In this book, we will introduce you to what simulations are, the types of simulations, what simulation-based learning is, and the benefits, challenges, and other considerations of using them.

Learning Outcomes

By the completion of the book, you will be able to:

• Understand what simulations and simulation-based learning are.
• List three necessary elements required for conducting effective simulations.
• Describe the benefits and drawbacks of simulation-based learning.

What are Simulations

^{Attribution: “Games vs Simulations” from Kapp (2021)}

Simulations (sims) are research or teaching techniques reproducing actual events and processes under test conditions (Tikkanen, 2023). They enable students (participants) to understand complex interactions of physical or social environmental factors and are commonly used in education. Educational simulations are teaching methods that test knowledge and skill levels by placing students in scenarios where they must actively solve problems (University of St. Augustine for Health Sciences, 2021).

History

Different simulations have been used throughout history, with earlier ones dating back to the mid to late 1800s when nurse trainees used anatomical models and task trainers (Singleton, 2020). Limb and full-body models were used to practice bandaging, bathing, and assisting mobility needs. More computerized (digital) sims came in the early 1900s, such as the “Link Trainer,” the first flight simulator for pilots entering WW2 combat fields, allowing quick training in rapidly changing environments at high speeds.

^{Attribution: “A bandaging class With Leg Models at the London Hospital Nurse Training Program” from (Singleton, 2020)
and “Link Trainer Simulation” from (OkraJoe, 2011)}

With vast applications in teaching, training, and testing across numerous industries, simulation technology has been improving and has become more realistic and immersive in providing users with an incredibly rich learning experience.

Today simulations are used in every field more than ever due to the advancements and their ability to replace real-life scenarios:

• In STEAM sciences, students can immerse in virtual reality science labs and use simulated tools they might not otherwise have access to: and engineers play out nuclear plant disasters beforehand (Caniglia, 2019).
• In social studies, students immerse in the refugee experience or use poverty simulators to discuss social inequalities and elicit empathy (Caniglia, 2019).
• Sports simulators are often used to replace off-season training gaps or get back on track for injured athletes (Caniglia, 2019).
• In the medical field, simulations have taken leaps, allowing teams of specialists to practice complicated operations just mere hours before the actual surgeries on the state-of-the-art three-dimensional printed replica of the exact patient (Weinstock, 2016). The simulation learning methodology is currently the primary tool used in training healthcare professionals and played a crucial role in meeting the challenges posed by the COVID pandemic. (Herrera-Aliaga & Estrada, 2022).
• In teacher preparation, simulations have been introduced only in the past decade and often complement student placements, enhance online studies, and address “experience gaps” by providing a chance to try out new teaching methods or practice challenging uncommon instructional skills, such as leading a conversation with a parent or guardian (Barshay, 2020; Cohen & Wong, 2021; Swinburn Online, 2020).
• In business, pilot and operator training,  agriculture, manufacturing, military, and so much more.

A study from 2014 “suggests that up to 50% of the traditional clinical time could be replaced by simulation,” and many places, such as the Virginia Board of Nursing, have authorized a percentage of robust simulation with debriefing to serve as the equivalent of direct patient care (Singleton, 2020).

Types of Simulations

There are three main overarching types of simulations commonly used today. Some of the ones seen in education, business, medicine and science are:

• Branching Scenarios or Stories – these require the learners to make a series of decisions through multiple choices to progress through an event. Think of this as a choose-your-own-adventure game, where the player (learners) picks what happens, followed by consequences (good or bad).
• Virtual Product(s) – typically, an object or objects of high-fidelity built to mimic real-work items. Learners can interact and play with them to test theories and practice skills.
• Virtual Labs – learners engage in a virtual product in an experience structured by tasks and goals to learn. Virtual labs can increase in difficulty (complexity) levels where students receive less and less helpful information as the simulation continues (Aldrich, 2009).

Fidelity

^{Attribution: “Low, Medium, and High Fidelity Simulations in Medical Training” from (Government of Western Australia Department of Health, 2014)}

Simulations experiences come in three various levels of fidelity or accuracy of real-life representation:

• Low-Fidelity – helps to master tasks and smaller key concepts. For example, basic case studies, scenarios, role-play, and others.
• Medium-Fidelity – provides more context and realism. For example, in medical training, this would be the use of mannequins or actors prepared to demonstrate a condition (Government of Western Australia Department of Health, 2014).
• High-Fidelity – provides an additional layer of realistic situations for a more authentic life-like experience (University of St.Augustine for Health Sciences, 2021).

