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Evaluating Clinical Simulations for Learning Procedural Skills: A Theory-Based Approach
Abstract
Simulation-based learning is becoming widely established within medical education. It offers obvious benefits to novices learning invasive procedural skills, especially in a climate of decreasing clinical exposure. However, simulations are often accepted uncritically, with undue emphasis being placed on technological sophistication at the expense of theory-based design. The author proposes four key areas that underpin simulation-based learning, and summarizes the theoretical grounding for each. These are (1) gaining technical proficiency (psychomotor skills and learning theory, the importance of repeated practice and regular reinforcement), (2) the place of expert assistance (a Vygotskian interpretation of tutor support, where assistance is tailored to each learner's needs), (3) learning within a professional context (situated learning and contemporary apprenticeship theory), and (4) the affective component of learning (the effect of emotion on learning). The author then offers four criteria for critically evaluating new or existing simulations, based on the theoretical framework outlined above. These are: (1) Simulations should allow for sustained, deliberate practice within a safe environment, ensuring that recently-acquired skills are consolidated within a defined curriculum which assures regular reinforcement; (2) simulations should provide access to expert tutors when appropriate, ensuring that such support fades when no longer needed; (3) simulations should map onto real-life clinical experience, ensuring that learning supports the experience gained within communities of actual practice; and (4) simulation-based learning environments should provide a supportive, motivational, and learner-centered milieu which is conducive to learning.
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Classroom role-play helps but lacks the distinctiveness of real conversations.
“Classroom role-play helps, but lacks the distinctiveness of real conversations (5).”
From Using generative AI for interview simulations to enhance student research skills in biology education (2025) · cites this paper as [5]
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BackgroundInfluentialLearn, See, Practice, Prove, Do, Maintain
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The Human Face of Simulation: Patient-Focused Simulation Training
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Self-citationWijnen-Meijer, M., Brandhuber, T., Schneider, A., & Berberat, P. O. (2022) · Journal of Medical Education and Curricular Development · doi:10.1177/23821205221091511 · Cited by 207
“This is in line with the literature on simulations: both good guidance by teachers and getting feedback are important for the learning effect.(3) This is consistent with the results of a comprehensive meta-analysis by Hattie (2008) into what factors produce a learning effect.”
ResultHolzinger, A., Kickmeier-Rust, M., Wassertheurer, S., & Hessinger, M. (2008) · Computers & Education · doi:10.1016/j.compedu.2008.08.008 · Cited by 197
“According to (Kneebone, 2005) four key areas underpin simulation-based learning: (a) gaining technical proficiency, (b) receiving expert assistance, (c) learning within a professional context, and (d) support of affective components of learning.”
BackgroundComplexity, risk and simulation in learning procedural skills
Kneebone, R. L., Nestel, D., Vincent, C. A., & Darzi, A. W. (2007) · Medical Education · doi:10.1111/j.1365-2923.2007.02799.x · Cited by 163
Self-citationDankbaar, M. E. W., Alsma, J., Jansen, E. E. H., van Merrienboer, J. J. G., van Saase, J. L. C. M., & Schuit, S. C. E. (2016) · Advances in Health Sciences Education · doi:10.1007/s10459-015-9641-x · Cited by 147
“Although simulation training is becoming widely established within medical education, too little attention is often paid to its effects on motivation and the clinical context (Kneebone 2005).”
BackgroundYuan, H. B., Williams, B. A., & Fang, J. B. (2011) · International Nursing Review · doi:10.1111/j.1466-7657.2011.00964.x · Cited by 154
“It is necessary to justify the value of use comparing high-fidelity and low-fidelity simulation (Kneebone 2005).”
MethodUsing Cognitive Load Theory to Inform Simulation Design and Practice
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“can help achieve a more positive learning outcome for learners, make a more robust and educationally sound learning environment, and create a safer health care environment overall (Kneebone, 2005).”
BackgroundInfluentialThe Use of Simulation in Emergency Medicine: A Research Agenda
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“Sound educational theory and design is every bit as important as technology in ensuring a valuable learner experience.(13) The cost of simulation can be substantial and should be weighed when considering alternative methods to meet learning objectives.”
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“There are also several recently published guidelines and frameworks regarding learning through simulation using different strategies [4,12,13,18,19,21,30,46,47].”
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To the point: medical education review of the role of simulators in surgical training
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“For example, in simulated environments, the learners’ needs become central, as opposed to education in clinical settings when the patients’ needs always get precedence over educational considerations [24, 25].”
