ACCN,  Mount Royal University, Calgary, Alberta, Canada.

Corresponding author:

Dr. Sandra Goldsworthy, Professor and Chair School of Nursing Mount Royal University, 4825 Mount Royal Gate SW, Calgary, AB. Canada. T3E 6K6

Funding and conflict of interest

The authors declare no conflict of interest in the completion of this research.

Sandra Goldsworthy, Joan Harris, Heather McLellan and Holly Feist are invited authors.  This article has not been peer-reviewed.

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