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Table 2 Data abstraction of the included studies (n = 37)

From: Status of Nordic research on simulation-based learning in healthcare: an integrative review

Authors and year Country Study aim(s) Study design Participants Simulation modality Key findings
Ameur et al. 2003 [63] Sweden To examine how contextual understanding influences performance in a virtual environment. Mixed methods
(result log, survey and in-depth interview)
n = 20
Medical students
Virtual reality
(AccuTouch‚ Endoscopy
Simulator, a bronchoscopy simulator)
The «patient group» with context manipulation perceived the simulation as more realistic than the “simulator group” did, as the latter were more focused on the psychomotor skill training.
Aspegren et al. 2006 [49] Denmark To determine the effect of a 13-h training in medical interviewing in pre-graduate medical education. QUAN non-randomized (Observation) (two randomized EG and one not randomized CG) n = 114
Medical students
Simulated patients (actor) A greater proportion of the medical students in EG1 and EG2 that underwent 13 h of training achieved better medical interviewing skills than students who did not undergo such training (CG3).
Bjørshol et al. 2011 [42] Norway To evaluate whether socioemotional stress affects the quality of CPR during advanced life support in a simulated manikin model. QUAN RCT (one EG with exposure to stress, one CG without exposure to stress) n = 60
Manikins (Resusci Anne Simulator®- Laerdal Medical) There were no significant differences in chest compression depth, compression rate, no-flow ratio, or ventilation rate between the two conditions. There was a significant increase in the subjective workload, frustration, and feeling of realism when the paramedics were exposed to socioemotional stress.
Bondevik et al. 2006 [57] Norway To examine how medical students view the use of an actor in communication and consultation education. Mixed methods (survey including free text) n = 188
Medical students
Simulated patients (actor) Almost all students (97%) viewed the use of a simulated patient as beneficial, valid, realistic, and close to reality, but pointed out the danger of exaggeration and the potential to miss nuances.
Creutzfeldt et al. 2012 [41] Sweden To explore medical students’ retention of knowledge and skills as well as their proficiency gain after pre-training using a multiplayer virtual world (MVW) with avatars for CPR team training. QUAN non-randomized (two EG and one CG) n = 30
Medical students
Virtual reality (MVW technology with avatars) EG2 displayed greater CPR-related knowledge than the CG3, EG1 scored in between. At start, EG1 and 2 adhered better to guidelines than CG3. Likewise, in EG2, no chest compression cycles were delivered at incorrect frequencies, whereas 54 (±44)% in CG3 (p < 0.05) and 44 (±49)% in EG1 were incorrectly paced; these differences disappeared during training.
Dahl Pedersen et al. 2006 [56] Denmark To evaluate interprofessional education in communication and collaboration in relation to ward rounds. Mixed methods (pre-test and post-test measurements) (surveys) n = 25 (12 nursing students and 13 medical students) Simulated patients (actors) The students evaluated the education very positively where the content and structure met their needs for interprofessional education regarding ward rounds.
Dieckmann et al. 2014 [72] Denmark To identify facilitators and barriers in a medicine label system to prevent medication errors in clinical use by health care professionals. QUAL (interview) n = 20 (10 nurses and 10 physicians) Manikins (in a hospital room and a medication room) The label design benefited from the standardized construction of the labels, the clear layout and font, and some warning signs. The complexity of the system and some inconsistencies (different meaning of colors) posed challenges, when considered with the actual application context, in which there was little time to get familiar with the design features.
Fuhrmann et al. 2009 [73] Denmark To evaluate the effect of multi-professional full-scale SBE of staff on the mortality and staff awareness of patients at risk on general wards. QUAN non-randomized (pre-test and post-test measurements) n = 1783 (1563 patients, 220 nurses and physicians) Manikins No significant differences were observed between the pre and post-intervention periods concerning the incidence of patients with abnormal vital signs, staff awareness of patients at risk, 30-day mortality or length of hospital stay among patients at risk.
Gabrielsen et al. 2016 [50] Norway To describe how nurses in a postoperative unit evaluated a SB communication course QUAN descriptive (survey) n = 40
Simulated patients (nurse) 53% reported that the simulation improved their comprehension about how to use the model. 33% reported their communication skills improved after the course.
