DEPARTMENT OF HEALTH

[Filed July 23, 2024, 3:18 p.m.]

Preproposal statement of inquiry was filed as WSR 23-17-011.

Title of Rule and Other Identifying Information: Nursing education simulation rule. The Washington state board of nursing (board) is proposing new WAC 246-840-5341 and amendments to WAC 246-840-534 to implement E2SSB 5582 (chapter 126, Laws of 2023).

Hearing Location(s): On August 27, 2024, at 12:00 p.m., at the Department of Health, Town Center 2, Room 166/167, 111 Israel Road S.E., Tumwater, WA 98501; or virtually. Please follow this link to register for the virtual hearing which will give you instructions to either join the meeting on a device, or to call in to the meeting on the phone https://us02web.zoom.us/meeting/register/tZ0ofuyrrjgsHt0FfE5-o88JqvVTVCi-7Xup. After registering you will receive a confirmation email containing information about joining the webinar. The public hearing will be hybrid. Participants can attend at the physical location or virtually by registering on Zoom.

Date of Intended Adoption: August 27, 2024.

Submit Written Comments to: Jessilyn Dagum, P.O. Box 47864, Olympia, WA 98504-7864, email https://fortress.wa.gov/doh/policyreview, fax 360-236-4738, beginning the date and time of this filing, by August 12, 2024, at midnight.

Assistance for Persons with Disabilities: Contact Jessilyn Dagum, phone 360-236-3538, fax 360-236-4738, TTY 711, email WABONRules@doh.wa.gov, by August 12, 2024.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The purpose of the proposed rule is to establish the requirements for use of simulation-based learning experiences as a substitute for required clinical and direct patient care experiences at a 1:2 ratio in licensed practical nurse (LPN), registered nurse (RN), or RN to Bachelor of Science in nursing (BSN) nursing education programs and amends the current simulation rule, WAC 246-840-534, to clarify that it only applies to the use of simulation at a 1:1 ratio.

Through the introduction of a new section, WAC 246-840-5341, the proposed rule establishes requirements for the use of simulation at a 1:2 ratio, where one hour of simulation counts for two hours of clinical placement learning. This section provides detailed definitions, requirements, and standards for simulation-based learning experiences, ensuring consistency and quality in their implementation across nursing programs.

Additionally, the proposed amendments to the existing section WAC 246-840-534 clarify that this rule applies to the use of simulation at a 1:1 ratio. The proposal is needed to provide clear and comprehensive regulations that align with legislative directives of E2SSB 5582 to adopt rules that allow for simulation at a 1:2 ratio.

Reasons Supporting Proposal: The proposed rule implements E2SSB 5582 by establishing a new section, WAC 246-840-5341, which allows for one hour of simulation to count for two hours of required clinical and direct patient care experience (1:2 ratio) in LPN, RN, or RN to BSN nursing education programs located in Washington state, as well as amends current section of rule, WAC 246-840-534, to clarify that particular section applies only to the use of simulation at a 1:1 ratio.

The proposed rule emphasizes the importance of maintaining high quality and high fidelity in simulation-based learning experiences while allowing for comprehensive and immersive clinical training and effective preparation for students' future roles as nurses. Overall, the proposed rule supports the advancement of nursing education in Washington state, promoting innovation, flexibility, and excellence in student training and preparation.

Statutory Authority for Adoption: RCW 18.79.010, 18.79.110; E2SSB 5582.

Statute Being Implemented: E2SSB 5582.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Washington state board of nursing, governmental.

Name of Agency Personnel Responsible for Drafting and Implementation: Jessilyn Dagum, 111 Israel Road S.E., Tumwater, WA 98504, 360-236-3538; Enforcement: Gerianne Babbo, 111 Israel Road S.E., Tumwater, WA 98504, 360-791-4607.

A school district fiscal impact statement is not required under RCW 28A.305.135.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Jessilyn Dagum, P.O. Box 47864, Olympia, WA 98504-7864, phone 360-236-3538, fax 360-236-4738, TTY 711, email WABONRules@doh.wa.gov.

