378581Let us start 2014 with renewed vigor and interest in simulation! To do that, I am going to take it way back and review the basics of simulation with a 2007 article that I consider landmark for understanding medical simulation and the role it plays in education by one of the leaders in the field, Dr. David Gaba. 

“Simulation is a technique – not a technology – to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner.” [1]

In this 2007 foundational article, Gaba seeks to provide clarity how simulation can be applied to health care education by delineating 11 different dimensions that are integral to help educators create a dynamic simulation scenario and curriculum for their learners. Ultimately the goal of a strong simulation program is to enhance medical education and therefore positively impact patient care and safety.


An educator should go through each of these dimensions when creating their program. Each dimension is unique but a pertinent component of a simulation program. Each dimension is reviewed in brief for this post, for more clarity and information, please read the journal article in its entirety.

1. The purpose and aim of the simulation activity

There are many reasons to conduct simulation training. Obvious among these reasons is knowledge transfer and procedural skills development, but also include using simulation to assess for team training, individual performance, and promotional evaluation.

2. The unit of participation in the simulation

Consider who the participants are for the educational program. One benefit of simulation is that it allows for team training. This was more fully explored on the blog post on Crisis Resource Management. But the unit of participation can also be interdisciplinary, cross-level, and large group such as during mass casualty incident simulations.

3. The experience level of simulation participants

Gaba makes the point that simulation should be used from the “cradle to the grave”. It has use for the most novice of learners (even at the elementary school level when learning basic science) as well as expert learners for recertification. But the curriculum must be appropriate to the level of the learners.

4. The healthcare domain in which the simulation is applied

Simulation training has application in general medical training, nursing training, and also through all the specialties including obstetrics, emergency medicine, anesthesia, and critical care, to name just a few. Similar to the experience level of the learners, the cases that are written must reflect and match the healthcare domain as well. Examples include shoulder dystocia cases for OB teams and central line sterility cases for critical care teams.

5. The healthcare disciplines of personnel participating in the simulation

Broaden your mind! Even nonclinical people can benefit from simulation such as clerical personnel that are critical during resuscitations, for example, ensuring that the patient has been registered and entered in the electronic medical record so that important tests such as CT scans can be pursued.

6. The type of knowledge, skills, attitudes, or behavior addressed in simulation

This essentially means outlining and specifying the objective and goals of each simulation scenario. It is not enough to create a simulation case of a cardiac arrest patient – rather the goals should focus on something such as – minimizing interruptions in chest compressions. Additionally, simulation is a great modality by which to discover the frameworks learners possess which manifests in their knowledge, attitudes, and behaviors [2].

7. The age of the patient being simulated

It goes without saying that knowing the patient type in the simulation case is very important. Gaba’s point in raising this is to always remember that any age patient can be used in simulation from geriatrics to newborn resuscitations.

8. The technology applicable or required for simulations

Simulations can be performed with standardized patients, low fidelity simulations with task trainers, high fidelity simulations with fully equipped manikins that can cry/vomit/seize, and even hybrid simulations by using a live person attached to a task trainer such as a birthing model. Simulation can even be done as low tech recreations as outlined in a previous blog post.

9. The site of simulation participation

Simulation centers are great and usually already set up with the software and hardware. But also consider the great outdoors. There are manikins that are designed to be used outdoors and have batteries so they do not require plug-ins for energy. Also consider in-situ simulations. For example, manikins can easily be wheeled to a trauma bay, an OR, or even the ED waiting room for simulation scenarios.

10. The extent of direct participation in simulation

Not all simulations require all the learners to actively participate. Videos from simulations can also be used as powerful educational modules. In the future, I hope explore the use of video streaming to engage a broader audience during simulation scenarios, where many of the learners would only engage through watching rather than participating.

11. The feedback method accompanying simulation

Although listed at the end, this is probably the most powerful aspect of the simulation – also known as the debriefing session. It can be as concise as 3 quick learning points gained from the simulation, or a more lengthy debrief with a 30-45 minute lively discussion.

So there it is! The 11 most important factors to consider in the creation and execution of a simulation curriculum. Please share your thoughts and experiences, especially if you have ideas to add to this list.


  1. Gaba DM. The future vision of simulation in healthcare. Simul Healthc. 2007 Summer;2(2):126-35. PMID 19088617
  2. Rudolph JW. There’s no such thing as “nonjudgmental” debriefing: a theory and method for debriefing with good judgment. Simul Healthc. 2006 Spring;1(1):49-55. PMID 19088574

Nikita Joshi, MD

Nikita Joshi, MD

ALiEM Chief People Officer and Associate Editor
Clinical Instructor
Department of Emergency Medicine
Stanford University
Nikita Joshi, MD


Emergency Medicine Doctor Associate Editor of ALiEM Gun Sense Advocate #FOAMed #Docs4GunSense #MomsDemandAction Tweets represent my own views and opinions