Hakoinen et al. 2014 [48] Finland To compare patient counseling performance in community pharmacies and health food stores by using a simulated customer buying a nutritional supplement. QUAL (structured data collection sheet was used to document each visit) n = 12 (6 personnel of the pharmacies and 6 personnel of the health food stores) Simulated patients (educated person acting according to pre-designed scenario) Compared to the pharmacies, the natural food stores did better since their customer service was faster and more convincing. Compared to natural food stores, the customer service remained more distant in pharmacies. In pharmacies, the information given to the customers was based on scientific facts while in natural food stores the wellbeing aspect was highlighted.
Haraldseid et al. 2015 [37] Norway To explore students’ perceptions of their learning environment in a CSL, and to increase the knowledge base for improving CSL learning conditions identifying the most important environmental factors according to the students. QUAL (focus group interview) n = 19
Nursing students
Manikins or simulated patients (peer students) The study documented students’ experience with the physical (facilities, material equipment, learning tools, standard procedures), psychosocial (expectations, feedback, relations) and organizational (faculty resources, course structure) factors that affect the CSL learning environment.
Høyer et al. 2009 [51] Denmark To describe physicians’ behavior as team leaders in a simulated cardiac arrest during inter-hospital transfer. QUAN descriptive n = 72
Manikins Chest compressions were initiated in 71 cases, ventilation and defibrillation in 72. The median times for arrival of the driver in the patient cabin, initiation of ventilation and chest compressions, and first defibrillation were all less than 1 min. Medication was administered in 63/72 simulations, after a median time of 210 s. Adrenaline was the preferred initial drug administered (58/63). Tasks delegated were ventilations, chest compressions, defibrillation, and administration of medication.
Jacobsson et al. 2012 [53] Sweden To analyze how formal leaders communicate knowledge, create consensus, and position themselves in relation to others in the team. Mixed methods (video-recordings and observation) n = 96 (32 registered nurses, 32 enrolled nurses and 32 physicians) Manikins (advanced human patient simulator) Leaders used coercive, educational, discussing and negotiating strategies to work things through. The leaders used different repertoires to convey their knowledge to the team, in order to create a common goal of the priorities of the work. Changes in repertoires were dependent on the urgency of the situation and the interaction between team members. When using these repertoires, the leaders positioned themselves in different ways, either on an authoritarian or on a more egalitarian level.
Jansson et al. 2014 [46] Sweden To evaluate the effectiveness of patient simulation education in the nursing management of patients requiring mechanical ventilation. QUAN RCT (questionnaire and observation) n = 30
Critical care nurses
Manikins After simulation, the average skill scores in the EG increased significantly in the final post-intervention observation. In the average skill scores, a linear mixed model identified significant time and group differences and time-group interactions between the study groups after the simulation. In contrast, the model did not identify any significant change over time or time-group interactions between groups in average knowledge scores.
Jäntti et al. 2009 [44] Finland To evaluate how much CPR is taught in lessons and in small groups in different institutions teaching different levels of emergency medicine providers, and to evaluate methods of teaching the different aspects of CPR quality in small groups. QUAN descriptive (survey) n = 42 (21 Institutes, 4 medical schools, 6 universities of applied science, 10 colleges, 1 emergency services college) Manikins The median for hours of theory lessons of CPR was 8 h (range: 2–28 h). The median for hours of small group training was 10 h (range: 3–40 h). The methods of teaching adequate chest compression rate were instructors’ visual estimation in 28.5% of the institutions, watch in 33.3%, metronome in 9.5% and manikins’ graphic in 28.5% of institutions. The methods of teaching adequate chest compression depth were instructors’ visual estimation in 33.3%, in manikins’ light indicators in 23.8% and manikins’ graphics in 52.3% of institutions.
Jensen et al. 2013 [54] Denmark To assess the potential benefits of a PCM for health care professionals involved in planning and coordination of patients with COPD and DM2, primarily focusing on the efficiency of the PCM, and secondary on satisfaction. Mixed methods (survey and interview) n = 18 (6 nurses, 6 General Practitioners and 6 hospital physicians) Simulated patients (health informatics experts) The results showed that health care professionals may benefit from a PCM. Furthermore, unexpected new possible benefits concerning communication and quality management emerged during the test and potential new groups of users were identified.