Simulation-Based Learning

^{Attribution: “Simulation Based Learning” from Udacity (2016)}

Simulation-based learning is the pedagogical approach of providing students with the opportunity to practice learned skills in real-life situations (University of St. Augustine for Health Sciences, 2021).

Required Elements of Effectively Implemented Simulations

For conducting effective simulations in any context/ industry, there are three necessary elements required:

1. Preparation – varies with the type and complexity of the simulation. To prepare students for the sims, facilitators will need to:
   • ensure sims meet learning outcomes/goals;
   • test the sim beforehand;
   • anticipate ways the simulation can go wrong and include this in their pre-simulation discussion with the learners.
2. Active Student Participation – students should predict and explain the outcome they expect the simulation to generate. Students must assume a role they may or may not know before the simulation.
3. Post-Simulation Debrief – the most crucial step to conducting an effective simulation. Debriefing is an essential methodology that encourages students to “know what,” “know how,” and “know why.” The instructor should:
   • provide sufficient time for students to reflect and discuss;
   • prepare questions to ask during the debrief to ensure students see alignment between the simulation and the course (Caniglia, 2019).

Simulations and Experiential Learning

^{Attribution: “Simulation Experiential Learning Cycle” from (Higgins et al., 2020)}

Simulation-based learning is excellent for enhancing learning and is in tune with new paradigms in education that are consistent with educational theories that support the use of experiential learning (Chernikova et al., 2020, Ontario Council for Technology Education, n.d.). Experiential learning follows pedagogical approaches that provide opportunities for learners to co-construct their learning through participating in rich experiences, reflecting upon them to derive broader meanings, and applying learning to influence decision-making. Furthermore, it promotes:

• a better grasp of concepts;
• improved engagement;
• higher achievement scores;
• improved students’ attitudes toward learning;
• increased student self-confidence;
• broader world-view and increased appreciation of the community;
• opportunities for reflection and mistakes becoming valuable experiences;
• well-being and equitable outcomes for all students, and more (Ontario Council for Technology Education, n.d.).

“During experiential learning opportunities, the emphasis is on the relationships between and among students, teachers, and community members, not the physical location;” thus, simulations and experiential learning can be particularly relevant in the context of restricted access to clinical settings, such as remote areas (Chernikova et al., 2020; Ontario Council for Technology Education, n.d.).

Benefits of Simulations

^{Attribution: “Benefits of Simulation-Based Training” from (Altamira, n.d.)}

The uniform approval of simulations among students and educators is a consistent theme throughout the literature (Spooner et al., 2012). Various studies highlight the following benefits of simulation-based learning:

• improved learning outcomes and increased long-term retention (Caniglia, 2019);
• controlled learning environments create uncommon scenarios, high-risk environments, and stressful situations (Spooner et al., 2012);
• no risk of harm or damage (Spooner et al., 2012);
• learners feel more comfortable and confident (University of St.Augustine for Health Sciences, 2021; Caniglia, 2019);
• more support to focus on the non-simulatable aspects of learning (Spooner et al., 2012);
• ability to explore ‘what if’ questions (BBC, n.d.);
• data is gathered on students, which can be used to understand better how learners progress, how they make decisions, and how long they take to make decisions (University of St. Augustine for Health Sciences, 2021);
• it can be cheaper than practice in the field or real-world training, depending on the context (BBC, n.d.);
• development of situational awareness as well as behaviour and communication skills (Spooner et al., 2012);
• gain active, hands-on experience (University of St.Augustine for Health Sciences, 2021).

Drawbacks of Simulations

Despite the many benefits of simulation-based learning, it is also essential to consider the disadvantages. Some of the drawbacks include the following:

• resource-intensive since space and equipment may need to be purchased or rented. Simulators can be very costly, which makes them out of reach for many teaching institutions (Spooner et al., 2012);
• require extensive planning to design the course effectively, develop the storyline, run the activity, facilitate debrief meetings, and accurately assess the results (Queen’s University, 2021);
• all participants have to actively participate and accept their roles. Students may get carried away or are not prepared for the simulation (Caniglia, 2019);
• inability to replicate the danger or stress of real-life situations making reactions less realistic (BBC, n.d.);
• not comprehensive enough to address the endless number of situations or problems that the learner may face in the real world;
• technology issues are detrimental to the simulation (BBC, n.d.).

