Nursing programs nationwide are facing challenges in admitting students due to a shortage of nursing faculty and limited clinical practicum sites, especially in rural areas (Green et al., 2022). Competition for clinical placements is intense, as nursing programs must vie with other healthcare professions to secure essential training opportunities (Data Spotlight, 2025). While the American Association of Colleges of Nursing (AACN) Essentials (AACN, 2021) does not prescribe a total number of clinical hours required for RN programs, several states do. Many clinical sites restrict the number of students and the hours they can complete further complicating program access. In response, a survey sponsored by the National Council of State Board of Nursing (NCSBN) found that up to 50% of clinical practicum hours can be replaced by simulation, showing comparable educational outcomes for students (Hayden et al., 2014). Presently, 41 states have adopted regulations for simulation in prelicensure nursing programs, with 23 states allowing up to half of the required clinical hours to be met through simulation (Smiley & Martin, 2023). North Dakota (ND) does not have a current requirement for clinical hours nor guidelines on simulation hours for RN programs. Despite having fourteen RN programs, evidence on simulation use in ND remains sparse.

ND has approximately 10,000 RNs licensed and working in the state (Healthcare Workforce Group, 2025). Of these practicing nurses, just over half (53.6%) have been educated at one of NDs 14 nursing schools. While the number of graduates has increased by 29%, combined admissions to RN programs across ND have dropped 15.6% between 2018 and 2023 (Healthcare Workforce Group, 2025). There is high variability of clinical hour requirements (432 to 930) between RN programs and all programs compete for clinical hours at a small pool of major health systems for student experiences (Nursing Education Annual Report: Fiscal Year 2022–2023, 2023). Similarly, there is no current standard requirement in the U.S. for clinical practicum hours with high variability across states and nursing programs (Smiley & Martin, 2023). It is also evident that schools require direct patient care clinical hours for 62–100% of the required hours, versus trading up to 50% of these hours for simulation (Nursing Education Annual Report: Fiscal Year 2022–2023, 2023).

Simulation in healthcare education encompasses a variety of methods designed to replicate real-world clinical situations for training purposes. This dynamic approach uses tools such as high-fidelity mannequins, virtual reality simulations, and standardized patient interactions to support hands-on learning (Roberts et al., 2019). Through simulation, learners can practice clinical skills, apply theoretical knowledge, and refine critical thinking abilities in a safe, controlled environment. Different forms of simulation offer unique benefits (Smiley, 2019). For example, task trainers allow skill practice, partial task trainers focus on specific procedures, and high-fidelity simulators enable complex, scenario-based training (Singh & Restivo, 2023). Additionally, virtual simulations and standardized patient encounters provide realistic clinical environments that enhance the learning experience by fostering interpersonal skills alongside clinical proficiency (Foronda et al., 2020).

The integration of simulation into nursing education represents a significant shift, especially as direct clinical placements have become increasingly limited (Smiley & Martin, 2023). Traditionally, nursing education relied primarily on direct patient care experiences to allow students to apply theoretical knowledge in real clinical settings (The Evolution of Nursing Education in America, 2024). However, logistical constraints, inconsistent exposure, and safety concerns have necessitated alternative approaches (Naga et al., 2025). During the COVID-19 pandemic, for instance, simulation became a crucial alternative to traditional clinical experiences, offering a standardized, safe environment where students can practice critical nursing skills such as decision-making and teamwork (Kaminski-Ozturk & Martin, 2023).

It is well known that clinical practice sites for nursing education are limited across the country, regardless of geography (American Association of Colleges of Nursing, 2025). Also, recruitment of nurses to rural areas is difficult but increases with clinical placement in a rural setting for student experiences (Glenister et al., 2024). Despite increasing academic-practice and community partnerships, very little clinical education takes place in rural or remote areas due to insufficient sites and infrastructure (Naga et al., 2025; Rusaanes et al., 2024). Even with more programs focusing on clinical and didactic experience with rural and underserved populations, graduates are ill prepared to work in rural settings (Patterson et al., 2024). Each nursing program delineates variety, or lack thereof, for student experiences in various settings and populations. Simulation incorporated into nursing education can augment or replace experiences that may be limited due to lack of number or variety of clinical sites. For instance, involving rural populations, sites, and culture in simulations can enhance knowledge and skills for rural practice (Smith et al., 2024).

Unfortunately, there are a significant number of unknowns with clinical placement and simulation use across the U.S., especially in programs serving rural areas. The literature is sparse on rural clinical practicum for nursing students and the available evidence is typically international. Australia and Canada have prolific literature on rural practice and rural nursing educational structures. While this information is extremely useful for U.S. nursing programs, the differences in healthcare systems, state and national policies, and nursing regulation cause difficulty in generalizing most evidence to the U.S.

The gap this study addresses is the use of simulation in nursing schools serving a rural state. Specifically, this study aims to determine the extent of simulation use in ND RN programs; identify barriers programs may have to increasing simulation use; ascertain whether programs are using simulation hours to replace clinical hours; and evaluate whether this substitution is primarily due to lack of clinical placement sites.