Simulation Training Beats Problem-Based Approach

Abstract & Commentary

By Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.

Dr. Hoffman reports no financial relationship to this field of study.

Synopsis: For fourth-year medical students, simulation-based learning was superior to problem-based learning in teaching assessment and management skills.

Source: Steadman RH, et al. Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills. Crit Care Med. 2006;34:151-157.

Despite favorable reviews, limited evidence supports the benefit of high fidelity human simulation (HFHS) in preference to more traditional forms of health care provider education. Steadman and colleagues compared the performance of 31 fourth-year medical students who were randomized to receive HFHS training or problem-based learning (PBL). On Day 1, all participants underwent a simulation-based assessment designed to evaluate their critical care skills. The assessment was conducted by 2 instructors blinded to group using a standardized 35-item checklist. The PBL group learned about assessment and management of dyspnea in a standard PBL format and the simulation group using HFHS. To equalize simulator education time, the PBL group received instruction about assessment and management of abdominal pain using the simulator, whereas the HFHS group was taught using the PBL format. During the final day of the course, both groups were evaluated on the assessment and management of dyspnea on the simulator. During these sessions, the "patient" presented with a chief complaint of shortness of breath from various etiologies, eg, asthma, COPD, anaphylaxis, pneumothorax, pulmonary edema, expanding neck hematoma. Each student was responsible for independently managing the "patient" and scored using the same 35-item checklist.

Scores were equivalent at baseline (P = .64) for the 2 groups. The HFHS group performed better (P < .0001) than the PBL group on the final assessment. When each participant’s change in score (% correct on the final assessment minus % correct on the initial assessment) was compared, the HFHS group also performed better. The mean improvement for the HFHS group was 25 percentage points vs 8 percentage points for the PBL group (P < .04).


In the critical care setting, practitioners must be able to quickly assess and appropriately manage critical events. Training to acquire these skills is challenging because patient well-being must supersede opportunity for skill acquisition. Exposure to suitable patients cannot be standardized and emergent events are often handled by practitioners with more experience, which limits student participation.

HFHS training offers the potential to overcome these obstacles by providing exposure to frequent, emergent, or rare events in a setting that facilitates evaluation of actions, decisions, and time to accomplish these. However, evidence supporting benefits of HFHS training remains limited. In this study, the authors were careful to match the training of both groups. Before the intervention, all participants attended the same didactic lectures on the test topic (dyspnea) and control topic (abdominal pain). During the intervention, the same instructors taught all PBL or HFHS sessions. Equivalent information and teaching time were provided to both groups and the rating format was identical for the initial and final assessment. The goal was to learn the skills needed to accomplish a primary and secondary survey and initiate appropriate critical care management. The primary difference was the more realistic simulation environment which consisted of actual equipment, monitors that modeled physiologic changes, and the presence of individuals who modeled actions of the critical care nurse and other health care personnel.

In the opinion of the authors, the simulation environment evoked a distinctly different, more engaged learning atmosphere versus the more reflective response elicited by the PBL-based case studies. Study findings suggest that HFHS led to improved performance, a finding that was especially impressive given the brief duration of the teaching session (< 15 minutes per student). Of note, the study did not attempt to evaluate skills in the critical care setting. Therefore, whether improved performance in the simulation laboratory translates to improved performance under real life conditions remains to be determined.