Ethical Considerations

The three most important ethical imperatives in the simulation are:

• the safety of patients, students and faculty members;
• preventing errors, and;
• enabling engaged learning.

Many ethical issues encountered in everyday practice can also be seen in simulation, such as ethical decision-making of who gets a ventilator or a hospital bed during an outbreak, “who lives and who dies” (triage) that doctors make daily in real-life settings; nevertheless, despite the growing acceptance of clinical simulation to enhance quality and safety in medical education, the question of whether students actually acquire and transfer the ethical principles that take place in a simulation setting is unknown (Budić et al., 2018; Frakt, 2020). Therefore, we must be cautious when relying on simulation-based learning as a replacement for clinical settings.

Equity Diversity and Inclusion (EDI) Considerations

Equity, Diversity, and Inclusion (EDI) must be seriously considered when implementing simulation-based learning to promote every student’s belonging and access to learning.

Current research has shown that racial diversity and cultural humility are not sufficiently present in simulation (Díaz et al., 2022). Issues such as sampling bias or confirmation bias are often present in simulations that stem from data used to develop the simulator, leading to inaccurate population representation or test results due to a lack of variations in possible routes (Liventsev et al., 2021). Furthermore, a lack of representation of diverse populations has been present.

A walk-through of the simulation center, game or activity and conducting EDI assessment can be implemented to avoid possible issues. This can be done by:

• taking notes of the signage and images exhibited (are photos of one particular race or gender repeatedly displayed?);
• examining the manikins and task trainers used (are they of multiple skin tones?);
• providing standardized patients with diverse looks, backgrounds, accents, and other features;
• ensuring simulation facilitators and participants are diverse;
• soliciting the opinions of the participating learners;
• involving learners in the development of the lessons and more (Díaz et al., 2022).

Assistive technology compatibility with simulators is another EDI consideration to ensure the simulation is accessible to all learners of all abilities. Ceaseless simulation-based math and science learning games and activities are developed yearly, yet few have been accessible to learners with visual and other impairments until recently. To promote EDI choosing simulations incorporating alternative input capabilities, audio description, sonification, and other features are of essence (Winters et al., 2020).

Conclusion

Simulations have been around for 100s of years; thus, “one can be certain that educational simulation tools will play an important part [in the] future” and are here to stay (George Brown College, 2018). Simulations allow students to learn concepts, accomplish mastery, and educate people on how a real-life situation operates (Coventry University, n.d.).

When wanting to implement simulations in your context, please do not forget the checklist below:

• The simulation must align with the learning outcomes of the lesson/module.
• Consider the types and fidelity level of simulations when choosing the appropriate one for your needs.
• A walk-through of the simulation beforehand will help eliminate any EDI concerns.
• Conducting a DEBRIEF discussion after the simulation is critical to student learning.

Assessment

Complete our short formative assessment to test your knowledge about simulations.

References

Aldrich, C. (2009, December 23). Because you can’t learn to ride a bicycle from a book. Association for Talent Development. https://www.td.org/magazines/td-magazine/because-you-cant-learn-to-ride-a-bicycle-from-a-book

Altamira. (n.d.). Benefits of simulation-based training [Image]. https://www.altamira.ai/blog/simulation-based-learning/

Barshay, J. (2020, April 20). Learning to teach from naughty avatars. The Henchinger Report. https://hechingerreport.org/learning-to-teach-from-naughty-avatars/

BBC. (n.d.). Modelling and simulation: Advantages and disadvantages. BBC News. https://www.bbc.co.uk/bitesize/guides/zyqfr82/revision/3

Budić, I., Pavlović, S., Stević, M., Petrov, I., Perić, V., Jović, M., & Simić, D. (2018). Medical simulation: Moral and ethical issues. Acta Medica Medianae, 57(1), 64-69. https://scindeks-clanci.ceon.rs/data/pdf/0365-4478/2018/0365-44781801064B.pdf

Caniglia. J. (2019). Simulations as a teaching strategy. Kent State University Center for Teaching and Learning. https://www.kent.edu/ctl/simulation-teaching-strategy

