critical review of simulation based medical education research

A critical review of simulation-based medical education research: 2003-2009

Affiliation.

• 1 Augusta Webster, MD, Office of Medical Education and Faculty Development, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611-3008, USA. [email protected]
• PMID: 20078756
• DOI: 10.1111/j.1365-2923.2009.03547.x

Objectives: This article reviews and critically evaluates historical and contemporary research on simulation-based medical education (SBME). It also presents and discusses 12 features and best practices of SBME that teachers should know in order to use medical simulation technology to maximum educational benefit.

Methods: This qualitative synthesis of SBME research and scholarship was carried out in two stages. Firstly, we summarised the results of three SBME research reviews covering the years 1969-2003. Secondly, we performed a selective, critical review of SBME research and scholarship published during 2003-2009.

Results: The historical and contemporary research synthesis is reported to inform the medical education community about 12 features and best practices of SBME: (i) feedback; (ii) deliberate practice; (iii) curriculum integration; (iv) outcome measurement; (v) simulation fidelity; (vi) skill acquisition and maintenance; (vii) mastery learning; (viii) transfer to practice; (ix) team training; (x) high-stakes testing; (xi) instructor training, and (xii) educational and professional context. Each of these is discussed in the light of available evidence. The scientific quality of contemporary SBME research is much improved compared with the historical record.

Conclusions: Development of and research into SBME have grown and matured over the past 40 years on substantive and methodological grounds. We believe the impact and educational utility of SBME are likely to increase in the future. More thematic programmes of research are needed. Simulation-based medical education is a complex service intervention that needs to be planned and practised with attention to organisational contexts.

Publication types

• Research Support, Non-U.S. Gov't
• Clinical Competence
• Education, Medical / methods*
• Educational Measurement / methods
• Outcome Assessment, Health Care / methods
• Patient Simulation
• Research Design

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A critical review of simulation-based medical education research: 2003–2009

2000, Medical Education

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A Critical Review of Simulation-Based Medical Education: An Advanced Opportunity for Next Generation of Medical Education

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Research Article | DOI: https://doi.org/10.31579/2690-8808/118

• Chenxiao Hu 1
• Kanghua Wang 1
• Xinlong Zhang 1
• Jianlin Wang 1
• Natalie Tai 3

1 The information Center, the 1st Hospital of Lanzhou University. 2 Department of obstetrics and gynecology, the First Hospital of Lanzhou University, Key Laboratory for Gynecologic Oncology Gansu Province, China. 3 University of Maryland. 4 Kent State University.

*Corresponding Author: Yun Lu, Nursing Institute, Kent State University 800 E Summit St, Kent, OH USA 44240, Qi Guang, The information Center, the 1st Hospital of Lanzhou University Donggang West Rd, Lanzhou China 730000.

Citation: Chenxiao Hu, Kanghua Wang, Xinlong Zhang, Natalie Tai3, Yun Lu, Qi Guang, et al. (2022). A critical review of Simulation-Based Medical Education: An Advanced Opportunity for Next Generation of Medical Education J. Clinical Case Reports and Studies 3(7); DOI: 10.31579/2690-8808/118

Copyright: © 2022 Yun Lu, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 20 April 2022 | Accepted: 14 June 2022 | Published: 06 July 2022

Keywords: simulation-based medical education (SBME); performance design; virtual system; platform real force feedback

Mistakes made by medical personnel may cause numerous medical errors and accidents, resulting in the death of patients. Therefore, it is imperative to increase overall medical knowledge and to improve the medical skills of caregivers during their education and training. Simulation-Based Medical Education (SBME) is a compelling method for medical training; it not only improves medical education quality and trainee confidence but also reduces medical error risk and keeps patients safe, increasing patients’ satisfaction. SBME provides valuable tools to address realistic, challenging problems in medical education. Multiple factors are carefully evaluated and incorporated into the simulator design to most accurately mimic the real clinical situation and to measure the teamwork competency and learning objectives. Those practices include performance designs, a virtual platform for invasive medical procedures and noninvasive medical operations, psychology simulation, the combination of simulation and live/replayed surgery observation, and platform real force feedback. Simulation is the key element for SBME. The use of simulation in education ensures compliance with the established norms for clinical diagnosis, treatment, and some specific emergency cases. Trainees can repeatedly practice and learn from SBME without the risk of medical accidents. Improving the design of simulators with sufficient fidelity to the clinical events, in reality, will improve the quality of SBME.

Simulation-Based Medical Education (SBME) is a widely accepted method to effectively improve the skills and knowledge of medical professionals and an approved, risk-free method during medical education [1, 2]. With the increased requirements for patients’ safety during medical procedures and the need to improve the quality of healthcare education, it requires SBME to incorporate the most updated data on medical performance [3, 4]. SBME was considered to be a milestone in remedial education, training, research and evaluation [5].

SBME provides valuable tools to address realistic, challenging problems in medical education. Multiple factors are carefully evaluated and incorporated in the simulator design to most accurately mimic the real clinical situation and to measure the teamwork competency and learning objectives [6-8]. These factors include but are not limited to simulation-based doctrine and practice, new science and technology, and new instruments and tactics.

It is noteworthy that plenty of medical errors are caused by mistakes made by healthcare providers or unskilled clinical technicians. According to the statistical analysis result from the Institute of Medicine, 44,000 to 98,000 deaths of patients are caused by the medical errors made during inpatient hospitalization every year [9, 10]. This number is even bigger than the number of persons who died from traffic accidents [11, 12], breast cancer [13], and AIDS [14-16]. Therefore, qualified clinical skills are closely associated with the survival rate of patients [17]. It is true for both in-hospital treatments and medical emergencies [17]. SBME provides opportunities for caregivers to practice, thus enhancing their clinical skills without touching real patients. Through repeated practice, healthcare providers could improve their clinical skills in both restorative procedures and emergency situations, therefore assuring the safety of patients during medical treatment [18]. 

