Simulation in clinical teaching and learning

Jennifer M Weller, Debra Nestel, Stuart D Marshall, Peter M Brooks and Jennifer J Conn
Med J Aust 2012; 196 (9): 594. || doi: 10.5694/mja10.11474
Published online: 21 May 2012
Factors driving simulation-based education
Modes of simulation

Simulation of the clinical environment can be achieved in a variety of ways:

Simulation fidelity

“Fidelity” describes the extent to which a simulation represents reality. It also refers to the psychological effect of “immersion” in the situation, or “being there”, and the extent to which the clinical environment is accurately represented.13 The degree of realism of a simulation technique, and thus the choice of simulator device, needs to be carefully matched with educational level, as too much realism and complexity can distract students, especially novices, from learning basic skills.14 For example, the steps for inserting a urinary catheter may be best learnt first using a part-task trainer where each step can be practised. The realism can then be increased by attaching the model to a simulated patient and adding in the requirement to simultaneously use effective communication skills.

Educational theory underpinning simulation

A major challenge with teaching and learning in clinical settings is that it is opportunistic and unstructured. This can be overwhelming for students who are often required to attempt tasks for which they are ill-prepared. SBE allows deconstruction of clinical skills into their component parts, so students can be presented with scenarios and tasks appropriate for their stage of learning, thus reducing the cognitive load.15 Without the complexities of dealing with real patients, students can focus on mastering basic skills and can more readily abstract principles from their experiences to apply in other settings.

Deliberate practice and feedback

A key advantage of SBE is the ability to create learning environments that facilitate deliberate practice.16 Students can rehearse their clinical skills within a structured framework in a focused and repetitive manner, thereby refining their skills until their performance becomes fluent and instinctive. Within the limitations of timetabling, practice can be distributed over multiple sessions of short duration, which promotes more meaningful learning than intense practice over fewer, but longer, study periods.17 Existing knowledge and skills can be built on incrementally, and the complexity of tasks calibrated to cater for different learning rates and styles.

The structured nature of SBE can enhance the quality of feedback to students, an important component of skills development and maintenance. It can also encourage reflective practice, whereby students learn to monitor their own performance.18

Evidence for effectiveness of simulation

Overall, research shows there is a positive relationship between SBE and learning outcomes. Applying Kirkpatrick’s framework for evaluating the impact of educational programs (Box 2),19 there is growing evidence that using simulation results in participant satisfaction, self-reported increased knowledge and improved performance.20

At present, however, there is a paucity of Kirkpatrick level 4 evidence on the impact of SBE on patient outcomes, but studies are now emerging.21-24,25 New approaches to synthesising data from qualitative and quantitative studies26 are also adding weight to the evidence reported in the research literature.

There are two important reasons why there is currently limited high-level evidence for the efficacy of SBE. The first is the wide range of modes of simulation, with limited transferability of evidence between different simulation contexts. Second, SBE is usually embedded within broader curriculum activities, making it difficult for its effects to be isolated from those of other educational interventions. It is in fact unhelpful to separate SBE from other learning methods, as “whole” rather than “isolated” elements are important for learning. Rather, it is the way in which SBE is incorporated into instructional design which determines its effectiveness.

Overall, the evidence at Kirkpatrick levels 1–3 suggests SBE makes a valuable contribution to learning for students, trainees and clinicians, especially for clinical and procedural skills, clinical decision making, patient-centred and interprofessional communication, and teamwork. Some SBE modes, however, are more suited for developing certain types of knowledge, attitudes and skills than others. For example, using virtual patients has been found to be helpful for developing clinical reasoning skills, but can lead to loss of the concept of patient-centred care.27

What the evidence also shows is that certain features and best practices need to be incorporated into SBE for it to achieve maximum impact. The twelve important features that optimise SBE are listed in Box 3 and explained in detail in the article by McGaghie et al.20

A national strategy for simulation-based education

Implementation of SBE needs a planned, thoughtful and coordinated approach. Currently, there is no cohesive strategy for simulation education and research in Australia, and successful programs depend to a large degree on local enthusiasts. The findings of the Health Workforce Australia (HWA) report on current and potential use of SBE in Australian medical education can be found on the HWA website (

Moving teaching away from the bedside reveals the real costs of medical education, with the need for dedicated teaching spaces, equipment and trained teachers. HWA is supporting the use of simulated learning and is providing funding for SBE, including $46 million capital and $48 million recurrent funding for 2010–11, and $20 million recurrent funding per annum subsequently. This funding is for all health care professions and will significantly enhance SBE capability and capacity in Australia, but the challenge to maintain some national cohesion remains. HWA has undertaken a review of opportunities for SBE to enhance efficiency and effectiveness of training of health professionals, and established a mechanism for SBE initiatives to develop capacity across Australia.29 HWA has also embarked on the development of a training program for simulation instructors.

