Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review
TL;DR: 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.
Abstract: SUMMARY 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 The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality.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:
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TL;DR: This article reviews and critically evaluates historical and contemporary research on simulation‐based medical education (SBME) and presents and discusses 12 features and best practices that teachers should know in order to use medical simulation technology to maximum educational benefit.
Abstract: Objectives This article reviews and critically evaluates historical and contemporary research on simulation-based medical education (SBME). It also presents and discusses 12 features and best practices of SBME that teachers should know in order to use medical simulation technology to maximum educational benefit.
Methods This qualitative synthesis of SBME research and scholarship was carried out in two stages. Firstly, we summarised the results of three SBME research reviews covering the years 1969–2003. Secondly, we performed a selective, critical review of SBME research and scholarship published during 2003–2009.
Results The historical and contemporary research synthesis is reported to inform the medical education community about 12 features and best practices of SBME: (i) feedback; (ii) deliberate practice; (iii) curriculum integration; (iv) outcome measurement; (v) simulation fidelity; (vi) skill acquisition and maintenance; (vii) mastery learning; (viii) transfer to practice; (ix) team training; (x) high-stakes testing; (xi) instructor training, and (xii) educational and professional context. Each of these is discussed in the light of available evidence. The scientific quality of contemporary SBME research is much improved compared with the historical record.
Conclusions Development of and research into SBME have grown and matured over the past 40 years on substantive and methodological grounds. We believe the impact and educational utility of SBME are likely to increase in the future. More thematic programmes of research are needed. Simulation-based medical education is a complex service intervention that needs to be planned and practised with attention to organisational contexts.
Medical Education 2010: 44: 50–63
1,459 citations
TL;DR: In comparison with no intervention, technology-enhanced simulation training in health professions education is consistently associated with large effects for outcomes of knowledge, skills, and behaviors and moderate effects for patient-related outcomes.
Abstract: Context Although technology-enhanced simulation has widespread appeal, its effectiveness remains uncertain. A comprehensive synthesis of evidence may inform the use of simulation in health professions education. Objective To summarize the outcomes of technology-enhanced simulation training for health professions learners in comparison with no intervention. Data Source Systematic search of MEDLINE, EMBASE, CINAHL, ERIC, PsychINFO, Scopus, key journals, and previous review bibliographies through May 2011. Study Selection Original research in any language evaluating simulation compared with no intervention for training practicing and student physicians, nurses, dentists, and other health care professionals. Data Extraction Reviewers working in duplicate evaluated quality and abstracted information on learners, instructional design (curricular integration, distributing training over multiple days, feedback, mastery learning, and repetitive practice), and outcomes. We coded skills (performance in a test setting) separately for time, process, and product measures, and similarly classified patient care behaviors. Data Synthesis From a pool of 10 903 articles, we identified 609 eligible studies enrolling 35 226 trainees. Of these, 137 were randomized studies, 67 were nonrandomized studies with 2 or more groups, and 405 used a single-group pretest-posttest design. We pooled effect sizes using random effects. Heterogeneity was large (I2>50%) in all main analyses. In comparison with no intervention, pooled effect sizes were 1.20 (95% CI, 1.04-1.35) for knowledge outcomes (n = 118 studies), 1.14 (95% CI, 1.03-1.25) for time skills (n = 210), 1.09 (95% CI, 1.03-1.16) for process skills (n = 426), 1.18 (95% CI, 0.98-1.37) for product skills (n = 54), 0.79 (95% CI, 0.47-1.10) for time behaviors (n = 20), 0.81 (95% CI, 0.66-0.96) for other behaviors (n = 50), and 0.50 (95% CI, 0.34-0.66) for direct effects on patients (n = 32). Subgroup analyses revealed no consistent statistically significant interactions between simulation training and instructional design features or study quality. Conclusion In comparison with no intervention, technology-enhanced simulation training in health professions education is consistently associated with large effects for outcomes of knowledge, skills, and behaviors and moderate effects for patient-related outcomes.
1,420 citations
Cites background or methods from "Features and uses of high-fidelity ..."
...Criterion B was fulfilled if (1) a randomized study concealed allocation or (2) an observational study controlled for another baseline learner characteristic....
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...We sought to answer 2 questions: (1) To what extent are simulation technologies for training health care professionals associated with improved outcomes in comparison with no intervention? and (2) How do outcomes vary for different simulation instructional designs? Based on the strength of the theoretical foundations and currency in the field, we selected 5 instructional design features(2,9) (curricular integration, distributed practice, feedback, mastery learning, and range of difficulty) for subgroup analyses (see eBox for definitions; available at http://www ....
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...Beyond descriptive analysis (2) 560 (91....
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...When authors reported multiple measures of a single outcome (eg, multiple measures of efficiency), we selected in decreasing order of priority (1) the authordefined primary outcome; (2) a global or summary measure of effect; (3) the most clinically relevant measure; or (4) the mean of the measures reported....
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...cComparability of cohorts criterion A was fulfilled if the study (1) was randomized or (2) controlled for a baseline learning outcome....
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TL;DR: The aim of this paper is to critically review what is felt to be important about the role of debriefing in the field of simulation-based learning, how it has come about and developed over time, and the different styles or approaches that are used and how effective the process is.
Abstract: The aim of this paper is to critically review what is felt to be important about the role of debriefing in the field of simulation-based learning, how it has come about and developed over time, and the different styles or approaches that are used and how effective the process is. A recent systematic
1,351 citations
TL;DR: Although the number of reports analyzed in this meta-analysis is small, these results show that SBME with DP is superior to traditional clinical medical education in achieving specific clinical skill acquisition goals.
