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The growing trend of simulation as a form of clinical education: a global perspective

  • Hamad Medical Corporation Ambulance Service

Abstract and Figures

Simulation as a credible mode of advanced clinical education is becoming well established throughout Europe, North America, and Oceania; however, similar developments are becoming increasingly visible outside of these continents. Educational concepts using simulation are better understood when people see beyond the ‘tool’, however technologically advanced it might be (Alinier, 2007a) and start to recognize the importance of the ‘technique’ employed to use it (Gaba, 2004). Reported activities emerging from Africa and predominately Asia is continuing to grow. From psychiatry objective structured clinical examination (OSCE) training in Iran (Taghva et al, 2010); the use of virtual patient simulators in Japan (Taguchi and Ogawa, 2010); to using simulators to teach advanced cardiac life support (ACLS) to paramedics in India (Delasobera et al, 2010), simulation as a form of clinical education is advancing globally. This article aims to highlight the recent advancement of simulation through examples of workshops and research occurring outside of Europe, North America, and Oceania, and begins to highlight some of the current simulation education centre projects that are being planned across the globe. Categories of simulation within this article refer to simulation education using standardized patients, patient simulators, mannequins, part-task trainers, computer-based simulation, and virtual reality simulators, primarily used for surgical skills training. This article aims to give readers a glimpse into some of the projects and research that is occurring within simulation education outside of the western world.
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Davies J, Alinier G, 2011. The growing trend of simulation as a form of clinical
education: a global perspective. International Paramedic Practice, 1(2):58-62
The Growing Trend of Simulation as a form of Clinical Education.
A Global perspective
Joanne Davies, RM , IBCLC, MSc, Midwife and Simulation Consultant, Sidra Medical and Research
Center, Qatar.
Guillaume Alinier, MPhys, PGCert, MIPEM, MInstP, NTF, SFHEA, Program Manager – Simulation, Sidra
Medical and Research Center, Qatar, and Professor of Simulation in Healthcare Education, University
of Hertfordshire, UK.
For correspondence:
Simulation as a credible mode of advanced clinical education is becoming well established
throughout Europe, North America, and Oceania however similar developments are
becoming increasingly visible outside of these continents. Educational concepts using
simulation are better understood when people see beyond the “tool” however
technologically advanced it might be (Alinier, 2007a) and start to recognise the importance
of the “technique” employed to use it (Gaba, 2004). Reported activities emerging from
Africa and predominately Asia is continuing to grow. From psychiatry OSCE training in Iran
(Taghva et al. 2010), the use of virtual patient simulators in Japan (Taguchi and Ogawa,
2010), to using simulators to teach ACLS to paramedics in India (Delasobera et al. 2010),
simulation as a form of clinical education is advancing globally. This paper aims to highlight
the recent advancement of simulation globally through examples of workshops and
research occurring outside of Europe, North America, and Oceania, and begin to highlight
some of the current simulation education centre projects that are being planned across the
globe. Categories of simulation within this paper refers to simulation education using
standardised patients, patient simulators, mannequins, part-task trainers, computer-based
simulation, and virtual reality simulators, primarily used for surgical skills training. This
paper aims to give readers a glimpse into some of the projects and research that is occurring
within simulation education outside of the western world.
With technological advances and a greater understanding of the educational benefits of
healthcare professionals being immersed in real life experiences for educational purposes,
simulation has grown into a popular modality of clinical training (Issenberg 2006).
Simulation has many roles to play in healthcare education, not only can it teach specific
skills but it is also becoming imperative in patient safety training, interdisciplinary training,
Patient Simulation
Computer Simulation
Clinical Education
International perspective
International Simulation Centres
communication, team training, and crisis resource management (Smith and Cole 2009).
