The increasing use of technology in healthcare, and higher public and patient expectations have both encouraged the development and use of innovative educational methods in healthcare education. The UK Government paper A High Quality Workforce - the Next Stage Review [1] recommended the development of a “strategy for the appropriate use of e-learning, simulation, clinical skills facilities and other innovative approaches to healthcare education” (p.42). The use of simulation has also been encouraged in a number of key Government documents worldwide, such as the US Institute of Medicine’s report To Err is Human: Building a Safer Health System [2].

More recently, the UK Government White Paper A Framework for Technology Enhanced Learning [3] argued that Innovative educational technologies, such as simulation provide unprecedented opportunities for health and social care students, trainees and staff to acquire, develop and maintain the essential knowledge, skills, values and behaviours needed for safe and effective patient care. Simulation is seen as an effective educational strategy that may be used to address the growing ethical issues around 'practicing' on human patients [4] and may therefore provide an effective way to increase patient safety, decrease the incidence of error and improve clinical judgment [5].

The potential risks to patients associated with learning 'at the bedside' are becoming increasingly unacceptable, and the search for education and training methods that do not expose the patient to preventable errors from inexperienced practitioners continues [5]. As Hobgood et al. [6] note, all the evidence shows that a significant proportion of adverse events in health care are caused by problems relating to the application of the 'non-technical' skills of communication, teamwork, leadership and decision-making. These are the cognitive and social skills that complement technical skills to achieve safe and efficient practice. Non-technical skills are seen as distinct from psychomotor skills [7], since they involve interactions between team members (e.g. communication, teamwork and leadership) or thinking skills such as the ability to read and understand situations or to make decisions, all of which assist with task execution. The accurate and consistent measurement of non-technical skills has been the subject of much debate in recent times [8, 9].

Fidelity in simulation has traditionally been defined as 'the degree to which the simulator replicates reality [10]'. Using this definition, simulators are labelled as either 'low' or 'high' fidelity depending on how closely they represent 'real life'. In order to simplify the definition of high fidelity simulation, the authors used a typology (Fig. 1) based upon that proposed by Cant & Cooper [11] which defined high fidelity simulation in terms of 'simulation that incorporates a computerised full-body manikin that can be programmed to provide realistic physiological response to student actions'.

Fig. (1). A typology of fidelity within simulation-based education adapted from Cant & Cooper [11].

Firstly, to review the body of evidence regarding the use of high fidelity simulation (HFS) in the development of non-technical skills for nurses, and secondly to identify the implications of the findings for nurse education and for future research in simulation.

A systematic search of the literature was undertaken for all articles in written in English between January 2000 and January 2011. The databases used were Web of Science, Ebsco host (CINAHL Plus, ERIC, Embase, Medline), Cochrane Library, SCOPUS, Science Direct, ProQuest and ProQuest Dissertation and Theses Database. Reference lists from relevant papers and the websites and databases of other simulation organisations (e.g. Society in Europe for Simulation Applied to Medicine) were also searched.

Quality Appraisal of the Studies

All three of the authors (RL/AS/MMS) were involved in the decision-making process (Fig. 2), and articles were included that were written in English between 2000-2011, involving either nurses or midwives using simulation as an educational strategy. In addition, the methodological approach had to be able to contribute to the body of evidence relating to simulation. It quickly became apparent from this, and other narrative reviews of the nursing simulation literature [11] that the traditional 'scientific' criteria used to assess the robustness of the studies did not necessarily apply.

Fig. (2). Flow chart for study selection process.

In practical terms, the team agreed to exclude all qualitative and descriptive papers, and took a pragmatic decision to review the quantitative pre- and post-test studies, quasi-experimental and single-test studies available, even though the robustness of their design may be open to question. The papers were reviewed according to the quality criteria suggested for assessing randomised controlled trials and case control trials by the Critical Appraisal Skills Programme (CASP) [12]. The designs of the studies were noted, and whether description of each step of the research enabled any degree of assessment of the rigour of the data and/or the statistical analysis used.

In all 16 articles were considered for final inclusion for the review, and of those articles, the study designs and methods used varied considerably, with correspondingly differing levels of validity and reliability demonstrated. In terms of the relative rigour of the papers, there were 3 RCTs, and 7 pre-test/post-test experiments or quasi-experiments using simulation as the educational intervention, of which 5 compared simulation with a control group taught by more traditional education methods. There were 6 other studies that used single interventions and simple post-test designs, and although these studies are not considered to be as robust as the experimental and quasi-experimental designs, the pragmatic decision was taken to include them for the purposes of completeness. This paper will therefore review the evidence for using simulation in relation to the development of the non-technical skills of interpersonal communication, team working, clinical leadership and clinical decision-making.