Currently, most of the necessary medical knowledge acquisition still relies on traditional learning methods such as textbooks and discussions. Most of the first clinical experiences of medical students or trainees come from the actual practice on patients supervised by mentors, which imposes the patient a potential safety risk [19]. Therefore, a practice platform that simulates actual medical situations with high fidelity is in urgent need of technical training in medical procedures. In summary, how to improve the fidelity of simulators in SBME becomes an important issue to address, and SBME would bean advanced opportunity for the next generation of medical education.  

A fidelity performance design

Medical education, as it stands now, is an education system that continuously embraces new technologies to enhance the learning experiences of students and have them better trained. The application of virtual experiences to improve the clinical training experience is not new to the medical field [20, 21]. The idea of imitation teaching in medical education, which uses a discrete simulation model for teaching and testing, is aimed to provide an initial practice experience to participants [20, 21]. It would be beneficial for participants to have a simulation experience that mimics symptoms of specific syndromes or side effects of various treatments [20, 21]. More importantly, simulation-based teaching conforms to the standards of clinical diagnosis, treatments and sometimes specific emergency scenarios [22]. One of the essential characteristics of SBME is simulation. It requires the simulators to react like a real patient. The result of such training depends heavily on the simulators’ fidelity [23]. In high-technology simulations, like Virtual Reality (VR), the simulated human model has been set up by using the trackball, HMDS (Head Mounted Display systems), feeling gloves, etc., allowing trainees to better understand the structure of internal organs. In addition, VR(Virtual Reality) technology has to determine advantages in some particular cases, such as long-distance remote surgery, complicated operation schedules, surgical result prediction, and even the development of new drugs [1]. The immersion practice environment ensures trainees a realistic environment and unique learning experience that could enhance traditional schooling results without risking the safety of any real patients.

Virtual platform in non-invasive medical operation

Medical history collection is the first step in diagnosis and treatment decisions. Medical students could improve their clinical interviewing and physical examination skills through a simulation teaching program. A widely used medical history training system includes a professional case library and realistic 3D models, providing simulation models for dozens of diseases in various organs or systems such as circulation, respiratory, urinary, endocrine, digestive, and obstetrics and gynecology [24-26]. These virtual human models and human-computer interactions encourage students to observe the "patient" from different angles. Virtual patients have vivid facial expressions as well as "sit and stand" positions. Additionally, they can answer questions, participate in the physical examination, and respond to different diagnostic instruments. 

In order to help trainees build their habit of critical thinking, current simulators are designed to create clinical scenarios that encourage trainees to do problem-solving. The simulating system automatically asks trainees to analyze the data presented to them and to draw specific conclusions for a given scenario [9, 13, 22]. It encourages trainees to imagine themselves in an office or ward. As trainees are learning the basics of physical diagnosis, it also requires them to integrate other factors such as disease etiology, pathology, physiology, and clinical manifestations to efficiently and accurately obtain a complete medical history and physical examination result [27]. It further develops through laboratory findings and imaging results to accurately diagnose the disease and make an appropriate treatment plan [27]. Practicing with this simulation system would help trainees acquire the medical skills in a stepwise way [27]. 

Psychology simulation

Sensory perception is one of the vital components of psychology. It is an abstract, psychological phenomenon that is not easy to contribute to. Simulation of sensory perception through a series of psychological instruments and equipment creates a platform for perceptual psychology experiments [28]. The stroboscope is an example of such an instruments. It decelerates a fast-cycled movement into a slowly moving one. Such an intense flashing/pulsing light at various frequencies can trigger epileptic seizures in people who are impacted by photosensitive epilepsy [29]. An experiment-specific project could include multiple instruments such as a stroboscope, reflector, stabilizer and multiple reaction condition testers to investigate certain target manifestations such as attention span [28]. Trainees would get trained and evaluated by operating the instruments and analyzing the results. Those above practices would not only make students get familiar with the abstract psychological phenomenon of sensory perception but also broaden the students' understanding of the underlying mechanisms involved [28]. This simulation system will help trainees build a solid foundation of clinical diagnosis and research in psychology.

Virtual platform for invasive medical procedures

A successful design of a medical simulator is based on multiple components, including thoroughly investigated medical background information, medical data collection and post-production data integration [30]. In general, designing a medical simulation model comprises two steps: raw digital data importing and medical image collection, including CT scans, MRI and ultrasound screening to accumulate sufficient tomography data, and image preprocessing, segmentation, registration, and complete digitalization of a whole human body or an organ. Specific tools and software are available for complete image processing [31].

Compared to traditional training with animal models, the simulation-based training models are safer, more intuitive, and more accurately reflective of real clinical situations. Yoshida summarized the trainees' initial impressions of a new virtual reality hysteroscopy trainer after they completed a hysteroscopy myomectomy and compared it to that of a widely used traditional training using animal models [32]. The trainees rated the training effects of the two different imitation methods, and it turned out that the simulation method scored significantly higher than the training using animal models for “a variety of training cases” and “performance assessment,” with the exception of “hysteroscopy myomectomy”, for which the simulation-based training tightened to the “gold standard” demonstrated by the training using animal model [32, 33]. 

Predictably, simulation-based training will partially replace animal-model-based training due to its outstanding advantage in data collection and reorganization [32, 34]. Data reception hardware with a 3D platform system is capable of connecting to the server to transmit data [32, 34]. Therefore, the system can give the command to the workstation to run the equipment in a virtual environment, and the system in a virtual environment can generate feedback to the trainee during the force-force feedback. The force feedback process allows the system server to generate force feedback instruction after receiving data processing information (force feedback, virtual touch) [30, 32, 34]. This process also enables the digital/analog (D/A) converter to adapt digital quantity feedback to analog and controls the workstation output force feedback to the trainee. 