BackgroundDistributed simulation – Accessible immersive training
Kneebone, R. L., Arora, S., King, D., Bello, F., Sevdalis, N., Kassab, E. S., Aggarwal, R., Darzi, A. W., & Nestel, D. (2010) · Medical Teacher · doi:10.3109/01421590903419749 · Cited by 125
“Simulation has the potential to address many of these issues (Aggarwal et al. 2006), provided that an immersive environment can be designed which meets the requirements of effective education without jeopardising patient safety (Kneebone 2005).”
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Self-citationApplications of simulation technology in psychiatric mental health nursing education
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Relative effectiveness of high‐ versus low‐fidelity simulation in learning heart sounds
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“This school is highly empirical with more extensive use of experimental and quasi-experimental research designs than, for example, the management school (Cant & Cooper, 2009; Fanning & Gaba, 2007; Kneebone, 2005; Steadman et al., 2006; Ziv et al., 2003).”
MethodBaile, W. F., & Blatner, A. (2014) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0000000000000019 · Cited by 107
Perfused fresh cadavers: method for application to surgical simulation
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Perspective: Simulation and Transformational Change: The Paradox of Expertise
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Self-citationCreutzfeldt, J., Hedman, L., Medin, C., Heinrichs, W. L., & Felländer‐Tsai, L. (2010) · Journal of Medical Internet Research · doi:10.2196/jmir.1426 · Cited by 92
“We concur with Kneebone [19], who has identified self-efficacy as an important feature of successful simulations in terms of learning and clinical outcomes, and we also suggest concentration and mental strain as important variables of learning and performance to be analyzed for the first time in CPR training [20-25].”
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“For example, Roger Kneebone (2005) warns against both seduction and technological fascination, where ‘‘Simulated environments are becoming widespread, and siren voices can be heard when approaching them’’; and ‘‘simulations are often accepted uncritically, with undue emphasis being placed on technological sophisticati…”
BackgroundInfluentialEngagement: what is it good for? The role of learner engagement in healthcare simulation contexts
Padgett, J. K., Cristancho, S., Lingard, L., Cherry, R. A., & Haji, F. A. (2018) · Advances in Health Sciences Education · doi:10.1007/s10459-018-9865-7 · Cited by 92
“2011; Issenberg and Scalese 2008; Kneebone 2005).”
Rehearsal: Simulating Conflict to Teach Conflict Resolution
Shaikh, O., Chai, V. E., Gelfand, M. J., Yang, D., & Bernstein, M. S. (2024) · CHI Conference on Human Factors in Computing Systems · doi:10.1145/3613904.3642159 · Cited by 144
“During roleplay, experts strive to make simulated scenarios both believable and grounded in a teaching framework [25, 46].”
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Simulation, safety and surgery
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“633 Risk averse 6/21 (29) 14/21 (67) 5/21 (24) Risk seeking 2/6 (33) 2/6 (33) 2/6 (33) Risk attitude—certain loss, n/n (%) 0.”
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“The simulation-based learning environment was created in accordance with the four criteria for designing effective simulations for learning procedural skills, based on the theoretical framework defined by Kneebone.(41) The ISEE virtual environment used for the course was specifically developed for practicing the logis…”
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“Students learn in different ways, however engagement in simulated scenarios that are relevant to clinical practice are likely to be an effective method of learning (Kneebone 2005).”
Psychometric properties of an integrated assessment of technical and communication skills
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Self-citationSimulation‐Based Learning for Midwives: Background and Pilot Implementation
Lathrop, A., Winningham, B. A., & VandeVusse, L. (2007) · Journal of Midwifery & Women s Health · doi:10.1016/j.jmwh.2007.03.018 · Cited by 71
“Allowing earners to make mistakes and experience the conseuences, unthinkable in the clinical setting, is considered n advantage of simulation-based learning.(3) Participants play the various roles in the simulated linical situation.”
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“The emotional content of learning experiences can be addressed during simulation as this is a safemodality throughwhich the emotional climate of a stressful clinical event can be replicated (Kneebone, 2005).”
