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Teaching and learning in simulated environments

Simulation is the reproduction of part or all of a clinical encounter through the use of manikins, computer-assisted resources and simulated patients. Advances in learning technologies have seen a massive rise in the availability and employment of high-fidelity simulators and simulation. However, low-fidelity resources have been used successfully for many years and, like the traditional teaching environments, need to be carefully incorporated into the spectrum of learning/training.

Thinking points

  • List the different types of teaching and learning that you would consider as simulation.
  • What are the features that make these positive learning experiences?



  • allows learners to practise in a safe, protected environment
  • allows observation of a ‘clinical episode’ without disturbing the natural cadence of the interaction
  • assists learners’ reflection of their strengths and weaknesses through teacher, peer and ‘patient’ feedback, including video analysis
  • allows teachers/staff to assess skills in an objective, reproducible manner
  • allows the reproduction of important clinical scenarios that may be rarely encountered in real life, e.g. anaphylaxis
  • allows assessment of complex interactions, skills and attributes that may be difficult to reproduce or assess, or are rarely experienced, e.g. working on call, multidisciplinary teamworking, discussing sensitive and/or important information with patients or carers.

Simulations vary in their relation (fidelity) to the real, lived experience.

Low-fidelity simulation might include using manikins to practise clinical examinations or procedures such as ophthalmoscopy or a vaginal examination. Manikins can also be used to rehearse the skills of simple clinical procedures such as suturing or the insertion of urinary catheters, intravenous cannulae and nasogastric tubes. Sometimes colleagues use each other to practise simple clinical procedures, e.g. taking a blood pressure or temperature.

The use of these relatively simple simulations may be augmented by incorporating them into clinical scenarios, contextualising their use and importance. This helps to introduce and reinforce good practice and generic issues such as hygiene, patient and staff safety, teamworking, communication, clinical reasoning and problem solving.

Low-fidelity simulation has a number of advantages:

  • it is easy to ‘house’ – may be used within a purpose-built skills centre or a classroom
  • it is relatively cheap to purchase, maintain and resource
  • it is portable – many of the manikins may be stored in a central location and moved to teaching areas when they are required
  • it is easy to store and secure
  • lower costs mean they are easier to duplicate and thus provide larger numbers/groups of learners with practice; they are therefore also easy to use in station-based assessments, where several synchronous circuits may be running
  • if sited in secure locations, it can be used for self-directed learning
  • it allows learners multiple practice attempts before attempting the skill on a real patient.

Meller (1997) sets out a typology of simulators used in medical education (see figure below).

High-fidelity simulation involves an active simulator or some manipulation of simulated parameters. High-fidelity simulators and simulation have high start-up costs, which has led to increasing partnerships between undergraduate and postgraduate training facilities, sharing experience, resources and costs. As the continuum of training between the latter years of medical school and the formative years of postgraduate training continue to blur, these partnerships will become increasingly important, both for sustainability of the resources and the education of trainees.

Typology of simulators

Thinking points

  • What is your experience to date of using high-fidelity simulation?
  • In respect to high-fidelity simulation, what do you think are the most important features for the learner? 

Issenberg et al. (2005) set out the features that make high-fidelity simulation a positive learning experience.

1. Feedback

As with many learning experiences, this was seen as the most important factor for the learner. Feedback can be instantaneous from video analysis, peer and tutor feedback, but may also be provided by the machine, allowing self-assessment and reflection. With video and computer analysis, data may be taken away by the learner for review and reflection at a later time or when revisiting the skill(s). Without feedback facilities, learners will often perpetuate poor practice.

2. Opportunity and access

If the learner is to derive maximum benefit from the simulation then they must be able to practise and revisit the skills often. At present, this is one of the principal limiting factors in the use of high-fidelity simulation in the UK, but this should improve with increased resources within medical schools and associate teaching trusts.

3. Individualised/adaptable learning facilities

The simulation/simulators should be able to be adapted to the needs of many learning/ training levels and abilities, and include a wide range of levels of difficulty. This facilitates the learner’s journey from novice to mastery.

4. Clearly defined training or learning outcomes

These need to be set against curriculum and assessment goals.

5. Validity

(a) Face validity – how realistic do the trainer and trainee consider the simulation to be?

(b) Concurrent validity – the skills practised in the simulation should be transferable to the clinical area. This is often a problem with low-level simulation, where important areas of the real-life experience are not addressed. Thus simulation becomes ‘instead of’, as opposed to ‘augmenting’, the real-life skills.

(c) Criterion validity – the simulation and scenarios have clearly defined learning/training outcomes.

(d) Predictive – the learners’ performance at any given time is predictive of their future performance.

(e) Construct validity – the simulation can differentiate participants along the expert–novice continuum. This is important in terms of learners ‘cheating the system’ by learning to score well on the simulator, rather than actually learning the skill. This is commonly seen when undergraduates learn itemised checklists for OSCEs.


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