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Training using medical simulation
  1. David J Grant1,2,
  2. Stephen C Marriage1
  1. 1Department of Paediatric Intensive Care, Bristol Royal Hospital for Children, Bristol, UK
  2. 2Bristol Paediatric Simulation Programme, Bristol Medical Simulation Centre, Bristol, UK
  1. Correspondence to Dr David Grant, Department of Paediatric Intensive Care, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8AE, UK; david.grant{at}


As the time available for medical education is shortened by reductions in training hours and the demands of modern healthcare delivery, educators are increasingly looking towards simulation as a means of providing safe and reproducible situations for clinical skills teaching, decision-making and team training. The tools available for simulation-based training have developed rapidly over the past 15 years. There is an increasing range of manikins and part-task trainers – devices that permit selected elements of a skill or task to be practised independently of a whole-body manikin. Those interested in simulation have also focused significantly on adult learning theory to ensure that the training offered through simulation is appropriate, effective and complementary to other educational approaches. By mapping simulated scenarios to the Royal College of Paediatrics and Child Health Curriculum for General Paediatric Training at Level 1, the authors have developed two complementary courses aimed at preparing the general paediatric trainee for progression to the middle grade role. It is hoped that such approaches will become integral to paediatric training in the future.

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Practical aspects of medical training have traditionally relied on an apprenticeship model for educating physicians. This form of experiential learning, or ‘learning by doing’, has dominated the culture of applied training throughout the world. However, traditional apprenticeship models in all sectors of healthcare training have increasingly been challenged by changes in healthcare delivery models and by reductions in training hours.1 2

In order to address some of these issues, during the past two decades there has been a rapid growth in the use of simulation-based educational methods for both undergraduate and postgraduate level healthcare training. Simulation training offers a controlled, safe and reproducible environment in which to practise clinical interventions and skills3,,6 and to improve performance in actual clinical situations.7 Recent studies have demonstrated, in some circumstances, that simulation can be more effective in preparing medical trainees to achieve proficiency in clinical skills than the traditional experiential methods.8,,10

Although training programs increasingly use simulation technology for delivery of training in critical skills, the use of simulators is not yet a standard component of general paediatric educational programmes.11 Likely reasons for this include a belief that traditional educational approaches have been successful – and are therefore sufficient – and a lack of equity in access to simulation facilities. Nevertheless, demands for the integration of simulation as an adjunct to the field of paediatric training date back many years.12 Over the past decade, an increasing recognition of the potential of simulation has led to calls from within the Royal College of Paediatrics and Child Health (RCPCH) to adopt simulation techniques as a tool in the education of paediatric trainees.13 14 In 2008 the UK Chief Medical Officer, Sir Liam Donaldson, chose to highlight simulation as offering “an important route to safer care for patients which… needs to be more fully integrated into the health service”.15

The development of medical simulation

The development of modern medical simulation as an educational tool can be viewed as a result of the synthesis of three separate strands: the recognition of the need for practical training, changes in the methods of medical education, and technological developments leading to the manufacture of affordable physiological simulators.

Simulated practical training can trace its origins to the development of manikins used in the teaching of basic life support and resuscitation. Over the years, other trainers have been introduced to teach more advanced skills such as intubation and the establishment of vascular access, and more sophisticated part-task trainers have been developed to address specific learning needs, such as laparoscopic surgical trainers and birthing simulators. Accumulating evidence demonstrates that the repetitive practice of skills leads to enhanced performance in the clinical environment.

Changes in the provision of medical education have also driven the growth of simulation. There has been international recognition of the fact that the rapid growth of information required of the modern medical practitioner, combined with reduced opportunities for clinical exposure, has led to a need for innovative methods to teach, practise and develop non-technical skills. Traditional educational methods such as lectures, seminars and tutorials all focus on the acquisition of scientific knowledge, whereas training in other areas of the curriculum such as patient care, technical abilities, interpersonal and communication skills, team working and professionalism, have traditionally been taught by example, largely through peripheral participation in clinical situations. As clinical exposure has been lessened by restrictions on the duration of medical training and hours of work, there has been a gradual recognition that some of these areas of training have become neglected.16 As a result, they are often performed badly and contribute a significant proportion of all medical errors.17

Third, the development of sophisticated mechanical simulators has allowed medical educators to develop innovative teaching methods and materials. Originally produced to address learning needs within the anaesthetic community, such manikins either have an internal physiology that allow them to respond directly to user intervention, or have life-like attributes (such as breath and heart sounds, arterial pulses and chest movement) which allow the educator to create quasi-realistic clinical scenarios.

