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Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review
Abstract
REVIEW DATE: 1969 to 2003, 34 years. BACKGROUND AND CONTEXT: Simulations are now in widespread use in medical education and medical personnel evaluation. Outcomes research on the use and effectiveness of simulation technology in medical education is scattered, inconsistent and varies widely in methodological rigor and substantive focus. OBJECTIVES: Review and synthesize existing evidence in educational science that addresses the question, 'What are the features and uses of high-fidelity medical simulations that lead to most effective learning?'. SEARCH STRATEGY: The search covered five literature databases (ERIC, MEDLINE, PsycINFO, Web of Science and Timelit) and employed 91 single search terms and concepts and their Boolean combinations. Hand searching, Internet searches and attention to the 'grey literature' were also used. The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality. INCLUSION AND EXCLUSION CRITERIA: Four screening criteria were used to reduce the initial pool of 670 journal articles to a focused set of 109 studies: (a) elimination of review articles in favor of empirical studies; (b) use of a simulator as an educational assessment or intervention with learner outcomes measured quantitatively; (c) comparative research, either experimental or quasi-experimental; and (d) research that involves simulation as an educational intervention. DATA EXTRACTION: Data were extracted systematically from the 109 eligible journal articles by independent coders. Each coder used a standardized data extraction protocol. DATA SYNTHESIS: Qualitative data synthesis and tabular presentation of research methods and outcomes were used. Heterogeneity of research designs, educational interventions, outcome measures and timeframe precluded data synthesis using meta-analysis. HEADLINE RESULTS: Coding accuracy for features of the journal articles is high. The extant quality of the published research is generally weak. The weight of the best available evidence suggests that high-fidelity medical simulations facilitate learning under the right conditions. These include the following: providing feedback--51 (47%) journal articles reported that educational feedback is the most important feature of simulation-based medical education; repetitive practice--43 (39%) journal articles identified repetitive practice as a key feature involving the use of high-fidelity simulations in medical education; curriculum integration--27 (25%) journal articles cited integration of simulation-based exercises into the standard medical school or postgraduate educational curriculum as an essential feature of their effective use; range of difficulty level--15 (14%) journal articles address the importance of the range of task difficulty level as an important variable in simulation-based medical education; multiple learning strategies--11 (10%) journal articles identified the adaptability of high-fidelity simulations to multiple learning strategies as an important factor in their educational effectiveness; capture clinical variation--11 (10%) journal articles cited simulators that capture a wide variety of clinical conditions as more useful than those with a narrow range; controlled environment--10 (9%) journal articles emphasized the importance of using high-fidelity simulations in a controlled environment where learners can make, detect and correct errors without adverse consequences; individualized learning--10 (9%) journal articles highlighted the importance of having reproducible, standardized educational experiences where learners are active participants, not passive bystanders; defined outcomes--seven (6%) journal articles cited the importance of having clearly stated goals with tangible outcome measures that will more likely lead to learners mastering skills; simulator validity--four (3%) journal articles provided evidence for the direct correlation of simulation validity with effective learning. CONCLUSIONS: While research in this field needs improvement in terms of rigor and quality, high-fidelity medical simulations are educationally effective and simulation-based education complements medical education in patient care settings.
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“While technological advancements offer promising solutions through digital platforms, high-fidelity simulations, and streamlined feedback mechanisms, significant challenges remain in ensuring alignment with varying curricula, gathering longitudinal evidence of student growth, and developing flexible implementation models that can accommodate diverse learning objectives and timelines [12,13].”
From Formative assessment and feedback in medical education: A practical guide: AMEE Guide No. 189 (2026) · cites this paper as [13]
In the citing paper
“However, it has been accepted that simulation facilitates learning when it is used in the appropriate conditions that include providing feedback, repetition, curriculum integration, individualized learning and controlled environment [28].”
From The virtual patient as a learning tool: a mixed quantitative qualitative study (2018) · cites this paper as [28]
In the citing paper
“This suggests that instructional strategies, whether technology-based or not, must include some solid principles from pedagogical theory that were incorporated to the VP course and some of what Issenberg et al. described as key for simulation-based learning [28].”
From The virtual patient as a learning tool: a mixed quantitative qualitative study (2018) · cites this paper as [28]
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Sugden, C., Aggarwal, R. K., Banerjee, A., Haycock, A., Thomas‐Gibson, S., Williams, C. B., & Darzi, A. W. (2012) · Annals of Surgery · doi:10.1097/sla.0b013e31825b6e9c · Cited by 29
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“Numerous studies regarding its efficacy have been conducted in the past decade, with well-described best practices of simulation-based medical education.(12) 24 Curriculum integration is one of the key factors in simulation-based medical education research.”
BackgroundMethodPukenas, E., Dodson, G. M., Deal, E. R., Gratz, I., Allen, E., & Burden, A. R. (2014) · Journal of Clinical Anesthesia · doi:10.1016/j.jclinane.2014.03.015 · Cited by 32
Saus, E.-R., Johnsen, B. H., & Eid, J. (2010) · PubMed · Cited by 29
Novel, Multimodal Approach for Basic Transesophageal Echocardiographic Teaching
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Harrison, C. M., & Gosai, J. N. (2016) · Trends in Cardiovascular Medicine · doi:10.1016/j.tcm.2016.08.009 · Cited by 29
“Technological innovation and educational development has allowed SBT applications to become more diverse and sophisticated(5).”