These points have also been emphasised in one of the latest annual reports from the Chief
Medical Officer for England (Donaldson, 2009) where the use of simulation at all levels is
strongly recommended. As described by one of the recognised pioneers, “When Integrated
appropriately into learning and competence testing, simulation plays an important role in
acquiring the critical and reflective thinking skills needed to provide competent, safe patient
care.” (Gaba 2004).
Many well established centres already exist across Europe, Australia, with the highest
number of simulation centres being located in the United States (BMSC, 2011). Centres such
as the Mayo Clinic Simulation Centre, Harvard, Hertfordshire, and Bristol are a very small
sample of institutions that have been pioneers in developing simulation programmes,
techniques, and simulation research across the disciplines (Alinier 2007b, Friedrich 2002,
Gardner 2007, Malec et al. 2007). The continents they represent also lead the way in
building a growing simulation community with societies and associations such as the Society
for simulation in Healthcare (SSH,, the Society in Europe for Simulation
Applied to Medicine (SESAM,, the Association for Simulated Practice
in Healthcare (ASPiH,, and the Australian Society for Simulation in
Healthcare (ASSH,
Simulation education across frontiers
A number of simulation facilities, programmes, and research projects have recently
emerged from or are taking place in Asia and Africa. In order to promote the development
of simulation in other parts of the world, some of the aforementioned societies support the
organisation of affiliated conferences in other continents such as the first Asia Pacific
conference which took place in June 2011 Hong Kong, affiliated with SSH, and the second
European/Latin-American meeting on Health Care Simulation and Patient Safety (ALASIC, in November 2011 in São Paulo, Brazil, affiliated with SESAM. In addition,
other initiatives such as workshops or humanitarian projects supported by industry help
simulation developments in many countries where simulation is not current practice due to
a simple lack of awareness, or for cultural or economical reasons. Such examples are the
“Helping Babies Breathe” project (Korioth 2010, which is
also backed up by the World Health Organisation (WHO), the American Academy of
Pediatrics and many other partners, and other courses run by experts in their field to update
clinicians on the current best practice as illustrated for example in Figure 1 in the United
Arab Emirates. Other activities include more realistic simulation workshops for educators
such as the ones illustrated on Figures 2 and 3 involving the University of Hertfordshire,
China, Mauritius, and Sri Lanka.
Although many of these activities have a limited short time effect, it is expected that they
will empower some enthusiastic participants to become the local educational pioneers and
implementers of the knowledge and ideas they will have acquired during the workshop. In
turn the simulation activities of these people will impact on others and more importantly
improve training standards, hence eventually benefit patients in the region.
Figure 1: Skills workshop for Obstetricians and Midwives organised by one of the co-authors
of this paper in Abu Dhabi, UAE (Photo used with the kind permission from the Baby Life
Line Charity, UK).
Figure 2: Example of an industry supported course run in Mauritius for medical and nursing
educators, and organised by one of the co-authors of this paper (Alinier et al. 2011).
Figure 3: Industry sponsored simulation facilitator workshop held in Hangzhou for
representatives from medical and nursing schools in China.
The published evidence of the globalisation of simulation
A PubMed search using the MESH terms; Education, patient simulation or computer
simulation, Africa or Caribbean region or Central America or Latin America or South America
or Antarctic Regions or Arctic Regions or Asia or Indian Oceans was performed to retrieve
relevant research articles published. The continents or regions of interest are shown in
green on Figure 4.
143 articles were found using this search criterion, of which 26 were eliminated as not
directly linked to simulation education or the research emerged from Europe, North and
Central America, or Oceania. The Middle East has been separated from Asia in the results
presented in Table 1 due to its unique economical context and the current expansion in
healthcare simulation activities in this particular region.
Figure 4: Map of the world showing the geographical regions included in the literature
search in green
Asia Middle
Number of articles found in PubMed
16 55 33 12 1 117
Percentage of articles from each
14% 47%
28% 10% 1% 100%
Table 1: Results of the PubMed search by continent or geographical region of interest.
Reviewing the trends within the published research.