This rule proposal, or portions of the proposal, is exempt from requirements of the Regulatory Fairness Act because the proposal:

Is exempt under RCW 19.85.025(3) as the rules only correct typographical errors, make address or name changes, or clarify language of a rule without changing its effect; and rule content is explicitly and specifically dictated by statute.

Explanation of exemptions: WAC 246-840-534 and 246-840-5341(2) are exempt under RCW 34.05.310 (4)(d), as the proposed changes include updating the term "commission" to "board" and other cleanup. WAC 246-840-5341(1) is exempt under RCW 34.05.310 (4)(e) as the proposed changes are dictated by statute regarding learning methods and use of simulations.

Scope of exemption for rule proposal:

Is partially exempt:

Explanation of partial exemptions: WAC 246-840-5341(1) explains who the rule applies to and under what circumstances and is exempt under RCW 34.05.310 (4)(e), as the proposed changes are dictated by statute. WAC 246-840-5341(2) is the definition section of the rule. The defined terms clarify usage throughout the section of rules. WAC 246-840-5341(2) is exempt under RCW 34.05.310 (4)(d), as the proposed changes clarify language.

The proposed rule does not impose more-than-minor costs on businesses. Following is a summary of the agency's analysis showing how costs were calculated. The Washington state legislature passed E2SSB 5582 (chapter 126, Laws of 2023), Nurses—Educational opportunities, and became effective July 23, 2023.

Current Situation/Rule: Currently, WAC 246-840-534 allows for simulation-based learning experience at a 1:1 ratio where one hour of simulation can count for one hour of required clinical and direct patient care experience.

History of the Issue: In 2023, the Washington state legislature passed E2SSB 5582, titled Nurses—Educational opportunities. This bill directed the board to adopt rules allowing for one hour of simulated learning to be counted as equivalent to two hours of clinical placement learning, with simulated learning accounting for up to 50 percent of the required clinical hours. As a result, the board is proposing amendments to WAC 246-840-534 and creation of a new rule section, WAC 246-840-5341, to align with the legislative mandate.

Proposed Rule: Throughout the process of developing the proposed rule, the board reviewed the best available evidence-based research related to clinical simulation and data around high-quality and high-fidelity simulation. The proposed rule clarifies various definitions and requirements related to simulation-based learning experiences, faculty qualifications, program management, and evaluation. The proposed new WAC 246-840-5341 outlines the use of simulation for clinical experiences at a 1:2 ratio in LPN, RN, or RN to BSN nursing education programs in Washington state. This means that one hour of simulation would count for two hours of required clinical and direct patient care experiences. Amendments to WAC 246-840-534 clarify that rule section applies to the use of simulation at a 1:1 ratio.

Need for the Proposed Rule: To clearly state the requirements for nursing education programs to utilize simulation at a 1:2 ratio, rule making is necessary. The proposed rule is needed to align with the legislative mandates of E2SSB 5582 which directs and authorizes the board to adopt rules which allow for one hour of simulated learning to be counted as equivalent to two hours of clinical placement learning, with simulated learning accounting for up to a maximum of 50 percent of the required clinical hours. The proposed rule allows for greater flexibility in utilizing simulation as a substitute for clinical experiences in nursing education programs. By adopting a 1:2 ratio, nursing programs can better meet their clinical hour requirements while potentially alleviating challenges associated with securing clinical placements, particularly in light of factors such as limited clinical sites and the limitations to in-person training experienced caused by the coronavirus disease 2019 (COVID-19) pandemic. The proposed rule aims to ensure that simulation-based learning experiences maintain quality standards, faculty qualifications, and program management protocols while also enhancing nursing education and better preparing students for clinical practice in a dynamic health care environment.

Probable Compliance Requirements: The probable compliance requirements for nursing education programs to adhere to the proposed rule include adjusting their curriculum to incorporate the new 1:2 ratio for simulation-based learning experiences, ensuring faculty receive appropriate training and certification in simulation pedagogy, obtaining endorsement or accreditation from approved simulation organizations, and implementing robust evaluation and quality improvement processes for simulation programs.

