• The number of people in training in hospitals has increased significantly, and at the same time, the training opportunities are fewer due to a reduction in working hours.

• Today’s patients do not want to be trained on.

• New guidelines, methods, drugs and tools are introduced frequently, but their full adaptation in practice takes up to 15 years. Simulation can help shorten this implementation phase. One of the many reasons for slow adaptation is resistance from the senior staff. Simulation can provide a safe yet convincing learning environment, also for senior staff, to stimulate the learners’ reflection of current practice. Such changes of attitude and introduction of new ways of working are often difficult for the adult learner. SBME seems to be a promising tool, as it is based on concrete experiences and reflections (Issenberg et al 2005).

• Patients are harmed as a result of incidents, and patient safety data indicate a need for improvement of skills; not only medical expertise skills, but also skills such as interdisciplinary communication and teamwork. The principles of crisis resource management (CRM) were derived from aviation and other high-risk industries and contribute to addressing these challenges. CRM is intended to help prevent and manage difficulties during healthcare, reflecting both the social-team-oriented and cognitive-individual-oriented aspects of human factors (Rall et al 2010a). Learning about CRM is a means to learning new skills and unlearning others, as well as changing attitudes. Anaesthesiology was one of the first specialties to adapt CRM training, and it is believed that this early adoption has contributed considerably to improvements in patient safety. Later, the term non-technical skill was introduced to describe the skills needed to supplement medical expertise or technical skills.

• Healthcare professionals are educated in silos of care, and this makes it difficult to function as a team. We need to change the way health professions are trained: a paradigm shift from mono-professional training to multi- and interprofessional training in order to improve patient safety. Crisis situations are especially challenging, as diagnosing and treatment might be difficult and time constraints might make the challenge greater. Such a complex situation requires a well-functioning team of experts from different specialties and different professions. Simulation provides the opportunity for the team to train together, exchange experiences and learn about mutual expectations and differences in the norms, values and beliefs of professionals from different backgrounds. This will help bridge the silos, especially when introduced in pre-graduate curricula.

• From a pedagogical view, we need to help adult learners to learn by introducing interactive methods. Adult learners are experimental learners, and they learn by going through certain steps in the learning cycle and doing so in different styles (Kolb 1984). SBME provides these types of opportunities. According to Knowles (1990), adult learners are problem centred, and they value learning that can be applied to actual problems that they meet in their clinical life. SBME provides the link between knowing and doing. Simulation scenarios combined with debriefings support reflection and improvement of own competences.

Advantages and drawbacks of simulation

The advantages of SBME are numerous. It is possible to train in a safe environment without endangering the patient. The design and implementation of scenarios can be adjusted according to the learner’s need. If, for instance, the learner needs more time for decision making, the deterioration of the patient can be slowed down. This is in contrast to the clinical situation, where physiology follows natural laws and the senior person will have to take over the treatment of the patient. In the simulated setting, education can be the primary priority, whereas in the clinical setting, patient safety always comes first. It is also possible to repeat the situation if the objectives are not met or the learner needs more training.

The major drawbacks of SBME are the high costs of the technology and the need for qualified instructors. The costs of taking the participants and the facilitators away from their clinical work are also substantial. On the other hand, the cost of harming the patients or delaying treatment is certainly higher, apart from the human suffering by all involved. One of the challenges is that it is difficult to prove that training has an impact on patient outcome.

Simulation modalities

Simulators used in medical education are educational tools that fall into the broad context of simulation-based medical education. A wide variety of different trainers and methods are available:

Different combinations of these modalities are frequently used, like a part task trainer and a simulated patient or a surgical simulator and a simulated patient or a patient simulator. Screen-based simulators are often used as pre-course preparation or post-course follow-up to maintain capabilities. Often a given learning objective is obtained by combining modalities on a course, for instance, training practical skills on a part task trainer and later in a procedural/surgical or patient simulator. At times the distinction between the modalities is not clear-cut and related to their use. Both manikin-based simulators and surgical simulators can be used and seen as task trainers as well as advanced simulators. Basing the distinction on the feature list of a simulator alone might not be adequate.

Improved simulation technology and concepts have resulted in greater acceptance by health professionals and an increased use of SBME (Khan et al 2011). Over the last two decades, the use of SBME has significantly increased, especially the use of advanced simulators. Contents of training vary with the tools available and between disciplines. For example, surgical simulators are primarily used for procedural skills training (medical expertise skills) and training is done by the individual doctor, at times immediately before this type of procedure is to be applied in an actual clinical case (Kneebone et al 2007). This is in contrast to SBME using patient simulators, which is often conducted for a group of learners or a real clinical team. Manikin-based simulations are frequently used to improve knowledge, attitude and behaviour towards patient safety. In any case, the role of a tutor and the responsibility for this type of training are very different from the role of a lecturer and tutor in a skills centre. Therefore, there is an increased interest in train-the-trainer concepts (see below). In the following sections, we discuss in more detail how and when to use SBME. We will focus on manikin-based simulators, but the principles are similar for other simulation modalities as well.