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Simulation learning modalities: Going beyond the basics

Staff development

After reading this article, you will be able to:

  • Describe various simulation modalities
  • Identify strengths and weaknesses of several simulation modalities

The phrase “simulation modalities” may conjure up a variety of images. For example, some think of a sophisticated training mannequin that produces computer-generated EKG printouts, responds to intubation efforts, and virtually behaves in ways similar to an actual patient. Others may think of an IV arm used solely for learning how to start IVs.

The point is, there is a wide range of simulation modalities and a vast potential for providing education via simulation.

One innovative educator has made simulation her area of expertise. Mary Holtschneider, RN, BSN, BC, MPA, NREMT-P, director of nursing practice and education at the North Carolina Nurses Association in Raleigh, is the National Nursing Staff Development Organization’s (NNSDO) liaison to the Society for Simulation in Healthcare’s Simulation Alliance Task Force. The task force members are working to develop scenarios, standards, and techniques for simulation use (NNSDO, 2008).

“There are so many people jumping on the simulation bandwagon that it’s becoming increasingly important to identify the various types of simulation and attempt to establish standards for their use,” says Holtschneider. “This way, optimal education outcomes are promoted.”

Low-fidelity simulation modalities

Low-fidelity simulations are described as those that feel the least real to the learner (Holtschneider, 2009; Mt. Hood Community College, 2009). These simulations can be paper- or computer-based and are generally static models that allow for very little learner interaction within the simulation.

Examples include computer- or paper-based tasks, mannequins that do not have the capability for providing feedback (e.g., a Resusci Anne that only offers computer printouts evaluating the accuracy of breaths and compressions), or an IV arm that allows students to practice IV insertion techniques without feedback devices (Holtschneider, Mt. Hood Community College).

Low-fidelity simulation modalities are relatively easy to implement and transport and less expensive to implement than more sophisticated modalities. However, they are the least real of the modalities and, therefore, do not provide learners with the experience or the feeling of actually working in real-life settings.

High-fidelity simulation modalities

Also referred to as high-fidelity human patient simulators (HPS), “[high-fidelity simulation modalities are] often the first thing people think about when we say simulation,” says Holtschneider.

When using an HPS, educators can implement a variety of scenarios that they can tape and play back for debriefing or guided reflection, as well as create blended simulations, incorporating actors assuming the role of patients with low-fidelity task trainers.

HPS is usually dependent on some type of computerized mannequin that allows the re-creation of the physical patient in a realistic physical clinical environment (Stanford, 2009a). Examples of HPS include the following (Holtschneider; Stanford, 2009a):

  • IV start training using computer interactive devices that allow the learner to see veins, arteries, muscle, nerves, and bones as underlying structures
  • Mannequins that breathe and stop breathing spontaneously, allowing learners to evaluate the effectiveness of their intubation techniques or how well they are bagging a patient
  • Actual or real-time displays of algorithms on EKG, oxygen saturation, and photo-realistic 3-D interactive graphics based on real patients

Mannequin-based simulators have become increasingly common in areas such as the operating room, ED, and critical care units, where life-threatening situations that require recognition and treatment often occur.

Some simulators can even mimic the effects of various drugs, track the distribution of the drug in the body, and determine the exact effects that a specific amount of the drug will have on the human body (Stanford, 2009a).

The costs associated with these types of simulation generally increase with the level of sophistication of the simulator. Complex simulators may also be more of a challenge to set up and transport than more simple simulation techniques. However, the level of realism introduced by high-fidelity simulation modalities truly brings the learner into an interactive, genuine work environment.

Standardized patient educators

A tactic that adds to the high-fidelity simulation modalities is the use of standardized patient educators (SP). SPs are educators who are specially trained to portray patients, family members, and, at times, even members of the hospital staff.

They are actors, but “really educators at heart,” says Holtschneider.

Using SPs lets learners engage in mock conversations with patients, deal with family members who are frightened and questioning, and cope with colleagues who may not be acting professionally.