Small businesses, such as nursing education programs, are likely to require various professional services to comply with the proposed rule. These may include:

1. Board approved endorsement or accreditation from a health care simulation organization, WAC 246-840-5341(8):


•	The current board-approved accreditation and endorsement programs are:
•	INACSL Endorsement: https://www.inacsl.org/endorsement-program.
•	SSIH Full Accreditation: https://www.ssih.org/Credentialing/Accreditation/Full-Accreditation.
•	SSIH Provisional Accreditation: https://www.ssih.org/Credentialing/Accreditation/Provisional-Accreditation.
•	Nursing education programs offering simulation at a 1:2 ratio must obtain board-approved certification or endorsement by June 30, 2029.
•	As of July 1, 2029, a nursing education program must obtain board-approved endorsement or accreditation prior to offering simulation-based learning experiences to students at a 1:2 ratio.
•	New nursing education programs receiving full board approval must obtain board-approved endorsement or accreditation within four years of receiving full board approval.

Simulation Program Manager Initial CHSE Certification, WAC 246-840-5341(10):


•	The simulation program manager must also hold a certified healthcare simulation educator (CHSE) certification, certified healthcare simulation educator-advanced certification (CHSE-A), or other board-approved certification in simulation by June 30, 2029.
•	As of July 1, 2029, the simulation program manager must have and maintain board-approved health care simulation educator certification prior to initiating simulation program management duties.

Simulation Program Faculty Individual Initial CHSE Certification, WAC 246-840-5341(11):


•	As of July 1, 2029, at least 10 percent of nursing faculty who facilitate simulation-based learning experiences must hold a CHSE or CHSE-A certification or other board-approved certification in simulation.

Professional Development, WAC 246-840-5341 (15)(c):

Identification and summary of which businesses are required to comply with the proposed rule using the North American Industry Classification System (NAICS).


•	For nursing faculty who facilitate simulation-based learning experiences and do not hold current CHSE, CHSE-A, or other board-approved certification, the nursing education program shall provide a means for faculty participation in simulation-related professional development that includes:


C.	At least eight hours of simulation-related professional development per year. Professional development includes activities that reasonably contribute to the professional knowledge and development of faculty for purposes of providing simulation-based learning experiences to students.

SBEIS Table 1. Summary of Businesses Required to

Comply to the Proposed Rule

NAICS Code (4, 5 or 6 digit)	NAICS Business Description	Number of Businesses in Washington State	Minor Cost Threshold
611210	Community Colleges (Junior Colleges) with Nursing Programs	32	$1,330.76
611310	Colleges, Universities and Professional with Nursing Programs	9	$24,053.97

Analysis of probable costs of businesses in the industry to comply to the proposed rule and includes the cost of equipment, supplies, labor, professional services, and administrative costs. The analysis considers if compliance with the proposed rule will cause businesses in the industry to lose sales or revenue.

New WAC 246-840-5341 Use of simulation for clinical experiences at a 1:2 ratio in LPN, RN, or RN to BSN nursing education programs located in Washington state.

Description: This rule introduces regulations governing the use of simulation for clinical experiences in LPN, RN, or RN to BSN nursing education programs in Washington state. The rule establishes a 1:2 ratio, allowing one hour of simulation to count as two hours of required clinical and direct patient care experiences. WAC 246-840-5341(1) explains who the rule applies to and under what circumstances and is exempt under RCW 34.05.310 (4)(e) as the proposed changes are dictated by statute. WAC 246-840-5341(2) is the definition section of the rule. The defined terms clarify usage throughout the section of rules. WAC 246-840-5341(2) is exempt under RCW 34.05.310 (4)(d), as the proposed changes clarify language. The requirement associated with these terms are established and analyzed below.