As reported in table 1, when excluding Europe, North and Central America, and Oceania, the
majority of the published research at present appears to be emerging from Asia. This trend
is clearly reflected in the number of centres that have opened in South East Asia in the
recent years and been registered on the informal and worldwide database of simulation
centres hosted by the Bristol Medical Simulation Centre website (Table 2, BMSC, 2011).
The reported projects from South East Asia use a mix of standardised patients, mannequin-
based simulation, and computer-based or virtual reality simulators. Researchers from Japan,
Korea, Malaysia, and China have published on the use of standardised patients as a mode of
assessing clinical performance in their clinical education programmes (Myung et al. 2010,
Taguchi and Ogawa 2010, Loh and Kwa 2009, Tai and Chung 2008), demonstrating that
simulation developments are not necessarily driven by the adoption of technology, but
rather by the adoption of a new educational modality underpinned by an emerging
pedagogy (“andragogy”, in fact as we are talking of adult education) engaging learners to
put safely in practice what they have learnt.
Name of Centre or Institution Country
Anhui Shengli Hospital (Chinese Public Hospital) China
Beihua University, Jilin Medical College China
Aomori Prefectural Hospital Japan
Seoul National University College of Nursing Seoul
Buddhist Tzu Chi General Hospital Taiwan
Chi-Mei Medical Center Taiwan Taiwan
Busan Fire Department Central Headquarters Korea
Universiti Malaysia Sabah Malaysia
Ngee Ann Polytechnic Singapore
SAAD Specialist Hospital Saudi Arabia
Al-Zarqa Private University Jordan
Arelano University Manila Philippines
University of Kwazulu-Natal Inkosi Albert Luthuli Central Hospital South Africa
University of Kwazulu-Natal Simulation Lab South Africa
Hospital Israelita Albert Einstein Brazil
University Diego Portales Chile
Table 2:
Examples of simulation centres that have opened since 2008 outside of Europe,
North America and Oceania (
This part of the world is also active in terms of simulation related technological
developments. For example, work from four related projects (the Visible Human Project, the
Visible Korean, the Chinese Visible Human, and the Virtual Chinese Human (VCH)) resulted
in serially sectioned images of whole cadavers becoming available worldwide and to be used
for interactive computer or virtual simulation applications (Tang and Chung 2010). The
researchers encourage the use of the data from their four human cadavers into virtual
reality surgical simulators with haptics capability.
Another region of the world which is currently experiencing a huge growth in building up its
simulation-based training capacity with well funded projects is the Middle East. Many large
scale simulation centres have recently opened or are in the planning or building phase in
Oman, Saudi Arabia, United Arab Emirates, and Qatar. It is expected that all of them will
adopt most simulation modalities and be fitted out with state-of-the-art simulation and
audio/visual equipment. These centres are being setup because of the recognised need to
expand their healthcare workforce and to keep clinical staff up to date with their practice.
The clinical workforce expansion will usually involve recruiting staff from all over the world
with a variety of skills and educational backgrounds. Simulation is one modality of learning
that is now being recognised as an evaluation technique to skill-validate healthcare workers;
hence these new simulation centres will play an important role in the recruitment and on-
boarding of new clinical staff to meet patient safety goals. This is in line with the philosophy
that simulation can be used to facilitate staff recruitment, improve safety, and foster
changes in work procedures and systems (Gaba 2004).
In this particular context simulation will have an even more significant role as clinical staff,
coming most probably from a wide range of cultural background, will need to adapt their
practice to a different cultural environment while ensuring patient safety and patient-
centred care at all times, and simulation will provide the most appropriate context for the
remodelling of clinical practice, to raise cultural awareness, and in some cases to up-skill to
clinical staff recruited.
Some of these centres are linked to the opening of a new hospital and are hence in a
unique position to fully integrate and use simulation to its maximum potential. The Sidra
Medical and Research Centre due to open next year in Qatar ( is one of these
examples which has a unique opportunity to conduct research on the effectiveness of
recruiting, on-boarding, and orientating new staff using a significant simulation component.
