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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 The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality.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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Postsimulation Debriefing to Maximize Clinical Judgment Development
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“Educational feedback from the teacher, part of the debriefing process, was the most important element of simulation when measuring effective learning.(6) The medical literature also emphasizes the importance of debriefing during simulation and facilitator characteristics that enhance learning.”
BackgroundSimulation and resident education in spinal neurosurgery
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“[34,51,53,55,61] Periodic feedback from an attending surgeon regarding simulation performance is also important for maximum benefit.[24,31,84]”
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“A systematic review on medical simulation [4] found out that providing feedback is the most crucial feature of a simulator.”
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“We have also seen an expansion of simulation modalities, from a focus on ‘high-fidelity’ mannequin-based simulations [8] to simulated patient methodology [9] to hybrid simulations that integrate various simulation modalities [10].”
BackgroundSimulation in teaching regional anesthesia: current perspectives
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Training using medical simulation: Figure 1
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“The scenarios were as follows: (1) a normal oral intubation; (2) a normal nasal intubation; (3) a tumour partly obstructing the larynx; (4) a tumour on the base of the tongue with very limited laryngeal access; (5) a retropharyngeal abscess; (6) a narrow laryngeal airway because of an obstructing lesion arising from t…”
MethodMalmström, B., Nohlert, E., Ewald, U., & Widarsson, M. (2017) · Acta Paediatrica · doi:10.1111/apa.13861 · Cited by 47
“The role of debriefing in simulation-based learning was the subject of a review by Fanning and Gaba (29), who pointed out that feedback, including debriefing, was the most important feature of simulation-based medical education (30).”
BackgroundSimulator training for maritime complex tasks: an experimental study
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“A substantial body of literature highlights the effectiveness of SBT across various medical disciplines, emphasizing its potential benefits in enhancing clinical skills acquisition [4,5].”
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Multiple Encounter Simulation for High-acuity Multipatient Environment Training
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“(2) Strategies to prepare educators to design, facilitate and assess simulation learning sessions are critical to optimize student learning in this educational environment (Issenberg et al., 2005; Kneebone, 2005; Ziv, Ben-David & Ziv, 2005).”
BackgroundWisborg, T., Brattebø, G., Brinchmann-Hansen, Å., & Hansen, K. (2009) · Scandinavian Journal of Trauma Resuscitation and Emergency Medicine · doi:10.1186/1757-7241-17-59 · Cited by 46
“They have been used for many different purposes, from skills training to decision making, from individual to group training [15].”
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“Similarly, meta-analyses of simulation research have demonstrated the importance of steadily increasing complexity adapted to learners’ abilities (Issenberg et al. 2005; McGaghie et al. 2010; themes 2 and 4d), and conclusions on sequencing from general education research also resonate with…”
BackgroundSørensen, J. L., van der Vleuten, C. P. M., Lindschou, J., Gluud, C. N., Østergaard, D., LeBlanc, V. R., Johansen, M., Ekelund, K., Albrechtsen, C. K., Pedersen, B. W., et al. (2013) · Trials · doi:10.1186/1745-6215-14-220 · Cited by 49
“However, being the first randomized trial comparing ISS with OSS, the trial has the potential to add some new insight with regards to the effect of authenticity in the setting for SBME and to inform future research in this field.”
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The Status of Human Simulation Training in Emergency Medicine Residency Programs
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Clinical simulation using deliberate practice in nursing education: A Wilsonian concept analysis
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Simulation in Pediatric Emergency Medicine Fellowships
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Deliberate practice as a framework for evaluating feedback in residency training
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“Some studies have linked deliberate practice with a positive effect on the acquisition of skills including oral presentations (Heiman et al. 2012), OSCE results (Duvivier et al. 2011), and simulator performance (Issenberg et al. 1999, 2005).”
BackgroundHow valid are commercially available medical simulators?
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“Many new tools focus on learning outside the confines of a traditional classroom, making them excellent resources for adult learners in professional settings (5).”
Structured debriefing in nursing simulation: students’ perceptions
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Justify Your Answer: The Role of Written Think Aloud in Script Concordance Testing
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“The postencounter debriefing session, a modified form of TA, is consistently recognized as the most important educational feature of high-fidelity simulations.(34,35) Studies have shown that group members who receive debriefing have increased posttest perfor-”
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The effects of team-training in intensive care medicine: A narrative review
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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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