Modalities and Essentials of Simulation Facility for Facilitation of Clinical Skills to Medical and Nursing Students: Need for the Present Era : Journal of Surgical Specialties and Rural Practice

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Modalities and Essentials of Simulation Facility for Facilitation of Clinical Skills to Medical and Nursing Students

Need for the Present Era

Sharma, Rakesh; Vishwas, A S; Jelly, Prasuna; Chadha, Lisa; Stephen, Shine1; Rao, Shalinee2

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Journal of Surgical Specialties and Rural Practice 3(1):p 1-5, Jan–Apr 2022. | DOI: 10.4103/jssrp.jssrp_18_21
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The use of simulation is a unique teaching–learning approach in medical and nursing education to empower undergraduates with desired clinical skills. Simulation duplicates the events from the real world and influences the learner in a naturalistic setup and evokes a real experience to the learner. This method of learning facilitates students to practice multiple times to attain proficiency in a particular technique without compromising on patient safety. They can rely on simulation exercises in clinical skill laboratories (CSL), which boost their confidence level, reduce anxiety, and promote satisfaction before performing or dealing in real clinical settings. Simulation has been widely used for formative evaluation and is a reliable assessment tool as it ensures a high level of objectivity. The simulation-based approach in undergraduate medical and nursing education is an effective way of learning that can be incorporated into the educational strategy. This article presents the evolutionary growth, modalities, prerequisites, usefulness, and challenges for simulation-based learning.


There is a rapid increase in medical and nursing educational institutions in the recent years, especially in India, owing to the growing demand for skilled doctors and nurses globally. There are approximately 540 medical institutions and 800 nursing institutions by 2020.[1] Every medical teaching institute differs from each other based on their financial funding and support, availability of resources, and need of the community. Teaching–learning modalities and experiences also vary among institutes,[23] based on the availability of resources (qualified personnel and infrastructure), which ultimately influences the quality of output of clinically skilled doctors, nurses, and other paramedical professionals. Systems approach in practice of medical education emphasizes the importance of input and processing in the making of the final product.[4]

Every professional field has enormously been influenced by technology in teaching/learning and working especially in the last two decades. One such approach is the use of simulation in medical and nursing education programs and training to overcome the complexities of quality performance in clinical practice.[5] It facilitates learning a wide range of clinical skills including management of critically ill patients[6] and can practice repeatedly until the desired skills are developed.[7] The application and scope of simulation-based education have developed tremendously in countries such as the USA, Middle East nations, and Australia recently, whereas it is still in the initial phase in low- and middle-income countries. It clearly indicates the need of setting up of appropriate guidelines and specifications for initiating simulation-based educational labs in medical and nursing education.[789101112] This article delineates the importance of simulation-based education, purposes and types of simulation, benefits and drawbacks of simulation-based education, and explains the guidelines for establishing simulation labs in medical and nursing profession.


Simulation-based learning in undergraduate medical and nursing education is fairly a new approach in education. The global scenario on the availability of simulation facility may differ comparatively from developing countries due to low income and low investment in resources. Nearly 98,000 patients lost their lives in the United States only because of human errors.[8] Data on such error rates may not come into the limelight until documented. Due to various reasons, such data are withheld, and actual global picture is not clear due to underreporting. It is quite rightly quoted “to err is human.”[8] However, we need to learn from mistakes and adopt corrective measures to reduce such medical errors to improve and ensure patient safety. One such approach adopted by the United Kingdom, Australia, and other developed countries is simulation-based learning in medical education and training in the past few years.[1013]

Simulation was implemented in evaluation of students in the form of objective structured clinical examination.[11] It is also used to train basic life support, advanced cardiac life support, pediatric advanced life support, and advanced trauma life support.[12]

”Simulation is a technique with closeness to reality which gives learner an opportunity to respond to almost similar real life-like conditions.[14] It is termed as a technique but not the technology for practice and learning that can be applied to many different disciplines and trainees.”[12] Simulation duplicates the real-world events and impresses the learner in a naturalistic setup as evoking real experiences.[15] In an institution that does not adopt a simulation approach due to a lack of resources, students get directly posted into patient care and even critical units to manage and may be incompetent to manage real-life cases. Hence, simulation can be an effective tool to overcome this lacuna by bridging the gap between theory and practical skills and gaining required competence. This method of learning facilitates student to learn and re-learn multiple times until they attain mastery on one particular technique.[12] As per Miller's Pyramid, learner moves from being a novice to expert for a particular skill which gives them confidence to perform and ensures quality patient care.