Jensen et al. 2015 [69] Denmark To describe a methodological approach for planning, preparing and conducting clinical simulations. Mixed methods (case study and questionnaire) n = 18 (6 nurses, 6 General Practitioners and 6 hospital physicians) Simulated patients (health informatics experts) Healthcare professionals can benefit from such a module. Unintended consequences concerning terminology and changes in the division of responsibility among healthcare professionals were also identified, and questions were raised concerning future workflow across sector borders. Furthermore, unexpected new possible benefits concerning improved communication, content of information in discharge letters and quality management emerged during the testing. In addition, new potential groups of users were identified.
Koponen & Pyörälä 2014 [62] Finland To explore medical students’ perceptions of 3 experiential learning methods, their attitudes to learning communication skills and their self-reported learning outcomes in 3 groups using different experiential methods: simulated patients, role-play, and theater in education. Mixed methods (questionnaire, focus group interviews and a survey) n = 132
Second-year medical students
Simulated patients Most students (84%) in each group found these methods suitable for learning interpersonal communication competence. There were no statistically significant differences in students’ perceptions. According to the students, these three methods had five special elements in common: the doctor’s role, the patient’s role, reflective participation, emotional reactions and teacher’s actions. The students’ self-reported learning outcomes were communication skills, knowledge of doctor-patient communication, patient-centeredness, and awareness of interpersonal communication competence. A few students reported no learning outcomes. These self-reported learning outcomes were similar in the three groups. The medical students’ attitudes toward learning communication skills became more positive during the pilot course. There were no significant differences in students’ attitudes in the three groups before and after the course.
Lauri 1992 [52] Finland To describe the development and testing of a computer simulation program designed to assess the decision-making process in the public health nurses’ work in child health care. QUAN descriptive (computer-based items) n = 61
Public health nurses
Computer-based simulator The results revealed some inconsistencies in the decision-making process with respect to the needs of the child and family as decisions were related more to the developmental stage of the child than to the unique needs of each family.
Lestander et al. 2016 [67] Sweden To explore the value of reflections after high fidelity simulation by investigating nursing students’ perceptions of their learning when a three-step Post-simulation Reflection Model was used. QUAL (descriptive) n = 16
Nursing students
Manikins (Laerdal® SimMan®) The main theme in the first written reflections was identified as “Starting to act as a nurse”, with the following categories: feeling stressed, inadequate and inexperienced; developing an awareness of the importance of never compromising patient safety; planning the work and prioritizing; and beginning to understand and implement nursing knowledge. The main theme in the second written reflections was identified as “Maturing in the profession”, with the following categories: appreciating colleagues, good communication and thoughtfulness; gaining increased self-awareness and confidence; and beginning to understand the profession.
Mjelstad et al. 2007 [70] Norway To describe a pilot study of using simulation (MATADOR) as a method for training trauma team in leadership, communication and coordination. QUAN non-randomized (survey and video-recordings) n = 24 (12 emergency nurse, surgeons, anesthesia residents, anesthesia nurses, 12 medical students) Virtual reality MATADOR allowed fatal interventions during advanced treatment of a multi-trauma patient, something two of the student groups did. In comparison, the specialist groups managed to stabilize the patient without selecting CT before the life-threatening bleeding was clarified. The specialists were consistently faster than the students to introduce therapeutic treatment.
Mondrup et al. 2011 [40] Denmark To evaluate the feasibility of the applied method, and to examine differences in the resuscitation performance between the first responders and the cardiac arrest team. QUAN descriptive No. of participants, NS (Nurses, nurse-assistants, medical residents, medical interns, anesthesia residents, anesthesia nurses, orderlies) Manikins (Resusci Anne Simulator- Laerdal Medical®) Data from 13 of 16 simulations was used to evaluate the ability of generating resuscitation performance data in simulated cardiac arrest. The defibrillator arrived after median 214 s and detected initial rhythm after median 311 s. A significant difference in no flow ratio was observed between the first responders and the resuscitation team. The difference was significant even after adjusting for pulse and rhythm check and shock delivery.
