OBJECTIVE: To measure the impact of the Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST(2) ACT) simulation program on nursing observations and practice relevant to patient deterioration in a rural Australian hospital. DESIGN: Interrupted time series analysis. SETTING: A rural Australian hospital. PARTICIPANTS: All registered nurses (Division 1) employed on an acute medical/surgical ward. INTERVENTION: The FIRST(2) ACT simulation program. OUTCOME MEASURES: Appropriate frequency of a range of observations and administration of oxygen therapy. RESULTS: Thirty-four nurses participated (83% of eligible nurses) in the FIRST(2) ACT program, and 258 records were audited before the program and 242 records after. There were statistically significant reductions in less than satisfactory frequency of observations (P = 0.009) and pain score charting (P = 0.003). There was no measurable improvement in the administration of oxygen therapy (P = 0.143), while the incidence of inappropriate nursing practice for other measures both before and after the intervention was too low to warrant analysis. CONCLUSION: FIRST(2) ACT was associated with measurable improvements in nursing practice.