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How is simulation used?

Simulation training extends from part task trainers or procedural training to the experience of full clinical situations (e.g. cardiac arrest). Table 1 lists the range of simulated experiences.

Simulated parts of the body can be used, for example, for cannulation, feeding, catheterisation or rectal examination. Some skills are practised in a ‘wet lab’ where animal and human tissue can be used e.g. for suturing. Basic (low fidelity) manikins are used for teaching basic and advanced life support. High fidelity manikin simulators with a vast number of programmed interactions and physiological responses can be used for individual or team scenario training.

High fidelity simulators also include those that are used for laparoscopic, endoscopic or delivery skills where the technology of virtual reality is employed. Some of these sophisticated simulators have ‘forced feedback’ (haptic) systems which enable the learner to ‘feel’ the endoscope going around the splenic flexure or to manipulate the ‘baby’ in a complicated delivery.

Fidelity is a term often used in discussing simulation, however one has to be careful as the same simulator can be seen as high or low fidelity depending on which features were being used and what is being taught. For example, traditionally a Simman 3g ™ is seen as a high fidelity manikin, however the simulator can be used to teach catheterisation.

Table 1 - The range of simulated experiences

  1. Games, classroom scenarios.
  2. Wet labs using human or animal tissue.
  3. Simulated patients.  Actors, healthy volunteers, standardised patients.
  4. Computer-generated virtual reality simulators (2D and 3D).
  5. Manikins and models of varying complexity. From part task trainers, such as cannulation arms to ‘complete’ bodies such as Simman™.
  6. Mock facilities including a simulated operating theatre, emergency departments, delivery suite, ambulance and wards.

Despite the ready availability of simulated body parts and 'kit', the integration of technical and non-technical skills is paramount in developing professional practice. In addition, to ensure patient safety, non-technical skills are an aspect of training that should be emphasised.  Analyses of adverse incidents indicate that the majority of causes of errors are in the non-technical skill domain, including communication failure, team failure, poor leadership or poor decision-making (Gawande et al., 2003).  However, the more complex the scenario, the more that teachers have to overcome learners’ disbelief in the simulation activity and this can be a major challenge. The Scottish Clinical Simulation Centre has looked at the integration of human factors into the medical curriculum and how to access the acquisition of those skills. They have developed behavioural markers for these skills in both the anaesthetic (ANTS) and surgical arenas (NOTSS) which help to break down the skills into more easily observed behaviours.

Kneebone’s research programme on the integration of technical and non-technical skills includes simulation training for rectal endoscopy which uses an endoscopy simulator with a simulated patient next to the simulator (2003). A sheet covers the patient and the trainee has to perform the task while talking and explaining to the ‘patient’ what he or she is doing.

Scenario simulation provides an excellent opportunity for interprofessional education with the ability to train real teams from work environments, e.g. introducing a new surgical technique, managing a roadside emergency involving pre-hospital care GPs and paramedics or containing an outbreak of a new infection. It is envisaged that simulation teaching will provide packages that any group could access and interact with other groups for relevant multidisciplinary situations.

Thinking point

What skills do you (and other teachers) need to acquire in order to make the most of such simulation opportunities in teaching technical and non-technical skills?

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