The key elements required for an effective national SBE program are infrastructure, curricular integration and trained personnel. A stocktake of existing simulation facilities is needed, followed by a rational development plan to ensure that limited resources are used wisely. The breadth and depth of learning experiences that the different modes of simulation can offer need to be understood, so SBE can be integrated into medical school programs. Critically, there needs to be investment in appropriately trained staff to manage these facilities, as well as training in curriculum development, evaluation and research.

Most health care facilities will want or need some type of simulation facility. The types of simulators and the staff needed to appropriately run facilities are the real issues. A “hub and spoke” model is likely to be the best solution, with major investment being made in communication technology to ensure effective interactions between facilities. Regional networks could be used to coordinate the development of learning programs, usage and research, but should not discourage local initiatives. Purchase of major infrastructure on a shared basis, and regional or national contracts for servicing of equipment may allow some economies of scale. Regional centres or even a national institute for health simulation could coordinate standards for simulation training programs and staff accreditation.30

In the United States, the Society for Simulation in Healthcare has gone some way towards developing an approach to accreditation for simulation programs, which could serve as a useful model.31 Lessons for further research and development may also be gained from other industries such as defence, aviation and construction.

Future directions

Simulation technology has rapidly evolved over the past few decades from simple part-task trainers to equipment with haptic feedback technology, as well as complex computer-driven mannequins and virtual reality. The accurate representation of real clinical settings and tasks by more sophisticated devices supports the ongoing development of SBE to help resolve problems in clinical education and health care delivery, especially in the areas of patient safety and assessment.


The past 10 years have seen a shift towards requiring practitioners to demonstrate competence in key skills — at medical school, vocational training and specialist training levels. Simulation is increasingly being used for these assessments,34 including at medical student level.35,36 It is likely that competency assessments will become more complex in the future; behavioural aspects and the ability to work in a team will be incorporated into assessments, rather than just technical skills or application of knowledge. There is emerging evidence of the reliability and validity of assessments using simulation for these aspects of medical education.37,38

1 Developing expertise in the management of acute heart failure


Interactive demonstration: A mannequin with an electrocardiogram and blood pressure monitor displays tachycardia and low blood pressure. A Swan–Ganz catheter shows that both left atrial pressure and pulmonary capillary wedge pressure are raised and cardiac output is reduced. Oxygen saturation falls as a result of ventilation–perfusion mismatch. A student is asked to give oxygen and a dose of frusemide. The students watch the change in physiological parameters as the treatment takes effect.

Preparatory skills

Skills station: Students are asked to administer oxygen to a “patient” with hypoxia. They need to assemble oxygen tubing and a mask, connect it to the oxygen outlet, turn on the oxygen and place the mask on the “patient”. Mistakes are used as learning opportunities.

Theory to practice

Pause and discuss: Students are presented with a “patient” with acute heart failure and are asked to initiate treatment. The first student raises the head of the bed and administers oxygen. The instructor stops the scenario and questions the students about their clinical reasoning. The next student then continues the management, inserting an intravenous line and giving frusemide.

Transition to night call

Immersive simulation: A senior student is called by a nurse to see a “patient” on a ward who is acutely short of breath. They need to gather information, diagnose the problem and begin treatment. They can call for help from their fellow students or from a senior colleague. The instructor manages the simulation remotely, providing input only when necessary. The subsequent debrief focuses on clinical reasoning and decision making in managing a patient who is breathless.

Working with the health care team

Immersive multidisciplinary simulation: A group of senior medical and nursing students are required to manage a “patient” who has become acutely breathless. The nurses know the ward environment and the “patient’s” background. The medical students know about breathlessness. Together they need to piece the story together, come up with a diagnosis and management plan, and implement it. The debrief that follows ensures appropriate knowledge and skills of the condition, and explores issues of communication, understanding of roles and capabilities, task coordination and shared decision making.

Provenance: Commissioned; externally peer reviewed.

  • Jennifer M Weller1
  • Debra Nestel2
  • Stuart D Marshall3
  • Peter M Brooks4
  • Jennifer J Conn5

  • 1 Centre for Medical and Health Sciences Education, University of Auckland, Auckland, NZ.
  • 2 Gippsland Medical School, Monash University, Churchill, VIC.
  • 3 Simulation and Skills Centre, Southern Health and Monash University, Monash Medical Centre, Melbourne, VIC.
  • 4 Australian Health Workforce Institute, University of Melbourne, Melbourne, VIC.
  • 5 Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC.


Competing interests:

No relevant disclosures.

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