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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 The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality.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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Implementation and effectiveness of a video‐based debriefing programme for neonatal resuscitation
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Piot, M., Dechartres, A., Attoe, C., Romeo, M., Jollant, F., Billon, G., Cross, S., Lemogne, C., Burn, C. L., Michelet, D., et al. (2021) · Journal of Advanced Nursing · doi:10.1111/jan.14986 · Cited by 83
Imperfect practice makes perfect: error management training improves transfer of learning
Dyre, L., Tabor, A., Ringsted, C. V., & Tolsgaard, M. G. (2016) · Medical Education · doi:10.1111/medu.13208 · Cited by 83
Got power? A systematic review of sample size adequacy in health professions education research
Cook, D. A., & Hatala, R. A. (2014) · Advances in Health Sciences Education · doi:10.1007/s10459-014-9509-5 · Cited by 82
“However, prior reviews have suggested that in many education research studies the sample size is small (Issenberg et al. 2005; Lineberry et al. 2013), and that authors rarely consider the anticipated effect size (Cook 2012), plan the sample size in advance (Michalczyk and”
BackgroundDelisle, M. E., Ward, M. A. R., Pradarelli, J. C., Panda, N., Howard, J. D., & Hannenberg, A. A. (2019) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0000000000000377 · Cited by 82
Development of Expertise in Surgical Training
Schaverien, M. V. (2010) · Journal of surgical education · doi:10.1016/j.jsurg.2009.11.002 · Cited by 90
Repetitive Pediatric Simulation Resuscitation Training
Auerbach, M. A., Kessler, D. O., & Foltin, J. C. (2010) · Pediatric Emergency Care · doi:10.1097/pec.0b013e3182043f3b · Cited by 82
“High-fidelity simulation allows educators to control the quality and quantity of pediatric resuscitation experiences.(4) After participating in simulation, most trainees and educators rate their experiences as excellent and feel that simulation should be required in training.”
BackgroundPark, C. S., Rochlen, L. R., Yaghmour, E. A., Higgins, N., Bauchat, J. R., Wojciechowski, K. G., Sullivan, J. T., & McCarthy, R. J. (2009) · Anesthesiology · doi:10.1097/aln.0b013e3181c62d43 · Cited by 82
Nurse Faculty Perceptions of Simulation Use in Nursing Education
Akhtar‐Danesh, N., Baxter, P. E., Valaitis, R. K., Stanyon, W., & Sproul, S. (2008) · Western Journal of Nursing Research · doi:10.1177/0193945908328264 · Cited by 82
“High-fidelity simulators provide an opportunity to enable students to engage in clinical activities without fear of harming a patient or themselves (Curl et al., 2007; Issenberg et al., 2005).”
BackgroundAbe, Y., Kawahara, C., Yamashina, A., & Tsuboi, R. (2013) · American Journal of Critical Care · doi:10.4037/ajcc2013229 · Cited by 82
“Specifically, we had the following 2 objectives: (1) to examine whether the novel procedure of simulation, by which use of a rubric is combined with repeated scenario simulations, is effective in improving the competency of individual participants (technical skill evaluation) and (2) to examine the effect of using sim…”
BackgroundResultInfluentialAn Overview of Virtual and Augmented Reality in Dental Education
Dut, M., Amariei, C., Bogdan, C. M., Popovici, D.-M., Ionescu, N., & Nucă, C. (2011) · Oral Health and Dental Management · Cited by 82
Using Testing as a Learning Tool
Yang, B. W., Razo, J. F., & Persky, A. M. (2019) · American Journal of Pharmaceutical Education · doi:10.5688/ajpe7324 · Cited by 98
Johnson, K. R., Ennis-Cole, D. L., & Bonhamgregory, M. (2020) · Human Resource Development Review · doi:10.1177/1534484320905910 · Cited by 81
“Virtual reality training can be more advantageous than traditional types of training, in that, there is opportunity for (a) repetitive practice with the simulation, (b) active participation, (c) accurate representation of real-life simulation, (d) opportunities for trainees to make and correct mistakes, (e) consistent…”
BackgroundPrion, S. K. (2008) · Clinical Simulation in Nursing · doi:10.1016/j.ecns.2008.08.002 · Cited by 88
DELIBERATE PRACTICEofMOTOR SKILLSinNursing Education: CPR AS EXEMPLAR
Oermann, M. H., Kardong‐Edgren, S., Odom‐Maryon, T., Hallmark, B. F., Hurd, D., Rogers, N., Haus, C., McColgan, J. K., SNELSON, C., Dowdy, S. W., et al. (2011) · Nursing Education Perspectives · doi:10.5480/1536-5026-32.5.311 · Cited by 81
“…practice that includes: focused and repetitive practice of carefully defined skills; assessment of performance with specific, corrective feedback (which is not graded); and opportunities for continued practice to retain skills (Ericsson, 2004; Issenberg et al., 2005; McGaghie et al., 2010).”
BackgroundCannon, W. D., Nicandri, G. T., Reinig, K. D., Mevis, H., & Wittstein, J. R. (2014) · Journal of Bone and Joint Surgery · doi:10.2106/jbjs.m.00779 · Cited by 81
A Review of Virtual Reality as a Medium for Safety Related Training in Mining
Tichon, J., & Burgess-Limerick, R. J. (2011) · QUT ePrints (Queensland University of Technology) · Cited by 81
Dilaveri, C., Szostek, J., Wang, A., & Cook, D. (2013) · BJOG An International Journal of Obstetrics & Gynaecology · doi:10.1111/1471-0528.12289 · Cited by 80
Twelve tips for the pre-brief to promote psychological safety in simulation-based education
Somerville, S. G., Harrison, N. M., & Lewis, S. (2023) · Medical Teacher · doi:10.1080/0142159x.2023.2214305 · Cited by 95
“Write clear intended learning outcomes with an appropriate level of challenge Purposeful crafting of ILOs is one of the pedagogical foundations of establishing a simulation activity (Issenberg et al. 2005).”