Safety is the foremost concern and hence is the main reason to rely on simulation exercise in clinical skill laboratories (CSL), where the learner may train himself in a safe environment.[16] Developing simulation-based learning as a health-care learning tool has popularly increased in the past few decades focusing on patient safety and ethical mitigations.[14] An important consideration of skilled trainer for simulation-based learning and strengthening the educational capacity to address crises related to human resources through potential faculty development has been proposed as one of the important strategies [Box 1].[17]


The history of simulation begins when Mrs. Chase, a doll maker by profession designed a life-size doll in 1911 to teach basic nursing skills.[14] Later in 1929, Mr. Edwin Albert Link, an American inventor and entrepreneur introduced flight simulators in aviation and the military to train the pilots to reduce errors and public safety. Technology-driven simulators came into existence in 1960 when Denson and Abrahamson, University of Southern California, built a full-body mannequin in 1960, known as “Sim One,” which was equipped with all anatomical shapes to practice endotracheal (ET) intubation and induction of anesthesia. Unfortunately, it was not accepted by the medical fraternity due to its high cost factor and resistance for a change from their traditional method.[1618]

A full-sized mannequin was developed by Mr. Harvey in 1968 which was equipped with cardiac auscultation facilities.[18] In 1980's, computer based simulators were introduced.[16] In the early 1990s, there was a rapid growth in the usage of advanced mannequin and human patient simulators (HPS) due to affordability and high fidelity.[15]


Modality refers to the method used for the simulation such as part task trainer, standardized patient, full-body interactive mannequin, screen-based simulation, or virtual reality (laparoscopy and ultrasound).


Simulation in professional training has exponentially increased in the past few years, especially in medical and nursing education.[14] The classification is based on how closely they imitate the real circumstances/situation set for skill performance and learner interactiveness with simulator. The various types of simulators used in training professionals are classified as below:

Low-fidelity simulation

The low fidelity simulation involves the practice of one or two skills and is most commonly used in nursing education for practicing basic skills. It is not interactive and lacks computer programming.[19] The advantage of low-fidelity simulation is that it is easy and simple to construct and even less expensive compared to other simulations. The disadvantage is that usually students can perform only one skill at a given time, for example, intubation and cardiopulmonary resuscitation.[20]

Medium-fidelity simulation

It is more realistic and superior to traditional learning methods and is suited for practicing physiological and pharmacological processes. The study experience would be more realistic compared to low-fidelity simulation. Still, it does not impart real practical skills, even if the basic teaching and learning concepts are cleared.[20]

High-fidelity simulation

High fidelity simulations, computerized mannequins, HPS with the latest technology, and wireless operation with various health-care scenarios have been developed in line with clinical skills laboratory (CSL) to create a completely natural environment for learners.[15] There are natural effects on the learner as these simulators cry, breathe, blink, move, etc., manually or automatically. Whole-body mannequins are designed to perform the desired intervention through computer operation. Satisfaction is high for high-fidelity simulators in providing knowledge and skill development, despite being costly.[17]

Physiological programming simulators

These are automated, programmed mannequins, and physiological responses to treatment/intervention will match realistic human reactions such as HPS.[20]

Nonphysiologic programming simulators

Nonphysical programming simulators operate manually rather than automatically. The parameters will be set before the operator intervenes and will need to be reset after every attempt such as computerized mannequins.[20]

