Simulation benefits learners. Today’s learners have had wide exposure to communication technology through high-speed computers, the Internet, and smartphones. Given this exposure and the learners’ expertise in its use, they are receptive and generally excited about educational experiences involving simulated situations because they offer a more active process and employ state-of-the-art technology.

Studies indicate that simulation improves learning [3, 4]. Simulation is especially effective in developing skills in procedures that require eye–hand coordination and ambidextrous maneuvers, such as laparoscopy and the use of fiber-optic airway scopes. Simulation training prepares learners to deal with unforeseen medical events, improves teamwork and communication skills, and increases confidence and performance.

Simulation benefits educators. At present, medical education focuses on outcome and competency. A growing body of research suggests that a combination of evaluation methods is necessary to properly assess the complex skills that constitute the practice of medicine [5–7]. Testing students with oral and written examinations may demonstrate knowledge acquisition, but testing with simulation shows that a student knows how to care for patients [8]. Simulation has the advantage of being able to assess measures, such as teamwork and professionalism, that are otherwise difficult to evaluate.

Simulation benefits hospitals. Medical institutions have enacted safe medical practices at all levels within their systems, and professional organizations have endorsed simulation-based training [9, 10]. SBME helps achieve these mandates. Procedural training using simulation decreases infection rates; increases students’ competence measured, as measured in the learning laboratory and during patient care delivery; and improves patient outcomes, as measured quantitatively [11, 12].

Simulation engages learners in a real-time and interactive format that provides opportunity for unlimited practice and allows mistakes to be made without harming an actual patient. This idea of deliberate practice, which originated from psychologist K. Anders Ericsson, is well known and studied [13–17]. Deliberate practice is demanding for learners, and it is an important principle of SBME. When used for medical education, it has the following requirements [18]:

Mannequins

Mannequins come in various shapes and sizes and can serve different purposes, including replication of the birthing process and imitation of an infant in distress secondary to congenital heart disease. Fidelity describes the extent to which the appearance and behavior of the mannequin imitate the appearance and behavior of an actual patient [19, 20].

The particular skills or learning objectives that are being taught dictate the type of simulator and level of fidelity that are necessary for a particular scenario. If the learning objective is to emphasize the timing and depth of chest compressions in a resuscitation scenario in an adult, a low-fidelity mannequin such as Resusci Anne® (Laerdal, Stavanger, Norway) can be used. This mannequin has limited responsiveness to learners’ interventions (i.e., it cannot demonstrate a return of spontaneous circulation if chest compressions are applied appropriately). If the objective is to have learners recognize when an arrhythmia becomes a cardiac arrest through loss of the pulse, then a higher-fidelity mannequin should be used. An example is SimMan® (Laerdal, Stavanger, Norway), a computer-driven mannequin that can simulate physical signs of cardiopulmonary management and provide feedback for learner interventions (e.g., produces tactile pulses).

Computer-Based Simulators

Screen-based simulation allows learners to participate in decision-making scenarios at their own pace, without an instructor. These commercially available programs cover a wide range of topics, from basic science to trauma and bioterrorism.

Patient–Actors (Standardized Patients)

They are trained individuals who are paid to participate in medical scenarios. They can contribute to the evaluation of the student’s history taking, understanding of the physical examination, and interpersonal and communication skills. The Association of Standardized Patient Educators holds annual conferences and promotes research and standards.

Part Task Trainers

These 3D devices simulate a specific task and give varying levels of feedback to the learner. For example, venipuncture arms, lumbar puncture trainers, and urinary catheterization devices may have only a sense of tactile feedback, whereas laparoscopy or endoscopy devices have computerized feedback incorporating haptic technology (touch and pressure) so that learners can learn eye–hand coordination as well as obtain the feel of the procedure.

The educational needs of your learners should be the primary consideration when creating a simulation curriculum. What do you want to teach? Do you need to use simulation for the acquisition of cognitive skills, technical skills, and interpersonal and communication skills, or perhaps all three? Determining your educational objectives is the single most important step toward identifying the resources that are needed to create a simulation program for your learners.

If your educational objectives are primarily cognitive, then problem-based or case-based learning can be an extremely effective way to teach. However, for the teaching of higher-order cognitive skills, such as critical assessment and management, a low- or high-fidelity human patient simulator (HPS) will be better able to meet your learning objectives [21]. The type and fidelity of mannequin should be based on the resources available and on the clinical case scenario being presented. For example, a child-sized mannequin would be most appropriate in a scenario calling for the resuscitation of a child.

When developing a case scenario to teach cognitive skills, it is important to consider the skill level of your learners. For example, novice learners should be able to manage a case scenario that simulates a straightforward asthma exacerbation, whereas advanced learners should be able to treat an asthma exacerbation with respiratory failure, requiring intubation and subsequent ventilator management. The amount of time to be allotted to the case scenario should be predetermined so that all learning objectives can be covered in the allotted time. Learners will not always react to the simulation in a predicted way, so cues should be offered throughout the scenario to ensure that it is progressing as designed. Cues can come from the HPS, actors, or the preceptor.

Feedback has been cited as the most important variable in simulation for fostering effective learning [25]. There are two broad types of feedback: formative and summative. Generally, debriefing takes the form of formative feedback because we want to improve performance rather than evaluate the learner’s actions as pass or fail (summative).

Rudolph et al. [26] designed a succinct four-step model for effective debriefing.