Data reception processing equipment (force feedback, virtual touch) can prevent action delay and jitter, especially in the process of simulating endoscopic operation. The 3D medical model processing server is connected to a 3D platform system server, providing access to a huge amount of medical data, including medical diseases, complications, and emergency models [35-37]. A virtual environment can be generated through the 3D platform system server, giving rise to the virtual instruments and virtual organs, among many other features. The display device comprises a platform system that is connected to the server, which is capable of casting the images during the training to a variety of devices (such as monitors, projectors, etc.), enabling the vision of each detailed medical scenario [37].

In the early '90s, a virtual surgical training platform was invented with the leg and abdominal surgery simulation at the forefront. Now, this virtual platform further includes a surgical lamp, virtual surgical instruments (such as scalpels, syringes, forceps, etc.) and virtual organs, etc. With the aid of feeling gloves, trainees can operate on a virtual human model [30, 38-40]. Moreover, with the help of silicon images and a virtual operating table, NASA's biological computer center rebuilt a virtual patient for facial plastic and reconstructive surgery [41]. By wearing specially-made feeling gloves, surgeons are able to restructure the patient's organs and bones by using the energizing track scanning pen and slime-relevant software. Physicians can clearly realize the prognosis of the disease and the outcome of the treatment. Without this system, it was difficult to explain the procedure to patients using layman’s terms [42]. Reconstitution of the virtual stereo image allowed patients to understand the process more clearly.

The faithful simulator could also be used in the clinic in reality. Surgeons can repeatedly simulate operations on screen, move the organs, search for the best operation procedures, and improve surgical proficiency with the help of virtual reality technology. Furthermore, it could help surgeons in remote surgeries in the future by planning cooperating plans, providing instructions in the operation process, predicting operation results, and improving living conditions for those who are physically challenged [43-45]. 

In reality, medical professionals are not in the situation of “fighting alone”. It is more complicated than in the simulating situation and often requires team responses. In order to be prepared for this situation, trainees are required to operate more than three advanced medical simulators [46]. Computer-operated, physiological function parameters such as heart rate, respiratory rate, blood pressure and temperature will adequately respond to any medical interventions such as artificial ventilation, chest compression, and induced hibernation in CPR (Cardio Pulmonary Resuscitation). This program emphasizes the collaboration of physicians and nurses, the prescription and implementation of medical orders, and the recording of clinical events in real-time [34, 47]. It is able to simulate many other parameters. VR simulator trainees are educated surgeons and doctors in many other medical subspecialties (e.g., interventional cardiologists) who work heavily in intricate and invasive procedures that may put real patients at risk. It should be kept in mind that such a medical situation can be complicated and volatile. Thorough data analysis and consideration of such situations should be practiced for future simulator designs and future SBME technology selection [45]. 

Platform real force feedback 

The nervous system is a complex, highly organized network that allows the transmission of signals throughout the body to control movements, sensations, thoughts and feelings [48]. During an operation, the nervous system works at many different levels. For instance, the operator’s fingers have susceptible receptors connected to the nerves that transmit information to the operator’s brain, the photoreceptors in the operator’s eyes perceive not only light but also the organ position, active bleeding sites, suture position and other pertinent information [49-54]. The operator’s brain is constantly sending out commands to control the fine movements of the fingers and wrist, which are particularly critical in such a vulnerable environment [50]. For a simulator, visual information is obtained through the virtual scene, and tactile information is obtained through force feedback devices. It would, in many senses, feels like a real operation because of the realistic resistance when cutting through muscles and bones. An US group employed a virtual surgery system named Haptic Workbench for training purposes [55]. It is a 3D imaging system that utilizes glasses and a mechanical arm with the integration of detailed human anatomy data to simulate realistic, high-resolution 3D virtual scenes [55]. In accordance with different training purposes, trainees can adapt the mechanical arm to various surgical tools, such as a scalpel or hemostatic forceps [56]. The system also has a tactile reflection through force feedback or cutting resistance. 

Highly restored simulation systems, such as ophthalmology operation simulation systems, which can create 3D images according to the structure of eyeballs, are capable of providing real-time tactile feedback. This would be an excellent educational resource for students, allowing them to simply observe or be more actively involved in different simulated activities, i.e., removing the lens of the eye, manipulating blood vessels, and observing various anatomical structures of the orbit [30, 32, 57-59]. The advanced simulator for the artery stent system has been applied on levels as high as vascular surgeons’ training [57]. The endovascular simulator provides an incredibly realistic feel to trainees [57]. Additionally, the simulator can measure and record the movement of multiple guidewires and catheters, as well as distinguish between proper and improper tip placement [34]. Trainees can receive objective feedback in a simulated surgery to enhance their skills and to provide an opportunity to obtain valuable experience. By practicing with the simulation system, the performance of the trainee can be scored[25, 26]. The score doesn’t merely depend on an arbitrary evaluation index, such as the time duration to finish the procedure. A certain amount of unique skills can be evaluated objectively. If an experienced trainee completes a technique training and gets a score, the score can be used as a benchmark of proficiency in this simulation system. To achieve this goal, a high level of simulation fidelity is a requirement for the system. A very precise simulation experience can ensure fewer variations among trainees and eliminate any remaining subjectivity throughout the process of training [37].

By using a simulator, almost all medical scenarios can be reconstructed, and various aspects of many medical procedures can be mimicked, including cutting, sewing, knotting, the use of titanium clips, and even bleeding. During the surgery, trainees can utilize the virtual instruments (clamps, ultrasonic knives, electric coagulation hooks, etc.) to practice minimally invasive endoscopic surgical procedures. From the data received from feedback signals to workstation output feedback force and virtual touch, these simulation activities continue to transform into an even more realistic experience. 

