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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 The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality.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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Benishek, L. E., Lazzara, E. H., Gaught, W. L., Arcaro, L. L., Okuda, Y., & Eduardo Salas, A. (2014) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0000000000000058 · Cited by 55
Ziesmann, M. T., Widder, S. L., Park, J., Kortbeek, J. B., Brindley, P. G., Hameed, M. S., Paton-Gay, J. D., Engels, P. T., Hicks, C. M., Fata, P., et al. (2013) · The Journal of Trauma: Injury, Infection, and Critical Care · doi:10.1097/ta.0b013e3182a925df · Cited by 55
Marker, S., Mohr, M., & Østergaard, D. (2019) · BMC Medical Education · doi:10.1186/s12909-018-1447-0 · Cited by 55
Jewer, J., Parsons, M. H., Dunne, C. L., Smith, A., & Dubrowski, A. (2019) · Journal of Medical Internet Research · doi:10.2196/14587 · Cited by 55
“Simulation-based medical education (SBME) has been shown to be an effective training approach because it can provide opportunities to practice infrequently encountered procedures [2-5] without compromising patient safety [6].”
Noyes, J. A., Carbonneau, K. J., & Matthew, S. M. (2021) · Journal of Veterinary Medical Education · doi:10.3138/jvme-2020-0026 · Cited by 54
Debriefing: The Essential Step in Simulation
Mayville, M. L. (2011) · Newborn and Infant Nursing Reviews · doi:10.1053/j.nainr.2010.12.012 · Cited by 54
“A recent and frequently cited systematic review of the literature on simulation in health education revealed 10 common elements that facilitate learning during simulation.(7) Although repetition and skills were declared valuable tools in simulation, nearly half (47%) of the studies reported that feedback was the most…”
BackgroundEich, C. B., Timmermann, A., Russo, S. G., Nickel, E. A., McFadzean, J., Rowney, D. A., & Schwarz, S. K. W. (2007) · British Journal of Anaesthesia · doi:10.1093/bja/aem051 · Cited by 54
Applying Educational Theory to Simulation-Based Training and Assessment in Surgery
Chauvin, S. W. (2015) · Surgical Clinics of North America · doi:10.1016/j.suc.2015.04.006 · Cited by 59
Amin, Z., Boulet, J. R., Cook, D. A., Ellaway, R., Fahal, A. H., Kneebone, R. L., Maley, M. A. L., Østergaard, D., Ponnamperuma, G. G., Wearn, A. M., et al. (2011) · Medical Teacher · doi:10.3109/0142159x.2011.565832 · Cited by 54
“Overall, advancements in simulator technology have opened the door for more authentic assessments that can be used to assess a much wider range of skills that, previously, were difficult to measure (Issenberg et al. 2005).”
BackgroundFletcher, D. J., Militello, R., Schoeffler, G. L., & Rogers, C. L. (2011) · Journal of Veterinary Medical Education · doi:10.3138/jvme.0711.073r · Cited by 54
Brewer, Z. E., Fann, H. C., Ogden, W. D., Burdon, T. A., & Sheikh, A. Y. (2016) · Journal of surgical education · doi:10.1016/j.jsurg.2016.02.005 · Cited by 54
Prelicensure Simulation-Enhanced Interprofessional Education
Palaganas, J. C., Brunette, V., & Winslow, B. W. (2016) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0000000000000175 · Cited by 54
Schoenherr, J. R., & Hamstra, S. J. (2017) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0000000000000226 · Cited by 55
A checklist for facilitating training transfer in organizations
Hughes, A. M., Zajac, S. A., Spencer, J. M., & Salas, E. (2018) · International Journal of Training and Development · doi:10.1111/ijtd.12141 · Cited by 61
Sullivan, A., Elshenawy, S., Ades, A. M., & Sawyer, T. (2019) · Cureus · doi:10.7759/cureus.5729 · Cited by 54
Bould, M. D., Naik, V. N., & Hamstra, S. J. (2011) · Canadian Journal of Anesthesia/Journal canadien d anesthésie · doi:10.1007/s12630-011-9633-0 · Cited by 49
“Issenberg’s group has performed a series of reviews on simulation-based education.(76,116) They identified feedback as the most important feature that promotes learning in simulation, but they noted a need for more research on how best to deliver feedback.”
BackgroundMultidisciplinary team simulation for the operating theatre: a review of the literature
Tan, S. B., Pena, G. N., Altree, M., & Maddern, G. J. (2013) · ANZ Journal of Surgery · doi:10.1111/ans.12478 · Cited by 53
“Research from different areas of health care has shown that feedback is the single most important feature of simulation-based medical education towards the goal of effective learning and that it is effective regardless of the format.(48) A comparative study in anaesthesia crisis management simulation demonstrated that…”
BackgroundStudents’ experiences of learning manual clinical skills through simulation
Johannesson, E., Silén, C., Kvist, J., & Hult, H. (2012) · Advances in Health Sciences Education · doi:10.1007/s10459-012-9358-z · Cited by 56
Does Perception of Usefulness of Arthroscopic Simulators Differ with Levels of Experience?