2. WAC 246-840-5341(3): Limitation on simulation hours - mirrors the standard set in statute of a max limit of 50 percent of clinical hours for a particular course that can be replaced by simulation-based learning experiences. It also outlines conditions under which exceptions may be granted.

3. WAC 246-840-5341(4): Exclusion of screen-based simulation - specifies that hours spent on screen-based simulation cannot be counted for clinical hours at the 1:2 ratio.

4. WAC 246-840-5341(5): Use of immersive technology - allows for the use of immersive augmented reality or virtual reality in simulation-based learning experiences, provided they are synchronously facilitated.

5. WAC 246-840-5341(6): Group size and engagement - sets limits on group size to ensure effective learning and engagement, specifies the roles of students in simulation scenarios, and mandates a plan for ensuring active engagement of all students.

6. WAC 246-840-5341(7): Faculty responsibilities - states that nursing faculty facilitating simulation-based learning experiences must not have operational responsibilities.

7. WAC 246-840-5341(8): Certification or accreditation requirement - mandates that nursing education programs must obtain and maintain endorsement or accreditation from an organization approved by the board, with specific deadlines for compliance.

8. WAC 246-840-5341(9): Program requirements - requires nursing education programs to have a strategic plan, resource management plan, policies and procedures, and defined qualifications for simulation operation support personnel.

9. WAC 246-840-5341(10): Simulation program manager certification - specifies certification requirements for the individual managing the simulation program, with deadlines for compliance.

10. WAC 246-840-5341(11): Faculty certification requirement - sets a deadline for a percentage of nursing faculty facilitating simulation-based learning experiences to hold specific certifications.

11. WAC 246-840-5341(12): Exceptions - outlines conditions under which exceptions may be granted for certification requirements, including the submission of a written plan and evidence of professional development.

12. WAC 246-840-5341(13): Faculty qualifications and competency - requires documentation of faculty qualifications, knowledge in simulation pedagogy, appropriate facilitation approaches, and ongoing competency in simulation-based teaching.

13. WAC 246-840-5341(14): Faculty development and evaluation - mandates a written plan for orienting, mentoring, and evaluating simulation program faculty.

14. WAC 246-840-5341(15): Faculty professional development - specifies requirements for professional development for faculty who do not hold specific certifications, including educational needs assessment and annual development plans.

15. WAC 246-840-5341(16): Learning experience criteria - sets criteria for simulation-based learning experiences to be student-centered, evidence-based, aligned with learning objectives, and supportive of psychological safety.

16. WAC 246-840-5341(17): Evaluation plan - requires a written plan for evaluation of students, simulation experiences, and facilitation, with data used for continuous quality improvement.

17. WAC 246-840-5341(18): Documentation - specifies that documentation required by the rule may serve as proof of compliance with endorsement or accreditation requirements.

18. WAC 246-840-5341(19): Prohibitions - lists circumstances under which nursing education programs may not use a 1:2 simulation ratio.

19. WAC 246-840-5341(20): Enforcement - specifies actions the board may take against programs not complying with certification or accreditation requirements.

Cost(s): Undertaking the costs to provide simulation at a 1:2 ratio is optional. Nursing educational programs could choose not to offer simulation-based learning experiences at this ratio and therefore not be subject to these costs. However, if a nursing education program does chose to offer simulation-based learning experiences at a 1:2 ratio, the probable costs associated would include training and certification expenses for faculty and simulation program managers. This encompasses the cost of certification exams, training materials, and potential fees linked with certification programs. Ongoing professional development for faculty, simulation program managers, and support personnel also incurs costs, covering training workshops, conferences, and educational resources aimed at enhancing simulation pedagogy skills. Additionally, there are fees associated with obtaining accreditation or endorsement from approved organizations.

In determining cost of compliance with the proposed rules, the board sent a survey to 43 Washington state deans and directors of nursing programs and 22 programs responded. The board asked the programs to provide an estimate of the funds their nursing program would require to implement the rule regarding simulation professional development (CHSE certification, yearly simulation professional development), open source materials, simulation endorsement or accreditation, and evaluation of 1:2 simulation for the first year and recurrent year.