Combination of simulation and live/replayed surgery observation

Yoshida and his collaborators indicated that a combined virtual reality endoscopy and colonoscopy simulator, in addition to the alternate laparoscopy surgical training, could significantly improve the effect of training [32, 34]. It was also shown to shorten the trainees’ initial learning curve, reduce the safety risk of patients, and lower the occurrence of complications related to the operation. 

It would be beneficial for trainees to engage in repeated virtual reality simulator training of laparoscopy for one week. This is especially true for training in specialized areas such as the hand. Such training achieved through a training module could improve the training efficiency. Training efficiency could also be improved by watching video demos of operations that encountered unexpected circumstances [32, 34]. The training should be focused on explanations of any unexpectancies and how to avoid them or deal with them [32, 34]. At the end of the sixth week, trainees participated in clinical surgery practice training [7, 8]. As a result of such training, the operation accuracy and speed of trainees regarding the surgical instruments were improved dramatically, as well as the basic skills of suture and knotting and a marked strengthened hand-eye coordination [32, 34].

Designer/trainee feedback

Designer/trainee feedback is one of the key components of the evaluation standards for simulation fidelity. It is very critical for SBME to design and plays important roles in medical education through SBME [9, 10]. The core elements of SBME are varieties, sources and impact. The variety lies in the summative and formative forms of performance feedback. The outcome of SBME does not require summative judgments, and simulation schooling increases learners’ clinical skills. A prime example of the medical simulation is the four-step model presented by Rudolph and his colleagues comprising of 1. observing the gap between desired and actual performance; 2. commenting on the performance gap; 3. investigating deeper into the basis for the performance gap, and 4. helping to close the gap through discussion and didactics [60]. However, some problems still remain even after the collection of feedback, including how to evaluate the quality of each feedback and how to translate the feedback to match the ultimate goal [20, 21, 61]. If the SBME equipment involves video or digital recordings, the question remains on how to train participants and instructors to adapt to the novel environment. As of today, feedback still has limits, and it is understood that performing a composite analysis is helpful in achieving a better training result.

Previous studies that focused on simulators have reported an evaluation of available technologies as supplementing training methods. Berridge et al. tested two training simulators, the endoscopic retrograde cholangiopancreatography (ERCP) mechanical simulator (EMS) and ex-vivo porcine stomach model (PSM), in ERCP training [62, 63]. It turned out that endoscopists who practiced with both models had a better understanding of the surgical performance and reported increased confidence during a real ERCP procedure. Because both PSM and EMS simulators were designed to be equipped with many accessories and to serve a broad range of training purposes, the training procedure using these two simulators was more authentic than other training using full computer-simulated platforms. Endoscopists who were trained with PSM and EMS expressed a preference for these training over traditional medical education methods [63]. 

Recently, more and more studies reported the benefits of engaging in simulation-based training in medical education. Farcas and his colleagues reported a remarkable improvement in technical skills, patient safety and overall performance in a group of medical students trained under the SBME program [59]. The improvement was attributed to the use of high-fidelity endovascular simulations in the vascular surgery course. In addition, engagement of the SBME increased students’ interest in the specialized area. 70% of students considered listing vascular surgery as a potential career option at the end of the course, compared to only 10% of students who expressed their interest. Almost all of the students’ vascular surgery knowledge had been expanded after the training [31, 59, 63].

Lastly, simulator-based courses may also provide the opportunity to pre-screen and recruit talented medical students into future surgical training programs. Yedavalli et al. reported that the simulation system might potentially be employed as a screening test for surgical talent [64, 65]. Trainees were divided into two groups [20, 26]. One group was trained on the simulator; the other group was trained on a video box trainer correlated with real operational performance. After completing the training program, the trainees in each group were tested on the training modality. Although students in both groups demonstrated improvements in terms of performance and final score in the screening tasks, the group trained on the simulator received a significantly higher score than the video-trained group [41]. Such scores could be translated to better operational performance. The impact of SBME has been studied by several different groups. These studies indicated that simulation training with force feedback produced significantly better performance than training programs without a feedback strategy [36, 62]. It is also true in clinical CPR practice, that SBME could have a positive influence on trainees’ clinical behavior.

Nowadays, most of the clinical technique is accumulated by learning from the actual patients after graduation. It is a continuously evolving issue to find the best way to deliver a useful, long-lasting method of education. Currently, a comprehensive reform of teaching and learning is happening worldwide. The reform of medical training represents the need to improve the traditional medical education methods and to look for more active and efficient ways of training. High-quality SBME will be an excellent tool that could improve medical education quality and trainees’ confidence, reduce the medical error risk in care provider practice, and increase patient safety. The needs for each particular simulation will be identified by accurately and thoroughly analyzing the simulation performance. Risks for patients in a clinical setting are often complex and volatile, especially during anesthesia, surgery, emergency treatment, etc. It depends on the correct judgment and quick completion of technical operations to reduce the risk of diseases, therefore protecting the safety of patients. The fidelity of SBME  _ENREF_1 rests on the thoroughness of medical knowledge and the environmental factors in clinical settings, which take time to develop.

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• Consensus article
• Open access
• Published: 21 May 2024

Global consensus statement on simulation-based practice in healthcare

• Cristina Diaz-Navarro 1 ,
• Robert Armstrong 2 ,
• Matthew Charnetski 3 , 4 , 5 ,
• Kirsty J. Freeman 6 ,
• Sabrina Koh 7 , 8 ,
• Gabriel Reedy   ORCID: orcid.org/0000-0002-1839-1949 9 ,
• Jayne Smitten 10 ,
• Pier Luigi Ingrassia 11 ,
• Francisco Maio Matos 12 , 13 , 14 &
• Barry Issenberg 15  

Advances in Simulation volume  9 , Article number:  19 ( 2024 ) Cite this article

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Simulation plays a pivotal role in addressing universal healthcare challenges, reducing education inequities, and improving mortality, morbidity and patient experiences. It enhances healthcare processes and systems, contributing significantly to the development of a safety culture within organizations. It has proven to be cost-effective and successful in enhancing team performance, fostering workforce resilience and improving patient outcomes.