BackgroundShoemaker, M. J., Riemersma, L., & Perkins, R. (2009) · Cardiopulmonary Physical Therapy Journal · doi:10.1097/01823246-200920010-00003 · Cited by 80
Simulation-based surgical education
Evgeniou, E., & Loizou, P. (2012) · ANZ Journal of Surgery · doi:10.1111/j.1445-2197.2012.06315.x · Cited by 87
Best evidence on high‐fidelity simulation: what clinical teachers need to know
Issenberg, S. B., & Scalese, R. J. (2007) · The Clinical Teacher · doi:10.1111/j.1743-498x.2007.00161.x · Cited by 80
“In 2005, we published a paper detailing the processes involved in a systematic literature review: the identification of articles, extraction of data, and analysis and synthesis of findings.(2) We searched five literature databases (ERIC, MEDLINE, PsycINFO, Web of Science, and TimeLIT) using 91 single search terms and…”
BackgroundMethodSelf-citationLehmann, R., Thiessen, C., Frick, B., Bosse, H. M., Nikendei, C., Hoffmann, G. F., Tönshoff, B., & Huwendiek, S. (2015) · Journal of Medical Internet Research · doi:10.2196/jmir.4141 · Cited by 82
“It is well known that educational feedback, such as that given in the VPs, is the most important feature of simulation-based education [33].”
Review article: Simulation in anesthesia: state of the science and looking forward
LeBlanc, V. R. (2011) · Canadian Journal of Anesthesia/Journal canadien d anesthésie · doi:10.1007/s12630-011-9638-8 · Cited by 79
“simulation-based training.(64,65) However, the format used for the instruction or debriefing following the simulation scenario does not appear to have a significant effect on learning.”
BackgroundCurran, V. R., Fleet, L. J., White, S. W., Bessell, C., Deshpandey, A., Drover, A., Hayward, M., & Valcour, J. E. (2014) · Advances in Health Sciences Education · doi:10.1007/s10459-014-9522-8 · Cited by 85
“The advantages of simulation-based learning include increased frequency of clinical experiences without training on real patients, meaningful feedback, repetitive practice and the ability to vary the presentation of clinical symptomatology to meet learners’ needs (Issenberg et al. 2005; Murphy and Halamek 2005).”
BackgroundBarnato, A. E., Hsu, H., Bryce, C. L., Lave, J. R., Emlet, L. L., Angus, D. C., & Arnold, R. M. (2008) · Critical Care Medicine · doi:10.1097/ccm.0b013e31818f40d2 · Cited by 79
“00 Male 6/18 (33) 12/18 (67) 5/18 (28) Female 2/9 (22) 4/9 (44%) 2/9 (22) Role, n/n (%) 0.”
Jung, B. F., & Reidenberg, M. M. (2007) · Pain Medicine · doi:10.1111/j.1526-4637.2007.00315.x · Cited by 79
Levin, O., & Flavian, H. (2020) · European Journal of Teacher Education · doi:10.1080/02619768.2020.1827391 · Cited by 92
Trends in Study Methods Used in Undergraduate Medical Education Research, 1969-2007
Baernstein, A., Liss, H. K., Carney, P. A., & Elmore, J. G. (2007) · JAMA · doi:10.1001/jama.298.9.1038 · Cited by 78
“Eighteen publications suitable for inclusion were published in nonEnglish languages, including German (9), Spanish (5), Arabic (1), Japanese (1), Portuguese (1), and Swedish (1).”
BackgroundMethodInfluentialIncorporating simulation in vascular surgery education
Bismuth, J. X., Donovan, M. A., O’Malley, M. K., Sayed, H. F. E., Naoum, J. J., Peden, E. K., Davies, M. G., & Lumsden, A. B. (2010) · Journal of Vascular Surgery · doi:10.1016/j.jvs.2010.05.093 · Cited by 78
“It has done an excellent job of using simu- Table III.”
BackgroundHuman factors in resuscitation: Lessons learned from simulator studies
Hunziker, S., Tschan, F., Semmer, N. K., Howell, M., & Marsch, S. C. U. (2010) · Journal of Emergencies Trauma and Shock · doi:10.4103/0974-2700.70764 · Cited by 78
“[50] Thus, studies based on simulated scenarios may be limited in generalizability.”
Nursing Student Perceptions of Intraprofessional Team Education Using High-Fidelity Simulation
Leonard, B., Shuhaibar, E. L. H., & Chen, R. (2010) · Journal of Nursing Education · doi:10.3928/01484834-20100730-06 · Cited by 78
Unannounced in situ simulations: integrating training and clinical practice
Walker, S. T., Sevdalis, N., McKay, A., Lambden, S., Gautama, S., Aggarwal, R. K., & Vincent, C. A. (2012) · BMJ Quality & Safety · doi:10.1136/bmjqs-2012-000986 · Cited by 78
Castanelli, D. J. (2009) · Anaesthesia and Intensive Care · doi:10.1177/0310057x0903700605 · Cited by 78
Cleland, J., Walker, K. G., Gale, M., & Nicol, L. G. (2016) · Medical Education · doi:10.1111/medu.13064 · Cited by 74
Marcus, H. J., Vakharia, V. N., Kirkman, M. A., Murphy, M., & Nandi, D. (2012) · Neurosurgery · doi:10.1227/neu.0b013e318270d010 · Cited by 77
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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