Abstract: Purpose This article presents a comparison of the effectiveness of traditional clinical education toward skill acquisition goals versus simulation-based medical education (SBME) with deliberate practice (DP). Method This is a quantitative meta-analysis that spans 20 years, 1990 to 2010. A search strategy involving three literature databases, 12 search terms, and four inclusion criteria was used. Four authors independently retrieved and reviewed articles. Main outcome measures were extracted to calculate effect sizes.
1,311 citations
TL;DR: Internet-based learning is associated with large positive effects compared with no intervention and with non-Internet instructional methods, suggesting effectiveness similar to traditional methods.
Abstract: Context The increasing use of Internet-based learning in health professions education may be informed by a timely, comprehensive synthesis of evidence of effectiveness. Objectives To summarize the effect of Internet-based instruction for health professions learners compared with no intervention and with non-Internet interventions. Data Sources Systematic search of MEDLINE, Scopus, CINAHL, EMBASE, ERIC, TimeLit, Web of Science, Dissertation Abstracts, and the University of Toronto Research and Development Resource Base from 1990 through 2007. Study Selection Studies in any language quantifying the association of Internet-based instruction and educational outcomes for practicing and student physicians, nurses, pharmacists, dentists, and other health care professionals compared with a no-intervention or non-Internet control group or a preintervention assessment. Data Extraction Two reviewers independently evaluated study quality and abstracted information including characteristics of learners, learning setting, and intervention (including level of interactivity, practice exercises, online discussion, and duration). Data Synthesis There were 201 eligible studies. Heterogeneity in results across studies was large (I2 ≥ 79%) in all analyses. Effect sizes were pooled using a random effects model. The pooled effect size in comparison to no intervention favored Internet-based interventions and was 1.00 (95% confidence interval [CI], 0.90-1.10; P Conclusions Internet-based learning is associated with large positive effects compared with no intervention. In contrast, effects compared with non-Internet instructional methods are heterogeneous and generally small, suggesting effectiveness similar to traditional methods. Future research should directly compare different Internet-based interventions.
1,241 citations
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TL;DR: This study has been able to establish the face, construct and content validity of the simulator and the potential for it to be an effective training tool.
Abstract: Background: Conventional training in bronchoscopy involves a trainee performing on a real patient under supervision. This method of training is not only expensive, but there is also
83 citations
TL;DR: While performance improved in VR, transfer of skill from VR to physical reality was not observed, and additional development and testing of VR as a training tool is warranted before its widespread use can be recommended.
Abstract: Background: Virtual reality (VR) is a potential tool for technical skills training. We tested the validity and instructional effectiveness of a prototype VR module for learning intravenous (IV) catheter placement. Methods: First-year medical students (n = 37), third-year medical students (n = 14), and surgical residents (n = 9) attempted two pretest IVs into each other, used the VR module for 12 minutes, and subsequently attempted two posttest IVs. Success or failure were recorded for each attempt. For each successful attempt, time and global rating of IV insertion were also recorded. Results: The pretest success rate was significantly different between groups (chi square=28.71, P 2,57 = 1.47, ns). Although there was improvement in all groups during VR training (F 2,114 = 44.16, P Conclusions: Significant differences between groups were observed in performance of IV insertion in physical reality. However, no significant difference was observed in performance in VR. Thus, performance in VR demonstrated neither construct nor concurrent validity. While performance improved in VR, transfer of skill from VR to physical reality was not observed. Additional development and testing of VR as a training tool is warranted before its widespread use can be recommended.
83 citations
TL;DR: Results show the new assessment measures provide an objective, reliable, and valid method of assessing students' physical examination techniques on the pelvic exam simulator.
83 citations
TL;DR: It is demonstrated that trainees who undergo a graduated training programme using simulators are initially more successful at awake fibreoptic nasotracheal intubation than those who have learned in the traditional manner.
Abstract: This study compared a graduated training programme with that of a traditional teaching method to facilitate the learning of the technique of fibreoptic nasotracheal intubation. Thirty-two anaesthesia trainees were randomly assigned to two groups. The graduated programme involved: practice on a bronchoscopy teaching model: exposure of the epiglottis and vocal cords in patients recovering from general anaesthesia; performance of fibreoptic nasotracheal intubation in awake sedated patients. The traditional programme involved: demonstration (on a patient) of one fibreoptic nasotracheal intubation by the instructor; performance of fibreoptic nasotracheal intubation (by the trainee) in awake sedated patients. Nasotracheal intubation was accomplished significantly more often by the trainess in the graduated programme (86 out of 96 (89.6%) v. 64 out of 96 (66.5%) (P
81 citations
TL;DR: This investigation aimed to explore the measurement properties of scores from a patient simulator exercise with a focus on the response of the immune system to treatment-related errors.
Abstract: Purpose This investigation aimed to explore the measurement properties of scores from a patient simulator exercise.
Methods Analytic and holistic scores were obtained for groups of medical students and residents. Item analysis techniques were used to explore the nature of specific examinee actions. Interrater reliability was calculated. Scores were contrasted for third year medical students, fourth year medical students and emergency department residents.
Results Interrater reliabilities for analytic and holistic scores were 0·92 and 0·81, respectively. Based on item analysis, proper timing and sequencing of actions discriminated between low- and high-ability examinees. In general, examinees with more advanced training obtained higher scores on the simulation exercise.
Conclusion Reliable and valid measures of clinical performance can be obtained from a trauma simulation provided that care is taken in the development and scoring of the scenario.
80 citations