As each area has progressed, educators have blended approaches central to these three strands to address the learning needs of modern-day trainees and clinicians. Simulation is not just used to teach resuscitation skills; many experienced simulators now give equal prominence to the behaviours and actions which result in the under-performance of all aspects of good medical care and are explicit in attempting to change attitudes and ways of acting. Increasingly, simulation is being taken into the workplace – so called in situ simulation – to teach key medical concepts and to explore concerns highlighted directly by clinical concerns (figure 1).

Figure 1

Simulated clinical scenario involving the acute management of an infant who has sustained a head injury in a road traffic collision. The manikin has been mocked up with a cervical collar, emergency tape and bags, has been intubated and has had intravenous access established.

The effectiveness of medical simulation

The rapid adoption of simulation technology as a result of these developments has not been without question. One consistent concern, raised by proponents and critics of the new technology alike, is whether simulation can be demonstrated to be effective. Issenberg and colleagues have comprehensively reviewed the published simulation literature in depth and concluded that there is sufficient evidence to show that high-fidelity medical simulations do facilitate learning when used in the right conditions.18 These conditions, which Issenberg acknowledges to be ideals and difficult to achieve in all circumstances, are listed in box 1.

Box 1

Conditions that facilitate learning in the simulated environment18

  • Provision of feedback: educational feedback is the most important feature of simulation-based medical education

  • Repetitive practice

  • Curriculum integration

  • Range of difficulty level

  • Utilisation of multiple learning strategies

  • Capture of clinical variation

  • Control of the environment

  • Individualised learning, through active participation

  • Defined outcomes and educational objectives

  • Simulator validity

The overall conclusions suggested by the literature are that simulation is best used as a complementary educational strategy to enhance learning derived from direct patient contact. It is at its most effective when used as a preparatory mode of education prior to real patient contact and is a tool that needs to be integrated with other educational events including clinical exposure, seminars, tutorials, lectures and self-directed learning.

Educational theory

Traditional healthcare education uses a combination of learning techniques. First, learning occurs through the delivery of organised, formal, curricula centred on the educator as teacher. Used to teach basic and applied sciences, the method has been shown to be an effective modality for new learning of an intensive nature. The second component uses informal learner-centred education. Malcolm Knowles has described the five key features of adult learners (box 2). During informal learning, trainees are initiated into the traditions of the community of medical practitioners and the practice world they inhabit. Within this informal approach, the educator becomes the facilitator of learning rather than the teacher. This is useful for stimulating educational interest and providing the best opportunity for practising and refining the knowledge learnt in formal approaches.

Box 2

Knowles' key features of the adult learner 28

  • Is independent and self-directing (has self-concept)

  • Has accumulated a great deal of experience which is a rich resource for learning (experienced)

  • Values learning that integrates with the demands of their everyday life (readiness to learn)

  • Is more interested in immediate, problem-centred approaches than in the subject-centred ones (orientation to learning)

  • Is more motivated to learn by internal drives than by external ones (motivation to learn)

Informal learning takes two main forms. First, trainees can learn on their own, giving them the freedom to explore outside the constraints of received views. Self-directed learning has the disadvantage that they have to rediscover information at source, gaining nothing from the accumulated experience of their peers and experienced practitioners. Such autonomous learning may not be time efficient and has been criticised for risking knowledge gaps.19

Second, trainees learn through an apprenticeship model offering direct exposure to real conditions of practice and patterns of work. In traditional curricula this occurs most often during clinical ward rounds and in outpatient teaching. Such models often function through the principle of legitimate peripheral participation.20 Trainees' involvement is legitimate as inexperienced members of a ‘community of practice’, peripheral in that their engagement is initially by performing minor roles under the supervision of more advanced practitioners, and participatory in that they acquire knowledge through experiential rather than theoretical learning.

Accepted educational theory suggests that as adults we all have different preferred learning styles. Kolb described adult learning styles based on a perception continuum (experiential vs conceptual learner) and a processing continuum (reflective vs experimental learner).21 Although we may each have a preferred learning style, we all follow a cycle of learning. Simply put, the learner has an experience on which they reflect, before conceptualising and repackaging it internally prior to experimenting with it again. This leads to a new experience and so the cycle starts again.

