FacebookTwitterLinkedInGoogle+RSS Feed
Fire EMSEMS TodayEMS Insider

Simulation-Based Assessment Facilitates Learning & Enhances Clinical Judgment


Educational programs are designed to scaffold learning to ensure students have the knowledge, skills and attributes necessary to prepare them for the workplace. In an under-resourced healthcare environment, graduates are more often expected to require minimal orientation and practice at a level in excess of beginning competence.1,2

Similar to nursing and other health related qualifications where access to clinical placements influences student preparation; paramedic education is challenged to find new ways in which to generate student experience, assess competence and ensure graduates meet industry requirements.

Simulation has proven to be a valuable tool for paramedic students to augment and develop skills to enhance learning. It provides an opportunity within a safe, supportive environment to practice clinical skills where individuals are able to bring their experience and knowledge into the classroom, reflect on their capability and understanding, and engage in an active intellectual learning environment.3

Paramedic education has traditionally used simulation and simulation-based assessment (SBA) as a means of preparing and assessing students for the prehospital work environment. This includes creating accident scenes and providing opportunities for intervention that allow students to demonstrate knowledge and skills in an often uncontrolled environment, providing unique opportunities for educators to assess student skills and competency to practice.4

Although simulation is identified for its contribution to learning, critics claim this doesn’t portray the complexities of the actual prehospital environment and question how effective assessment is when undertaken in a controlled setting.

Issues related to the authenticity of simulation are widely acknowledged in the literature.5,6 These have largely been addressed with developing technology and incorporating the use of actors and simulated patients in immersive teaching and assessment events.

SBA is now acknowledged as an effective strategy for teaching and learning within the healthcare industry. This article reviews the history of SBA, identifies the advantages and challenges for the use of SBA in paramedic education and discusses a debriefing process designed to enhance learning and assessment processors.


There’s a dearth of research in relation to paramedical education, and less on the subject of SBA. 5–9

Due to the limited number of published papers that are EMS-specific, authors who have studied the use of SBA in paramedic education have had to access allied healthcare professional journals, especially those on medicine and nursing, for evidence-based information.10

To increase the professional standing of paramedic education, more research needs to be undertaken in relation to SBA.

History of Simulation

The aviation industry was one of the first to implement simulation as an educational tool to reduce the number of airline crashes attributed to human error within the cockpit. The focus and use of simulation in aviation was on developing cognitive, psychomotor and affective domains of learning and included assessment.11-12 It was found that simulation and the use of SBA was valuable in enhancing practice competence of pilots and reducing errors.

This experience provided insights into how simulation might be successfully incorporated in other fields—including medicine, nursing, and more recently, paramedical education—to reduce patient care errors.

Advantages of SBA

Reducing patient care errors: There are certain interventions and clinical tasks healthcare personnel undertake which have the potential to adversely impact patient safety and are designated “high risk.” Some of these tasks are implemented infrequently. Pediatric intubations, for example, are rare in relation to the number of pediatric patients who require this level of airway management.

Low frequency combined with the inability for clinicians to practice and maintain competency tasks such as this may become a high-risk intervention where the patient safety may be compromised. The retention of competence and ability to undertake the procedure is essential to ensure patient safety. Competence and retention of a particular skill decreases within six months and in order for task competency to be retained, tasks need to be practiced more frequently.6

Simulation can address ongoing competency issues by preparing paramedics for dealing with uncommon conditions where high-risk verses low–frequency treatment of patient is an issue.6

Regular use of SBA has been found effective for maintaining skills for infrequently used interventions that have a high risk to patient safety and provide a means to ensure that clinicians maintain a high level of competency, make accurate clinical judgment, and thus reduce unsafe practices that impact their patients.6

Enhancing clinical judgment: The cornerstone of professional practice is clinical judgment. This involves thinking processes that result in the most appropriate action for a specific context/situation. In the absence of sound clinical judgment, clinical practice becomes a technical operation requiring direction from a decision maker.13

