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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 (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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“Debriefing helps students put the simulation into perspective (Rhodes and Curran, 2005) and explore the emotional, affective components of patient situations in a safe environment (Kneebone, 2005).”
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“Simulation that incorporates the affective (emotional) component of learning can be effective (Kneebone, 2005) provided that the experience replicates real clinical encounters to the best extent possible.”
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“In the theory-based learning model by Kneebone (30), active learning must be based on simulation, including actual clinical practice, and considering four essential aspects: (1) The gain and retention of technical competence, through sustained and deliberate practice in a safe environment, in order”
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Cricothyroidotomy In Situ Simulation Curriculum (CRIC Study)
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“By incorporating training within the actual workplace, learners benefit from context-specific skill acquisition, a key component of simulation-based procedural skills education.(25) During the ISS session, the equipment and room set up were identical to that used in an actual resuscitation.”
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“Kneebone (2005) also highlights that a clinical simulation should only practice a small, well defined skill.”
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“These educational theories provide the theoretical bases for the use of simulation; which has been demonstrated to enhance effective learning (Kneebone, 2005).”
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“Fidelity or high engineering has been proven to not always be associated with better educational benefits compared to simpler interventions (Kneebone 2005; De Giovanni et al. 2009).”
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“Other research studies in nursing have also reported findings similar to those of Kneebone.(4) Benner et al(5) reported that simulation-based learning enables nurses to practice skills, get feedback from instructors, and learn from patients’ reactions and outcomes.”
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“The criteria for simulation-based learning were previously addressed by Kneebone (2005) (39).”
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“선행연구[6-8]에 의하면, 고충실 도 환자 모형 시뮬레이터(high-fidelity patient simulator)를 활용한 실습교육, 표준화 환자를 활용한 실습교육 등에 대한 국내 연구들 에서 간호 수행 능력, 의사소통 능력, 임상 판단 및 관리 능력, 지식 습득, 수업 만족도, 비판적 사고, 문제 해결 능력 등이 향상되었다 고 보고하였다.”
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Klass, D., Tam, M. D. B. S., Cockburn, J., Williams, S. M., & Toms, A. P. (2008) · European Radiology · doi:10.1007/s00330-008-1090-y · Cited by 19
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“However, according to studies on use of clinical simulation in similar contexts, teacher guidance is influential for students ’ learning progress [27].”
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“Simulated learning has created an increasingly attractive alternative education strategy in many settings, and one that may enhance clinical competence.(33,34) However, the available healthcare education literature indicates there is a lack of empirical research determining the efficacy and effectiveness of simulation…”
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Using Simulation to Teach Echocardiography
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Remember to breathe: teaching respiratory physiology in a clinical context using simulation
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“Work has identified four key areas that underpin simulation-based learning, and, although these are more directed toward the acquisition of procedural skills within clinical practice, they could as easily be applied to the use of simulation in the early years of learning (14).”