Tuijthof, G. J. M., de Visser, P. H. B., Sierevelt, I. N., van Dijk, N. C., & Kerkhoffs, G. M. M. J. (2011) · Clinical Orthopaedics and Related Research · doi:10.1007/s11999-011-1797-y · Cited by 53
“[13], who identified a top 10 list of most important educational criteria for medical simulators.”
BackgroundCharacteristics of Simulation Activities at North American Medical Schools and Teaching Hospitals
Huang, G. C., Sacks, H., DeVita, M. A., Reynolds, R., Gammon, W. L., Saleh, M., Gliva‐McConvey, G. A., Owens, T. L., Anderson, J., Stillsmoking, K. L., et al. (2012) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0b013e318262007e · Cited by 53
“A significant amount of research provides evidence of the benefits of simulation.(1,2) Use of simulation is growing rapidly; the Society for Simulation in Healthcare (SSH), the largest academic society for simulation, has experienced a 16-fold increase in membership since its inception in 2004 and an average of 25% an…”
BackgroundInterprofessional resuscitation rounds: a teamwork approach to ACLS education
Dagnone, D., McGraw, R. C., Pulling, C., & Patteson, A. (2008) · Medical Teacher · doi:10.1080/01421590701769548 · Cited by 53
“Medical simulation, including high-fidelity human patient simulators, has been shown to be effective in health sciences education (Dunn et al. 2004; Issenberg et al. 2005), but there are limited reports of specifically using it to enhance inter-professional teamwork skills (Howard et al. 1992;…”
BackgroundGirzadas, D. V., Clay, L., Caris, J., Rzechula, K. H., & Harwood, R. A. (2007) · Medical Teacher · doi:10.1080/01421590701513698 · Cited by 52
“The lack of unequivocal evidence for simulation-based assessment of residents clearly calls for further research in this sector of medical education (Issenberg et al. 2005).”
BackgroundA blended approach to invasive bedside procedural instruction
Lenchus, J. D., Issenberg, S. B., Murphy, D., Everett‐Thomas, R., Erben, L., Arheart, K. L., & Birnbach, D. J. (2010) · Medical Teacher · doi:10.3109/0142159x.2010.509412 · Cited by 53
“The effectiveness of using such simulation devices has been previously described (Issenberg et al. 2005; Hutton et al. 2008).”
MethodActual vs perceived performance debriefing in surgery: practice far from perfect
Ahmed, M., Sevdalis, N., Vincent, C. A., & Arora, S. (2013) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2013.01.007 · Cited by 53
Simulation in Emergency Medicine Training
Eyck, R. P. T. (2011) · Pediatric Emergency Care · doi:10.1097/pec.0b013e3182131fe0 · Cited by 54
Zimmermann, K., Holzinger, I. I. B., Ganassi, L., Esslinger, P., Pilgrim, S., Allen, M. L., Burmester, M., & Stocker, M. (2015) · BMC Medical Education · doi:10.1186/s12909-015-0472-5 · Cited by 52
“Recently published studies show a good impact of simulation training for technical as well as non-technical skills [9–17].”
BackgroundAlbanese, M. A., Mejicano, G. C., & Gruppen, L. D. (2008) · Academic Medicine · doi:10.1097/acm.0b013e31818c6638 · Cited by 54
A Patient Safety Approach to Setting Pass/Fail Standards for Basic Procedural Skills Checklists
Yudkowsky, R., Tumuluru, S., Casey, P., Herlich, N., & LeDonne, C. (2014) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0000000000000044 · Cited by 52
“Emergency medicine (4) Not specified (5) Nurse practitioner students (20) Not available Phlebotomy, IV insertion”
BackgroundRevista Española de Anestesiología y Reanimación
Macaya, M. B. (2016) · Cited by 52
Ahmed, R. A., Atkinson, S. S., Gable, B. D., Yee, J. C., & Gardner, A. K. (2016) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0000000000000177 · Cited by 52
Mastery learning: how is it helpful? An analytical review
Siddaiah‐Subramanya, M., Smith, S., & Lonie, J. M. (2017) · Advances in Medical Education and Practice · doi:10.2147/amep.s131638 · Cited by 52
“This finding is common among junior trainees and among senior trainees when performing a new procedure and can be improved by individualizing the instructions as reiterated in a review by Issenberg et al.9”
Influential
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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