The 22 nursing education programs responding reported the following associated costs: The cost reported in the survey ranged from $2,000-$100,000 for simulation professional development (CHSE certification, yearly simulation professional development). For simulation endorsement or accreditation, the cost reported ranged from $2,000-$150,000. In terms of evaluation of 1:2 simulation for the first year and recurrent year, programs responses ranged from $0-$150,000. Lastly, programs reported the estimated amount of funds needed for open-source materials for simulation (training modules, case studies, etc.) ranged between $0-$60,000. The total reported estimated amount of funds programs would need to implement the proposed rule ranged between $4,000-$460,000 (SA Table 2).

SBEIS Table 2. Estimate of Cost for Nursing Education

Programs from Cost Survey*

Estimate of the Funds the Nursing Program Would Require:	Average**	Median	Range
Simulation Professional Development (CHSE certification, yearly simulation professional development)	$20,069	$13,500	$2,000 - $100,000
Simulation Endorsement or Accreditation	$18,175	$5,000	$2,000 - $150,000
Evaluation of 1:2 Simulation for first year and recurrent year	$26,712	$6,000	0 - $150,000
Open-Source Materials for Simulation (training modules, case studies, etc.)	$9,919	$3,000	0 - $60,000
TOTAL	$74,875	$35,000	$4,000 - $460,000

**Calculations are not summed by row or by column and represent stand alone figures.

*Costs are rounded up to nearest dollar.

The board and department do not anticipate a loss of revenue. Obtaining the required accreditation, CHSE certification, and open source materials may make a school more attractive to prospective students and thus may increase revenue.

Summary of All Cost(s): The probable costs of implementing WAC 246-840-5341, including training, equipment, administrative expenses, professional development, and accreditation fees.

SBEIS Table 3. Summary of Probable Cost(s)

WAC Section and Title	Probable Cost(s) Description	Probable Cost(s) Estimate
WAC 246-840-5341(8)	Simulation Endorsement or Accreditation	$2,000 - $150,000
WAC 246-840-5341(10) WAC 246-840-5341(11) WAC 246-840-5341(15)	Simulation Professional Development (CHSE certification, yearly simulation professional development)	$2,000 - $100,000
WAC 246-840-5341(14) WAC 246-840-5341(17)	Evaluation of 1:2 Simulation for first year and recurrent year	0 - $150,000
WAC 246-840-5341(9) WAC 246-840-5341(13)	Open-Source Materials for Simulation (training modules, case studies, etc.)	0 - $60,000

Analysis on if the proposed rule may impose more-than-minor costs for businesses in the industry. Includes a summary of how the costs were calculated: Yes, the costs of the proposed rule is $4,000 - $460,000 which is more than the minor cost threshold ($1,330.76 and $24,053.97).

Summary of how the costs were calculated: The board calculated the costs associated with each section of WAC 246-840-5341 by conducting a comprehensive analysis of the requirements outlined in the proposed rule. This analysis involved consulting with interested parties, such as nursing education programs, simulation experts, and accreditation bodies, to gather information on potential costs. Additionally, the board reviewed existing data on simulation program expenditures, faculty training costs, accreditation fees, and other relevant expenses to estimate the financial impact of compliance. By considering these factors and estimating the resources needed to meet the requirements of each section, the board developed a comprehensive understanding of the probable costs associated with implementing the proposed rule.

Determination on if the proposed rule may have a disproportionate impact on small businesses as compared to the 10 percent of businesses that are the largest businesses required to comply with the proposed rule: No, the board believes the proposed rule does not have a disproportionate impact on small businesses as compared to the 10 percent of businesses that are the largest businesses required to comply with the proposed rule.

Explanation of the determination: The board believes the proposed rule, WAC 246-840-5341, does not have a disproportionate impact on small businesses compared to the largest 10 percent of businesses required to comply. The rule requirements, such as faculty certification, simulation equipment, and professional development, apply uniformly across all nursing education programs, regardless of size. The cost and administrative efforts needed to comply are anticipated to be proportionate to the resources available to both small and large institutions, ensuring an equitable implementation process.

