Simulation based learning (SBL) is an active learning method that provides learners with exposure to realistic clinical situations using life-like examples in a safe environment.

Active learning strategies offer learners opportunities to develop their critical thinking, problem-solving, and reflection skills. It also promotes learners engagement and transfer of knowledge and skills into practice. (McGaghie et al. 2014, Shin et al. 2015, Reising et al. 2017, Jakobsen et al. 2018.)

Simulations can be carried out using human patient simulators (HPSs) or standardized patients (SPs). High-fidelity, computer-driven HPSs are appropriate in contexts where learners are supposed to practise e.g. assessing patients’ vital signs. The high-fidelity HPSs are human-like and anatomically correct. The computerization enables a variety of physiological responses and actions (e.g., patients’ voices, lung sounds with rising of the chest, heart rates and palpable pulses, cyanoses). Different vital functions can be programmed for HPSs and monitors to simulate different diseases or conditions. By using HPSs, it is possible to practice realistic and concurrent planning of nursing interventions and to have real-time response for further interventions (Arthur et al., 2013, Howard et al., 2010, Smith et al. 2012).

In scenarios that require the patient or client to move, shuffle, or communicate naturally, such as in patient examination or therapeutic communication situations, SPs are more appropriate (Slater et al. 2016, Webster 2014). An SP can be an actor or role-player who is trained to simulate illness or a real patient who has been trained to present his or her illness; in both cases, the presentation of illness is standardised (Barrows 1993, Stayt 2012). In addition, SPs have been demonstrated to enhance the learners’ cultural sensitivity and cultural competence and hence are essential in perspective of confirming culturally diverse simulation learning (Bahreman & Swoboda 2016, Foronda et al. 2018).

Once learners have accepted their roles and agreed to their level of responsibility in the simulation, the instructor executes the simulation that holds a level of realism. Realism is confirmed physically, conceptually, and psychologically. Transferable learning occurs when the learning objectives and learner readiness are compatible with the experience represented in simulation. Physical fidelity will support psychologic fidelity, but poorly designed scenarios cannot achieve realism with high technologic or physical fidelity alone. (Paige et al. 2013, Hamstra 2014.)

Important part of psychological fidelity is also to consider potential opportunities to demonstrate patients´ diversity, including e.g. family, gender, age, ethnic, and psychosocial factors and how equivalent they are to reality. Other health care providers within the simulation could also demonstrate diversity, consisting of variation of sex and background across all provider roles and avoidance of stereotypes of negative characterizations. (Sabus 2016.)

Click here to read about what a well arranged Simulation consists of

  • Instructor(s) who is expert in the content of the simulation (e.g. anesthesia nursing, social care, pediatric nursing etc.) and also in simulation pedagogy
  • Opportunities for learners to rotate roles in different simulation scenarios to gain multiple perspectives and experience to give and receive feedback.
  • Both technical and non-technical skills emphasized in the objectives.
  • Learning objectives are clear and frame the discussion that occurs during simulation and debriefing. At the same time, unanticipated learning opportunities will undoubtedly present as an excellent ‘teachable moments’.
  • Time-out / time-in technique (stopping and restarting the simulation) can be used, particularly when SP’s are used. Time-out can be used, if the scenario needs to be suspended for some reason (e.g. if a serious error occurs), the instructor is able to provide support for the learners to think what is happening and why and what is e.g. the correct intervention. After the discussion, the simulation can continue.

Glossary of terms


Simulation as a mechanism, such as the imitation of vital functions; or simulation scenario, which means a larger learning process developed around of a specific problem or situation.

Task training model (low-fidelity, static)

Includes static body parts or anatomic models, used for learning and training simple procedures, such as intramuscular injection.


A simulated practise/patient case (action), takes place in the simulated environment or in real clinical setting (in situ) in accordance with the planned schedule (i.e., the learning objectives are accomplished).

