Simulation in healthcare: A taxonomy and a conceptual framework for instructional design and media selection

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Practice points

Simulation in healthcare is not a monolithic concept and includes vastly different educational experiences. An educational activity using healthcare simulation can be described through a framework consisting of four levels: instructional medium, simulation modality, instructional method, and presentation. The “zone of simulation matrix” identifies those events that are best adapted for simulation learning. The framework identifies four different simulation modalities: procedural simulation, computer-based simulation, simulated clinical immersion, and SP, with the added methodology of hybrid simulations. Each is best suited for specific competency domains or learning outcomes. “Presentation” describes the low-level details that can affect the design of an educational activity. It includes elements related to feedback, fidelity (realism), choice of simulator type, scenario design, and team composition.

Figure 1. The levels of ID for an educational experience using healthcare simulation. Each progressive level constitutes the building blocks for the level directly above it.

Figure 2. The zone of simulation matrix. The model is based on two characteristics of clinical situations, acuity (severity) and opportunity (frequency) that define four areas of varying dynamics. The zone of simulation identifies those situations where healthcare simulation may be advantageous over other instructional media.

Figure 3. The four simulation modalities, which are broad descriptions of the simulation experience. Modalities show areas of overlap that constitute hybrid simulations.

Table 1  Description of the simulation modalities that constitute level 2 of the ID framework

Simulation modality	Description
Computer-based simulation	Simulation modality in which the user interacts with the simulation through a screen-based interface. It can be used for a variety of learning outcomes.
Hybrid simulation	Simulation experience that combines two or more simulation modalities.
Procedural simulation	Simulation modality in which a simulator allows training of specific psychomotor skills and their associated procedures.
Simulated clinical immersion	Simulation modality in which the environment, real or simulated, plays an important role and reproduces the actual clinical or work environment. The experience may involve actors, patients or patient simulators. It is typically used for training in patient management, clinical diagnosis, and patient safety competencies.
Simulated patient	Simulation modality in which an actor, a patient, or a patient simulator plays the role of an actual patient (also called standardized patient). It is typically used for training in patient management, clinical diagnosis and affective objectives.

Table 2  Important elements of presentation for simulation experiences, along with their major characteristics and descriptors

Presentation element	Characteristic	Descriptors
Feedback	Type	Outcome feedback: Knowledge of the results or outcomes of the individuals’ actions. Process feedback: Feedback providing descriptive information of the processes performed and required, aimed at facilitating learning.
	Source	The task itself: Feedback provided by the simulator responding realistically to trainees’ actions (natural feedback) or expanded to convey additional information (augmented feedback). An observer (expert-directed feedback): Feedback provided by an external subject-matter expert having observed the performance. This often takes place during debriefing sessions. Other learners (peer feedback): Feedback provided by other learners involved in the educational experience. The learner (self-feedback): Self-assessment of one's performance
	Timing	Synchronous: Feedback provided during simulation Immediate: Feedback provided immediately after simulation Delayed: Feedback provided after a delay
Fidelity	Patient (physical) fidelity	Describes how closely the patient feature reproduced in the simulation matches the “real world” feature. Two metrics can be used to measure and report patient fidelity. Resolution: Whether a required feature from the real world is reproduced in simulation. Accuracy: The degree to which a feature of real world is adequately reproduced in simulation.
	Environment fidelity	Describes how closely the environment feature reproduced in the simulation matches the “real world” feature. Two metrics can be used: resolution and accuracy.
	Temporal fidelity	Describes how closely time flows in the simulation compared to reality. Two metrics can be used: resolution and accuracy.
Simulator type	See Table 3
Scenario	Design
Team	Composition	Actors Single discipline Interdisciplinary (interprofessional) Work unit
Other	Duration of training sessions
	Intervals of training sessions
	Location	Dedicated setting In situ

Table 3  Descriptions and examples of available simulator types

Type of simulator	Description	Example
Actor	An individual who takes on a specific role during a simulation session. An actor can be a paid individual, a confederate, or another learner (role-playing).	A paid individual that plays the role of a family member during a simulation session on communication skills.
Computer (or web) application	A computer-based program, delivered either locally or through the Internet, that reproduces, in whole or in part, actual systems or equipment.	Virtual Anesthesia Machine (University of Florida)
Organic	A procedural simulator that uses organic material for skills training.	Animals Human cadavers Organic tissue
Part-task trainer	A synthetic simulator that replicates specific components of a patient or a system, for skills training.	TraumaMan System (Simulab Corporation) Advanced Catheterization Trainer (Limbs & Things)
Patient	An actual patient who takes on his or her own role during a simulation session.
Patient simulator	A life-size mannequin representing a patient, which can simulate several behaviors and characteristics of an actual patient.	iStan® (CAE Healthcare) SimMan® 3G (Laerdal Medical) Noelle® (Gaumard Scientific)
Virtual patient	A computer-based program that allows the learner to interact with a pre-programmed patient through a screen-based interface (i.e., computer screen)
Virtual reality	A synthetic simulator used for skills training, which provides the learner with a realistic interface and outputs the results through a computer.	Virtual I.V.™ (Laerdal Medical) LAP Mentor™ (Symbionix)
Virtual world	A computer-based program that allows the learner to be immersed, through a screen-based interface (i.e., a computer screen), in the digital recreation of an environment or setting. The learner often interacts with the simulation through a digital persona, or “avatar”.	Second Life® (Linden Lab) Massively Multiplayer Online Games (MMOG) Virtual ED (Stanford University)

Table 4  Adaptation of simulation modalities to specific learning outcomes domains

	Simulated clinical immersion	Procedural simulation	Computer-based simulation	SP
Rote knowledge	–	+	+++	+
Techniques and procedures	+	+++	++	+
History, physical exam and patient counseling	+	–	+	+++
Clinical reasoning and patient management	+++	–	++	+++
Teamwork and crisis management (patient safety competencies)	+++	–	++	+
Ethics and beliefs	++	+	+	++

Note: – not adapted; + weakly adapted; ++ moderately adapted; +++ strongly adapted.

Figure 4. Media and simulation modalities selection chart A (continued in Figure 5). Diamond shapes correspond to key decision points (questions). Rectangles with dark borders correspond to appropriate media and simulation modalities. Text in red and bold corresponds to preferred modalities. AND/OR decision points suggest that several competency domains can be considered at the same time (potentially leading to the use of hybrid modalities). CBS: Computer-Based Simulation; pt: Patient; SCI: Simulated Clinical Immersion; SP: Simulated Patient; VR: Virtual Reality.

Figure 5. Media and simulation modalities selection chart B (continued from chart A in Figure 4). Diamond shapes correspond to key decision points (questions). Rectangles with dark borders correspond to appropriate media and simulation modalities. Text in red and bold corresponds to preferred modalities. AND/OR decision points suggest that several competency domains can be considered at the same time (potentially leading to the use of hybrid modalities). CBS: Computer-Based Simulation; PE: Physical exam; Hx: History; pt: Patient; SCI: Simulated Clinical Immersion; SP: Simulated Patient.