A copy of the detailed cost calculations may be obtained by contacting Jessilyn Dagum, P.O. Box 47864, Olympia, WA 98504-7864, phone 360-236-3538, fax 360-236-4738, TTY 711, email WABONRules@doh.wa.gov.

Alison Bradywood DNP, MN/MPH, RN, NEA-BC

Washington State Board of Nursing

AMENDATORY SECTION(Amending WSR 16-17-082, filed 8/17/16, effective 9/17/16)

WAC 246-840-534Use of simulation for clinical experiences at a 1:1 ratio in LPN, RN, or RN to BSN nursing education programs located in Washington state.

(1) An LPN, RN, or RN to BSN nursing education program may use simulation as a substitute for traditional clinical experiences((, after approval by the commission))in WAC 246-840-531 at a 1:1 ratio, where one hour of simulation counts for one hour of required clinical experience, not to exceed ((fifty))50 percent of its clinical hours for a particular course.

(a) Simulation as used in this section means a technique to replace or amplify real experiences with guided experiences evoking or replicating substantial aspects of the real world in a fully interactive manner.

(b) The nursing education program shall have an organizing framework providing adequate fiscal, human, technological, and material resources to support the simulation activities.

(c) Simulation activities must be managed by an individual who is academically and experientially qualified and who demonstrates currency and competency in the use of simulation while managing the simulation program.

(d) The nursing education program shall have a budget sustaining simulation activities and training of the faculty.

(e) The nursing education program shall have appropriate facilities, educational and technological resources and equipment to meet the intended objectives of the simulation.

(f) All faculty involved in simulations, both didactic and clinical, shall have training in the use of simulation and shall engage in ongoing professional development in the use of simulation.

(g) Faculty to student ratios in the simulation lab must be in the same ratio as identified in WAC 246-840-532 for clinical learning experiences.

(2) Faculty shall organize clinical and practice experiences based on the educational preparation and skill level of the student.

(3) Qualified simulation faculty must supervise and evaluate student clinical and practice experiences.

(a) The nursing education program shall demonstrate that simulation activities are linked to programmatic outcomes.

(b) The nursing education program shall have written policies and procedures on the following:

(i) Short-term and long-term plans for integrating simulation into the curriculum;

(ii) An identified method of debriefing each simulated activity; and

(iii) A plan for orienting faculty to simulation.

(c) Debriefing as used in this section means an activity following a simulation experience that is led by a facilitator, encourages reflective thinking, and provides feedback regarding the participant's performance.

(d) The nursing education program shall develop criteria to evaluate simulation activities.

(e) Students shall evaluate the simulation experience on an ongoing basis.

(f) The program shall include information about use of simulation in its annual report to the ((commission))board.

WAC 246-840-5341Use of simulation for clinical experiences at a 1:2 ratio in LPN, RN, or RN to BSN nursing education programs located in Washington state.

(1) This section applies to LPN, RN, or RN to BSN nursing education programs providing simulation-based learning experiences as a substitute for clinical and direct patient care experience hours required in WAC 246-840-531 at a 1:2 ratio, where one hour of simulation counts for two hours of required clinical and direct patient care experiences.

(2) The definitions in this section apply throughout this section unless the context clearly requires otherwise:

(a) "Active engagement" means each student maintains a level of engagement that is conducive to the students' achievement of learning objectives.

(b) "Active observer" means a student that is engaged in the clinical scenario by observing the active participants and providing feedback that contributes to the students' achievement of learning objectives.

(c) "Active participant" means a student that is directly engaged in the clinical scenario by way of a role assignment that contributes to the students' achievement of learning objectives.

(d) "Context" means a simulation-based learning experience should be contextualized within a situation or backstory to provide a realistic starting point from which the structured activity begins. The complete picture of this context may be given verbally to the learners, found in the patient's file, or be revealed if requested through adequate inquiry.

