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Limitations of simulation

Thinking point

What are the main barriers that you can identify to introducing simulation into your teaching?


Although simulation is widespread, popular with learners and teachers, and technological developments are leading to the availability of more and more complex simulators, much of the published work has been descriptive rather than grounded in evidence-based research (Issenberg et al., 2005). Contemporary research is now focusing on a more analytical, evaluative and inter-disciplinary perspective to identify how best (often costly) simulation can be used.

Simulation is not a substitute for health professionals learning with and from real patients in real clinical contexts, but is best used to teach practical or technical skills prior to working with patients and to replicate clinical scenarios in a safe and controlled environment: ‘Simulation is a technique, not a technology’ (Gaba, 2004).

Although the technology can become confining and some learners and teachers find it hard to suspend disbelief, it is important that the seductive powers of simulation technology do not lead to dependency and produce a ‘new reality’ leading to learners being over-confident when they move to the ‘real world’ (Kneebone et al., 2005). The whole point of simulation is to connect with and prepare learners for more effective professional practice; this includes helping learners make the transition to performing skills with real patients.  Simulation must be valid. Poor validity is associated with a lack of realism. In some simulators, novices can out-perform an expert, which questions the validity of that simulation. Typically this would also lead to a lack of correlation with other outcome measures.

When considering simulation activities, teachers need to think how well they can be controlled (tractability), how well they match the real world (correspondence) and how well they involve learners meaningfully (engagement).   A common misconception is around fidelity, as mentioned previously; high fidelity simulation is often seen as better than low fidelity.

Maran and Glavin (2003) suggest that the range of fidelity available is almost all potentially useful, but that many simulators are underused due simply to a lack of clear educational goals. Teachers therefore need to learn how to use simulation activities through faculty development and experience so as to make the most of resources and learning opportunities for their students or trainees and to integrate such activities within educational programmes, not as a bolt-on. Many simulation centres now offer training for teachers in the educational use of simulation.

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