BackgroundAn Interprofessional Simulation-Based Learning Activity for Nursing and Physiotherapy Students
Dennis, D. M., Furness, A., Duggan, R., & Critchett, S. (2017) · Clinical Simulation in Nursing · doi:10.1016/j.ecns.2017.06.002 · Cited by 29
Wilson, E., Hewett, D. G., Jolly, B. C., Janssens, S., & Beckmann, M. M. (2018) · Advances in Simulation · doi:10.1186/s41077-018-0080-7 · Cited by 29
Lövquist, E., Shorten, G., & Aboulafia, A. (2012) · Medical Teacher · doi:10.3109/0142159x.2011.600359 · Cited by 29
“…scientists, engineers) are concerned with the building of VR-based simulations (Grottke et al. 2009), clinicians evaluate the existing systems (Seymour et al. 2002; Larsen et al. 2009) and educators/ educationalists discuss the training principles (Issenberg et al. 2005; Salas et al. 2009).”
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Simulation-Based Training for Colonoscopy
Preisler, L., Svendsen, M. B. S., Nerup, N. A., Svendsen, L. B., & Konge, L. (2015) · Medicine · doi:10.1097/md.0000000000000440 · Cited by 29
“In a review of 109 studies, Issenberg et al 27 concluded that high-fidelity medical simulations are education-ally effective and simulation-based education models complement medical education in patient care settings.”
BackgroundSimulation-based Assessment to Reliably Identify Key Resident Performance Attributes
Blum, R. H., Muret-Wagstaff, S. L., Boulet, J. R., Cooper, J. B., & PETRUSA, E. R. (2018) · Anesthesiology · doi:10.1097/aln.0000000000002091 · Cited by 28
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Fugate, J. M. B., Tonsager, M. J., & Macrine, S. L. (2025) · Behavioral Sciences · doi:10.3390/bs15040468 · Cited by 36
“These benefits translate into improved patient outcomes and reduced healthcare costs (Le Cook et al., 2013; Issenberg et al., 2005), establishing it as a fundamental pillar of health-care clinical training (Saleem & Khan, 2023) that provides a safe and effective environment for learners to develop…”
A Suggested Core Content for Education Scholarship Fellowships in Emergency Medicine
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Vertebroplasty Performance on Simulator for 19 Surgeons Using Hierarchical Task Analysis
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“4 million Canadians [22] and 10 million Americans [23].”
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“Whether simulation training is undertaken as part of a group or as an individual, it is recommended that this should be adapted to the level of the trainee(s) (Issenberg et al., 2005; Ennen and Satin, 2010).”
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“Over the past years, evidence has been gathered which supports the effectiveness of skills lab teaching with respect to patient safety, the physician-patient relationship and performance in clinical exams [1-4].”
The Educational Practices Construct of the NLN/Jeffries Simulation Framework: State of the Science
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Simulation, Human Factors and Defence Anaesthesia
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Time matters – Realism in resuscitation training
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“A systematic review identified feedback and repeated practice as the two most important features of simulation-based medical education [4].”
BackgroundScientific strengths and reported effectiveness: a systematic review of multiliteracies studies
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Simulation-Based Education in Trauma Management: A Scoping Review
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Use of Simulators in Teaching and Learning: Paramedics’ Evaluation of a Patient Simulator?
Wyatt, A., Archer, F. L., & Fallows, B. (2007) · Australasian Journal of Paramedicine · doi:10.33151/ajp.5.2.412 · Cited by 28
Simulated learning environment (SLE) in audiology education: A systematic review
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“Feedback is one of the essential elements in learning and assists students in self-evaluating their understanding and practical skills (Issenberg et al, 2005; Strong et al, 2012).”
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Metadata
- Authors
- Barry Issenberg, S., Mcgaghie, W. C., Petrusa, E. R., Lee Gordon, D., & Scalese, R. J.
- Affiliations
- Northwestern University (US)
- Duke Medical Center (US)
- University of Miami (US)
- Venue
- Medical Teacher
- Publisher
- Informa UK Limited
- Published
- 2005-01
- Volume
- 27
- Issue
- 1
- Pages
- 10-28
- ISSN
- 0142-159X (ISSN-L)
- 1466-187X
- OpenAlex
- W2162661914
- Cited by
- 3,966
- References
- 203
- Citations by year
- 2026: 311 · 2025: 239 · 2024: 194 · 2023: 177 · 2022: 198 · 2021: 245 · 2020: 224 · 2019: 233 · 2018: 191 · 2017: 178 · 2016: 227 · 2015: 252 · 2014: 199 · 2013: 233 · 2012: 190
- FWCI
- 9.61
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Medical Teacher (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Education › Simulation-Based Education in Healthcare
- Health Sciences › Medicine › Surgery › Surgical Simulation and Training
- Social Sciences › Education › Innovations in Medical Education
- Keywords
- high-fidelity simulation, simulation-based medical education, medical education, instructional feedback, repeated practice, curriculum integration, task difficulty, student outcomes, research quality, graduate medical education, student motivation, learner confidence, student self-efficacy, student self-assessment, student self-regulation, learner autonomy
- MeSH terms
- Clinical Competence, Education, Medical, Humans, Research Design, Software, Patient Simulation, Total Quality Management, Medical Errors
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