Mäkitie et al. 2008 [64] Finland To develop computerized tomography and computer-based models of skull using rapid prototyping and manufacturing. QUAL n = 4
Medical students
Virtual reality (Computer-based virtual modeling using four different test models) The models are suitable for learning rough anatomic structures, for example in basic level in medical teaching. When practicing microsurgery, the lack of microscopic details and rough structure decrease the usefulness of the model, so far. However, this method can provide first feeling to ear surgery, as was experienced by the residents.
Naess et al. 2011 [43] Norway To measure the quality of advanced CPR during simulation training, and to assess if the results are in accordance with the Norwegian guidelines of 2005. QUAN descriptive n = 64 (48 nurses and 16 physicians) Manikins (Resusci Anne Simulator- Laerdal Medical®) The quality of advanced CPR performed was in accordance with the Norwegian guidelines of 2005. The algorithm was followed correctly in almost every scenario, and the technical performance was good. Current results indicate no unnecessary hands-off time.
Poikela et al. 2015 [66] Finland To examine how two different teaching methods resulted in students’ meaningful learning in a simulated nursing experience. QUAL (quasi-experimental) (video-recordings) n = 52
Nursing students
Computer-based simulator The students who used a computer-based simulation program were more likely to report meaningful learning themes than those who were exposed to a lecture method.
Reierson et al. 2013 [38] Norway To describe and discuss the key issues and challenges in the light of their importance for developing and implementing The Model of Practical Skill Performance. QUAL (action research) n = 6
Nursing teachers
Simulation modality NS Six key issues and challenges were identified; anchoring the action research in the faculty structure, repeated dialog meetings between action research group and faculty, adapting the teacher and student roles in the simulation skills center, unequivocal understanding of the model as a theoretical and normative learning tool, curriculum consistency, and teachers’ engagement and enthusiasm.
Rosqvist & Lauritsalo 2013 [55] Finland To find out how nurses and physicians participating in SB trauma team training using a manikin perceived the training and its effects on their professional trauma management know-how. Mixed Methods (questionnaire) n = 169
Manikins (Laerdal® SimMan®) SB trauma team training was reported to have an effect on teamwork and communication. Most of the participants (96%) agreed that the simulation training was useful, irrespective of occupational group, length of working experience or number of simulation training sessions. The changes in working practices as a result of the training, reported by the participants on both the personal and team levels, ranged from single items of information and skills to overall professional development. The training was seen as providing a template that helped participants to remember relevant issues when caring for real trauma patients. It was also considered a useful induction method for new employees. Some of the participants with experience of SB trauma training had experienced the transfer of learned know-how from a simulation environment to clinical practice.
Saaranen et al. 2015 [68] Finland To produce information which can be utilized in developing the simulation method to promote the interpersonal communication competence of master-level students of health sciences. QUAL (descriptive) (essays) n = 47 (Master students of health sciences; nursing leadership, management, preventive nursing science, nurse teacher education) Simulated patients (students) Planning of teaching, carrying out different stages of the simulation exercise, participant roles, and students’ personal factors were central to learning interpersonal communication competence.
Salminen et al. 2014 [58] Finland To create a model for a virtual patient in primary care that facilitates medical students’ reflective practice and clinical reasoning. QUAL (focus group interview) n = 24 (10 primary care physicians and 14 medical students) Computer-based simulator (Virtual patient) Findings show good acceptance of the model by students. Use of the virtual patient was regarded as an intermediate learning activity and a complement to both the theoretical and the clinical part of education, filling out the gaps in clinical knowledge. It was regarded as authentic and the students appreciated the immediate feedback; the structure of the model was interactive and easy to follow. The VP case supported their self-directed learning and reflective ability.
Silvennoinen et al. 2016 [45] Finland To analyze data (videos and parametric data) that was saved to simulator as well as participants’ perceptions, collected using questionnaires. QUAN descriptive (questionnaire) n = 20
Computer-based simulator (Endoscopy simulator-GI Mentor) The results showed that the skills of the trainees had improved, especially with regard to fluency of endoscopy movement, time spent with clear view, and performance time. The trainees themselves assessed the improvement in their skills similarly, the greatest improvement being reported in coordination, handling the endoscope, and maintaining a clear view; while the least improvement was reported in procedure planning and paying attention to ergonomics during the procedure. Participants’ suggestions for improvement of the course included increasing personal feedback and theory lessons.