It is widely accepted that communication failures are one of the leading causes of inadvertent patient harm worldwide [13]. As Leonard et al. [14] note, formal training for effective communication and teamwork has historically been largely ignored. Unfortunately, the clinical environment in which healthcare takes place is becoming a progressively ever more complex 'socio-technical' system, and the inherent limitations of human performance mean that communication and team training have now become a significant aspect of healthcare training and education. Research into healthcare communication using simulation has tended to focus upon communication as an integral part of teamwork and team training however; there have been a small number of studies which have looked at the use of simulation in training for medical 'handover'. The handover of patient-specific information from one care giver to another has been identified as a high risk process, as it forms a patient safety-critical interface in which crucial information may be lost, inaccessible or misunderstood.

Most of these patient handover studies have used junior doctors or medical students [15], although one has involved nursing staff [16]. This pre/post test observational study took place in a 5 bedded medical 'step-down' High Dependency Unit, and used direct observation of the patient handover of 25 nurses, scored by a checklist. The educational intervention incorporated three simulation-based nurse shift handover scenarios into a teamwork and communication workshop. The authors found that there was a statistically significant increase in the quality and quantity of information handed over after the simulation intervention, and that communication using interpersonal verbal skills relevant to patient safety were improved.

Effective teams are social entities that use shared knowledge, skills, attitudes, goals, and monitoring of own and others’ performance to achieve high quality teamwork [17]. Arising out of crew resource management (CRM) training in the aviation industry, healthcare team training typically involves the assimilation of learning theory principles and team behaviours, the practice of these, and the provision of high quality feedback [18]. As Baker et al. [18] note, the challenge for educators is that healthcare teams are often unpredictable, such that a group of competent individual professionals can combine together to create an incompetent team.

Teamwork in healthcare is further complicated by the fact that a number of individuals who have probably not previously worked with each other, and might not even be familiar with each other have to collaborate for the benefit of the patient in a complex and dynamic clinical environment. in addition, team composition and context may change constantly within a clinical environment characterised by quickly developing and confusing situations, information overload, time constraints, and high risks for patient safety.

As with intra-team communication, clinical leadership is usually regarded simply as a component of team training education. In a recent study, Radovich et al. [28] used three high fidelity simulation scenarios to enable neophyte nurse leaders to develop their leadership skills during the management of difficult interpersonal situations. Radovich et al. found that the use of simulated scenarios increased the participants' self-confidence, and gave them a much better understanding of the skills required to manage the type of complex interpersonal situations that occur within healthcare teams. Although Radovich et al. focused upon the use of simulation from the perspective of an educational programme for nurse managers, the generic leadership skills that the simulated scenarios addressed (interprofessional communication, organisational understanding, crisis management and negotiation skills) are equally applicable to the skills required in leading teams in crisis situations.

Situation awareness (SA) is a relatively new concept within healthcare and is defined by Endsley [29] as ‘the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning and the projection of their status in the near future’ (p. 36). However in simple terms, SA may be seen as knowing 'what is going on' in any given situation, and involves the individual's perception and understanding of what is happening, and their prediction of what may happen in the future. Good SA is now recognised as an integral part of competent clinical practice, particularly in crisis situations, however up until now it has not been actively measured in nursing or team performance.

Both Endacott et al. [30] and Cooper et al. [31] looked at both situation awareness (SA) and clinical decision making as part of a much wider study into the management of acute patient deterioration, and used the Situation Awareness Global Assessment Technique (SAGAT), a well-validated assessment tool for measuring SA. This was done as part of the assessment of 51 final year undergraduate student nurses undertaking two simulated scenarios relating to the management of an acutely deteriorating patient. Using a SAGAT questionnaire with 17 yes/no questions, both studies stopped the scenario at random points and looked at the students' global appreciation of their situation, their perception of the patient's physiological condition, their understanding of the clinical problem and how the scenario may progress. Overall they found that the students focused primarily upon the purely physiological aspects of the scenarios, and lacked a more global appreciation of the situations they were involved in. More recently, Cooper et al. [32] carried out a further study to examine Registered Nurses' management of deteriorating patients in a small rural hospital in Australia. They used a single intervention design, with 35 RNs undertaking two acute care OSCEs, during which their SA was assessed. They found that overall the RNs lacked SA and that their SA scores were correspondingly low. The authors argue that the use of simulation as an educational strategy would be a positive way to equip these RNs with the skills to better manage the acutely deteriorating patient. All three of these studies appear to indicate that nurses consistently lack SA, and that this will need to be addressed by nurse education in the future.