Through an international collaborative effort, an iterative consultation process was conducted with 50 societies operating across 67 countries within six continents. This process revealed common healthcare challenges and simulation practices worldwide. The intended audience for this statement includes policymakers, healthcare organization leaders, health education institutions, and simulation practitioners. It aims to establish a consensus on the key priorities for the broad adoption of exemplary simulation practice that benefits patients and healthcare workforces globally.

Key recommendations Advocating for the benefits that simulation provides to patients, staff and organizations is crucial, as well as promoting its adoption and integration into daily learning and practice throughout the healthcare spectrum. Low-cost, high-impact simulation methods should be leveraged to expand global accessibility and integrate into system improvement processes as well as undergraduate and postgraduate curricula. Support at institutional and governmental level is essential, necessitating a unified and concerted approach in terms of political, strategic and financial commitment.

It is imperative that simulation is used appropriately, employing evidence-based quality assurance approaches that adhere to recognized standards of best practice. These standards include faculty development, evaluation, accrediting, credentialing, and certification.

We must endeavor to provide equitable and sustainable access to high-quality, contextually relevant simulation-based learning opportunities, firmly upholding the principles of equity, diversity and inclusion. This should be complemented with a renewed emphasis on research and scholarship in this field.

Call for action We urge policymakers and leaders to formally acknowledge and embrace the benefits of simulation in healthcare practice and education. This includes a commitment to sustained support and a mandate for the application of simulation within education, training, and clinical environments.

We advocate for healthcare systems and education institutions to commit themselves to the goal of high-quality healthcare and improved patient outcomes. This commitment should encompass the promotion and resource support of simulation-based learning opportunities for individuals and interprofessional teams throughout all stages and levels of a caregiver’s career, in alignment with best practice standards.

We call upon simulation practitioners to champion healthcare simulation as an indispensable learning tool, adhere to best practice standards, maintain a commitment to lifelong learning, and persist in their fervent advocacy for patient safety.

This statement, the result of an international collaborative effort, aims to establish a consensus on the key priorities for the broad adoption of exemplary simulation practice that benefits patients and healthcare workforces globally.

Introduction

Healthcare simulation is “a technique that creates a situation or environment to allow persons to experience a representation of a real event for the purpose of practice, learning, evaluation, testing, or to gain understanding of systems or human actions” [ 1 ]. Beyond education and training, it plays a pivotal role in optimizing healthcare systems, thereby enhancing healthcare delivery, promoting staff well-being and improving patient safety and outcomes [ 2 , 3 ].

The dynamics of knowledge sharing and interaction within healthcare communities have evolved significantly in recent years, driven by exponential access to virtual platforms [ 4 ]. This transformation has heightened awareness of the diverse landscape of simulation practices in healthcare worldwide. This underscores the need for a unified global position on needs, solutions and priorities. A consensus-driven process enabled thoughtful consideration of key variations in conditions and practices, ultimately fostering global alignment on future directions [ 5 ].

This collaboration, facilitated by the Society for Simulation in Europe (SESAM) and the Society for Simulation in Healthcare (SSH), aims to articulate a global perspective on the current scope of simulation-based practice and gain consensus on future guidance. It emphasizes the crucial role of simulation in enhancing healthcare practices and education, as well as its far-reaching impact. The resulting recommendations aim to promote widespread adoption of simulation practices, benefiting patients and healthcare workforces globally. Policymakers, healthcare organization leaders, health education institutions, and simulation practitioners are the intended recipients of this valuable insight.

A global perspective has been rigorously crafted through extensive and iterative consultation. Representatives from 50 national and international simulation societies and networks distributed across 67 countries were actively engaged in this collaborative effort.

The chosen themes for discussion encompassed key healthcare challenges, the current landscape of simulation use, and ethical considerations within simulation practice. Prior to virtual encounters, relevant questions were emailed, and initial input was thoughtfully provided during structured online meetings during November 2023. All individual contributions were inclusively aggregated through an implicit approach, and emerging themes were summarized into narrative statements and tables.

Consensus on the identified themes was attained during face-to-face meetings held in January 2024. Subsequently, key areas were prioritized through an online survey. The initial draft of this document was produced in February 2024, and then shared with all contributors for peer review. Out of 24 responses, every comment received was thoroughly considered and significantly contributed to the final production of this document.

Current state of simulation practice in healthcare

Healthcare simulation finds application across the spectrum of health and care, involving all clinical disciplines and allied professions including dental, mental health and social care. Within this context, simulation practice serves educational and non-pedagogical uses. It encompasses activities such as device, process, system testing, system integration, quality improvement, research and innovative approaches [ 2 , 3 ]. Contributions obtained during consultation have highlighted that simulation serves as an adjunct to therapeutic interventions. It is employed in diverse situations, including complex case-by-case surgical planning, aiding pain management during labor, supporting cognitive behavioral therapy in mental health settings and facilitating the training of social skills for autistic patients.

Furthermore, there has been an exponential integration of simulation approaches into quality improvement and patient safety efforts within healthcare teams, departments, and organizations.

Notably, simulation transcends the confines of healthcare systems. It emerges as an excellent public engagement tool and plays a crucial role in multi-agency team preparedness for disaster management.

