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Journal ArticleDOI

Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review

01 Jan 2005-Medical Teacher (Taylor & Francis)-Vol. 27, Iss: 1, pp 10-28
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 The aim was to perform the most thorough literature search possible of peer-reviewed publications and reports in the unpublished literature that have been judged for academic quality.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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Citations
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Journal ArticleDOI
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

Journal ArticleDOI
07 Sep 2011-JAMA
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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Journal ArticleDOI
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

Journal ArticleDOI
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

Journal ArticleDOI
10 Sep 2008-JAMA
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

References
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Journal ArticleDOI
08 Oct 2003-JAMA
TL;DR: Excess length of stay attributable to medical injuries ranged from 0 days for injury to a neonate to 10.89 days for postoperative sepsis, excess charges ranging from 0 dollar for obstetric trauma (without vaginal instrumentation) to 57 727 dollars for post operative sepsi, and excess mortality ranged from0% for obstetrical trauma to 21.96% for postoperatively-related deaths.
Abstract: ContextAlthough medical injuries are recognized as a major hazard in the health care system, little is known about their impact.ObjectiveTo assess excess length of stay, charges, and deaths attributable to medical injuries during hospitalization.Design, Setting, and PatientsThe Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) were used to identify medical injuries in 7.45 million hospital discharge abstracts from 994 acute-care hospitals across 28 states in 2000 in the AHRQ Healthcare Cost and Utilization Project Nationwide Inpatient Sample database.Main Outcome MeasuresLength of stay, charges, and mortality that were recorded in hospital discharge abstracts and were attributable to medical injuries according to 18 PSIs.ResultsExcess length of stay attributable to medical injuries ranged from 0 days for injury to a neonate to 10.89 days for postoperative sepsis, excess charges ranged from $0 for obstetric trauma (without vaginal instrumentation) to $57 727 for postoperative sepsis, and excess mortality ranged from 0% for obstetric trauma to 21.96% for postoperative sepsis (P<.001). Following postoperative sepsis, the second most serious event was postoperative wound dehiscence, with 9.42 extra days in the hospital, $40 323 in excess charges, and 9.63% attributable mortality. Infection due to medical care was associated with 9.58 extra days, $38 656 in excess charges, and 4.31% attributable mortality.ConclusionSome injuries incurred during hospitalization pose a significant threat to patients and costs to society, but the impact of such injury is highly variable.

1,036 citations


"Features and uses of high-fidelity ..." refers background in this paper

  • ...For example, Stephen J. Lurie, former Senior Editor of the Journal of the American Medical Association, recently published an essay titled, ‘Raising the passing grade for studies of medical education’ (Lurie, 2003)....

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  • ...…the US Institute of Medicine’s To Err is Human (Kohn et al., 1999) and a subsequent empirical study reported in the Journal of the American Medical Association (Zahn & Miller, 2003), have drawn attention to the perils of healthcare systems worldwide (Barach & Moss, 2002; Brennan et al., 1991)....

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  • ...Medical errors, patient safety and team training Recent studies and reports, including the US Institute of Medicine’s To Err is Human (Kohn et al., 1999) and a subsequent empirical study reported in the Journal of the American Medical Association (Zahn & Miller, 2003), have drawn attention to the perils of healthcare systems worldwide (Barach & Moss, 2002; Brennan et al., 1991)....

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Journal ArticleDOI
TL;DR: The OSATS demonstrates high reliability and construct validity, suggesting that it can effectively measure residents' technical ability outside the operating room using bench model simulations.
Abstract: Background A new approach to testing operative technical skills, the Objective Structured Assessment of Technical Skill (OSATS), formally assesses discrete segments of surgical tasks using bench model simulations. This study examines the interstation reliability and construct validity of a large-scale administration of the OSATS. Methods A 2-hour, eight-station OSATS was administered to 48 general surgery residents. Residents were assessed at each station by one of 48 surgeons who evaluated the resident using two methods of scoring: task-specific checklists and global rating scales. Results lnterstation reliability was 0.78 for the checklist score, and 0.85 for the global score. Analysis of variance revealed a significant effect of training for both the checklist score, F(3,44) = 20.08, P Conclusions The OSATS demonstrates high reliability and construct validity, suggesting that we can effectively measure residents' technical ability outside the operating room using bench model simulations.

1,020 citations

Journal ArticleDOI
01 Sep 1999-JAMA
TL;DR: Some benefits of simulation technology include improvements in certain surgical technical skills, in cardiovascular examination skills, and in acquisition and retention of knowledge compared with traditional lectures.
Abstract: Changes in medical practice that limit instruction time and patient availability, the expanding options for diagnosis and management, and advances in technology are contributing to greater use of simulation technology in medical education. Four areas of high-technology simulations currently being used are laparoscopic techniques, which provide surgeons with an opportunity to enhance their motor skills without risk to patients; a cardiovascular disease simulator, which can be used to simulate cardiac conditions; multimedia computer systems, which includes patient-centered, casebased programs that constitute a generalist curriculum in cardiology; and anesthesia simulators, which have controlled responses that vary according to numerous possible scenarios. Some benefits of simulation technology include improvements in certain surgical technical skills, in cardiovascular examination skills, and in acquisition and retention of knowledge compared with traditional lectures. These systems help to address the problem of poor skills training and proficiency and may provide a method for physicians to become self-directed lifelong learners.

884 citations


"Features and uses of high-fidelity ..." refers background or methods in this paper

  • ...The multimedia intervention engaged the medical students in deliberate practice of cardiology bedside skills using 10 computer-based teaching modules linked to the ‘Harvey’ cardiology patient simulator (Issenberg et al., 1999b)....

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  • ...…has placed increased reliance on simulation technology in the last two decades to boost the growth of learner knowledge, provide controlled and safe practice opportunities and shape the acquisition of young doctors’ clinical skills (Issenberg et al., 1999a; Gaba, 2000; Fincher & Lewis, 2002)....

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  • ...A recent cohort study conducted at five academic medical centers (Duke, Emory, Miami, Mt. Sinai, Northwestern) illustrates the utility of deliberate practice in medical education (Issenberg et al., 1999b)....

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  • ...The cost effectiveness of simulation-based medical education has been addressed in many other reports (e.g. Gaba, 2000; Issenberg et al., 1999, 2002) that frequently make a strong case about the costs of not using simulation technology in medical education....

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  • ...Simulations are becoming an integral part of medical education at all levels (Issenberg et al., 1999a; Gaba, 2000)....

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Book
01 Nov 1994

872 citations

Journal ArticleDOI
TL;DR: The Cochrane Collaboration has evolved in response to this challenge and will eventually cover all areas of health care and contributors in many countries and specialties are preparing and maintaining systematic reviews of RCTs, and reviews of other evidence when appropriate.
Abstract: In an influential book published more than twenty years ago, Archie Cochrane drew attention to our great collective ignorance about the effects of health care, and explained how evidence from randomized controlled trials (RCTs) could help us to use resources more rationally. He recognized that people who want to take more informed decisions about health care do not have ready access to reliable reviews of the available evidence. In 1979, he wrote: "It is surely a great criticism of our profession that we have not organised a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomised controlled trials." The Cochrane Collaboration has evolved in response to this challenge and will eventually cover all areas of health care. Contributors in many countries and specialties are preparing and maintaining systematic reviews of RCTs, and reviews of other evidence when appropriate. These reviews will be disseminated using electronic media through the Cochrane Database of Systematic Reviews.

672 citations