Accessible Simulation: A Necessity in Nursing Education.

Simulation is expanding rapidly in nursing education, but a focus on simulation accessibility is lacking. How accessible is simulation training for students with disabilities, and is simulation used optimally to benefit these students? We conducted an extensive literature search of the CINAHL® database using the keywords nursing simulation, disability, accessibility, and universal design—as well as combinations of these terms. Surprisingly, there was minimal to no emphasis on simulation accessibility in nursing education via scholarly publications and conference abstracts. Publications focusing on ways to assist nursing students with disabilities generally do not identify the simulation setting as a means of accessibility. On the basis of our findings, we suggest that increasing emphasis is needed on developing simulation technologies and laboratories with a Universal Design (UD) focus. Further, we assert that simulation is an ideal avenue and setting to increase accessibility for nursing students with disabilities, thus diversifying the profession. Increasing disability diversity is particularly needed within nursing education, as advocated by the National League for Nursing (2016). Although higher technology in simulation opens more doors for many students, ironically it can close doors for students with disabilities. For example, if a simulation facilitator is acting as the voice of a manikin from a separate room, how is the student who is deaf and reads lips able to participate? One solution is UD. A primary UD principle involves designing for a wider range of people to benefit everyone, thus respecting diversity and increasing accessibility. The cause of the inequity is addressed, thus reducing the need for accommodations. At its core, UD embraces the social model of disability where barriers result from the environment, rather than the prevailing medical model where barriers result from a deficit in the person. Thus, rather than focusing on changing a particular element for a specific individual’s needs, the focus is on changing the entire process to benefit everyone’s needs. A focus on UD can involve removing physical barriers such as developing highfidelity manikins with incorporated voice recognition software and screens to display captions. Those with hearing loss, for example, would not need to request captioning accommodations with their associated fees, as captioning would be available for all students through UD. Even those who would not typically use captioning may find the added input beneficial. In UD, varied instructional strategies are used to meet the needs of as many people as possible. Overall, UD instruction is not used widely because of lack of knowledge by nurse educators (Levey, 2018). Levey recommended that nursing programs consult with UD instruction experts and that UD instruction be incorporated into the National League for Nursing’s Certified Nurse Educator Program. More research on UD instruction is needed in the nursing profession. By starting with a more level playing field through UD, stigma toward nursing students with disabilities could be lessened. Although time consuming and costly up front, advocating for UD at the beginning stages of simulation technology development will lead to an ongoing streamlined and equitable process. The Future of Nursing 2020–2030 has a strong emphasis on social determinants of health (Wakefield et al., 2019). Imagine the positive effects of incorporating a disabilityinformed nursing curriculum including UD and simulation accessibility on the inclusion of people with disabilities into nursing. Individualization is still needed when universality is incorporated. GrifulFreixenet, Struyven, Verstichele, and Andries (2017) advised applying UD in a flexible manner, accounting for individual student learning needs. Thus, some accommodations still may be necessary even when UD is used, and certainly in situations where UD has not been implemented. We propose that the simulation laboratory setting is an ideal, yet perhaps overlooked, environment to carry out accommodations either prior to or in place of clinical experiences in order to increase accessibility. Simulation as a pedagogical approach allows all nursing students the opportunity to practice and learn from mistakes without harm to patients, by replicating clinical scenarios. Although the percentage of allowable simulation to replace clinical hours varies by state (International Nursing Association for Clinical Simulation and Learning, n.d.), when outcomes were compared among nursing students receiving up to 50% simulation (instead of clinical time) in a large-scale longitudinal randomized control trial conducted by the National Council of State Boards of Nursing, no significant differences were found on clinical competency, nursing knowledge, or pass rates on the nursing board examination (Hayden, Smiley, Alexander, Kardong-Edgren, & Jeffries, 2014). The ethical principle of justice involves equitable treatment, which does Accessible Simulation: A Necessity in Nursing Education