Featured Article Emerging Evidence Toward a 2:1 Clinical to Simulation Ratio: A Study Comparing the Traditional Clinical and Simulation Settings Nancy Sullivan, DNP, RN a, * , Sandra M. Swoboda, RN, MS a , Tonya Breymier, PhD, RN, CNE b , Laura Lucas, DNP, APRN-CNS, RNC-OB, C-EFM a , Janice Sarasnick, PhD, MSN, RN c , Tonya Rutherford-Hemming, EdD, RN, CHSE d , Chakra Budhathoki, PhD a , Suzan (Suzie) Kardong-Edgren, PhD, RN, ANEF, CHSE, FSSH, FAAN c a Johns Hopkins University School of Nursing, Baltimore, MD, USA b University of Dayton, School of Education and Health Sciences, Dayton, OH, USA c Robert Morris University, School of Nursing and Health Sciences, Moon Township, PA 15108-1189, USA d School of Nursing, College of Health and Human Services, University of North Carolina in Charlotte, Charlotte, NC 28223 USA KEYWORDS simulation; traditional clinical; clinical/simulation ratio; Millers pyramid; clinical nursing education Abstract Background: There is limited evidence comparing the clinical and simulation environments. Methods: This multicenter observational study compared traditional clinical to simulation on the type, number, and level of educational activities as determined by Miller’s Pyramid. Results: Forty-two students’ experience revealed that skills, physical assessment, teaching, and crit- ical thinking activities occurred more frequently in simulation, with safety interventions more common in clinical. In addition, in simulation, students performed a greater percentage of activities in higher levels of Millers Pyramid, ‘‘Knows How’’; 12.8% as compared with 8.6% in clinical, and ‘‘Does’’; 66.3% as compared with 46.2% in clinical. Notably, the activities in ‘‘Does’’ were completed in approximately 1/ 5 of the time in simulation; 440 minutes, as compared with clinical; 2,137 minutes. Conclusion: The intensity and efficiency of simulation was demonstrated through the completion of more activities in higher levels of Millers Pyramid in significantly less time than clinical providing emerging evidence toward a 2:1 clinical to simulation ratio. Cite this article: Sullivan, N., Swoboda, S. M., Breymier, T., Lucas, L., Sarasnick, J., Rutherford-Hemming, T., Budha- thoki, C., & Kardong-Edgren, S. (S.) (2019, -). Emerging evidence toward a 2:1 clinical to simulation ratio: A study comparing the traditional clinical and simulation settings. Clinical Simulation in Nursing, Vol(X), 1-8. https://doi.org/10.1016/j.ecns.2019.03.003. Ó 2019 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved. The clinical experience has been previously perceived as the gold standard of experiential learning in medical surgical nursing education. It provides students with the Clinical Simulation in Nursing (2019) - , 1-8 www.elsevier.com/locate/ecsn This work was supported by the International Nursing Association for Clinical Simulation and Learning Debra Spunt Research award. The au- thors have no conflict of interest to report. * Corresponding author: nsulliv@jhmi.edu (N. Sullivan). 1876-1399/$ - see front matter Ó 2019 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.ecns.2019.03.003