Learning through simulation: The messy reality


In the context of improving patient safety, simulation-based medical education (SBME) is regarded as pivotal in the development of critical non-technical skills & clinical decision-making amongst healthcare professionals (Department of Health, 2011). Through complete task scenario and deliberate practice, SMBE is considered to be well suited to the complexity of clinical performance and utilises a blend of educational strategies to achieve the desired learning outcomes (McGaghie et al, 2011).  

 SBME is strongly under-pinned by constructivist pedagogy, which uses experiential learning constructs and critical reflection (Kolb, 1084). Additionally, SBME also draws on intrinsic and extrinsic motivation (Malone and Lepper, 2007) to promote psychological authenticity during the learning experience (Rudolph, et al, 2007, Dieckmann et al, 2007).  

 Supported by Maslow’s ‘hierarchy of needs’ (1943), some simulation educators have argued that successful SMBE is reliant upon careful, thorough and supportive preparation of participants is necessary to establish a safe and confidential educational space for the participants to perform optimally. In simulation that is aimed at developing crisis resource management / team leadership / team followership knowledge and skills, the utility of SBME can replicate realistic clinical pressure ‘in the moment’. This approach enables participants to more closely feel what is it like to be ‘under-pressure’ in context of their normal clinical work. They should be in a situation where they can conduct clinical decision-making, supported by the knowledge that they are performing in a secure, educational environment. 

 The Messy Reality 

In the last 20 years or so it has become apparent that healthcare, in the context of addressing the patient safety failures, has began to understand, assimilate and apply human factors/ergonomics science (HFE) to the complexity work of inherent in the delivery of healthcare. It is no surprise then, that those of us who are healthcare educators have gone on to appreciate that applying HFE science offers an appealing methodology with which to understand and bridge the performance gap between ‘work-as-imagined’/‘work-as-prescribed and ‘work-as done’ (Shorrock and Williams, 2016). The reality of operational performance has been described as a ‘messy reality’ (Shorrock, 2017)  are there many examples of this occurring in healthcare (Hindsight, 2017). 


Figure 1. The Messy Reality (Steve Shorrock, 2016)

An essential component in the achievement of high-quality SBME outcomes is structured debriefing. Sufficient time, perhaps two to three times more than that afforded to the scenario (Neil and Wooten, 2011) is advocated so that participants can be guided through a deep reflective exploration of the ‘work-as-done’ that unfolded during the scenario. Conventional approaches to debriefing and feedback have been largely based on the Pendleton ‘sandwich’ model (Pendleton, 1998). However, more contemporary methods of debriefing strongly encourage active, reflective participation that include debriefing with good judgement (Rudolph et al, 2007), debriefing as a learning conversation (Denning, 2010) alongside other constructivist models (Fanning & Gaba, 2007; Kriz, 2010) and are evidenced as being effective (Neil and Wooten, 2011). Taking this a step further, by framing debriefing with a combined HFE and constructivist lens is very appealing. 

The educational appeal of integrating HFE into SBME is that is appears to offer a particularly useful adjunct to post-scenario debriefing that incorporates much of the complexity of the ‘messy reality’. Integrating HFE with contemporary debriefing approaches should augment the provision of participants with a safe, reflective platform by providing a clearer focus within which to reflectively discuss their performances within the scenario.  Facilitation of participants to actively, critically reflect as to how and why they conducted their ‘work-as-done’ as the scenario unfolded and how the performance compared to how they imagined the scenario would ‘play out’ to how they perceived they would perform  (work-as-imagined) helps those participants to better understand their performance variability as well as the nature and sources of (self) identified performance gaps. This is of course expected (through facilitated critical reflection) to better enable students to adjust their performance variability to bring it into acceptable limits, that is, provide safer practice when they return to clinical activity.  