Gudayu, T. W., Badi, M. B., & Asaye, M. M. (2015) · Education Research International · doi:10.1155/2015/346182 · Cited by 18
“Kneebone [15] suggests that simulation may be an effective method of learning because it implicates four key facets of education in Midwifery and Nursing: developing technical proficiency through practice of psychomotor skills and repetition; assistance of experts which is tailored to students’ needs; situated learnin…”
MethodClinical Coaching Cards: A Game of Active Learning Theory and Teaching Techniques
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The Simulated Ward: ideal for Training Clinical Clerks in an Era of Patient Safety
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“Kneebone [15] outlined the characteristics of successful simulation exercises, including practice within a safe environment, access to expert”
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Surgical skills training restructured for the 21st century
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Self-citationMcInerney, P. A., & Green-Thompson, L. P. (2017) · The JBI Database of Systematic Reviews and Implementation Reports · doi:10.11124/jbisrir-2016-003110 · Cited by 16
“Although high-fidelity simulation learning environments provide safe learning opportunities for students to learn and practice skills, they need to be used thoughtfully and with conscious intent of learning outcomes.(9) The restriction on the number of hours worked per week does not apply in the current context, but t…”
BackgroundLydon, S., Burns, N., Healy, O., O'Connor, P. E., McDermott, B. R., & Byrne, D. (2017) · BMJ Simulation & Technology Enhanced Learning · doi:10.1136/bmjstel-2016-000154 · Cited by 16
Medical student responses to clinical procedure teaching in the anatomy lab
Wilson, D. R., & Nava, P. B. (2010) · The Clinical Teacher · doi:10.1111/j.1743-498x.2009.00349.x · Cited by 16
Evaluation of students’ clinical performance post-simulation training
Bowman, A. L., Reid, D., Harreveld, B., & Lawson, C. (2020) · Radiography · doi:10.1016/j.radi.2020.10.002 · Cited by 18
Playful Simulations Rather Than Serious Games
Pelletier, C., & Kneebone, R. L. (2015) · Games and Culture · doi:10.1177/1555412014568449 · Cited by 18
Self-citationRuggenberg, S. (2008) · USF Scholarship Repository (University of San Francisco) · Cited by 15
Lee, J. Y., Mucksavage, P., & McDougall, E. M. (2011) · Journal of Endourology · doi:10.1089/end.2011.0432 · Cited by 15
Song, Y. A. (2014) · Korean journal of women health nursing/Yeoseong geon'gang ganho hag'hoeji/Yeoseong geon-gang ganho hakoeji · doi:10.4069/kjwhn.2014.20.4.246 · Cited by 15
Non-technical factors influence laparoscopic simulator performance among OBGYN residents
Ahlborg, L., Hedman, L. R., Rasmussen, C., Felländer‐Tsai, L., & Enochsson, L. B. (2012) · Gynecological Surgery · doi:10.1007/s10397-012-0748-2 · Cited by 15
“, one’s belief in one’s ability to succeed in specific situations [15].”
BackgroundCourse in Prehospital Major Incidents Management for Health Care Providers in Saudi Arabia
Bajow, N. A., Alassaf, W., & Cluntun, A. A. (2018) · Prehospital and Disaster Medicine · doi:10.1017/s1049023x18000791 · Cited by 15
“Simulation-based learning is becoming widely recognized in medical education because it offers clear, recognizable benefits for new trainees to learn invasive procedural skills, especially in environments outside hospitals and clinics, such as disaster scenes.(27,29) Only the prehospital components were included in th…”
BackgroundSinha, S. N., & Page, W. (2014) · ANZ Journal of Surgery · doi:10.1111/ans.12665 · Cited by 14
“The pre- and post-course evaluations of the course fulfilled the criteria of simulation-based education evaluation proposed by Kneebone et al.16 The marked improvement in organizing theatre time for emergency cases from 11.6% to 58.2% (P = 0.00) can be attributed to the fact that even senior students are never involve…”
MethodInfluentialTechniques of cadaver perfusion for surgical training: a systematic review
Bellier, A., Chanet, A., Belingheri, P., & Chaffanjon, P. C. (2018) · Surgical and Radiologic Anatomy · doi:10.1007/s00276-018-1997-1 · Cited by 14
Ramjeeawon, A., Sharrock, A. E., Morbi, A. H. M., Martin, G., Riga, C., & Bicknell, C. D. (2020) · Journal of surgical education · doi:10.1016/j.jsurg.2020.03.023 · Cited by 14
The Medical Virtual Patient Simulator (MedVPS) Platform
Nedungadi, P., & Raghu Raman, R. (2015) · Advances in intelligent systems and computing · doi:10.1007/978-3-319-23036-8_5 · Cited by 14
“The clinical realism of a simulation and the feedback provided within a simulation [3] helps improve learning and performance [4].”