(e) "Fidelity" means the level of realism associated with a particular simulation-based learning experience; fidelity can involve a variety of dimensions, including:

(i) Physical factors such as environment, equipment, and related tools;

(ii) Psychological factors such as emotions, beliefs, and self-awareness of participants;

(iii) Social factors such as participant and instructor motivation and goals;

(iv) Culture of the group; and

(v) Degree of openness and trust, as well as participants' modes of thinking.

(f) "High stakes evaluation" means an evaluation that has major implications or consequences based on the result or the outcome, such as merit pay, progression, or grades.

(g) "Screen-based simulation" means a simulation presented on a computer screen using graphical images and text, similar to the popular gaming format, where the learner interacts with the interface using keyboard, mouse, joystick, or other input device.

(h) "Simulation" means an educational technique that replaces or amplifies real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.

(i) "Simulation-based learning experiences" means structured facilitated activities that represent actual or potential situations that allow students to demonstrate, develop, or enhance knowledge, skills, or attitudes and provide an opportunity to analyze and respond to realistic situations in a simulated environment. Simulation-based learning experiences include the entire set of actions and events from initiation to termination of an individual simulation event. For purposes of counting simulation hours using 1:2 ratio, simulation-based learning experiences include the synchronously facilitated prebriefing, clinical scenario, and debriefing, but do not include asynchronous preparation activities such as readings or case reviews.

(j) "Simulation operations support personnel" means an individual who is involved in the preparation, operations, implementation, or delivery of the simulation-based learning experience but does not have primary responsibility for the experience. Responsibilities may include, but are not limited to, preparing the environment, operating equipment and technology, and voicing roles.

(3) Simulation-based learning experience hours may not exceed 50 percent of clinical hours for a particular course. The board may grant exceptions to a nursing education program demonstrating difficulty in locating clinical placement for a particular curriculum content area required by WAC 246-840-539 and 246-840-541, or 246-840-542.

(4) Screen-based simulation hours may not be counted for clinical hours at the 1:2 ratio.

(5) A simulation-based learning experience can include the use of immersive augmented reality or virtual reality so long as it is synchronously facilitated.

(6) Group size shall be limited to the number of students who can be actively engaged in a simulation-based learning experience such that it is conducive to learning, and shall not exceed 10 students for every one nursing faculty member who facilitates a simulation-based learning experience. Each student shall participate in the hands-on nurse role in each simulation-based learning experience and when not in that role, as an active observer or active participant in another role that contributes to the students' achievement of learning objectives. The program shall have a plan for ensuring active engagement of all students that includes participation of each student in the hands-on nurse role and use of an observer engagement tool.

(7) The nursing faculty member who facilitates a simulation-based learning experience must not have operational responsibilities.

(8) The nursing education program must obtain and maintain endorsement or accreditation from a board-approved organization that provides endorsement or accreditation in health care simulation. A nursing education program offering simulation at a 1:2 ratio must obtain board-approved certification or endorsement by June 30, 2029. As of July 1, 2029, a nursing education program must obtain board-approved endorsement or accreditation prior to offering simulation-based learning experiences to students at a 1:2 ratio. New nursing education programs receiving full board approval must obtain board-approved endorsement or accreditation within four years of receiving full board approval.

(9) The nursing education program shall have:

(a) A strategic plan for the simulation program;

(b) A plan to manage simulation space, equipment, and personnel resources for the simulation program;

(d) Defined qualifications of simulation operation support personnel.

(10) The simulation program must be managed by an individual who has all of the academic and experiential qualifications required of nursing faculty. The simulation program manager must also hold a Certified Healthcare Simulation Educator (CHSE) certification, Certified Healthcare Simulation Educator-Advanced certification (CHSE-A), or other board-approved certification in simulation by June 30, 2029. As of July 1, 2029, the simulation program manager must have and maintain board-approved health care simulation educator certification prior to initiating simulation program management duties.

(11) As of July 1, 2029, at least 10 percent of nursing faculty who facilitate simulation-based learning experiences must hold a CHSE or CHSE-A certification, or other board-approved certification in simulation.