Improvement in clinical judgment assists in decreasing clinical error in hospital and prehospital environments. Simulation and SBA incorporate theory and practice, improve the clinical judgment of students and is a key driver for inclusion of this pedagogy in curricula. Student exposure to simulation can increase knowledge integration and assists in the formulation of clinical reasoning and decision making.14

This is of particular importance for student paramedics who must be vigilant, have an ability to think critically and execute accurate clinical judgment to detect life-threatening changes in patient conditions. The ability to think critically, generate alternatives, select an alternative, implement and reassess, solve problems, and communicate are requirements of everyday practice. With improved clinical judgment and clinical reasoning skills, students’ confidence in clinical situations should increase. As experience in clinical situations increase, so does confidence or self-efficacy. These students have a better chance at not only succeeding in their clinical goals, but they’re also more likely to use and test clinical skills.15

To further enhance the development of clinical judgment and clinical reasoning in nursing, Tanner’s Clinical Judgment Model has been used for over three decades to assist nurses to resolve complex, ambiguous, and conflicting situations.16

The model has four components: noticing, interpreting, responding and reflection.16

1)      Noticing includes patient assessment where a nurse recognizes changes in a patient’s condition and responds effectually.

2)      Interpreting is where the nurse analyses the patient information and prioritizes care for the patient.

3)      Responding is the nurse’s calm, confident and professional approach to the situation using effective communication. A patient care plan is implemented with skillful and well-planned judgment.

4)      Reflection is when the nurse evaluates and analyzes the patient care plan to ensure the care was appropriate.17

Tanner’s model is also useful in educating  paramedics, who work in an uncontrolled work environment and at times as solo practitioner for long durations, responsible for constantly reviewing the patient, their vital signs, and implementing treatment while transporting the patient to the hospital. The model has been adapted to conform to more traditional approaches and language used within paramedicine and provides a framework for facilitating the development of clinical judgment.17

The adapted model, referred to as the 3IR, includes four key components:

1)      Identification of changes in the patient’s condition by engaging in continual reassessment;

2)      Interpretation of assessment finding and generate alternatives for patient care;

3)      Implementation of a treatment plan; and

4)      Reevaluation of the patient and the effectiveness of treatment.

            When framed around a series of questions and used in post-simulation debriefing, this model enhances student learning by providing a systematic approach to assessment, facilitates critical awareness and insight of patient needs, and assists the student to determine an appropriate treatment plan. The model also provides a framework for educators assessing student performance in SBA by providing generic criteria and performance indicators.

Facilitating Learning

In the Australasia region, the Council of Ambulance Authorities defines competence as “the consistent application of knowledge and skill to the standard as required by the industry in the workplace; it embodies the ability to adapt to new situations and environment”.18 In assessing competence, activities should not be limited to reciting facts but instead should provide an opportunity for students to demonstrate deep learning and understanding. Instead of simply regurgitating information, assessment methods should be focused on evidence of achievement.19

Simulation provides opportunities to assess domains of learning. This includes cognitive, psychomotor and afferent attributes. For example, presenting students with a scenario where a patient requires cardiac monitoring presents an opportunity to assess the cognitive domain. The students’ understanding of signs and symptoms and potential underlying pathology necessitating monitoring can be evaluated. The psychomotor function of applying electrodes to the patient in the correct location demonstrates application of knowledge and ability to perform specific skills. Student communication, professional behavior and manner highlight afferent components of practice.

SBA can assist students to develop clinical skills by providing opportunities to consolidate learning and decision making skills.11,20

Providing activities that are realistic with high levels of environmental fidelity enhance this by facilitating a deeper level of learning. When constructing simulation for teaching or assessment, the fidelity of practice scenarios including environmental, physical, psychological and technical fidelity should be carefully considered by educators. For paramedicine, fidelity is the extent to which the simulation can replicate the authenticity of case scenarios and the reality of the pre-hospital environment. Functional fidelity in simulation is considered the degree in which the simulation is “fit for purpose,” that is, the level of simulation fidelity needed in order for a simulation exercise to achieve its goal .9

There are three levels or classifications of fidelity in learning events. These are low, medium and high fidelity.3

Low fidelity simulation is where learning outcomes focus on repetition and the development of psychomotor skills may employ the use of a part task trainer or manikin body part. Here the environment and context of practice may be of lesser importance to mastering a particular procedure or skill. These experiences have a tendency to be tutor lead and constructed around a practical/ laboratory type session.

