Best Practices in Simulation Planning

At the recent International Conference on Residency Education, several speakers emphasized the importance of planning when using expensive simulation labs. Residents who train exclusively on high fidelity simulators frequently complain about the complexity and confusion of learning in this manner. I decided to write an article about the best way to plan the use of 4-step progressive simulations.


a. Begin by analyzing what competencies should be taught in this manner. Dangerous, painful, rare and embarrassing procedures make the best candidates. Determine what level of competency is required depending on the level of the resident. Set objectives for each stage.
b. Create learning activities including written instructions for each level of the progressive process described in the following document. Train preceptors to provide the necessary role modeling.
c. Create assessment tools appropriate for each level.
d. Train raters to use the assessment tools.

1. Intentional Role Modeling

An experienced preceptor demonstrates (without comment to the trainee) the complete procedure including interactions with patients/families and team members. This provides the student with an understanding of the goal of training including completion time, explanations given to the patient, safety measures etc.
This step may involve watching a video if an experienced preceptor is not available for observation.

2. Low Fidelity Simulation

Image from Antonacci, D.M. & Modaress, N. (2008). Envisioning the Educational Possibilities of User-Created Virtual Worlds. AACE Journal. 16 (2), pp. 115-126. Chesapeake, VA: AACE. Retrieved from
Low fidelity simulations use learning resources such as videos, animations and virtual reality with written procedural guides. Ideally this will involve a self directed process whereby the learner learns the basic step by step mechanics and can repeatedly use the required resources until they believe they have reached an understanding of the objective.
Assessment at this stage uses multiple choice and listing questions; either paper based or online with a pass mark of >80%. Learners must have the option to retest at this stage.

3. Mid Fidelity Simulations

Mid fidelity simulators are the body parts task trainers that expose students to the tools used to complete procedures in a portable, minimally complex manner. Again students practice with minimal supervision or peer support until they feel confident to undergo formal testing. Direct observation by raters or a lab supervisor followed by a feedback session is the usual test at this stage. Students should be allowed to retest after returning to the simulation if they don’t demonstrate proficiency.
The student now has the basic knowledge and tool proficiency to move to the interactive level.

4A. Interactive Hybrid Patient Simulation

Image copyright Roger Kneebone
Hybrid simulations are used for simple procedures which might be painful or embarrassing for patients to have beginners practice. Simulated body parts are attached to standardized patients who act out pre-arranged scenarios and provide feedback to the learner during the debriefing. More expensive than mid level task trainers, this level allows for the inclusion of interaction skills. Direct observation is the standard assessment.

4B. Interactive High Fidelity Simulation

The most expensive and complex type of simulators are the full body mannequins that require participants to practice technical + communication skills in complex scenarios. In some cases, participants may experience planned and unplanned disaster scenarios. Ideally the mannequins themselves provide immediate feedback about how well the patient is progressing because of the participants’ actions. Debriefing with a skilled preceptor is required after each session. Video observation by trained raters is the standard summative assessment.
For more complete information about simulations, see