The value of healthcare simulation is vast and encompasses a wide array of tools and practices. These include, but are not limited to part task trainers, patient simulators (i.e. manikins), cadaveric simulation, and standardized patients or simulated participants portraying patients, relatives, by-standers, and healthcare colleagues. It also includes telesimulation, computer-based simulation, tabletop exercises, data modeling and extended realities including augmented reality, virtual reality, mixed reality, and haptic feedback models. As a community of practice, we provide unique opportunities to learn, rehearse and enhance the wide array of capabilities required to care for all patients, from carrying out simple procedures to managing rare and life threatening situations. We nurture the development of patient-centered communication skills, situational awareness, decision making, team working, leadership and other essential professional behaviors. We continue to innovate and adapt, developing new initiatives according to emerging needs, such as the delivery of packaged simulation materials to students in order to facilitate remote learning during the COVID-19 pandemic. Likewise, this creativity is crucial when supporting healthcare learning in low resource and rural settings, with an increasing use of telesimulation and “pack-and-go” equipment.

Contributions received during the consultation process highlighted the universal challenge of disparities in access to simulation education and resources across geographical areas and socio-economic contexts as well as between different institutions and specialties. Different professions continue to learn within isolated silos, with insufficient opportunities for interprofessional education, particularly in clinical environments. These inequities result in uneven development of competencies, and are encountered at both undergraduate and postgraduate levels, revealing a clear imperative to integrate simulation into healthcare curricula and into everyday learning opportunities within healthcare organizations.

Additional challenges reported include insufficient standardization of simulation training programmes and inadequate quality assurance of practices, particularly related to assessment and faculty development. A novel challenge arises from the impact of the COVID-19 pandemic on student development. Not only have students experienced reduced exposure to clinical environments, but also to in-person simulation. Consequently, they might initially perceive immersive settings as intimidating.

However, simulation offers global opportunities to support healthcare capabilities. For instance, it aids in preparing health professionals as they enter the workforce. Additionally, simulation helps mitigate skill degradation, especially in the context of high-risk low-frequency situations such as cardiopulmonary resuscitation performance by healthcare personnel or bystanders.

Overcoming healthcare challenges

The consultation process has identified healthcare challenges with a global reach (Table  1 ). These challenges encompass significant inequalities in access to healthcare and safety culture, extending to education and training for healthcare professions at undergraduate and postgraduate levels. Financial constraints contribute to disparities in healthcare and education, with lower income countries experiencing the most pronounced effects. The consequences of inadequate funding and resource allocation reverberate throughout healthcare systems and culture, limiting the onboarding, upskilling, and continuing education of healthcare staff and teams. Ultimately, these challenges have a negative impact on the workforce, patients, and societies at large.

The role of simulated practice in overcoming these challenges is paramount. For example, simulation has demonstrated a positive impact in reducing education inequities, leading to reductions in mortality and morbidity in low-resource areas [ 6 , 7 ]. In addition, it supports improvements in patient experiences [ 8 ]. Simulation interventions contribute to the optimization of healthcare processes and systems, and to organizational safety culture [ 9 , 10 , 11 ]. They have proven to be cost-effective and successful in enhancing team performance [ 12 ], while also fostering workforce well-being and resilience [ 13 , 14 ]. It is indisputable that simulation improves healthcare practices, such as central venous catheter placements, leading to a decrease in related infections, and improving patient outcomes [ 15 , 16 ].

Simulation can help adapt to the changing demands on healthcare systems, for instance preparing clinicians to manage complexity [ 17 ], and supports the development of skills for health and social care professionals in caring for an aging population [ 18 ]. Additionally, it improves team performance in managing trauma victims and mass casualty disasters [ 19 , 20 ].

Other evolving challenges include the ongoing transformation of healthcare practice and education from technological developments. While there is little regulation regarding their introduction, staff digital skills often lag behind, impacting the adoption curve for technological changes in healthcare settings. Regardless, the increasing volume of health data necessitates innovative methods for management and interpretation, including the use of modeling, analysis and simulation [ 20 ].

Ethical considerations

Ethical considerations focus on issues that may be interpreted as “morally right or wrong, just or unjust” [ 21 ]. These considerations help to ensure that all individuals involved in healthcare simulation are treated and treat others with integrity, respect, empathy, and compassion.

The consultation process revealed a wide array of ethical considerations of importance to the global healthcare community (Table  2 ). A foundational requirement is to promote equitable access to high-quality healthcare, including dental, mental health, and social care. Simulation complements the development and refinement of caregiving skills, which are essential for all practitioners to deliver the excellent healthcare that every patient deserves. Therefore, global availability of healthcare simulation is an ethical imperative. Concurrently, opportunities for simulation faculty development must be identified globally, with consideration of their affordability in low-resource settings.

As with all relevant tools, medicines, and interventions, healthcare simulation must be employed ethically. This includes a commitment to and adherence with common guidelines, such as the standards produced by the International Nursing Association of Clinical Simulation and Learning (INACSL), the Association for Simulated Practice in Healthcare (ASPiH) and the Association of Standardized Patient Educators (ASPE), as well as the Healthcare Simulationist Code of Ethics [ 22 , 23 , 24 , 25 ].

Encouraging and fostering a shared safety culture mindset is critical. This ensures the psychological and physical safety of all participants, protects personal and patient information, and removes “blame and shame” feedback from learning and operational culture [ 23 ]. Furthermore, learners should be supported in the process of experiential learning with integrity and transparency, and in accordance with best practices [ 25 ].

Diversity, equity, inclusion, and accessibility principles are essential in simulation and healthcare practice [ 26 ]. By intentionally integrating these principles, we create a more culturally competent and responsive environment. Teams, institutions, and broader healthcare contexts must actively manage complex cultural relationships. Additionally, fostering equitable collaborative partnerships across all levels of care and education is crucial.

While incorporating advancing technologies into healthcare simulation is valuable, it is equally important to proceed judiciously. We should minimize potential unforeseen negative learning outcomes by carefully evaluating and implementing these innovations.

As fellow stewards of the planet, we bear a collective responsibility. Encouraging a shared mindset of sustainability and conservation is imperative [ 27 ].