It will involve skill validation and competency assessment through Objective Structured
Clinical Examination (OSCE) and scenario-based simulation type sessions (Alinier 2003,
Seropian 2003).
More established centres do exist in Saudi Arabia, Bahrain, and Israel. The Israel Centre for
Medical Simulation (MSR), is a comprehensive, national, multimodality, multidisciplinary
medical simulation centre dedicated to enhancing hands-on medical education,
performance assessment, patient safety, and quality of care by improving clinical and
communication skills (Ziv et al. 2006). This pioneering centre uses an "error-driven"
educational approach, which recognizes that errors provide an opportunity to create a
unique and beneficial learning experience (Ziv et al. 2005) whereby participants have the
opportunity to temporarily “live through” the consequences of their errors in a safe
environment and be guided in their reflection process during a post-simulation debriefing
session. Allowing participants to make errors in the simulation environment is expected to
help them learn not to make the same errors in the clinical setting, and hence to enhance
patient safety.
One third of the published research analysed however came out from less resource rich
areas such as Africa and South America. Similarly to the majority of the work emerging from
Asia, the projects within these continents also appeared to utilise standardised patients and
part-task trainers to provide simulated modes of education to healthcare workers. Some of
these projects are part of wider initiatives supported by the WHO and other professional
bodies as in the earlier example of the “Helping Babies Breathe” programme. An innovative
idea that is being used to provide education to birth attendants are a low-tech pregnancy
simulation device called “Mama Natalie” (Figure 5) in combination with an inflatable baby
called “Neo Natalie” which are commercialised by Laerdal Medical. This helps to address the
high costs of purchasing sophisticated mannequins and associated maintenance but instead
requires the use of an actor who plays the role of the pregnant woman. It creates a form of
hybrid simulation experience whereby what can be considered a part-task trainer is used
alongside a standardised patient as used, for example, in the assessment of communication
skills during a simple clinical procedure such as suturing (Kneebone et al. 2002). "Mama
Natalie" will be used to teach midwives in developing countries how to handle deliveries
and emergency situations to increase the skills of the birth attendants in order to reduce
maternal and infantile mortality and morbidity. This project has been put in place to help
the WHO meet its goal of reducing child morbidity by two thirds from 1990 levels by 2015
(Korioth 2010). Data is presently being collected to monitor the effect of this training
intervention in terms of clinical outcome ( and
14 In addition to this a team of clinicians from the USA and
Ghana striving to reduce maternal mortality has worked on the development of a low-cost
simulator for bimanual compression training for the management of postpartum
haemorrhage in the developing world (Perosky et al. 2011). They report that research is
ongoing in this application.
The use of standardise patients has also been effective in developing education programs
for healthcare workers and community health projects such as the management of sexually
transmitted diseases in urban pharmacies in Gambia and evaluating client-provider
interactions within clinical settings (Leiva et al. 2001, Huntington and Schuler 1993).
Another example that highlights the importance of simulation training in a resource
restricted area is an educational programme in Botswana, Africa, organised by the
Department of Surgery, Toronto Western Hospital, Canada (Okrainec et al. 2009). A total of
20 surgeons and trainees participated in a 3-day Fundamentals of Laparoscopic Surgery
(FLS) course. This was the first time the FLS program was taught in Africa and it enabled the
participants to significantly improve their FLS technical skills, however most of the local
surgeons did not reach the FLS passing scores. From the outcome of this training
intervention, we can conclude that more than 3 days may have been required to help
surgeons perform at a satisfactory level to obtain FLS certification. From our perspective,
this programme highlights the importance of such courses being customised to the learners
and the local context to develop the clinicians’ skills.