Technology advancement has led to the availability of simulators for patient treatment and diagnosis, digital information systems, telemedicine and telenursing, pharmacogenomics, and inpatient treatment options associated with technical evaluation for robotic surgery. In this era, virtual teaching and learning require technical literacy and need enthusiasm of students and teachers to adapt to the wireless virtual mode in education.[21] Opportunities for students to practice all skills in the true clinical field in a way is limited and may impact professional development, which can be supplemented in the clinical skill laboratory.[15]


Traditionally, the clinical wards and outpatient consultation rooms, operation rooms are a place of learning where student practices and develop clinical skills. In the present era, clinical skills laboratory (CSL) is an appropriate place to practically demonstrate and train students in clinical skills through simulation exercises individually and as a team.[19]

The educational approach for the learning process and clinical skill development in CSL can utilize varied simulation modules such as role-playing, computer games, static mannequins, standardized patients, computerized mannequins, and highly advanced human patient simulation.[15]

In the simulation laboratories, students can have wide learning experiences, which includes anatomy (virtual dissection table and gross anatomy) and physiology of body systems, clinical examination skills (such as gravid uterus height, fetal heart sounds, and breast lump), invasive techniques (arterial blood gas analysis, ascitic tap, tracheostomy, cricothyroidotomy), regional anesthesia (blue phantoms-ultrasound guided), and emergency care.[12]

Skills such as communication, situation analysis, clinical judgment, and care planning cannot be learned with theory alone. There is a need to improve interpersonal and psychomotor skills, especially in medical and nursing education simulations.[18] Simulation facility can largely help in attaining skills pertaining to the affective domain.


Simulation laboratory should be a central facility located in a convenient place between hospital and college for easy accessibility. The design and physical setup of the laboratory must be planned and earmarked for further expansion to be done in a phased manner due to economic constraints. The entire set-up can be divided into soundproof multiple cubicles to run multiple stations and parallel sessions for multiple batches simultaneously. The interior of a laboratory should have enough open spaces with shelves, mirrors, and cabinets (to store items) toward the wall. Sturdy tables are required, which is kept in the center of the room for demonstrating and performing skills. There should be enough space between the table and side cabinets. There should be digital display boards, movable whiteboards, instructor cabins (to run scenario), audio and video recording equipment for debriefing.[9] Setup should be realistic and natural as a simulation environment (for example, critical care unit, neonatal-intensive care unit, and labor ward), in which trainees can perform tasks for a familiar situation. Apart from all these, specific simulations should have accessories such as ET tubes, nasogastric (NG) tubes, electrocardiogram leads, emergency medicine, and fluids to care for the cardiac arrest patient (simulators).[912] One of the most important requirements for a skill lab is specialized simulation instructor well versed with simulation technology and a curator for skill lab maintenance. Uninterrupted power supply Wi-Fi connection and closed-circuit, high-resolution camera (due to expensive items) are other essential requirements.

The institutions with a paucity of funds to establish clinical simulation lab (CSL) can opt for simple mannequins for students to perform basic procedures that are inexpensive and do not require a specialized technician. For simulation-based learning, it is just not having a proper infrastructure but equally important is having skilled instructors to deliver skills appropriately to the trainee.[18] The process of establishing a simulation lab in an educational institution should fulfill the following criteria[9] [Figure 1].

Figure 1:
Process for the establishment of simulation lab

Vision, mission, and goals

The institutional educational strategy should promote simulation program/laboratory as a part of the educational strategy.[9] A feasible vision and mission statement should be formulated that meet the institutional goals and should be stated appropriately.


The simulation program is to be determined in the annual budget as either a funded project or a nonfunded one. The key stakeholders involved in planning and implementing the institutional vision and goals for the simulation program/laboratory should decide on a long-term or short-term strategy.[9]

Infrastructure and resources

The size and space of the skill laboratory differ from institute to institute based on the mission, objectives, type of organization, and funding, also depend on the number of learners at a time. As per the medical council commission, the recommended space size for a skill laboratory is 600 square meter (6458.35 sq. ft.) for the intake of 150 MBBS student annually.[22]