Recommendations

The global consultation process has yielded several key themes for recommendations (Table  3 ). The subsequent recommendations aim to provide alignment and direction to simulation professionals, healthcare systems, healthcare education institutions, and global leaders.

First and foremost, it is necessary to advocate for the benefits that simulation brings to patients, staff and organizations. Promoting its adoption and integration into daily learning and practice across the entire spectrum of healthcare is essential. Beyond enhancing care providers’ and teams’ performances, simulation can also empower patients by providing new perspectives and fostering necessary responsibilities and beneficial behaviors, ultimately leading to improved patient outcomes.

Political, strategic and financial support at an institutional and governmental level is vital. Ensuring the sustainability of simulation facilities, programmes, and workforce requires concerted efforts and commitment.

Exploring low-cost high-impact simulation methods can expand its use throughout the training continuum. Particularly in interprofessional learning contexts, such approaches can be transformative. Simultaneously, integrating simulation into system improvement processes as well as undergraduate and postgraduate curricula, should follow a collaborative, prudent approach based on best practices.

There is a global agreement that simulation must be used appropriately. To enhance its effectiveness, we propose several key strategies:

Development and use of evidence-based tools to ensure the quality of healthcare practice. These tools should be aligned with recognized standards of best practice and evolve alongside simulation methodologies.

Invest in faculty development to enhance their expertise in simulation practice.

Rigorously evaluate all simulation activities to maintain quality standards.

Establish quality-assured approaches for accrediting, credentialing, and certifying (and recertifying) simulation programs and practitioners

Provide equitable access to high-quality, contextually relevant simulation-based learning opportunities. To achieve this, it is critical to cultivate the support necessary to ensure consistent resourcing for healthcare simulation.

Leverage telesimulation and virtual approaches to facilitate accessibility across the spectrum of professions and practice, including rural, remote and low-income areas.

Uphold the principles of equity, diversity and inclusion both within and via simulation.

Be mindful of the environmental impact of simulation activities.

Encourage a renewed emphasis on research and scholarship in order to progress as a community of practice. Focus on simulation-specific initiatives and explore novel ways to integrate simulation into broader healthcare research and innovation.

Call for action

Healthcare simulation serves a greater purpose beyond its own existence. Its mission is to elevate the performance of healthcare providers, teams and systems, ultimately leading to improved health outcomes for patients, communities, and societies. To achieve this transformative impact, it will require a concerted effort by leaders and policymakers, healthcare systems, healthcare education institutions, and simulation practitioners to promote and enhance this critical capability as a means of improving patient outcomes across the globe.

To this end, we propose several key actions:

We propose that policymakers and leaders formally acknowledge and embrace the benefits of simulation in healthcare practice and education, which ultimately enhance patient outcomes by:

Committing sustained resources to simulation.

Mandating the use of simulation within education, training, and clinical environments.

Being explicit in how simulated experiences may augment or replace clinical experiences for learners in residency and pre-licensure status.

We recommend that healthcare systems and healthcare education institutions commit to the goal of high-quality healthcare and improved patient outcomes by:

Promoting healthcare simulation as a critical and necessary learning tool throughout all phases and levels of a caregiver’s career.

Providing the necessary resourcing for healthcare simulation, including staff, equipment, space, and curricular context.

Using healthcare simulation to create interprofessional education and training opportunities.

Fostering and adhering to healthcare simulation best practice standards.

Cultivating simulation-capable faculty and mentors.

We call on simulation practitioners to:

Promote healthcare simulation as a critical learning tool.

Adhere to best practice standards.

Perform to the highest levels of personal integrity and ethical behavior.

Commit to lifelong learning.

Persist in their fervent advocacy for patient safety.

We hope that this global statement contributes to increasing the visibility of simulation in healthcare, and guides the coordination of simulation and healthcare strategies and policies worldwide.

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Perioperative Care, Cardiff and Vale University Health Board, Wales, UK

Cristina Diaz-Navarro

School of Health Professions, Eastern Virginia Medical School, Norfolk, VA, USA

Robert Armstrong

Simulation-Based Education and Research, Dartmouth Health, Lebanon, NH, USA

Matthew Charnetski

Geisel School of Medicine, Dartmouth College, Hanover, NH, USA

School of Health Professions Education, Maastricht University, Maastricht, Netherlands

The Rural Clinical School of Western Australia, The University of Western Australia, Perth, Australia

Kirsty J. Freeman

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Nursing Education and Development, Sengkang General Hospital, Singapore, Singapore

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Gabriel Reedy

School of Nursing, Hawai’i Pacific University, Honolulu, Hawaii, USA

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Hospitais da Universidade de Coimbra, Coimbra, Portugal

