Twenty-first-century healthcare is a complex and demanding arena. Today's hospital environment is more complex than in previous years while patients move through the system at a much faster pace. Newly graduated nurses are challenged in their first year with the healthcare needs of complex patients. Nurse educators and nurse leaders differ in opinions regarding the readiness of newly licensed nurses. Despite these opposing views, there is no argument that today's hospitalized patients need expert nurses to care for them. This study explores the development of competence in newly graduated nurses using simultaneous multi-patient simulations (SMPS). This quantitative study analyzed several program outcomes at a south Texas baccalaureate nursing program utilizing SMPS in the final course. The outcomes measurements included the results of a computerized adaptive exam, a comprehensive exit examination, first-time NCLEX-RNRTM pass rates, and results of the Performance-Based Development System (PBDS) assessment evaluation of newly licensed nurses at a local South Texas hospital system. There were 600 participants divided into two groups, those who underwent the SMPS and those who did not. Groups were then compared for group differences in exam scores and NCLEX-RNRTM pass rates. Additionally, a smaller subset of participants employed at a local hospital system utilizing a critical thinking assessment tool was evaluated for group differences between those who participated in the SMPS and those who did not participate during their undergraduate nursing education. The findings revealed that students who undertook SMPS scored significantly higher on the computer adaptive test when compared to students who did not participate in the SMPS. The SMPS group also passed the NCLEX-RNRTM on the first attempt at statistically significantly higher rates. Scores of the comprehensive exit examination demonstrated higher results in the group exposed to SMPS but were not found to be significant differences. The PBDS assessment did not show significant differences between the groups. In related data analysis, the comprehensive admission testing scores were positively correlated to passing the computerized adaptive exam, the exit examination, and passing the NCLEX-RNRTM exam on the first attempt. The findings of this study have implications for nursing programs and their use of simulations. Multi-patient simulations are an expensive, time-intensive teaching strategy but demonstrate positive student outcomes in this study and are believed to be worth the time and expense; simultaneous multi-patient simulations, even more so. Recommendations for future research include a qualitative study to provide a further understanding of the transition to practice for newly graduated registered nurses to assist nursing programs with teaching strategies and innovations designed to improve overall nurse performance and competency. [The dissertation citations contained here are published with the permission of ProQuest LLC. Further reproduction is prohibited without permission. Copies of dissertations may be obtained by Telephone (800) 1-800-521-0600. Web page: http://www.proquest.com/en-US/products/dissertations/individuals.shtml.]