Multiple cubicles for skill stations to accommodate at least 8–10 students will be practically appropriate to conduct parallel sessions for a large group simultaneously in different cubicles. The high-fidelity simulator room should be soundproof and has an adjacent instructor room to run the scenario as well as keep the main processing unit for gas units. The preferred location for storage is 250 square foot (sq. ft.) is essential for every 1200 sq. ft. of simulation lab space and an area adjacent to the simulation lab to perform separate debriefing from the simulation area.[9] A separate wet lab area is required with washbasin having water supply and drainage with a granite slab for preparing moulage for simulation. Devices, models, and different types of simulators (as previously classified) are also needed to set up a clinical skill lab.[9] Provision should be made for facilities such as wireless, multi-media, audiovisual aids, heating, ventilation and air conditioning, suction, and vacuum, for the student such as washroom, drinking water, and restroom. Some disposable equipment and material, such as handwashing, gloves, mask, and rubber catheters, are required while performing procedures, even on the mannequins.

Trained manpower

Simulation lab may not be put to its complete use with a lack of trained personnel. There would be hesitancy among teachers to bring it to use for learners. Institute on setting up the simulation lab should also ensure training of their teachers and producing skilled instructors to deliver the skills to students. A curator/technical supervisor well versed with technology and device handling skills is essential for the overall maintenance of skill lab. Lab attendants are required for taking care of mannequins and items in skill lab.


  • Simulation-based learning is beneficial for trainees, trainers, patients, and health-care agencies.[1223] This learning strategy improves clinical practice and has a direct impact on quality of patient care by reducing medical errors, mitigating ethical issues, and resolving clinical dilemmas. In the health-care profession, simulation-based learning is highly applied with adult learners; therefore, it is considered empirical learning with a significant component as debriefing[24]
  • The use of virtual simulation in nursing education reduces time to skill achievement and enhances content retention as it promotes deep learning. Furthermore, learners show a positive attitude in the virtual simulation.[18] Simulation-based learning can create a learning cycle of briefing-debriefing and feedback, along with an assessment of skill performance. In simulation environments, learners not only practice technical skills but also nontechnical skills in the form of teamwork, team dynamics, decision-making, communication skills, personal attention, and self-awareness[25]
  • Simulation-based learning can increase the level of confidence among students before a performance during training. It helps in reducing the level of anxiety and makes the student stress free and increases their satisfaction level[20]
  • Simulation is one of the useful modality to replace training in true clinical setup due to its control over the sequence of tasks offered to the trainee, provides an opportunity for the trainer to support and guide the trainee, and provides safety and prevent dangerous situation by creating tasks that rarely occur in reality. The ultimate goal would be engaging the trainee to experience the simulated scenario with effective feedback[26]
  • The application of simulation-based learning is not new, especially in medical institutions where there is zero tolerance for any deviation from set standards. This helps in alleviating practical errors and maintaining a culture of safety.[25]

A comparative study by Tosterud et al. on the nursing students' perception of various simulations reported that they were highly satisfied with the implementation of scenarios irrespective of the simulation method used. Findings of this study suggest that simulation of varying degrees of fidelity could be used in nursing education.[27] A meta-analysis by Kim et al. on the effectiveness of simulation-based nursing education depending on fidelity recommends that simulation-based nursing educational interventions have resilient educational effects in the psychomotor domain. However, the use of a variety of educational interventions is necessary to meet all the educational goals.[28]


  • Since human body is a complex system, it cannot be fully replicated models and mannequins
  • Economic constraints restrict from setting up and maintaining simulation labs in many institutes.

Establishment of well-equipped simulation lab improves the quality in health care. Simulation should be integrated in the medical and nursing education curriculum to enhance acquaintance. Adherence to the guidelines in the establishment of simulation labs improves the standards of education.


Simulation is a “copy to” application to artificially mimic reality in the setup state. Simulation-based learning has been an ever-evolving trend in professional education. Its inclusion in the course curriculum as a teaching–learning method would promote better skill acquisition and patient safety. In the current trend fostering competency-based curriculum, a simulation-based education should be adopted in medical and nursing education for skill development, knowledge enhancement, communication, and building team dynamics.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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Clinical competence; medical education; nursing education; patient safety; simulation

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