The dynamic nature of contemporary healthcare requires nurses to assume ever more complex roles, which in turn, necessitates the acquisition of higher level critical thinking skills. It is argued that the development of these skills enhances the practitioners’ ability to address complex or unfamiliar situations, and that nurses with high quality clinical reasoning skills will have a positive impact on patient outcomes, particularly when faced with complex care situations.

Both Howard [33] and Schumacher [34] compared the use of simulation as an educational intervention to develop students' critical thinking abilities. Critical thinking was defined as the ability to reason, deduce, and induce based upon current research and practice findings, which Howard argued was the foundation for sound clinical decision-making in nursing. Howard's study was a multi-site, quasi-experimental pre/post-test design, with a sample of 49 nursing students randomly allocated to the intervention group (simulation) or control (interactive case study) group. An exam was used to assess the students' critical thinking, and analysis revealed a significant difference in critical thinking ability with the simulation group scoring significantly higher on the post-test when compared to the case study group with respect to critical thinking abilities (p= 0.07). Using a similar definition of critical thinking, Schumacher compared three different educational strategies (formal classroom teaching, high fidelity simulation and a combination of the two methods). Like the Howard study, this study used an examination designed to measure application and analysis at a cognitive level. The issue here for both studies would seem to be the appropriateness of a written examination as a measurement of critical thinking.

Ravert [35] also compared the effects of regular education plus simulation, regular education plus case study and regular education alone on students' critical thinking skills. A pre-test/post-test design was used with a cohort of 64 undergraduate nursing students, with the sample divided into three groups (2 experimental groups and one control group). The control group participated in the regular education process alone. The non-simulation group had five case study sessions and the simulation group participated in five weekly, one-hour simulation sessions.

Pre- and post-test intervention evaluations of critical thinking were obtained through the administration of non-discipline specific, statistically valid and reliable instruments. Analysis of test scores revealed improvements in post-intervention test scores across all groups however differences among groups lacked statistical significance. Ravert acknowledged that results of the study should be interpreted with caution, insofar as neither of the critical thinking measurement instruments used had been designed specifically for use with nursing students.

There is much intuitive and anecdotal evidence for the effectiveness of simulation in the acquisition of non-technical skills in healthcare, however the research evidence is limited and often contradictory. One of the challenges for this review therefore was to identify why there are a number of studies which have produced equivocal results, and why some have found a significant difference between the impact of simulation and other educational methods, and some have not. It may be argued that one of the main reasons for the large number of equivocal results in simulation education, other than the methodological deficiencies in many of the studies, is that the researchers are simply asking the wrong questions, or looking at the wrong things in the wrong way.

In recent times there has been a broad acceptance of simulation in healthcare education, although the studies attempting to assess its worth have found hard data to confirm the effectiveness of simulation elusive, particularly in relation to non-technical skills [38]. It should be remembered that in comparative terms simulation is still a relatively new educational strategy in healthcare education, and consequently the evidence base for simulation is comparatively small, although growing quickly.

It would be very easy to dismiss simulation due to the relative lack of 'hard' evidence as to its effectiveness, particularly in the field of nurse education. The most important point to make, supported by the evidence from simulation-based medical education, is that whilst there are no negative findings, there are many positive findings that we may draw upon. For example, simulation is positively associated with significantly improved interpersonal communication skills at patient handover [16], and it enables the effective development of transferable, transformational leadership skills [28]. It has also been clearly shown to improve team behaviours in a wide variety of clinical contexts and clinical personnel, associated with improved team performance in crisis situations [10, 19, 21-22, 23-25]. Simulation has also given an insight into how we might better address the development of situation awareness in nursing students, and provided the direction for further study in this area [30-31]. From a cognitive skills perspective, simulation has also been demonstrated to improve students' critical thinking and clinical reasoning in complex care situations, using a number of different measuring tools [33-35] and to aid the development of students' self-efficacy and confidence in their own clinical abilities.

As already noted earlier, there may be other educational strategies (e.g. interactive case studies) that also provide participants with these skills, and indeed a number of the studies in this review did use simulation to complement other educational strategies. It should be noted however that the findings from the 'SaFE' study [25-27] indicated that there was no benefit in the use of traditional didactic team teaching in combination with simulation. What is clear from this review and others, is that simulation is able to provide participants with an interactive and immersive learning environment in which to learn, that is safe and controlled so that the participants are able to make mistakes, correct those mistakes in real time and learn from them, without fear of compromising patient safety. Participants in simulation are also able to rehearse the clinical management of rare, complex or crisis situations in a valid representation of clinical practice, before practising on patients. In summary, the most powerful single argument for simulation remains that participation in simulation-based education appears to help to prevent participants from making mistakes in the future, by providing a set of clinical circumstances in which it is permissible to make mistakes and learn from them.

The authors confirm that this article content has no conflicts of interest.