BackgroundMitchell, E. L., Lee, D. Y., Sevdalis, N., Partsafas, A. W., Landry, G. J., Liem, T. K., & Moneta, G. L. (2010) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2010.07.040 · Cited by 70
Brewin, J., Tang, J. J., Prokar Dasgupta, A., Khan, M. S., Ahmed, K., Bello, F., Kneebone, R. L., & Jaye, P. (2014) · British Journal of Urology · doi:10.1111/bju.12875 · Cited by 70
Self-citationSurgical Expertise in Neurosurgery
Gélinas-Phaneuf, N., & Maestro, R. F. D. (2013) · Neurosurgery · doi:10.1227/neu.0000000000000115 · Cited by 75
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Learning Surgical Communication, Leadership and Teamwork Through Simulation
Bearman, M., O’Brien, R., Anthony, A. A., Civil, I. D., Flanagan, B. T., Jolly, B. C., Birks, D., Langcake, M., Molloy, E., & Nestel, D. (2011) · Journal of surgical education · doi:10.1016/j.jsurg.2011.07.014 · Cited by 65
van Duijn, A. J., Swanick, K., & Donald, E. K. (2014) · Journal of Physical Therapy Education · doi:10.1097/00001416-201410000-00015 · Cited by 63
Preparing Residents Effectively in Emergency Skills Training With a Serious Game
Dankbaar, M. E. W., Roozeboom, M. B., Oprins, E. A. P. B., Rutten, F., van Merriënboer, J. J. G., van Saase, J. L. C. M., & Schuit, S. C. E. (2016) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0000000000000194 · Cited by 62
“Furthermore, attention to student motivation is often neglected in simulation programs.(7) As a result, learners tend to use them to reach certain learning outcomes but avoid continuous practice.”
BackgroundLiaw, S. Y., Koh, Y., Dawood, R. B. M., Kowitlawakul, Y., Zhou, W., & Lau, S. T. (2013) · Nurse Education Today · doi:10.1016/j.nedt.2013.04.026 · Cited by 61
“This is supported by Kneebone's et al. (2004) proposed conceptual framework for creating closer links between simulation and clinical practice to facilitate learning to take place in context.”
BackgroundMethodContinuing Medical Education Effect on Physician Knowledge Application and Psychomotor Skills
O’Neil, K. M., & Addrizzo-Harris, D. J. (2009) · CHEST Journal · doi:10.1378/chest.08-2516 · Cited by 60
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“Self-efficacy has been emphasized as an important feature of medical simulator training [18].”
BackgroundPatient-specific Rehearsal Prior to EVAR: A Pilot Study
Desender, L. M., Rančić, Z., Aggarwal, R. K., Duchateau, J., Glenck, M., Lachat, M. L., Vermassen, F. E. G., & HERZEELE, I. V. (2013) · European Journal of Vascular and Endovascular Surgery · doi:10.1016/j.ejvs.2013.03.006 · Cited by 58
Using Standardized Patients in Nursing Education
Sarmasoğlu, Ş., Dinç, L., & Elçin, M. (2015) · Nurse Educator · doi:10.1097/nne.0000000000000188 · Cited by 58
Review of Simulation in Pediatrics: The Evolution of a Revolution
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A simulation-based curriculum to introduce key teamwork principles to entering medical students
Banerjee, A., Slagle, J. M., Mercaldo, N. D., Booker, R., Miller, A., France, D. J., Rawn, L., & Weinger, M. B. (2016) · BMC Medical Education · doi:10.1186/s12909-016-0808-9 · Cited by 57
The role of collaborative interactivity in the observational practice of clinical skills
Grierson, L., Barry, M., Kapralos, B., Carnahan, H., & Dubrowski, A. (2012) · Medical Education · doi:10.1111/j.1365-2923.2011.04196.x · Cited by 52
Medical Simulation: The New Tool for Training and Skill Assessment
Carroll, J. D., & Messenger, J. C. (2008) · Perspectives in biology and medicine · doi:10.1353/pbm.2008.0003 · Cited by 52
Contextualized Simulation and Procedural Skills: A View from Medical Education
Kneebone, R. L., & Baillie, S. (2008) · Journal of Veterinary Medical Education · doi:10.3138/jvme.35.4.595 · Cited by 56
Self-citationThe 100 Most Cited Articles on Healthcare Simulation
Walsh, C., Lydon, S., Byrne, D., Madden, C., Fox, S., & O'Connor, P. E. (2018) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0000000000000293 · Cited by 56
Theory and Simulation-Based Education: Definitions, Worldviews and Applications
Nestel, D., & Bearman, M. (2015) · Clinical Simulation in Nursing · doi:10.1016/j.ecns.2015.05.013 · Cited by 50
“Commonly described theories in simulation-based education associated with the development of technical skills include mastery learning (McGaghie, Issenberg, Barsuk, & Wayne, 2014), experiential learning (Bearman, Nestel, & Andreatta, 2013), deliberate practice (Marcus, Vakharia, Kirkman, Murphy, & Nandi, 2013; Chee, 2…”
BackgroundA review of the role of simulation in developing and assessing orthopaedic surgical skills.