The Association for Standardized Patient Educators (ASPE) is an international organization for professionals in the field of SP methodology. Its goals are to (ASPE, 2009):

  • Enhance the professional growth and development of its members
  • Advance SP research and related scholarly activities
  • Establish standards of practice
  • Foster patient-centered care

SPs are used in a variety of academic settings, such as medical and nursing schools. In addition, their use is now becoming more common in clinical environments because they add another dimension of reality. However, they also add to the cost. Organizations hiring these educators must screen them carefully and hire only those persons qualified to assume such roles.

Serious gaming

The term “serious gaming” involves the use of video game technology to add another dimension to the learning process. Learners function within specific rules and guidelines while playing interactive computer-based games.

These games generally present a complex healthcare situation (e.g., multiple casualties from a terrorist attack arriving at an ED) that requires the learner to intervene appropriately.

Although the game format is viewed as a fun way to learn, the games offer deadly serious scenarios. Serious gaming is an increasingly popular training mechanism. There are even conferences on the use of this technology, such as the Games for Health Conference, which was held in Boston in June (Games for Health, 2009).

Video and computer games can be developed fairly quickly and can simulate functional entities in various clinical settings. However, they can be expensive to develop, and learners must have appropriate training in their use. In addition, they require the availability of adequate equipment for learners (Holtschneider).

Desktop simulations and virtual worlds

Desktop simulations and virtual worlds can be run on a desktop computer and only need a screen, mouse, and audio inputs and outputs. The learner can view data, see the patient via animation, perform diagnostic or treatment interventions, and interact with the patient by typing or, in some cases, actually speaking with the patient.

An advanced approach to this type of simulation allows several participants to participate in a virtual world simultaneously. Learners can interact with each other, the patient, and others in this world. A distinct advantage of this type of simulation is the ability to interact with various healthcare team members as well as the patient and family (Stanford, 2009b).

Virtual reality and visualization

Virtual reality is a computer-generated world that allows the learner or group of learners to experience various stimuli, often in a 3-D presentation (Holtschneider; Stanford, 2009c).

Learners typically wear head-mounted displays to receive visual and auditory cues. They can interact in the computer-generated world from various sites or be in a physical space in which they can interact with others (Holtschneider).

Virtual reality is a rapidly developing field and is one of the few mediums to give learners the best approximation of a true sense of realism. However, the creation of a complex virtual patient and treatment setting that will provide the most thorough and detailed training experience can be time-consuming and expensive. It requires a complete computer model of the patient environment; a way to track visual, audio, and touch fields; adequate hardware for all sensory modalities; and hardware to compute all models, track inputs, and produce outputs in real time (Stanford, 2009c).

This overview of simulation modalities shows that the word “simulation” refers to several teaching methods, from the simple to the complex. These variations, as well as the differences in complexity, make it important to have standards and guidelines in place for their optimal use and best possible learner outcomes.


Association for Standardized Patient Educators (2009). “Welcome to the Association of Standardized Patient Educators.” Retrieved October 1, 2009, from

Games for Health (2009). “About Us.” Retrieved October 1, 2009, from

Holtschneider, M.E. (2009). “Simulation Learning Modalities: Going Beyond Sim Man!” Concurrent session, NNSDO 2009 convention, July 11, 2009, Philadelphia.

Mt. Hood Community College (2009). “Fidelity Simulators.” Retrieved October 1, 2009, from

National Nursing Staff Development Organization (2008). “Collaborative Efforts Across Organizations: Building a Simulation Alliance.” Journal for Nurses in Staff Development 24(6): 303–304.

Stanford School of Medicine (2009a). “Mannequin-Based Patient Simulation.” Retrieved October 1, 2009, from

Stanford School of Medicine (2009b). “Desktop Simulations and Virtual Worlds.” Retrieved October 1, 2009, from

Stanford School of Medicine (2009c). “Virtual Reality and Visualization.” Retrieved October 1, 2009, from sim_modalities/virtual_reality.html.


Adapted from The Staff Educator, November 2009, HCPro, Inc.