Medium fidelity simulation introduces greater levels of realism and complexity, requiring students to apply a more holistic approach and introduce technically advanced manikins to replicate vital signs and allow students to undertake more complicated procedures. These experiences are more authentic and provide students with more responsibility and scope to respond to clinical situations with support.

High fidelity simulation scenarios replicate clinical environments, are immersive in nature, and may involve the use of highly technically advanced manikins or standardized patients/patient actors. These simulations provide students with opportunities to engage in advanced skills, exercise clinical reasoning and take responsibility for responding to situations that replicate real-life clinical events in detail. These events often employ audiovisual technology to capture student activity and are followed by formal debriefing.

Studies show that students find the experience gained from high fidelity SBA provided clinical challenges that called for leadership and clinical decision making responsibility they may not have the opportunity to exercise to in clinical environments. Participants found these learning opportunities enhanced their critical thinking, self-confidence, problem solving, and ability to integrate theory into practice.3,20

Debriefing is an important aspect of the learning experience in SBA. This provides an opportunity for the student to review their performance and engage in a discussion with educators. Through this engagement, students are given the opportunity to develop reflective practice skills.

These skills can be used to self-assess students’ performance. In doing so debriefing promotes clinical reflection, results in identification of clinical problems, and further assists in the development of clinical reasoning and decision making. This enhances learning and provides an opportunity for error correction, promotes insight and consolidates competence.

When surveyed on the usefulness of debriefing, 95% percent of 300 survey participants stated that debriefing assisted in the identification and management of patients’ problems, assisted in providing a rationale for action and for understanding reasons for treatment such as medication and fluid management. For this reason debriefing is considered a necessity in SBA.20

The process of debriefing will be dependent on the purpose of the aims and objectives of the simulation, and will confirm learning and direct future education needs.19,21,22

Ideally students should lead the discussion with the educators supporting them to critically evaluate performance. Where simulation is used for the purpose of summative assessment, the debriefing is led by the educator. This should be in accordance with the marking criteria, constructive and highlight future development and learning needs. Debriefing allows the evaluation of strengths and weaknesses, and changes can be made to appropriately address the students’ needs. 22

Challenges of SBA

While the advantages of SBA are hailed for supporting the development of confidence and competence, SBA presents challengers that need to be considered.

Student anxiety: Anxiety and fear of failure are well documented in the literature.23 Anxiety can arise from several factors including: fear of performing in front of peers, lack of confidence in practice ability, discomfort being filmed, fear of peer retribution, and exposure of weakness in debrief or lack of knowledge about the expectations of SBA. For these reasons, careful planning is required to avoid stress and students must be supported to ensure the psychosocial environment is conducive to learning.

Educators should provide a pre-brief session designed to educate the student about how the SBA experience is structured, the learning outcomes and expectations regarding performance, marking criteria and implications if this is an assessed course component. For example, if the SBA is based around assessment of the patient and survey of an accident scene, the student must be given clear instruction regarding performance expectations.

Where students aren’t given clear instruction or have no time to practice  skills, performance anxiety may adversely impact the students ability to achieve. Pre-briefing as described above assists in addressing these issues.

Cost of running SBA: The financial cost in providing high–fidelity SBA can be high. This is often related to the use of technology, which includes software, hardware, manikins, patient actors and moulage. A patient simulator and related equipment can cost from $20,000–$360,000 and often requires dedicated space and trained operating staff.5 This expense increases when conducting large mass casualty scenarios. The cost verses benefits must but considered in the learning outcomes of the student when implementing SBA.