Standardised patient

An actor or student playing the role of the patient as realistically and consistently as possible. SP can be an actor or role-player who is trained to simulate illness and particular symptoms; in both cases, the presentation of illness is standardised.

Full scale simulation (or scenario based simulation) (medium-fidelity to high-fidelity)

A simulation in a realistic environment, when a computer-driven, human-size mannequin is used (patient simulation). The mannequin is programmed for vital functions (e.g., heart and lung sounds, pulse oximetry), responding to the treatment and the instructor can act as the voice of the “patient”.
Comprehensive and standardised exercises, which are carefully planned and focus on core competency outcomes instead of individual skills. In nursing they are based on a scenario of an authentic client situation, where both technical and non-technical skills are practiced.

Patient / Client Vignettes

These short vignettes describe patients/clients with diverse characteristics and diverse needs.  While reading these, consider how you could  incorporate such perspectives into simulation-based learning scenarios.

Man with hearing aid

Transgender person

27 year old lesbian woman

Rosaleen Mc Donagh, a 52-year-old traveller lady was admitted to the medical ward with unstable blood sugars.

Aamil Saab, a 62-year-old Muslim gentleman who has resided in Cork for five years was admitted to the acute coronary unit with a myocardial infraction

Emma, 2 years, suffers from recurrent otitis media i.e. ear infection. She also suffers from recurrent respiratory infections.

Martti 88 years has cardiovascular diseases, including hypertension and diabetes, and has gout.

Learner, Patient and Tutor Testimonials

In this section we have provided real feedback from those involved in the simulation training. We hope these give an insight into some of the process and practices involved

Bachelor’s Degree Programme in Nursing –student Hanine Zaier (Savonia University of Applied Sciences)

Video Guides

In this section we have provided real feedback from those involved in the simulation training. We hope these give an insight into some of the process and practices involved

Guide to useful links

Who’s Recommendation is thisSource of InformationWhy are these Resources useful
Tracy Mclelland
Associate Dean (International) and the Research and Knowledge Transfer Lead in health with extensive health services management experience and a professional background in both physical and mental health nursing
Health Education England-Simulation websites



Victorian Simulation Alliance
All these links are a really useful starting point to fin out what the Sector thinks about Simulation in Health Care. The ASPIH site in particular has a wealth of information and links to some really useful conferences
Marja Silén-Lipponen
Principle Lecturer in Nursing, PhD
Chung HS, Dieckmann P and Issenberg SB article It is time to consider cultural differences in debriefing from Simulation in Healthcare 2013 8(3),166-70I felt a thrilling experience when I read an article about culturally-based simulation debriefing. The article made me realize that the way in which my own culture is practiced is not always right and suitable for students from other cultures.

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After understanding the message of the article I began to implement a more sensitive debriefing. Since that comprehension, I have much better understood, that even in our own culture, all students don´t have the same values of life and beliefs e.g. about openness and communication. So the understanding of debriefing is not anymore black and white for me, instead it is different shades of gray and occasionally glitters of other colors as well.

Debriefing is a critical component of simulation-based learning. It helps to consolidate knowledge and skills by utilising reflective practice. In Western cultures, debriefing is often conducted by using rather standardized models. Trust on those models is based on an assumption that an average student talks actively, shows feelings and participates shared reflection in a learning situation. These characteristics rise from the cultural values, beliefs and norms which determine in society if certain behavior and manifestations are acceptable and desirable or not. E.g. each culture has its own relatively unique style of communication, sharing of feelings and friendship roles. Thus, it can be said, that many Western Cultures rely on a high level of individualism, low power distance and equality of gender. In contrast, many Non-Western cultures have different cultural values and beliefs, which give plenty of reasons why debriefing needs to be conducted in a modified way.

