Simulation Best

Resources for Educators

Why Simulation?

Simulation is a technique to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner (1). Simulation technology has long been used to facilitate safe and standardized training for various industries which have great risk in ‘learning on the job’ (2, 3). While it was first adopted by the military and the aerospace industry, simulation in the medical field has been used to simulate medical scenarios to reduce the rate of medical mistakes. Simulation scenarios offer learners a chance to practice procedures in a low-risk setting, to the point where they become masters before ever performing on a patient (4).

In 1999, the Institute of Medicine published To Err is Human: Building a Safer Health System, warning about the scope of medical errors and significant gaps in quality. In the broader medical landscape, almost 5% of medical deaths are a result of medical mistakes” (5). There is good evidence that using simulation as part of a larger training initiative can improve patient outcome and reduce medical error (6, 7, 8). The use of simulation for health professional education is strongly recommended by the WHO because it leads to greater acquisition, retention, and transfer of technical and non-technical skills (9). While Medical Simulation Technology has gained widespread acceptance in the broader medical field such as Nursing and Emergency Care, new simulation technology is beginning to be available for our discipline of hearing healthcare. 

The current state of practice for various courses and labs inside of our hearing healthcare program is to practice various procedures on classmates or volunteers. While there is merit to students becoming comfortable working on a human subject, this approach has numerous downsides:

  • Liability and risk for student or volunteer harm
  • Limited ability to train before they see patients (cannot teach on-ear high gain hearing aids, hearing tests on actual patient, cerumen management, earmold impression risks, etc)
  • Lack of standardized evaluation metrics (everyone may be evaluated and trained on different ‘ear anatomies’ leading to variation of experience)
  • Limited ability for trainees to train since supervision is needed
  • Difficulty to scale our training efforts due to individual supervision needed for each trainee

In addition to these risks, there is clear evidence that the way in which clinicians were effectively trained has caused numerous downsides in clinical practice. According to various studies, hearing aids are not being accurately fitted to target more than 50% of the time, with one study finding that greater than 70% of fittings may be off target by >10dB (10, 11). In the emerging competency of cerumen management, almost half (48%) of the audiologists who had completed residential AuD programs believed that their training programs inadequately prepared them to perform Cerumen Management. (12).

Figure 1. Miller's Pyramid, showing the optimal path in which medical professionals become experts in their field.

How Simulation Helps Educators

The goal of hearing healthcare training iniatives is to develop knowledgeable professionals capable of providing safe, highly competent, and skilled patient care. Simulation is the solution for not only mitigating risk and standardizing a highly skilled workforce of medical professionals, but in recognizing our organization as a leader in cutting edge technology and next generation training opportunities. Simulation training has been supported by the ASHA Council for Clinical Certification in Audiology and Speech-Language Pathology, allowing up to 10% of the hours required for a student’s supervised clinical experience to be obtained through simulations”(13).

Direct benefits to educators include but are not limited to:

  • Eliminate liability and risk for our trainees and patients
  • Increase quality of clinicians due to more training able to be had before direct work with patients (“From the nursing literature, we know that up to 50% of clinical education experiences can be replaced with simulation, and yield the same clinical outcomes” (14))
  • Reduce instructor time required for supervision of clinicians and easier supervision of larger groups/labs/cohorts
  • Increase reputation of our organization within the broader higher education landscape and within the hearing healthcare community
  • Increase standardization of training and evaluation metrics for fair evaluations
  • Increased equity for trainees to dedicate more or less time training based on their own comfort level

How Simulation Helps Organizations & the Field

In addition to the benefits above that will also assist your organization, there are broader implications of simulation technology:

  • Increased reputation of organization for being ‘cutting edge’ or 'investing in their staff' leading to assist in recruiting initiatives
  • Increased ability to scale organization and increase cohort sizes for increased revenue
  • Eye-catching tool for recruitment at local and international conferences and events
  • Increase positive word-of-mouth of the organization through amount of educational support available
  • Be known for producing high-performing, high-quality professionals 

This technology can be utilized within the organization for more than just training our clinicians, but for taking with us to recruiting events to show off our focus on cutting-edge technology. It is expected that new enrollments will occur as a direct result of this promotion as new potential students are actively looking for and requesting simulation technology and an organization to offer the best training tools to support their career.

In addition to the benefits above in the previous two sections, a key advantage of simulation technology for the broader community and country is to have more highly trained and highly skilled medical professionals. Medical errors are an all too common side effect of training sites not being able to provide a wide enough experience to trainees before they enter clinical practice.

Another source of benefit is to keep our professionals employed inside of our industry for longer with less turnover. Our medical system relies on consistent access to high quality care, with the number of medical professionals needed growing in the years ahead with the aging population. Using nursing as an example, every year registered nurse turnover costs a hospital between $5.2M to $9M (15). Supportive training with simulation tools to build confidence of the new professional and offer opportunities for professional development and safe skills development can ‘ease’ clinicians into the profession better and minimize ‘shock’ of what they encounter in their clinical practice.

getting started with simulation

While experiential learning by the use of simulation provides a much more immersive experience for students, it does come with some important considerations and best practices. 