BackgroundHIGH FIDELITY SIMULATION IN NURSING EDUCATION: CONSIDERATIONS FOR MEANINGFUL LEARNING
Welman, A.-M., & Spies, C. (2016) · Trends in Nursing · doi:10.14804/3-1-42 · Cited by 14
The unexpected and the non-fitting – considering the edges of simulation as social practice
Dieckmann, P. (2020) · Advances in Simulation · doi:10.1186/s41077-020-0120-y · Cited by 13
Meek, M. E., Meek, J. C., Hollowoa, B. R., Li, R., Deloney, L. A., & Phelan, K. D. (2018) · Academic Radiology · doi:10.1016/j.acra.2018.05.019 · Cited by 13
Simulation training for emergency medicine residents: time to move forward
Langhan, T. S. (2008) · Canadian Journal of Emergency Medicine · doi:10.1017/s1481803500010575 · Cited by 13
Learning and Collaboration Technologies. Technology-Rich Environments for Learning and Collaboration
Zaphiris, P., & Ioannou, A. (2014) · Lecture notes in computer science · doi:10.1007/978-3-319-07485-6 · Cited by 13
Fadzli, S., Yahaya, J. B., Deraman, A., Hamdan, A. R., Halim, L., Yahaya, N. Z., Zahari, M. S. M., & Rais, I. A. I. (2019) · Education and Information Technologies · doi:10.1007/s10639-019-09996-y · Cited by 13
“It often accepted uncritically, with the undue emphasis on technological sophistication at the expense of theory-based design (Kneebone 2005).”
BackgroundEtablierung eines Skills Labs in der Tiermedizin in Deutschland
Dilly, M., Tipold, A., Schaper, E., & Ehlers, J. P. (2014) · Europe PMC (PubMed Central) · doi:10.3205/zma000912 · Cited by 13
Surgical Training and Simulation Laboratory at Baystate Medical Center
Earle, D. (2006) · Surgical Innovation · doi:10.1177/155335060601300109 · Cited by 13
“Educators in each of the program areas seek to achieve (1) the definition of training objectives, (2) the assignment of experience-appropriate training objectives to trainees, (3) the assignment and performance of specific training protocols to achieve objectives, (4) the determination of efficacy of training, and (5)…”
BackgroundPerry, S., Bridges, S., & Burrow, M. F. (2021) · European Journal Of Dental Education · doi:10.1111/eje.12699 · Cited by 14
Guerrero, J. G., Tungpalan-Castro, G. M., Fergani, B. A., Gomma, N. H., Hafiz, A. H., & Pingue-Raguini, M. (2022) · Computers & Education X Reality · doi:10.1016/j.cexr.2022.100002 · Cited by 12
“…a key strategy for enhancing knowledge and skill acquisition, including improving the quality and safety of clinical practice (Batista et al., 2014; Heimann et al., 2013; Kneebone, 2005; Lapkin et al., 2010; McGaghie, 2010; Meakim et al., 2013; Padilha, 2019; Pinar et al., 2015; Yuan et al., 2012).”
BackgroundAssessment Methodology for Computer-Based Instructional Simulations
Koenig, A. D., Iseli, M. R., Wainess, R., & Lee, J. J. (2013) · Military Medicine · doi:10.7205/milmed-d-13-00217 · Cited by 12
Fever and Seizure in a Young Infant: A Simulation Case
Rideout, M., & Raszka, W. V. (2016) · MedEdPORTAL · doi:10.15766/mep_2374-8265.10468 · Cited by 12
Learning Social Work through Role Play: Developing More Confident and Capable Social Workers
Banach, M., Rataj, A. C., Ralph, M., & Allosso, L. (2020) · The Journal of Practice Teaching in Health and Social Work · doi:10.1921/jpts.v17i2.1308 · Cited by 12
Effects of High-Fidelity Virtual Training Simulators on Learners' Self-Efficacy
Holbrook, H. A., & Cennamo, K. S. (2014) · International Journal of Gaming and Computer-Mediated Simulations · doi:10.4018/ijgcms.2014040104 · Cited by 12
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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