Figure 5: Example of a low-cost simulation device for hybrid simulation, the Laerdal Mama
Natalie birthing trainer. Picture used with the kind permission from Laerdal Medical
These are examples of how even with limited resources; educational programmes can be
delivered using various modalities of simulation. Numerous other educational activities
using simulation must be occurring globally but without any research infrastructure hence
limiting the chances of the work ever being published and shared with the simulation
community for wider dissemination.
As many more simulation centres and education programmes are developing, more
research will start to appear from outside the more developed simulation communities. The
effect on patient outcome of enhanced education through simulation may be more visible
outside of the western countries where no form of simulation was previously used.
Educational projects aiming at reducing maternal and infantile mortality and morbidity are
currently ongoing in several African, South American, and Asian countries. Collaborations
across geographical frontiers through voluntary, sponsored, or humanitarian projects,
regional conferences, workshops, and technological developments have a significant role to
play in the development and use of simulation practice in parts of the world where it is not
commonly used for training and education for cultural or economical reasons, or simply due
to a lack of awareness of the learning opportunities offered by simulated practice. Some of
the initiatives presented in this paper demonstrate that simulation training does not
necessarily require the purchase of highly sophisticated and expensive equipment to run
hands-on and highly beneficial training sessions. The development of clear and concise
learning objectives along with the approach adopted by the educators play an important
part in the learning experience. The resources required to achieve the intended learning
outcomes can often be kept to a minimum. Existing simulation programmes or courses
sometimes need to be adapted to the local context to be run successfully or with the
desired effect.
The authors would like to express their gratitude to Tracy Havlin, Clinical Planning
Consultant - Library at the Sidra Medical and Research Center in Doha, Qatar for doing the
PubMed literature search.
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Key Points
Simulation is growing internationally.
Research projects driven by experts from
established centres and using various modalities of
simulation are being conducted in parts of the
world were simulation activities were previously
very scarce.
Simulation related research outside of Europe, USA
and Oceania mainly stems from Asia.
Many new and large centres are under
development especially in the Middle East.
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The University of Hertfordshire is currently setting up the largest medical simulation centre in UK and it is being presented in this article with some background information. It includes a range of simulated clinical and community environments and makes use of modern patient simulators that will enhance the students' learning experience.
Healthcare has come to appreciate the value of simulation and its role in education, training, evaluation and research. This article reviews simulator technology and the role of simulation in obstetrics. The scope and nature of the obstetric literature published between January 1950 and July 2007 were reviewed. A total of 84 out of the 305 articles identified met criteria for inclusion in this review, most (59/84) having been published since 2000. The field of obstetrical simulation has grown substantially over the past decade. Thus far, the literature supports simulation as an essential tool for practicing routine and critical events, and improving technical proficiency and teamwork. Simulation can serve as a strategy for improving procedural and behavioral skills, potentially mitigating adverse perinatal events. More research is needed to determine whether obstetrical simulation leads to a significant reduction in the risk of birth-related injury and improved birth outcomes.
Hiroshima University Hospital used the Objective Structured Clinical Examination (OSCE) as a formative and summative assessment tool to evaluate trainees' competence. To reflect on Hiroshima University Hospital experience of OSCEs in postgraduate training in terms of OSCE structure and trainees' perception of the OSCE they attended. A total 27 OSCEs implemented in Hiroshima University Hospital from 2000 to 2009 were examined. The OSCE in postgraduate training, Hiroshima University Hospital, was influenced by many factors from organisational and pedagogical perspectives, and changed to meet social and curriculum needs. At each OSCE, all examinees were required to answer an anonymous questionnaire, which consisted of ten checklists, just after their experience of OSCE. Five hundred and forty trainees who attended each OSCE were required to answer a questionnaire and 510 were returned (94.4%). In the comparison between formative and summative OSCEs, the number of trainees who answered "the OSCE is meaningful" in formative OSCE was significantly higher than that in summative OSCE (P < 0.001). In the comparison between before and after the 2006/2007 academic year, trainees who indicated that OSCEs were meaningful increased after 2006/2007 (P < 0.05), and trainees who felt they were evaluated appropriately by these OSCEs increased after 2006/2007 (P < 0.01). Trainees viewed OSCEs positively and appreciated their effectiveness from a pedagogical perspective, and OSCE positively affected the trainees' approach to learning. A ten-year process of OSCE change has helped with educational reforms because of its adaptability. Flexible attitudes to change are necessary for stakeholders to achieve the desired reforms.
