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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 The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality.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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Pelvic Examination Skills Training With Genital Teaching Associates and a Pelvic Simulator
Seago, B. L., Ketchum, J. M., & Willett, R. M. (2012) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0b013e31823b9e46 · Cited by 35
Patterson, M., Militello, L. G., Bunger, A., Taylor, R. G., Wheeler, D. S., Klein, G. A., & Geis, G. L. (2016) · Journal of Cognitive Engineering and Decision Making · doi:10.1177/1555343416629520 · Cited by 36
“Simulation fosters effective learning through active learner engagement, repetitive practice, the ability to vary difficulty and clinical complexity, as well as diagnostic performance measurement and intra-experience feedback (Issenberg et al., 2005; Okuda et al., 2009).”
BackgroundCollecting Validity Evidence for Simulation‐Based Assessment of Point‐of‐Care Ultrasound Skills
Jensen, J. K., Dyre, L., Jørgensen, M. E., Andreasen, L. A., & Tolsgaard, M. G. (2017) · Journal of Ultrasound in Medicine · doi:10.1002/jum.14292 · Cited by 35
Laschinger, S. J., Medves, J., Pulling, C., McGraw, R. C., Waytuck, B., Harrison, M. B., & Gambeta, K. (2008) · JBI Library of Systematic Reviews · doi:10.11124/jbisrir-2008-223 · Cited by 35
HIGH-FIDELITY PATIENT SIMULATION: A DESCRIPTIVE WHITE PAPER REPORT
Rodgers, D. L., & Rodgers, L. (2007) · Cited by 35
Preparing Pediatric Nurses: The Role of Simulation-Based Learning
Broussard, L., Myers, R., & Lemoine, J. (2009) · Issues in Comprehensive Pediatric Nursing · doi:10.1080/01460860802610178 · Cited by 35
Integrative Learning Through Simulation and Problem-Based Learning
Walshe, N., O’Brien, S., Murphy, S., & Hartigan, I. (2011) · Clinical Simulation in Nursing · doi:10.1016/j.ecns.2011.08.006 · Cited by 35
Item difficulty in the evaluation of computer‐based instruction: An example from neuroanatomy
Chariker, J. H., Naaz, F., & Pani, J. R. (2012) · Anatomical Sciences Education · doi:10.1002/ase.1260 · Cited by 35
“Second, it is frequently observed that the literature on the evaluation of computer-based instruction varies widely in outcome (Issenberg et al., 2005; Cook et al., 2008).”
BackgroundMoral imagination in simulation-based communication skills training
Chen, R. P. (2011) · Nursing Ethics · doi:10.1177/0969733010386163 · Cited by 35
“Simulation-based education for communication skills training Clinical simulation has been used in health professional education for several decades.(16) It provides learners with the opportunity to practice and develop clinical skills,(17) manage critical or crisis events in the patient care setting(18) and develop sk…”
MethodBreckwoldt, J., Gruber, H. G., & Wittmann, A. (2014) · Springer international handbooks of education · doi:10.1007/978-94-017-8902-8_25 · Cited by 36
Development and validation of the Simulation Learning Effectiveness Inventory
Chen, S., Huang, T., Liao, I., & Liu, C. (2015) · Journal of Advanced Nursing · doi:10.1111/jan.12707 · Cited by 34
Studnek, J. R., Fernandez, A. R., Shimberg, B., Garifo, M., & Correll, M. (2011) · Academic Emergency Medicine · doi:10.1111/j.1553-2712.2011.01208.x · Cited by 34
“Simulation has become a standard in the assessment of entry level competency in medical education.(20) It has also been shown to be useful in teaching new skills to experienced providers or for refresher training on skills that are not often used.”
BackgroundDisaster medicine training in family medicine: a review of the evidence.
Huntington, M. K., & Gavagan, T. F. (2011) · PubMed · Cited by 34
Wehbe–Janek, H., Song, J., & Shabahang, M. M. (2011) · Journal of surgical education · doi:10.1016/j.jsurg.2010.12.005 · Cited by 34
Jeffries, P. R., Beach, M., Decker, S., Dlugasch, L. B., Groom, J. A., Settles, J., & O'Donnell, J. M. (2011) · Nursing Education Perspectives · doi:10.5480/1536-5026-32.5.316 · Cited by 34
Cherry, M. G., Brown, J., Neal, T. J., & Shaw, N. B. (2010) · Medical Teacher · doi:10.3109/01421591003596600 · Cited by 35
“This model has been used by other BEME review groups (Issenberg et al. 2005) and, once modified, fitted the outcome measures of the review.”