In addition non-monetary cost in implementing SBA needs to be considered, including:5,6,8

  • Preparation time, including preparing for patient actors regarding the patient’s condition, vital signs, medical history, medications and applying moulage.
  • Staff costs/time associated with overseeing SBA, restocking and resetting the simulation scene, and assessing students.
  •  Purchase and preparation of equipment.

Designing low-cost, high-impact simulation can be achieved by using a group approach, thereby reducing the overall number of simulation events and using volunteer actors. For example, students are assigned to “respond to” a sudden infant death syndrome case. On arrival, a grieving mother is on the telephone to the communication center. The mother is holding a neonatal manikin, and is very emotionally withdrawn.

The level of fidelity using an actor has the potential to evoke high emotional impact on students. This triggers a need for engagement that initiates a response where the students believe they’re dealing with a real-life scenario and respond accordingly.

The costs of providing a scenario like this are low. From previous experience the authors have found similar events very realistic. Debriefing indicates these types of events provide excellent triggers for assessing competence, consolidate learning and demonstrate that an important factor in SBA financial costs can be minimized.

SBA Models & Impact on Assessment

SBA uses two primary simulation models: those structured to meet the needs of assessing individuals and those structured to assess groups.

Where individual students are engaged in SBA, the number of students per cohort will dramatically affect the amount of time required and subsequently impact on the overall cost of SBA. For example, if each SBA session lasts 20 minutes and there are 250 students to assess, 83 hours would be required to complete the SBA exercise.

The alternative is to timetable students for SBA in groups. This may reduce the amount of time needed to undertake SBA and is conducive to assessing group work and communication; however, group assessment can also be problematic.

Where individual grades need to be awarded, managing the impact of performance of other students’ performance on an individual’s ability to achieve and how this is managed needs to be carefully considered. This is especially important when students are completing a summative assessment.

Additionally, situations where patient actors deviate from the script need to acknowledged. Situations like this can adversely impact student performance, and educators may find themselves having to take into account behaviors and skills that don’t match grading criteria. Careful preparation of patient actors is required to avoid this. Assessors’ experience and understanding of the practice environment is equally essential.


Although there’s been limited paramedical research on simulation and SBA, other healthcare providers have recognized their value. It’s an advantageous educational tool with the potential to influence a student’s feelings, beliefs and behaviors in relation to patient care.

Although there are challenges surrounding the management of student anxiety, assessment and cost, careful preparation and planning for these issues are manageable. SBA’s contribution to facilitating learning, enhancing clinical judgment, and improving patient care can give our industry confidence that graduates are competent and work-ready.

Simulation is an educational tool that can be used to develop and refine clinical skills of the student in a controlled environment before they progress to becoming practicing clinicians.24 It provides opportunities for students to practice skills frequently and under assessment conditions demonstrates professional paramedic competencies have been achieved and can be maintained. The main endpoint of SBA is to ensure that there’s a reduction in clinical errors which impact on the safety of the patient.

Acknowledgement: The authors wish to acknowledge the Queensland Combined Emergency Services Academy in assisting with the development of this article.


1. Greenwood J. Critique of the graduate nurse: An international perspective. Nurse Educ Today. 2000;20(1):17–23.

2. White D, Oelke N, Besner J, et al. Nursing scope of practice: Descriptions and challenges. Nurs Leadersh (Tor Ont). 2008;21(1):44–57.

3. Reilly A, Spratt C. The perceptions of undergraduate student nurses of high-fidelity simulation-based learning: A case report from the University of Tasmania. Nurse Educ Today. 2007;27(6):542–550.

4. Wellard S, Bethune E, Heggen K. Assessment of learning in contemporary nurse education: Do we need to standardized examination for nurse registration? Nurse Educ Today. 2007;27(1):68–72.

5. Alinier G, Hunt B, Gordon R. Effectiveness of intermediate–fidelity simulation training technology in undergraduate nursing education. J Adv Nurs. 2006;54(3):359–369.

6. Lammers R, Byrwa M, Fales W, et al. Simulation-based assessment of paramedic pediatric resuscitation skills. Prehosp Emerg Care. 2009;13(3):345–356.