Serially sectioned images of whole cadavers have become available through the work of four projects: the Visible Human Project, the Visible Korean, the Chinese Visible Human, and the Virtual Chinese Human (VCH). For the VCH, new techniques and equipment were developed and applied to two female and two male cadavers to overcome some of the limitations noted in previous studies. In this article on the VCH, the procedures described are those used on a male cadaver. The cadaver was young with little to no pathology; there were no flat back artifacts because the cadaver was frozen and embedded in the upright position. Sectioned images (intervals, 0.2 mm) were of exceptional quality and resolution (0.1 mm-sized pixels). Several specific structures were outlined (intervals, 0.6 mm) to acquire segmented images, from which surface models were constructed. The VCH data are to be distributed worldwide and are expected to encourage other investigators to produce useful three-dimensional images and develop interactive simulation programs for clinical practice.
Abstract Objective: Reliability and validity of OSCE has been confirmed in different medical disciplines. However, it has not been studied in the filed of psychiatry, especially among psychiatric residents. The present study is designed for this aim. Method: An expert panel of renowned psychiatry lecturers from all over the Country, designed an OSCE of 9 stations. Each station took12 minutes, and two raters would complete the checklists independently. In 8 stations, there were Standardized Patients (SPs). Findings: 22 residents from 7 national medical universities participated. Face and content validity of the OSCE were determined by several discussion sessions on selecting feasible test objectives, with psychiatry lecturers and the Chairperson of Board Examination on Psychiatry. Construct validity was computed by comparing the residents’ OSCE scores to the scores rendered by their supervising professors. Concurrent validity tested the correlation between OSCE scores and the scores of Written and Oral Board Examinations, promotion exams, and psychiatry entrance examination. For reliability, interrater reliability, internal consistency and interstation reliability were assessed. Conclusion: In this first psychiatric OSCE in Iran, significant validity and reliability were observed. Keywords : OSCE, validity , reliability
Data on the efficacy of the simulation and multimedia teaching modalities is limited, particularly in developing nations. This study evaluates the effectiveness of simulator and multimedia educational tools in India. Advanced Cardiac Life Support (ACLS) certified paramedic students in India were randomized to either Simulation, Multimedia, or Reading for a 3-h ACLS refresher course. Simulation students received a lecture and 10 simulator cases. The Multimedia group viewed the American Heart Association (AHA) ACLS video and played a computer game. The Reading group independently read with an instructor present. Students were tested prior to (pre-test), immediately after (post-test), and 3 weeks after (short-term retention test), their intervention. During each testing stage subjects completed a cognitive, multiple-choice test and two cardiac arrest scenarios. Changes in exam performance were analyzed for significance. A survey was conducted asking students' perceptions of their assigned modality. One hundred and seventeen students were randomized to Simulation (n=39), Multimedia (n=38), and Reading (n=40). Simulation demonstrated greater improvement managing cardiac arrest scenarios compared to both Multimedia and Reading on the post-test (9% versus 5% and 2%, respectively, p<0.05) and Reading on the short-term retention test (6% versus -1%, p<0.05). Multimedia showed significant improvement on cognitive, short-term retention testing compared to Simulation and Reading (5% versus 0% and 0%, respectively, p<0.05). On the survey, 95% of Simulation and 84% of Multimedia indicated they enjoyed their modality. Simulation and multimedia educational tools were effective and may provide significant additive benefit compared to reading alone. Indian students enjoyed learning via these modalities.