Thomas, G. W., Johns, B. D., Marsh, J. L., & Anderson, D. D. (2014) · PubMed Central · Cited by 50
Dilly, M., Read, E. K., & Baillie, S. (2017) · Journal of Veterinary Medical Education · doi:10.3138/jvme.0216-030r1 · Cited by 49
Hsu, L., Huang, Y.-H., & Hsieh, S. (2014) · Patient Education and Counseling · doi:10.1016/j.pec.2014.03.010 · Cited by 49
“Simulation deliberately places the learner’s needs at the center of attention and provides the opportunity to create conditions of best practice for teaching [52].”
BackgroundResultHur, H. K., Park, S., Shin, Y. H., Lim, Y. M., Kim, G., Kim, K. K., Choi, H. O., & Choi, J. H. (2013) · The Journal of Korean Academic Society of Nursing Education · doi:10.5977/jkasne.2013.19.2.228 · Cited by 47
Sheckter, C. C., Kane, J. T., Minneti, M., Garner, W. L., Sullivan, M. E., Talving, P., Sherman, R., Urata, M. M., & Carey, J. N. (2013) · Journal of surgical education · doi:10.1016/j.jsurg.2013.02.008 · Cited by 47
Odhayani, A. A., & Ratnapalan, S. (1984) · Medical Teacher · doi:10.3109/01421598409010589 · Cited by 47
Bandali, K. S., Parker, K., Mummery, M., & Preece, M. (2008) · Journal of Interprofessional Care · doi:10.1080/13561820701753969 · Cited by 49
“(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).”
BackgroundPeri-resuscitation echocardiography: Training the novice practitioner
Price, S., Ilper, H., Uddin, S., Steiger, H. V., Seeger, F. H., Schellhaas, S., Heringer, F., Ruesseler, M., Ackermann, H., Via, G., et al. (2010) · Resuscitation · doi:10.1016/j.resuscitation.2010.07.001 · Cited by 46
Integrating Surgical Skills Education into the Anatomy Laboratory
Zaid, H. B., Ward, D., Sammann, A., Tendick, F., Topp, K. S., & Maa, J. (2008) · Journal of Surgical Research · doi:10.1016/j.jss.2008.08.012 · Cited by 45
“retention, potentially increasing confidence, student safety, and improving patient care [7].”
BackgroundOne Drop at a Time: Research to Advance the Science of Simulation
Cook, D. A. (2010) · Simulation in Healthcare The Journal of the Society for Simulation in Healthcare · doi:10.1097/sih.0b013e3181c82aaa · Cited by 43
“The simulation research of which I speak requires relentlessly building on previous work, 27 critically appraising and testing theory, 29,30 and systematically— programmatically 31 —refining our understanding of how to use the tools at our disposal to teach and assess.”
MethodVázquez, J. A. I., Rodríguez‐Núñez, A., Penas, M. P., Sánchez-Santos, L., Cegarra-García, M., & Barreiro-Díaz, M. V. (2007) · BMC Emergency Medicine · doi:10.1186/1471-227x-7-18 · Cited by 44
“All skill stations and test scenarios were designed beforehand using CPR instructor manuals [18,20,21].”