Chernikova, O., Heitzmann, N., Stadler, M., Holzberger, D., Seidel, T., & Fischer, F. (2020). Simulation-based learning in higher education: A meta-analysis. Review of Educational Research, 90(4), 499–541. https://doi.org/10.3102/0034654320933544

Cohen, J. & Wong, V. (2021, November 17). Using classroom simulators to transform teacher preparation. Brookings. https://www.brookings.edu/blog/brown-center-chalkboard/2021/11/17/using-classroom-simulators-to-transform-teacher-preparation/

Coventry University. (n.d). Why do we need simulation. Future Learn. https://www.futurelearn.com/info/courses/simulation-for-logistics-an-introduction/0/steps/66018

Díaz, D. A., Everett-Thomas, R., & Foronda, C. (2022, September 14).  Redesigning simulation-based learning environments to promote DEI and cultural humility. Josiah Macy Foundation. https://macyfoundation.org/news-and-commentary/redesigning-simulation-based-learning-environments-to-promote-dei-and-cultural-humility

Frakt, A. (2020, March 24). Who should be saved first? Experts offer ethical guidance. New York Times. https://www.nytimes.com/2020/03/24/upshot/coronavirus-rationing-decisions-ethicists.html

George Brown College. (2018, November 16). How simulation tools are transforming education and training. https://www.etcourse.com/simulation-tools-transform-education-and-training.html

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Herrera-Aliaga, E., & Estrada, L. D. (2022). Trends and Innovations of simulation for twenty first century medical education. Frontiers in Public Health, 10. https://doi.org/10.3389/fpubh.2022.619769

Higgins, D., Hayes, M., Taylor, J., & Wallace, J. (2020). Simulation Experiential Learning Cycle [Image]. MedEdPublish, 9(36), 36. https://doi.org/10.1111/eje.12551

Kapp, K. (2021, June 29). Games vs simulations [Video]. YouTube. https://www.youtube.com/watch?v=j6wemosp2sw

Liventsev, V., Härmä, A., & Petković, M. (2021). Towards Effective Patient Simulators. Frontiers in Artificial Intelligence, 4. https://doi.org/10.3389/frai.2021.798659

OkraJoe. (2011, December 19). Link trainer [Video]. YouTube. https://www.youtube.com/watch?v=MEKkVg9NqGM

Ontario Council for Technology Education. (n.d.). Experiential learning. https://www.octe.ca/en/resources/online-learning-experiential-learning

Queen’s University. (2021). Simulation-based experiential learning: Faculty toolkit. https://www.queensu.ca/experientiallearninghub/sites/qelhwww/files/uploaded_files/Simulation%20Toolkit/Simulation%20EL%20Faculty%20Toolkit%20%20Final%20Final%20April%208.pdf

Singleton, M. (2020, July 31). Flashback friday – practice Makes perfect: The history of simulation. University of Virginia. https://www.nursing.virginia.edu/news/flashback-history-of-simulation/

Spooner, N., Hurst, S., & Khadra, M. (2012). Medical simulation technology: Educational overview, industry leaders, and what’s missing. Hospital Topics, 90(3), 57–64. https://doi.org/10.1080/00185868.2012.714685

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Tikkanen, A. (2023, February 11). Simulation- scientific method. Britannica. https://www.britannica.com/science/simulation

Tong, P. & Bil, C. (2007, January). The link trainer [Image]. Research Gate. https://www.researchgate.net/figure/The-Link-Trainer-1_fig1_288205920

Udacity. (2016, June 6). Simulation based learning [Video]. YouTube. https://www.youtube.com/watch?v=66-Pq2o1ze4

University of St. Augustine for Health Sciences. (2021, September 1). How simulations in education benefits students and the patients. https://www.usa.edu/blog/simulation-in-education/

Weinstock, P. (2016, March 7). Lifelike simulations that make real-life surgery safer [Video]. YouTube. https://www.youtube.com/watch?v=tRD3dNCMzh4

Winters, R. M., Harden, E. L., & Moore, E. B. (2020, October). Co-designing accessible science education simulations with blind and visually-impaired teens. In Proceedings of the 22nd International ACM SIGACCESS Conference on Computers and Accessibility (pp. 1-4). https://mikewinters.io/wp-content/uploads/2021/01/Winters-ASSETS-2020.pdf