In many complex task situations in SBME it may be necessary for learners to reflect and critical evaluate their performance against guidelines / protocols / policies / procedures that ordinarily determine the ‘work-as-prescribed’ elements of healthcare practice (for example, advanced life support or sepsis guidelines). The application of HFE elements in this context further strengthens the focus and authenticity of the participant’s learning experiences and the emergence of important ‘take-away’ points which are intended for learners to continue to reflect on as they translate learning into clinical practice.  


The argument that is being presented in this blog is to state that there is significant potential to further improve patient outcomes if a more explicit HFE approach is taken in SBME as it further strengthens the focus of the educational intervention on improving ‘work-as-done’/‘work-as-prescribed’ in the clinical field, it should also promote the ability to adjust to unforeseeable situations that may require and accept adaptive behaviours. If the simulation scenario is purposefully designed to accommodate HFE elements alongside established educational strategies, then we may further improve both educational and patient safety outcomes. Post scenario debriefing, where participants conduct ‘work-as-disclosed’ provides the most favourable opportunity for better learning, providing that it is skilfully facilitated by enthusiastic educators that integrate critical reflection on ‘work-as-done’ alongside ‘work-as-imagined’ and ‘work-as-prescribed’.  

Such an approach would move SBME away from being mostly ‘work-as-imagined’ towards a ‘work-as-done’/‘work-as-prescribed’ perspective, it should effectively reduce individual and team performance variability, promote better decision-making and lead to safer patient care when transferred into clinical practice. 

A blended learning educational strategy that includes the use of authentic, deep immersion SBME is likely to promote patient safety and better improve the behavioural skills associated clinical decision-making, team leadership, team followership and limit performance variability. 


Denning,. K. (2010). Debriefing as a learning conversation. Resuscitation Council UK. On-line. https://mobilesim.files.wordpress.com/2011/03/debrief-as-a-learning-conversation.pdf 

 Department of Health. (2011). A Framework for Technology Enhanced Learning. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215316/dh_131061.pdf 

Dieckmann, P., Gaba, D. and Rall., M. (2007). Deepening the Theoretical Foundations of Patient Simulation as Social Practice. Simulation in Healthcare. 2. 183-193. 

Fanning, R. M., Gaba, D.M. (2007) The Role of Debriefing in Simulation-Based Learning. Simulation in Healthcare, 2, 115-125. 

Hindsight 25 (2017) http://www.eurocontrol.int/sites/default/files/publication/files/hindsight25.pdf 

Kolb, D.A. (1984). Experiential Learning: Experience as the source of learning and development. Prentice Hall. New Jersey. 

 Kriz, W.C. (2010). A systemic-Constructivist Approach to the Facilitation and Debriefing of Simulations and Games. Simulation Gaming. 41(5). 663-680. 

 Maslow, A. H. (1943). A Theory of Human Motivation. Psychological Review, 50(4). 370-396.  

McGaghie, W.C., Issenberg, B.S., Cohen, E.R., Barsuk, J.H. and Wayne, D.B. Does Simulation-Based Medical Education With Deliberate Practice Yield Better Results Than Traditional Clinical Education? A meta-Analytic Comparative Review of the Evidence. Academic Medicine. 86(6). 706-711.   

Neill, M.A. and Wooten, K. (2011) High-Fidelity Simulation Debriefing in Nursing Education: A Literature Review. Clinical Simulation in Nursing, 7,e161-e168. 

Pendleton, D., Schofield, T., Tate, P. and Havelock, P. (1984). The Consultation: An Approach to Learning and Teaching. Oxford University Press. Oxford. 

 Rudolph, J. W., Simon, R., Dufresne, R., Raemer, D.B. (2006) There’s NO Such Thing as “Nonjudgmental” Debriefing: A Theory and Method for Debriefing with Good Judgment. Simulation in Healthcare, 1, 49-55. 

 Shorrock, S., and Williams, C. (2016). Human Factors & Ergonomics in Practice. CRC Press. London. 

Shorrock, S. (2017) https://humanisticsystems.com/2017/01/13/the-archetypes-of-human-work/ 




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