(12) The board may grant an exception to the requirements that the simulation program manager and at least 10 percent of nursing faculty who facilitate simulation-based learning experiences must hold a board-approved certification if the following conditions are met:

(a) The program has a written plan for the simulation faculty and simulation program manager to obtain CHSE, CHSE-A certification, or other board-approved certification, within three years of application for exception;

(b) The simulation program manager and simulation faculty participate in professional development under subsection (15) of this section; and

(c) Evidence of orientation, mentorship, and evaluation of the simulation faculty and the simulation program manager is maintained and available to the board for review upon request.

(13) All nursing faculty who facilitate simulation-based learning experiences must be academically and experientially qualified and demonstrate competency in the use of simulation. Accordingly, nursing education programs shall document:

(a) Nursing faculty who facilitate simulation-based learning experiences have specific knowledge and skills in simulation pedagogy;

(b) The facilitative approach is appropriate to the level of learning, experience, and competency of the students; and

(c) Facilitation occurs throughout the simulation-based learning experience which aims to support students in achieving expected outcomes. The facilitation methods include prebriefing to prepare students for the simulation, and a debriefing, feedback session, or guided reflection exercise.

The nursing education program may maintain documentation of simulation nursing faculty's current CHSE, CHSE-A, or other board-approved certification as proof of compliance with subsection (13)(a) and (b) of this section.

(14) The nursing education program shall have a written plan to orient, mentor, and evaluate the simulation program manager and nursing faculty who facilitate simulation-based learning experiences.

(15) For nursing faculty who facilitate simulation-based learning experiences and do not hold current CHSE, CHSE-A, or other board-approved certification, the nursing education program shall provide a means for faculty participation in simulation-related professional development that includes:

(a) A simulation-related educational needs assessment;

(b) An annual professional development plan; and

(c) At least eight hours of simulation-related professional development per year. Professional development includes activities that reasonably contribute to the professional knowledge and development of faculty for purposes of providing simulation-based learning experiences to students.

(16) The nursing education program shall ensure that simulation-based learning experiences are:

(a) Student-centered and evidence-based;

(b) Aligned with appropriate and measurable student learning objectives;

(d) Supportive of the students' psychological safety.

(17) The nursing education program shall have a written plan for evaluation of the students, the simulation-based learning experience, and facilitation of the simulation-based learning experience as follows. The evaluation data shall be used for continuous quality improvement, including to inform group size.

(a) When using simulation-based learning experiences for evaluation of students, the method of evaluation shall be determined before the simulation-based experience and criteria for formative, summative, and high-stakes evaluation are met;

(b) All students shall provide a meaningful assessment of all elements of each simulation-based learning experience including prebrief, clinical scenario, debrief, and facilitation by the faculty;

(c) All students shall provide a meaningful assessment of their engagement and achievement of learning objectives while in the hands-on nurse, active participant, and active observer roles in each simulation-based learning experience; and

(d) Nursing faculty shall provide a meaningful assessment of each simulation-based learning experience including prebrief, clinical scenario, debrief, facilitation, design, and student achievement of the learning objectives.

(18) If documentation required by this section is also required to maintain board-approved endorsement or accreditation in health care simulation, then that documentation may serve as proof of compliance with this section.

(19) Nursing education programs may not use a 1:2 ratio if:

(a) The program is on conditional approval from the board under WAC 246-840-558;

(b) The program is on conditional or probationary status from a nursing accrediting body;

(c) The program's first time National Council Licensure Examination (NCLEX) pass rates are below 80 percent for two consecutive years; or

(d) The program is on a plan of correction for a deficiency related to providing simulation-based learning experiences at either a 1:1 ratio under WAC 246-840-534 or a 1:2 ratio under this section.

(20) The board may take action as identified in WAC 246-840-558 against a nursing education program offering simulation-based learning experiences at a 1:2 ratio that does not obtain or maintain a board-approved endorsement or accreditation as required by this section.