Simulation Learning

Learning happens on a continuum. Understanding the foundational theories that inform SBE allows facilitators to plan effective simulation experiences using appropriate methods, and to respond in effective ways if participants have trouble. We will briefly highlight some of the foundational learning theories that underpin SBE.

Simulation learning is not intended to introduce brand new concepts. It is most applicable when learners start to pilot developing knowledge and skills in their practice, when they evaluate their skills to improve them, and eventually when they embed their skills into practice.

Simulation-based education methods are highly consistent with the principles of adult learning. Learning is mainly self-directed, guided by facilitators. Learners are expected to draw on their own experience to accomplish a task. SBE plays to the internal motivations of the learners by presenting realistic scenarios where learners see the direct benefit of their learning.

Experiential simulation learning builds on Kolb’s (1984) experiential learning theory (ELT): knowledge is built through the transformation of experience.

Adapted from: Figure 1. Learning Cycle based on Kolb Experiential Learning Theory, by Seyed Masoud Hosseini, Hamideh Amery, Ali Emadzadeh, & Saber Babazadeh, licensed CC BY 4.0.

SBE creates space for learners at all points of the cycle and across the continuums outlined by Kolb’s ELT. It gives learners a concrete experience to feel and observe, and the opportunity to think through a process or experiment through trial and error. SBE allows learners to practice in a safe environment where they can make mistakes, learn from mistakes, and develop confidence in their ability to care for patients. This occurs without risk to real patients as they are practicing in a simulated care environment (Jeffries et al., 2016).

It is important to consider Cognitive Load Theory during the planning process of SBE. Cognitive Load Theory proposes that working memory can only process a certain amount of new information at a given time. (Reedy, 2015). If used appropriately, the SBE should build on the base knowledge of the learner and focus on problem solving related to only a few specific objectives at a time. Facilitators should avoid surprising learners with irrelevant information or distractors, which may derail them from achieving the intended outcomes. For example, an SBE related to an entry level skill such as IV insertion might not require a high-fidelity mannikin and monitors with numerous alarms.

In simulation-based education, traditional psychomotor skills training has evolved to become what is known as procedural skills training in labs. Task trainers, manikins and simulated patients are used to teach psychomotor skills along with other foundational skills such as safety and effective communication skills. The use of simulation for procedural skills training allows learners to practice skills in a safe, simulated environment, to make mistakes and to receive feedback to improve performance (Billings & Halstead, 2016; Hawley, J., & Fagan, B. 2019). Simulation also provides learners with the opportunity to learn high acuity, low opportunity (HALO) procedural skills, which they may rarely be exposed to in clinical practice.

Skill development occurs in a continuum as novice learners learn to interpret their environment and use its context to inform and guide their actions. This concept is backed by some theories like Benner’s Novice to Expert theory and the Dreyfus model of skills acquisition which discuss how learners gain new skills and knowledge from novice to expert stage (Benner, 2001; Thomas & Kellgen, 2017).

According to Benner’s conceptual framework, novice-learners tend to apply new knowledge inflexibly and linearly without considering the context from the environment. As learners progress from novice to expert, they learn to organize clinical situations based on relevance and importance and with more analytical and abstract thinking. This promotes critical thinking, better decision making and improved patient care. Using Benner’s theory as a framework when designing simulations provides learners with a levelled approach to skills development, which increases the potential for optimal patient care in clinical practice (Brien et al., 2023).

Figure 12.6 Transitioning to the PN Role, from Health Alterations by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License.

Simulation also facilitates procedural skills integration and mastery learning in healthcare education by providing opportunities for deliberate practice. Evidence shows that deliberate practice is an effective educational strategy that improves both skills and clinical competence and is an alternative to traditional methodology for skills mastery (Gonzalez & Kardong-Edgren, 2017).

Watch this video on deliberate practice:

  Deliberate Practice: Achieve Mastery in Anything

SBE facilitators should incorporate the deliberate practice model because it helps users to progress from novice to mastery of practice through intentional repetition of skills. Mastery of clinical skills should emphasize continuous reflection and skilled facilitators or peers should provide immediate, frequent, and meaningful feedback.

Rapid cycle deliberate practice (RCDP), introduced by Hunt and colleagues in 2014, takes the concepts of deliberate practice and mastery learning a step further. In SBE, this technique includes debriefing sessions which are rapidly cycled between repeated deliberate practice and directed formative feedback until learners master the required skills (Hunt et al., 2014). These practice models can be applied to more basic skills, such as donning and doffing personal protective equipment, or to more complex ones such as acting as team leader in advanced life support training.

Original Nova Scotia Health graphic based on: Gonzalez & Kardong-Edgren, 2017.

Repetition with meaningful feedback is important, but personal reflection is necessary to consolidate learning. Reflection is a process of learning by reviewing experiences and forms an integral part of skills development in SBE (Mezirow, 1997). Relating back to Kolb’s ELT, learners acquire knowledge by reflecting on their actions, processing this reflection, and planning how this experience might apply in future situations. The use of a structured model of reflection during simulations and clinical practice is important in enhancing skills development (Wain, 2017). This explains why the debriefing phase of an SBE is so crucial.

Simulations use a constructivist learning approach in which a learner is provided opportunities to compare their prior learning, experiment and expand their understanding by using new knowledge and skills during the simulation, and then reflect to construct their own knowledge and meaning from the experience (Brandon & All, 2010). This reflection can be done individually, but Vygotsky’s Social Learning Theory highlights the value of reflection on simulation experiences as a group. This theory suggests that social interaction is central to learning experiences. Learners draw on the experiences of others, in addition to their own, to master a skill.

Gibbs' Reflective Cycle is a commonly used cyclical model of reflection that explores 6 stages of an experience:

• Description
• Feelings
• Evaluation
• Analysis
• Conclusion
• Action plan

Most debriefing models mirror Gibbs' Reflective Cycle.