At AHead, we recommend educators do the same as trainees - find a use case or two that is valuable, and begin trying things! You don't know what will work in your organization and curriculum until you try it yourself. Do you have a cerumen management training coming up or a class? Pretend you're the trainee, and test the different techniques through simulation. AHead provides a wealth of resources to try to get you up to speed as fast as possible, but you will still need to customize them for your organization and what matters most to you.

Ramping up your simulation initiatives and redeveloping your curriculum can take more time and resources, at least initially, since it requires the teacher to obtain the simulator and create a lesson that effectively utilizes the simulator and achieves the learning goals. Furthermore, ensuring that the learning objectives were achieved can be more complicated to assess (16).

Prebriefing is a way the instructor can set the framework for the purpose and the goals of the simulation. Prebriefing allows the instructor to set the tone of the exercise and create an environment where learners feel comfortable and free to engage in the activity without fear of judgement or criticism (17). Simon et al. (18) explain that “Healthcare professionals take psychological risks when they allow their performance to be watched and analyzed by peers and instructors.”

Another important area is reflective observation, where the student thinks about their experience and their knowledge. This is why it is important to debrief after a simulation to ensure that learning has not only taken place but also that the students have met the learning goals and, if not, this is also an opportunity for the instructor to reflect on how to improve the lesson to achieve the desired objectives. Debriefing discussions provide an opportunity for students to review and examine their entire experience, thoughts and actions, and use this insight to further develop their skills and transfer them during encounters with real patients. Turner (19) states that “Debriefing is a fundamental aspect within simulation. It is crucial to maximize learning and to translate the lessons learnt to improve real clinical performance, and thus to reduced medical error.”

The instructor can also consider having the students create a ‘Learning Portfolio’ as described by Zubizarreta (20). The learning portfolio is a “flexible tool that engages students in a process of continuous reflection and collaboration” (20). Zubizarreta recommends that the learning portfolio follow a simple layout, as shown in Figure 2, involving these core components: Reflection, documentation, and collaboration. 

Since a learning portfolio is a tool, how it is used and for what purpose is completely up to the individual. The portfolio can also exist in any format such as electronically or written. For a detailed guide on how to create a learning portfolio see the resources section.

Figure 2. The learning Portfolio model. There are 3 interconnected areas involved with the learning portfolio. Zubizarreta, J. (n.d.)


A detailed document prepared by Schwartz (21) suggests a framework to use, which involves contemplating the following questions:

  • Are there areas in the course where simulation can be used effectively?
  • Are there simulated activities that will meet learning goals?
  • Will the simulated activity balance with other parts of the course?
  • How will the activity be evaluated?

In regards to audiology, we suggest considering whether;

  • A particular lesson/training in which learners are being put at risk?
  • A particular lesson/training that learners are having difficulty understanding and implementing?
  • A particular lesson/training that is always difficult for trainers to teach effectively? (22)

There are numerous resources available that provide instructions on how to incorporate simulation into learning. To help you get started the following are guidelines to assist in setting up your experiential learning activity.  

Creating a Simulation Exercise

1) Lesson Determine skill technique being taught
2) Materials Consider the equipment needed and whether the students will need to share
3) Assessment Define the evaluation criteria
4) Pre-brief Ensure that the students understand the goals of the simulation, why this activity is important and what the simulation will be able to provide, and are comfortable with the exercise. This includes knowing who will be observing the activity (i.e. instructor only, small group, or entire class).
5) Action During the simulation, the instructor should monitor the students progress (this could also involve probing questions), ensure that they are able to follow the instructions outlined in the prebriefing, and whether additional activities are necessary to supplement/enrich the students learning.
6) Debrief Just as important as the actual learning experience is the student’s reflection on the activity. It may be necessary to guide the students through reflection so that they can get the most out of this exercise. In addition to the student’s own thoughts about the exercise is the instructor’s feedback on the activity.

Referenced Here

  1. Gaba DM. The future vision of simulation in health care. Qual Saf Health Care. 2004 Oct;13 Suppl 1(Suppl 1):i2-10. doi: 10.1136/qhc.13.suppl_1.i2. PMID: 15465951; PMCID: PMC1765792.

  2. Al-Elq AH. Simulation-based medical teaching and learning. J Family Community Med. 2010 Jan;17(1):35-40. doi: 10.4103/1319-1683.68787. PMID: 22022669; PMCID: PMC3195067.

  3. Lateef F. Simulation-based learning: Just like the real thing. J Emerg Trauma Shock. 2010 Oct;3(4):348-52. doi: 10.4103/0974-2700.70743. PMID: 21063557; PMCID: PMC2966567.