Previously I did not think about debriefing from the point of different cultural views and most likely made some mistakes during debriefing when eencouraged exchange students to actively participate in the discussion highlighting their own attitudes and feelings. I thought they should be able to join in the learning conversation similarly than our own students and thus I tried to even gently push them in the more active roles.
Acas provides practical support and guidance to better manage equality and diversity in organisations.
Commission for Equality and Human Rights and monitors human rights and equality
Equality Challenge Unit Equality Challenge Unit is the first full time office devoted to promoting equality and diversity in higher education
Diversity in Diction is a comprehensive guide put together by the TUC and Unison on the appropriate use of language.
Age UK UK aims to improve later life for everyone through information and advice,campaigns, products, training and research.
ACAS on Age Regulations
Disability Equality Challenge Unit
Business Disability Forum containing facts and information on the effective employment of disabled people.
Mind aims to help people take control of their mental health.
Fawcett Society and research issues of relevance to UK women.
Opportunity Now to improving employment opportunities for ethnic minorities across the UK.
Institute of Race Relations Institute of Race Relations website has a quiz on race in the UK.
Race for Opportunity to improving employment opportunities for ethnic minorities across the UK.
BBC - Religion BBC website on religion is a great online resource for finding out about religious diversity in the UK.
Guardian - Gay rights Guardian website is updated daily and this area focuses on gay rights - both in the workplace and outside of it.
MESMAC community organisation supporting the local LGBT community.
Stonewall gay, lesbian and bi-sexual rights. Site contains news and information on employment, legal and campaign issues.
Trans Staff and Students in Higher Education Equality Challenge Unit guidance on supporting trans staff and students.

Advice center

Oamk SimLab – Simulation environments in Oulu University of Applied Sciences

Oulu University of Applied Sciences has a versatile simulation and studio environment ecosystem – Oamk SimLab, which is used in education, training, and as well for testing future health technology products and welfare services.

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The first studios were established in 2009. At first, we trained teachers as simulation instructors and integrated simulations into emergency training of nurse, midwifery and public health nurse education courses. The second, our focus was to develop patient/ client/ family centred interprofessional (IP) team training by using simulation education. Today we have IP simulation courses integrated in curricula of medical and all health care study programs.

PhD, Senior Lecturer Tiina Tervaskanto-Mäentausta from OAMK made her dissertation some time ago about simulation and is very eager to develop simulation pedagogy more. “Why not to use simulations more in learning to care for the ethnic people, gender and age based questions and everyday life of disabled and older people. We have already integrated simulations to social care education and have some examples of scenarios about ethnic family with children and also scenarios of child protection cases. We also have developed a special “enabled home” environment to train and probe suitable technology to live at home when there are problems in everyday life.”

Tiina also adds that training in SimLab is effective. “ Based on the students’ feedback, training in simulation environment with real life scenarios is effective. Students have so far started to trust and respect on different types of expertise and learned patient/ client/ family centred care and services. In the future society, students need competencies to solve complicated problems of the people, often using mobile connections. More and more important is to learn social skills, how to communicate, how to face people with different background. In simulation students can use all their senses while they act, observe and reflect; the future pedagogy turns more and more into active learning methods and into digital and authentic environments. In Oulu we are connected to OuluHealth Network to share and learn to work together for the healthier future.”

Design from Oulu – Oamk SimLab

Simulation center “Taitokeskus” is a modern simulation and skill lab for health care students and professionals in Tampere.

The director of the center, Nina Hutri-Kähönen, MD, Docent in Pediatric Medicine, Specialist qualification of a medical instructor Faculty of Medicine and Health Technology, likes the idea of interprofessional co-working and collaboration and trusts simulation as a comprehensive method for learning cultural awareness in overall health care sector.

MD Hutri-Kähönen says: “We are living in multicultural society and the demands for the health care are changing. Thus the diversity of health care teams is increasing. Simulation pedagogy is a good way to learn cultural awareness.”

See more about the skill center in the web pages. Skill center can be found from the Facebook, Instragram and Twitter.