Simulation-based education fits the Kolb learning cycle well. It allows the learner to experience an event and participate in facilitated reflection using effective debriefing techniques, before experimenting again. This setting lends itself to deliberate practice. The repeated performance of an intended cognitive or psychomotor skill in a focused domain, coupled with rigorous skill assessment, allows the learner to receive specific informative feedback and then to improve their performance in a controlled environment.

Evidence shows that simulation-based education complements, but does not duplicate, training involving real patients in clinical settings. Simulation-based education is best placed to prepare learners for real patients. It allows them to practise and acquire skills needed to care for patients and speeds their progression along the learning curve from novice to expert. Most medical errors occur due to systems failure rather than individual error and while traditional medical education has focused on individual learning of delivery of care to individual patients, it has not focused on the importance of teamwork and the development of safe systems. The controlled environment of the simulated scenario allows for such aspects of practice to become the focus of the resulting debriefing session.

Matching simulation to formal training requirements

In 2007, the RCPCH published a new curriculum for postgraduate medical education, which was approved by the Postgraduate Medical Education and Training Board. This curriculum was revised in 2010 and lists training requirements for paediatricians in all three training levels.22

A focus of Level 1 training is the ability to recognise, diagnose and manage a range of common paediatric presentations. Overall, 83% of medical acute attendances have been ascribed to one of six conditions: breathing difficulty, febrile illness, diarrhoea, abdominal pain, seizure and rash.23 The RCPCH guidance insists that workplace assessments at Level 1 must cover at least these six areas. However, the Curriculum for Paediatric Training General Paediatrics for Level 1 Training sets out additional competences trainees “should acquire” by the end of their training.22

In total, more than 800 competences are listed in the Curriculum for Paediatric Training, more than 500 (65%) of which are expected to be completed by the end of Level 1 training and 235 (45%) of which are listed as acute competences. Many of the competences listed are condition-specific, yet relate to presentations that occur infrequently and which have a time-critical aspect to their management. For example, trainees are expected to be able to “initiate” therapy in paroxysmal supraventricular tachycardia, in continuing seizures and in children presenting with raised intracranial pressure; “lead” resuscitation in children with acute diabetic ketoacidosis, septic shock and anaphylaxis; and “institute appropriate therapy” in acute severe asthma. Other key medical emergencies include croup, acute abdominal pain and the hyperkalaemia associated with acute renal failure.

Bristol Paediatric Simulation Programme: key competences and step-up courses

Key competences

In 2009, the Bristol Paediatric Simulation Programme developed a proposal for a simulation-based course, aimed at Level 1 paediatric trainees, which would address training needs in specific, acute areas of competence which were felt to be difficult to assess in normal clinical practice. In developing the course, a small group of interested clinicians reviewed the then current Curriculum for Paediatric Training (2007) and abstracted all the acute competences. Each was then reviewed by hand against agreed selection criteria: scenarios had to deal with acute time-critical situations, where key knowledge, skills and practical experience could directly affect patient outcome. Applicability for delivery of educational material within a simulated environment was considered as a second factor. A shortlist of potential clinical scenarios was developed which was considered by a group of four clinicians, each experienced in paediatric simulated scenario development. From this shortlist a final selection was made consisting of eight clinical presentations: seven were felt suitable for simulation and the eighth – diabetic ketoacidosis – for a blended approach involving an interactive slide-based workshop. These eight presentations – dubbed ‘key competences’ – are listed in box 3.