MethodIgnacio, J., Dolmans, D. H. J. M., Scherpbier, A. J. J. A., Rethans, J., Chan, S. W., & Liaw, S. Y. (2016) · BMJ Simulation & Technology Enhanced Learning · doi:10.1136/bmjstel-2015-000097 · Cited by 42
Persson, J. (2016) · Applied Ergonomics · doi:10.1016/j.apergo.2016.07.007 · Cited by 43
A Surgical Skills Elective to Expose Preclinical Medical Students to Surgery
Sammann, A., Tendick, F., Ward, D., Zaid, H. B., O’Sullivan, P., & Ascher, N. L. (2007) · Journal of Surgical Research · doi:10.1016/j.jss.2007.03.034 · Cited by 43
Liaw, S. Y., Chan, S. W., Scherpbier, A. J. J. A., Rethans, J., & Pua, G. G. (2011) · Resuscitation · doi:10.1016/j.resuscitation.2011.08.021 · Cited by 42
Shorten, G., ROBERTIS, E. D., Goldik, Z., Kietaibl, S. A., Niemi‐Murola, L., & Sabeļņikovs, O. (2020) · European Journal of Anaesthesiology · doi:10.1097/eja.0000000000001201 · Cited by 46
Liaw, S. Y., Sutini, Chua, W. L., Tan, J. Z., Levett-Jones, T. L., Ashokka, B., Pan, T. L. T., Lau, S. T., & Ignacio, J. (2022) · Journal of General Internal Medicine · doi:10.1007/s11606-022-07557-7 · Cited by 45
“Furthermore, the emotional climate of a stressful clinical event can be replicated using immersive simulation-based learning.(5) Apart from stress management interventions, LeBlanc (2009) emphasised the need to provide individuals and teams with specific training to optimise performance during stressful events.”
BackgroundDevelopment and Validation of Simulation Training for Vaginal Hysterectomy
Greer, J. A., Segal, S., Salva, C. R., & Arya, L. A. (2013) · Journal of Minimally Invasive Gynecology · doi:10.1016/j.jmig.2013.06.006 · Cited by 41
McGraw, R. C., Chaplin, T., McKaigney, C. J., Rang, L. C. F., Jaeger, M. T., Redfearn, D., Davison, C., Ungi, T., Holden, M., Yeo, C. T., et al. (2016) · Canadian Journal of Emergency Medicine · doi:10.1017/cem.2016.329 · Cited by 41
“9 With respect to skills such as USG CVC insertion there is, however, a paucity of evidence for the speci fi c type and volume of simulator practice required to achieve technical pro fi - ciency.”
InfluentialCristancho, S., Moussa, F., & Dubrowski, A. (2011) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2011.02.011 · Cited by 41
Striving for Better Medical Education: the Simulation Approach
Sakakushev, B. E., Marinov, B. I., Stefanova, P. P., Kostianev, S. S., & Georgiou, E. K. (2017) · Folia Medica · doi:10.1515/folmed-2017-0039 · Cited by 40
Understanding student concerns about peer physical examination using an activity theory framework
Wearn, A. M., Rees, C. E., Bradley, P., & Vnuk, A. K. (2008) · Medical Education · doi:10.1111/j.1365-2923.2008.03175.x · Cited by 38
A meta-analysis for comparing effective teaching in clinical education
Huang, P., Haywood, M., O’Sullivan, A., & Shulruf, B. (2019) · Medical Teacher · doi:10.1080/0142159x.2019.1623386 · Cited by 38
“While scenario-based learning is classically associated with the learner and patient safety, we propose that teacher safety is also ensured because he can gauge the trustability of the student in a controlled fashion (Kneebone 2005; Chen et al. 2015).”
BackgroundJunior physician skill and behaviour in resuscitation: A simulation study
Høyer, C. B., Christensen, E. F., & Εika, B. (2008) · Resuscitation · doi:10.1016/j.resuscitation.2008.10.029 · Cited by 39
Metadata
- Authors
- Kneebone, R.
- Affiliations
- St Mary's Hospital (GB)
- Corresponding author
- Kneebone, Roger
- ORCID
- Kneebone, Roger
- Venue
- Academic Medicine
- Publisher
- Oxford University Press (OUP)
- Published
- 2005-06
- Volume
- 80
- Issue
- 6
- Pages
- 549-553
- ISSN
- 1040-2446 (ISSN-L)
- OpenAlex
- W2054537285
- Cited by
- 423
- References
- 18
- Citations by year
- 2026: 17 · 2025: 17 · 2024: 17 · 2023: 14 · 2022: 14 · 2021: 19 · 2020: 19 · 2019: 26 · 2018: 25 · 2017: 21 · 2016: 26 · 2015: 31 · 2014: 31 · 2013: 23 · 2012: 26
- FWCI
- 2.06
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Academic Medicine (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
- simulation-based training, procedural training, medical education, psychomotor skill acquisition, deliberate practice, situated learning, affective learning, student-centered learning environment, skill consolidation
- MeSH terms
- Computer-Assisted Instruction, Computer Simulation, Education, Medical, Evaluation Studies as Topic, Humans
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