MethodPulijala, Y., Ma, M., & Ayoub, A. F. (2017) · Springer eBooks · doi:10.1007/978-3-319-51645-5_8 · Cited by 34
Haukedal, T. A., Reierson, I. Å., Hedeman, H., & Bjørk, I. T. (2018) · Nursing Research and Practice · doi:10.1155/2018/7437386 · Cited by 35
Pierce, C., Corral, J., Aagaard, E., Harnke, B., Irby, D. M., & Stickrath, C. R. (2020) · Medical Teacher · doi:10.1080/0142159x.2019.1708294 · Cited by 37
Yu, P., Pan, J., Wang, Z., Shen, Y., Li, J., Hao, A., & Wang, H. (2022) · BMC Medical Education · doi:10.1186/s12909-022-03150-y · Cited by 36
Secomb, J., McKenna, L., & Smith, C. (2012) · Journal of Clinical Nursing · doi:10.1111/j.1365-2702.2012.04257.x · Cited by 34
KnowPain-50: A Tool for Assessing Physician Pain Management Education
Harris, J. M., Fulginiti, J. V., Gordon, P., Elliott, T. E., Davis, B. E., Chabal, C., & Kutob, R. M. (2008) · Pain Medicine · doi:10.1111/j.1526-4637.2007.00398.x · Cited by 34
“SPs and structured clinical examinations have been used in educational settings to enhance learning and evaluate student performance [ 25 ] and in clinical settings to calibrate computer-based clinical vignettes [18], but, to our knowledge, they have not been previously used to refine physician KAB surveys.”
MethodRecent advances in scenario-based training for medical education
Cannon‐Bowers, J. A. (2008) · Current Opinion in Anaesthesiology · doi:10.1097/aco.0b013e3283184435 · Cited by 35
Deering, S. H., Rosen, M. A., Eduardo Salas, A., & King, H. B. (2009) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0b013e31819aaf2a · Cited by 34
What is evidence? Reflections on the AMEE symposium, Vienna, August 2011
Thistlethwaite, J. E., Davies, H. T. O., Dornan, T., Greenhalgh, T., Hammick, M., & Scalese, R. J. (2012) · Medical Teacher · doi:10.3109/0142159x.2012.671561 · Cited by 34
“Ross was a member of the topic review group (on medical simulation) who published the first BEME systematic review in 2005 (Issenberg et al. 2005), and since that time, this paper has consistently been among the most cited and most downloaded references from Medical Teacher; a subsequent update of…”
BackgroundSelf-citationPreliminary evaluation of a virtual reality-based simulator for learning spinal anesthesia
Kulcsar, Z., O'Mahony, E., Lövquist, E., Aboulafia, A., Šabova, D., Ghori, K., Iohom, G., & Shorten, G. (2012) · Journal of Clinical Anesthesia · doi:10.1016/j.jclinane.2012.06.015 · Cited by 34
“Several important features and aspects of simulators that lead to effective learning were identified by Issenberg et al [22].”
BackgroundChiarchiaro, J., White, D. B., Ernecoff, N. C., Buddadhumaruk, P., Schuster, R. A., & Arnold, R. M. (2016) · Critical Care Medicine · doi:10.1097/ccm.0000000000001583 · Cited by 36
Changing Times, Evolving Issues: The Faculty Shortage, Accelerated Programs, and Simulation
(2006) · Journal of Nursing Education · doi:10.3928/01484834-20060301-01 · Cited by 34
Udani, A. D., Harrison, T. K., Mariano, E. R., Derby, R. E., Kan, J. M., Ganaway, T., Shum, C., Gaba, D. M., Tanaka, P. P., Kou, A., et al. (2016) · Regional Anesthesia & Pain Medicine · doi:10.1097/aap.0000000000000361 · Cited by 36
“Simulation-based medical education (SBME) as an educational strategy has been shown to increase knowledge, provide opportunities for practice, allow for assessment, and develop the practitioner's clinical skills.(7) However, application of SBME can vary in technology used, instructional site, feedback method, and more.”
Crichton, M. (2016) · Cognition Technology & Work · doi:10.1007/s10111-016-0396-9 · Cited by 34
Laschinger, S. J., Medves, J., Pulling, C., McGraw, R. C., Waytuck, B., Harrison, M. B., & Gambeta, K. (2008) · The JBI Database of Systematic Reviews and Implementation Reports · doi:10.11124/01938924-200806070-00001 · Cited by 34
Jones, A., & Sheppard, L. A. (2011) · Internet Journal of Allied Health Sciences and Practice · doi:10.46743/1540-580x/2011.1338 · Cited by 33
Shaw‐Battista, J., Belew, C., Anderson, D., & van Schaik, S. M. (2015) · Journal of Midwifery & Women s Health · doi:10.1111/jmwh.12393 · Cited by 33
Stokes-Parish, J. B., Duvivier, R. J., & Jolly, B. C. (2016) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0000000000000211 · Cited by 33
“This jarring can significantly impact the purpose of the learning; instructional design of simulation is critical to its success.(2,32) Applying the framework by Rule(29) to moulage, one can hypothesize that it must have real worldness to facilitate authentic learning.”
Background
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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