  5. Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Institute of Medicine (US) Committee on Quality of Health Care in America. Washington, DC: National Academies Press (US); 2000

  6. Barsuk JH, McGaghie WC, Cohen ER, et al. Simulation-based mastery learning reduces complications during central venous catheter insertion in a medical intensive care unit. Crit Care Med. 2009;37;2697–2701.

  7. Barsuk JH, Cohen ER, Potts S, et al. Dissemination of a simulation-based mastery learning intervention reduces central line-associated bloodstream infections. BMJ Qual Saf. 2014;23;749–56.

  8. Nishisaki A, Keren R, Nadkarni V. Does simulation improve patient safety? Self-efficacy, competence, operational performance, and patient safety. Anesthesiol Clin. 2007 Jun;25(2):225-36. doi: 10.1016/j.anclin.2007.03.009. PMID: 17574187.

  9. World Health Organization (2013). Transforming and scaling up health professionals' education and training: World Health Organization Guidelines 2013. World Health Organization. hdl:10665/93635. ISBN 9789241506502.

  10. McCreery RW, Bentler RA, Roush PA. (2013) Characteristics of hearing aid fittings in infants and young children. Ear Hear 34: 701–710

  11. Leavitt R, Bentler R, Flexer C. (2017) Hearing aid programming practices in Oregon: fitting errors and real ear measurements. The Hearing Rev 24:30–33

  12. Johnson CE, Danhauer JL, Rice EN, and Fisher SK. Survey of audiologists and cerumen management. Am J Audiol 2013;22(1):2–13.


  14. Hayden JK, Smiley RA, Alexander M, Kardong-Edgren S, Jeffries PR. The NCSBN national simulation study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation. 2014 Jul 1;5(2):S3-40.


  16. University of New South Wales (UNSW) (2018, July 26). Simulations. Retrieved May 4, 2021, from %3F,more%20 engaging%20interaction%20by%20learners

  17. Fanning, R.M. (2007). The role of debriefing in simulation-based learning. Simulation in  Healthcare: The Journal of the Society for Simulation in Simulation-Based Learning, 2(2), 115-125, doi: 10.1097/SIH.0b013e3180315539

  18. Simon, R., Raemer, D.B., & Rudolph, J.W. (2010). Debriefing assessment for simulation in healthcare (DASH)© Rater’s Handbook. Center for Medical Simulation, Boston, Massachusetts. handbook.2010.Final.Rev.2.pdf

  19. Turner. J. ( 2018 April, 6). PGME Debriefing Guidance.

  20. Zubizarreta, J. (n.d.). The learning portfolio: A powerful idea for significant learning

  21. Schwartz, M. (2012). Practices in Experiential Learning. Ryerson University.

  22. Koch, R. (2021). The year of new learning, simulation, and CARL. Canadian Audiologist

Additional Resources

Alanazi, A.A., Nicholson, N., & Thomas, S. (2017). Use of simulation training to improve knowledge, skills, and confidence among healthcare students: A systematic review. J Allied Health Sci Prac, 15(3), Article 2.

Brown, D. (2017). Simulation before clinical practice: The educational advantages.

Kerner, R. (2018). Five advantages of experiential learning.  advantages-of-experiential-learning

Koch, R., Saleh, H., Folkeard, P., Janeteas, C., Agrawal, S.K., Ladak, H.M., & Scollie, S. (2020). Skill transference of a probe-tube placement training simulator. J Am Acad Audiol, 31, 40-49.

Kolb, A.Y., & Kolb, D.A. (2017). Experiential Learning Theory as a Guide for Experiential Educators in Higher Education. experiential-learning-theory-guide-for-higher-education-educators.pdf

Lateef F. (2010). Simulation-based learning: Just like the real thing. Journal of emergencies,  trauma, and shock, 3(4), 348–352.

McDougall, E.M. (2015). Simulation in education for health care professionals. British Columbia Medical Journal, 57 (10), 444-448. health-care-professionals

National University of Ireland Maynooth. (n.d.). Experiential learning. Retrieved May 7, 2021, from experiential-learning/experiential-learning-0.

Turner. J. ( 2018 April, 6). PGME Debriefing Guidance. Retrieved May 11, 2021, from

University of Windsor. (n.d.). Why experiential learning?

New Simulation in Communication Sciences and Disorders Textbook:

For more information on Zubizarreta’s Learning Portfolio, refer to:

Zubizarreta, J. (n.d.). The Learning Portfolio: A Powerful Idea for Significant Learning.

The Post-Graduate Medical Education Centres at Western Sussex Hospitals NHS Foundation Trust have a variety of simulation resources aimed toward a medical audience. Their Debriefing Guidance document provides numerous examples of debriefing styles. For more information, refer to: 

Another great resource created by the Center for Health Sciences Interprofessional Education Research and Practice at the University of Washington is a free, eight-module course that guides you through the entire process of getting to know more about simulation and creating simulation lessons. The target audience is within the nursing field but it still has lots of great material for audiology. For more information, refer to: 

University of Washington. (2021). Teaching with simulation lessons. Accessed May 11, 2021, from -lessons/