Box 3

Acute paediatric presentations covered by the key competences course

  • Paroxysmal supraventricular tachycardia

  • Prolonged seizures

  • Raised intracranial pressure

  • Acute diabetic ketoacidosis

  • Septic shock

  • Acute severe asthma

  • Acute upper airway obstruction

Having developed the course, scenarios and associated learning materials, a case was made to the School of Paediatrics within the local Severn Deanery with two underlying purposes: first, to embed key competences as a 1-day course within the locally-delivered training curriculum, such that it would be a required element of training for all Level 1 paediatric trainees within the region; and second, to obtain funding such that the course could be delivered without cost to the participants. The School of Paediatrics agreed funding and the course is now established within the local training programme. To date more than 70 trainees have undertaken the course, with direct exposure to each of the eight course elements. This ensures that over 500 direct training episodes have taken place, with each participant able to be involved directly in the management of time-critical medical emergencies. Feedback from the participants has consistently evaluated the course extremely highly as an educational method. In immediate anonymised post-course feedback, 97% of candidates evaluated the course as excellent or good. Candidates were encouraged to write general comments regarding their experience of the course. These observations were overwhelmingly positive, suggesting that the educational objectives of the course were met. This reflects the authors' previous experience, wherein participants' feedback in a similar simulated paediatric emergency course was formally evaluated. Using a five-point Likert scale, treated as interval-level data, responses were assigned values of 0–4, where four represented the highest perception of educational value. Analysis of over 730 assessments of individual scenarios showed that the mean rating for a variety of simulated scenarios was 3.50 for veracity and 3.54 for educational content.

Step-up to level 2 training

A second, complementary course for trainees has been developed in parallel with the key competences course. There is little published information on how paediatric trainees cope with the transition from Level 1 to Level 2 training (transition from senior house officer to specialist registrar) in the old training grades), although anecdotally many find anticipation of the step stressful and worrying. A published study of Dutch paediatric specialist registrars also found high levels of reported stress following the transition, the most important attributes of which were individual responsibility, fear of poor outcomes, and inadequate performance of required procedures. Significantly higher levels of stress were found in relation to the treatment of older children than with neonates.24

Step-up is a course that focuses on ‘crisis resource management’ and is offered to trainees immediately before transition to Level 2 training. Crisis resource management focuses on teamwork and behavioural issues, giving participants a greater awareness of the importance of effective communication, teamwork and situation awareness, with regard to crisis avoidance and management of resources. The Severn School of Paediatrics has again funded the course, which has run for the first time this year. Participants will be drawn from trainees who have already undertaken the key competences course and will therefore have had some exposure to simulation as an educational modality.

The future

Following the Chief Medical Officer's report in 2008, the Department of Health commissioned a study to inform the development of a vision of the appropriate use of simulation, set out within A High Quality Workforce.25 Among other things, it highlighted the considerable simulation resources that were already available to the 16 deaneries within the UK, largely within established simulator centres. However, the simulated clinical environment can only function reliably as a context for clinical learning if its outcomes can be transferred to the real clinical environment. The validity of the transfer depends on the fidelity with which the simulated clinical environment represents the real clinical environment.

There is emerging evidence that in some instances local, point-of-care delivery of simulation is more effective than simulation centre-based delivery.26 The authors believe that simulation education should be incorporated into all paediatric curricula at a local level to allow for team-based deliberate practice of high-risk, low-volume events. However, to ensure sustainability and the continued development of such local delivery programmes, it is of critical importance that simulation educators delivering local activities are supported by established simulation centres to ensure high quality and continuing faculty development and support.

The international simulation community have debated the role of simulation in assessment and revalidation for some time. In Israel simulation has been used in the assessment of regional anaesthetic techniques.27 Implementation of simulation as an assessment tool has been established in anaesthetic exams across the world. The Royal College of Anaesthetists (UK) has incorporated a simulation scenario into the Primary Fellowship of the Royal College of Anaesthetists OSCE assessment for several years as a non-scoring station. They found a strong correlation between the performance of candidates in the simulation station and the traditional scoring stations (personal communication, September 2009).

Our experience in running key competences courses is that trainees want to use the opportunities the course provides as a vehicle for assessment. Participants are given the opportunity to provide anonymised feedback at the end of each course and the majority feel that the situations are realistic enough to allow for assessments of directly observed practice and case-based discussion. However, it is the authors' belief that although there are some aspects of competence that may be better assessed in a simulated environment than by traditional methods, it is essential that a practitioner has achieved simulator competence (experienced in a simulated clinical environment) prior to assessment of clinical competence. Therefore, we believe that it is essential to embed simulation within all our other education delivery models, prior to embarking on the inclusion of simulation into assessment techniques.


The authors would like to acknowledge the central contribution made to the development of the key competences and step-up courses by Dr Patricia Weir and Dr Margrid Schindler.



  • Competing interests None.

  • Provenance and peer review Commissioned; externally peer reviewed.

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