7. Fero LJ, O'Donnell JM, Zullo TG, et al. Critical thinking skills in nursing students: Comparison of simulation-based performance with metrics. J Adv Nurs. 2010;66(10)2182-2193.

8. Radhakrishnan K, Roche J, Cunningham H. Measuring clinical practice parameters with patient simulation: A pilot study. Int J Nurs Educ Scholarsh. 2007;4:1–11.

9. Wyatt A, Archer F, Fallows B. Use of simulation in teaching and learning: Paramedics’ evaluation of a patient simulation. Journal of Emergency Primary Health Care;5(2):1–11.

10. Regener H. A proposal for student assessment in paramedic education. Med Teach. 2005;27(3):234–241.

11. Lathrop A, Winningham B, VandeVusse L. Simulation–based learning for midwives: Background and pilot implementation. J Midwifery Womens Health. 2007;52(5):492–498.

12. Rosen KR. The history of medical simulation. J Crit Care. 2008;23(2):157–166.

13. Higgs J, Jones M, editors: Clinical reasoning in the health professional, 2nd edition. Butterworth-Heienmann: Melbourne, Australia, 2002.

14. Levett-Jones T, Gersbach J, Arthur C, et al. 2010. Implementing a clinical competency assessment model that promotes critical reflection and ensures nursing graduates’ readiness for professional practice. Nurse Educ Pract. 2011;11(1):64–69.

15. Thomas C, Mackey E. Influence of a clinical simulation elective on baccalaureate nursing student clinical confidence. J Nurs Educ. 2012;51(4):236–239.        

16. Dillard N, Sideras S, Ryan M, et al. A collaborative project to apply and evaluate the clinical judgment model through simulation. Nurs Educ Perspect. 2009;30(2):99–104.

17. Tanner CA. Thinking like a nurse: A research-based model of clinical judgment in nursing. J Nurs Educ. 2006;45(6):204–211.

18. Council of Ambulance Authorities. (June 2010.) Paramedic professional competency standards v.2. Retrieved June 3, 2014, from http://caa.net.au/downloads/ppcs.pdf.

19. Brown S. Assessment for learning. Learning and Teaching in Higher Education. 2004–2005;(1):81–89.

20. Wotton K, Davis J, Button D, et al. Third-year undergraduate nursing students’ perceptions of high-fidelity simulation. J Nurs Educ. 2010;49(11):632–639.

21. Dochy F, Segers M, Sluijsmans D. The use of self-, peer and co-assessment in higher education: A review. Studies in Higher Education. 1999;24(3):331–350.

22. Pacsi AL. Human simulation in nursing education. J N Y State Nurses Assoc. 2008–2009;39(2):8–11.

23. Cioffi J. Clinical simulation: development and validation. Nurse Educ Today. 2001;21(6):477–486.

24. Rudd C, Freeman K, & Smith P. (Nov. 29, 2010.) Use of simulated learning environments in paramedicine curricula. Health Workforce Australia. Retrieved June 3, 2014, from www.hwa.gov.au/sites/default/files/sles-in-paramedicine-curricula-201108.pdf.


EMS Week: A Time to Reflect and Call For Action in America

The celebration of EMS Week is a great opportunity to take a few moments and review one of the most historic documents in EMS history.

Rethink the Way EMS Does Patient Care Reports

EMS must let go of the idea prehospital care documentation is strictly about billing and creating a legally defensible record of events.

Littleton (Colo.) Fire Rescue Rolls Out Their Take on Mobile Integrated Healthcare

Firefighters and paramedics staff special vehicles to deliver unique care fast.

Crew Resource Management Can Improve Crew Efficiency

Crews performing in unison offer better learning opportunities.

Serving the Psychological Needs of Your Employees

How does your agency help employees cope with the traumas and stressors of EMS?

Pro Bono: Privacy within Mass Casualty Incidents

HIPAA compliancy in MCIs is challenging but feasible.

Features by Topic

Featured Careers




Learn about new products and innovations featured at EMS Today 2015


JEMS Connect




Blogger Browser

Today's Featured Posts