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Simulation is an experiential learning process which provides a safe environment for learning, preventing the risk of patient harm. A review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach to explore the question: What is the state of the science on the evidence of learning outcomes in high-fidelity simulation in undergraduate nursing education? This synthesis included 20 research studies focusing on evaluating outcomes of high-fidelity simulation in undergraduate pre-licensure baccalaureate nursing students. Studies were excluded if they did not use high-fidelity simulation for the intervention group, or they evaluated faculty outcomes. Simulation design and practices are identified and discussed regarding dose and fidelity. Outcome measures reviewed include increasing levels of thinking: Remembering/Understanding/Applying (knowledge/skills), Analyzing/Perception, and Evaluating/Creating outcomes. Design of high-fidelity simulation in the nursing literature is being grounded in outcome variables with increasing levels of thinking (Bloom's Taxonomy) and based in pedagogical and nursing judgment theoretical frameworks. Reliable measurement tools are used. There is a need for a more comprehensive measurement of clinical competence that extends evaluation to clinical practice outcomes. Additional research is needed on retention of simulation learning over time and assessing transference of simulation learning into clinical nursing practice.