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Contributions

We wish to acknowledge all societies and networks that have contributed to this document and the individuals who have represented their perspectives: African Simulation Network, Jo Park-Ross; Asociación de Simulo-Educadores de Puerto Rico (ASEPUR), Widalys González-Ortiz; Association for Simulated Practice in Healthcare (ASPiH), Colette Laws-Chapman; Association of Standardized Patient Educators (ASPE), Lou Clark and Shawn Galin; Australian Society for Simulation in Healthcare (ASSH), Kellie Britt and Belinda Judd; Brazilian Society of Simulation in Healthcare, Carolina Felipe Soares Brandão, Jose Roberto Generoso Junior and Itamar Magalhaes; Canadian Alliance of Nurse Educators using Simulation, Jane Tyerman; Canadian Simulation Network, Timothy Willett; China Medical Education Association, Li Li; Comité Internacional de Colaboración Científica entre asociaciones de Simulación (CICCAS), Andres Diaz-Guio; Deutsche Gesellschaft zur Förderung der Simulation in der Medizin, Marcus Rall and Stephan Prückner; Dutch Society for Simulation in Healthcare (DSSH), Ulrich Strauch; European Society for Artificial Organs (ESAO), Frank R. Halfwerk; European Society of Anaesthesiology and Intensive Care (ESAIC), Crina Burlacu; Extracorporeal Life Support Organization (EuroELSO), Frank R. Halfwerk; Federación Latinoamericana de Simulación Clínica y Seguridad del Paciente, Andres Diaz-Guio; Finnish Simulation Network (FinnSim), KirsiMarja Metsavainio; Global Network for Simulation in Healthcare,Lennox Huang and Pam Jeffries; Healthcare Simulation Users Network in Turkey, G. Ulufer Sivrikaya; Hong Kong Society for Simulation in Healthcare, Albert Chan; International Network for Simulation-based Pediatric Innovation, Research and Education (INSPIRE), Tensing Maa and Kimberly Stone; International Nursing Association for Clinical Simulation and Learning (INACSL), Desiree Diaz, Laura Gonzalez, and Ashley Franklin; International Pediatric Simulation Society (IPSS), Justin Jeffers and Kimberly Stone; Irish Association for Simulation, Crina Burlacu and Paul O’Connor; Japan Association for Simulation-based Education in Healthcare Professionals, Ichiro Kaneko; Malaysian Society for Simulation in Healthcare (MaSSH), Zaleha Mahdy, Ismail Mohd Saiboon and Thiruselvi Subramaniam; New Zealand Association for Simulation in Healthcare (NZASH), Brad Peckler: Pakistan Simulation Network, Faisal Ismail; Pan Asia Society for Simulation in Healthcare (PASSH), Ashokka Balakrishnan and Sayaka Oikawa; Pediatric Simulation Training and Research Society (PediSTARS), Geethanjali Ramachandra: Polish Society of Medical Simulation, Marek Dabrowski, Gregorz and Aleksandra Steliga; Portuguese Society for Simulation Applied to Health Sciences (SPSim), Gustavo Norte; RegSim Vest, Sigrun Qvindesland; Saudi Society of Simulation in Healthcare (SSSH), Abdulaziz M. A. Boker; Sociedad Argentina de Simulación (SASIM), Carla Prudencio; Sociedad Chilena de Simulación Clínica (SOCHISIM), Soledad Armijo-Rivera and Mario Zuniga; Sociedad Dominicana Simulación Clínica (SODOSICLI), Pablo C. Smester; Sociedad Ecuatoriana de Simulación en Ciencias de la Salud para Seguridad del Paciente, Betty Bravo; Sociedad Española de Simulación Clínica y Seguridad del Paciente (SESSEP), Aida Camps-Gómez; Sociedad Mexicana de Simulación en Ciencias de la Salud, Edgar Israel Herrera Bastida; Società Italiana di SIMulazione in MEDicina (SIMMED), Pier Luigi Ingrassia; Société Francophone de Simulation en Santé (SoFraSimS), Dan Benhamou and Fouad Marhar; Society for Simulation Applied to Medicine of Moldova, Andrei Romancenco; Society for Simulation in Europe (SESAM), Francisco Maio Matos, Pier Luigi Ingrassia and Doris Ostergaard; Society for Simulation in Healthcare (SSH), Barry Issenberg and Jayne Smitten; Swedish Association for Clinical Training and Medical Simulation (KlinSim), Magnus Berndtzon; The Gathering of Healthcare Simulation Technology Specialists (SimGHOSTS), Yixing Chen and Erica Hinojosa; Ukrainian Simulation Network, Halyna Tsymbaliuk; Victorian Simulation Alliance, Debra Nestel; Vital Anaesthesia Simulation Training (VAST), Adam Mossenson.

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Competing interests.

CDN is the Chair of the Board of Trustees at the TALK Foundation, Chair of the Scientific Committee for SESAM – the Society for Simulation in Europe, and a member of the executive committee at the Association for Simulated Practice in Healthcare (ASPiH).

RA is a Past President of the Society for Simulation in Healthcare, and Chair of the Global Advocacy Task Force, Society for Simulation in Healthcare. RA has an equity stake serves in an unsalaried role as the Director of Simulation and Technology in eTrainetc, LLC, a healthcare simulation company.

MC is Secretary of the Board of Directors of the Society for Simulation in Healthcare. He is Past Secretary and Member of the Board of Directors for SimGHOSTS. MC provides consulting services as a contractor to CAE Healthcare for simulator and center design.

KJF is Secretary of SESAM – the Society for Simulation in Europe, and is an Associate Editor of the International Journal of Healthcare Simulation.

SBLK is Vice Treasurer, Pan Asia Simulation Society in Healthcare.

GR is Editor-in-Chief of Advances in Simulation.

JS is Immediate Past President of the Society for Simulation in Healthcare, and an Editorial Board Member of Quality Advancement in Nursing Education (QANE)—Avancées en formation infirmières.

PLI is President-Elect of SESAM—the Society for Simulation in Europe, Immediate Past-President of Società Italiana di SIMulazione in MEDicina (SIMMED), and co-founder and editorial director of SIMZINE.

FMM is President of SESAM – the Society for Simulation in Europe, and Chair of the European Society of Anaesthesiology and Intensive Care (ESAIC) Connectivity Taskforce.

BI is Professor of Medicine and Director of the University of Miami Michael S Gordon Center for Simulation and Innovation in Medical Education. The University of Miami has agreements with Laerdal Medical and the American Heart Association to develop and disseminate simulation-based training programs. Any associated revenue is directed back to the University of Miami. No personal income or royalty is realized by the individual. BI is the current President of the Society for Simulation in Healthcare.

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Diaz-Navarro, C., Armstrong, R., Charnetski, M. et al. Global consensus statement on simulation-based practice in healthcare. Adv Simul 9 , 19 (2024). https://doi.org/10.1186/s41077-024-00288-1

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