Tella et al. 2015 [39] Finland To explore and compare Finnish and British nursing students’ perceptions of learning about patient safety in academic settings to inform nursing educators about designing future education curriculum. QUAN descriptive (questionnaire) n = 195
Nursing students
Simulation modality NS Both student groups considered patient safety education to be more valuable for their own learning than what their programs had provided. Training patient safety skills in the academic settings were the strongest predictors for differences, along with work experience in the healthcare sector. To prepare nursing students for practical work, training related to clear communication, reporting errors, systems-based approaches, interprofessional teamwork, and use of simulation in academic settings require comprehensive attention, especially in Finland.
Thesen et al. 2004 [59] Norway To describe a course in CPR for healthcare workers in primary care. QUAN descriptive n = 141 (32 physicians, 17 nurses, 92 medical secretaries, paramedics, assistant nurses, personal assistants) Manikins (computer based) 54 of 61 who responded to the survey said that it was useful education in their daily work. 5 wanted this course every other year or less seldom, while the rest wanted the course once or twice a year. More than half of the participants answered that the theory, practical exercises and the level of theory was suitable.
Toivanen et al. 2012 [61] Finland To describe psychiatric nurses’ experiences of patient simulation as teaching and learning method in in-service training in somatic emergencies. QUAL n = 8
Psychiatric nurses
Manikins The results indicated that patient simulation was a versatile and effective method of in-service training in somatic emergencies for psychiatric nurses. The nurses felt the teacher had an important role in promoting a positive learning atmosphere and it was important that their work profiles were taken into account in designing the simulation scenarios. The nurses thought they could utilize the education in developing their work and pointed out the need for regular training in somatic emergencies, using patient simulation to ensure their competence.
Utsi et al. 2008 [47] Norway To evaluate a method for interprofessional training in emergency handling, receiving and stabilization of seriously injured patients in primary care. Mixed methods (pre-test and post-test) n = 119 (27 physicians, 44 nurses, 48 paramedics, medical secretaries, assistant nurses) Manikins The participants reported a significant increase in their confidence in their own role and with the order of necessary actions. 91% would recommend the course to peers.
Westfelt et al. 2010 [71] Sweden To present health care professionals’ perception of collaboration and safety in the emergency department, and to demonstrate how such teamwork for safety can be implemented. QUAN non-randomized n = 55 (22 nurses, 13 assistant nurses, 3 anesthesia nurses, 6 surgeons, 2 urologists, 9 anesthesia residents) Manikins (Laerdal® SimMan®) The participants evaluated interprofessional team training with simulation as very satisfactory. Nurses and nurse assistants addressed the need for a deeper collaboration by employing an established training method in their own working environment. It is possible to train teams in a realistic environment without using real patients.
Wisborg et al. 2009 [36] Norway To examine the participants’ assessment of their educational outcome after training with either a simulated patient or simple resuscitation manikin. QUAN RCT (survey and focus group) n = 104 (32 physicians, 53 nurses, 19 radiographers and lab technicians) Manikins and simulated patients (nurse or a medical student) Participants assessed their educational outcome to be high, unrelated to the order and appearance of patient model. There were no differences in assessment of realism or feeling of embarrassment. Participants felt that the choice between the educational modalities should be determined by the simulated case, with high interaction between teams, and interaction enhanced by using a standardized patient.
Østergaard et al. 2008 [35] Denmark To describe a framework for the development of a team training course and to describe the development of multiprofessional team training in Denmark and its connection to patient safety. QUAN non-randomized No. of participants, NS
Nurses, surgeons, anesthetists, radiologists, secretaries and hospital orderlies
Manikins and simulated patients The use of the framework was illustrated by the existing multiprofessional team training in advanced cardiac life support, trauma team training, and neonatal resuscitation.
  1. CG control group, CPR cardio-pulmonary resuscitation, CSL clinical skills laboratory, EG experimental group, No number, NS not stated, PCM Planning and Coordination Module, QUAL qualitative, QUAN quantitative, RCT randomized control trial, SB simulation-based, SBE simulation-based education