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as well as “full-mission” simulations (Beaubien
& Baker, 2004). Alinier (2007) analyses typolo-
gies of educationally-focused medical simulation
tools, and identifies six technological simulation
levels based on their functions and the fidelity
of the experience they can provide to healthcare
students. These levels include:
and mental models that they use to make sense
of their experiences, and that cannot be directly
transmitted or transferred between individuals.
A learning approach that is based on construc-
tivist principles and that has become increasingly
popular in medical and healthcare education in
recent decades is problem-based learning (PBL)
(Savery & Duffy, 1995). As discussed earlier,
clinical simulations can be designed so as to
provide students with practice in problem-based
decision making, based on real-life situations.
Both PBL and constructivism emphasize the role
of the learner as an active creator rather than a
passive recipient of information, and recognize
the learner as the chief architect of knowledge
building (Barrows & Tamblyn, 1980; von Gla-
serfeld, 1987). At the heart of the PBL process is
the aim of stimulating an inquiring attitude and a
search for understanding (Margetson, 1993). PBL
encourages students to learn in a self-directed
fashion through questioning, probing, showing
curiosity, discussing, hypothesizing, making
decisions, and collborating with others to work
towards the solution problems representative of
practice (Hmelo-Silver, Duncan, & Chinn, 2007;
Sims, 2009). Barrows and Tamblyn (1980) sug-
gest the use of a hypothetical-deductive model,
which consists of four steps or stages, as a means
of facilitating and scaffolding the PBL process:
1. Written simulation
2. Three-dimensional models/mannequins
3. Computer/software simulation
4. Role-play patients
5. Intermediate fidelity patient simulators
6. Interactive patient simulators.
Alinier describes a variety of learning ex-
periences that can be achieved by each level,
highlighting the need for educators to recognize
how simulations can enhance cognitive learning
when they are appropriately incorporated teaching
and learning strategies. The next section explores
how both cognitive and social constructivist learn-
ing theories and strategies can be used to guide
and inform the design and use of simulations in
healthcare education.
Constructing Clinical experience
through Simulation
Constructivist learning theory is an essential
consideration for educators seeking to design
effective educational simulations. Constructiv-
ist approaches derive from the work of theorists
such as Dewey (1929), Piaget (1972), Vygotsky
(1978), and Bruner (1986). The fundamental tenet
of constructivism is the idea that by reflecting
on his or her experiences, the learner constructs
a personal understanding of the world (Wiggins
1998; Jonassen, Peck, & Wilson, 1999; McLough-
lin & Luca, 2000). From a constructivist point
of view, learners build or “negotiate” meaning
for a concept from their interpretation of its use
in one or more contexts that they have observed
or experienced. They generate their own rules
1. A theoretical hypothesis is generated.
2. From this theoretical hypothesis comes a
prediction.
3. An event is then observed or experimented
to determine whether the hypothesis is con-
firmed or refuted.
4. Through reflection, changes are made to the
student's cognitive understanding.
Linked to the concept of PBL is the notion of
experiential learning (Kolb, 1984), which is par-
ticularly suited to learning a profession whereby
the integration of theory and practice occurs in
a cyclic process to enable the learner to develop
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