Background: Simulation-based education in pre-licensure nursing programs is increasing exponentially as alternative clinical teaching experiences. Implementing quality simulation experiences is resource intensive, cost limiting, with limited evidence of the impact on learning outcomes. Standards of Best Practice: SimulationSM identify formal training is essential for quality debriefing, including providing a psychologically safe learning environment. However, a recent nationwide survey of 150 nursing schools identified only 40% of programs formally train simulation facilitators. In addition, there are limited valid and reliable instruments measuring reflective thinking as a learning outcome and debriefing competence.

Purpose: The first paper reviewed literature on psychological safety in nursing pre-licensure simulation and assessed alignment with Edmondson's work-team learning model. A second paper described reflective thinking measured by the Reflective Thinking Questionnaire (RTQ), and explored RTQ scores in relation to facilitator training length and Debriefing Assessment for Simulation in Healthcare Student Version (DASH-SV)(c) scores. A third paper explored the psychometric qualities of the RTQ.

Methods: Using a quasi-experimental, cross-sectional, nonequivalent, two-group design, pre-licensure nursing students were surveyed using the RTQ and the DASH-SV (N = 99). The six facilitators had varied experience and training. Descriptive and bivariate analyses examined RTQ subscales in relation to student characteristics and DASH-SV(c) scores in relation to student and facilitator characteristics. MPLUS was used for CFA of the RTQ to explore how well a hypothesized model based on pre-licensure nursing students fit sample data.

Results: Simulation-based nursing education literature demonstrates alignment with Edmondson's work-team learning model, although only 10 articles met inclusion criteria. RTQ subscale scores did not differ across differing facilitator characteristics. Students rated 1-day trained facilitators higher in establishing psychological safety and provoking in-depth discussions compared to 5-day trained facilitators. Confirmatory factor analysis of the RTQ supported the hypothesized model from the literature, although model fit remains inadequate. Conclusions: No associations were found between 1-day and 5-day facilitator training and student reflective thinking. Although a small single-site study with limited measures, nursing schools should require 1-day training at a minimum. It is imperative to conduct more rigorous simulation studies to establish efficacy of simulation as a training methodology, development conceptual frameworks, and improve measures.