AACN Advanced Critical Care
Volume 27, Number 1, pp. 56-61
The History of Simulation and Its
Impact on the Future
Michelle Aebersold, RN, PhD
ABSTRACT
Simulation has had a long and varied his-
tory in many different fields, including avia-
tion and the military. A look into the past to
briefly touch on some of the major histori-
cal aspects of simulation in aviation, mili-
tary, and health care will give readers a
broader understanding of simulation’s his-
torical roots and the relationship to patient
safety. This review may also help predict
what the future may hold for simulation in
S imulation has had a long and varied
history in many different fields. In such
areas as aviation and the military, simulation
is more advanced and has become part of the
common process of training and certification.
This article describes the history of simulation
in various fields, including aviation, military,
education, and the health sciences (nursing).
To fully embrace the power of simulation and
understand the critical role it plays in patient
safety, we must understand the history of
simulation and how it is used in areas outside
of health care. This article touches briefly on
some of the major historical aspects of use of
simulation in aviation, military, and health
care, as well as describing how education has
used simulation. This review will give readers
a broader understanding of simulation’s his-
torical roots and its relationship to patient
safety. This look into the past may also help
predict what the future may hold for simula-
tion in nursing.
56
© 2016 AACN
nursing. Health care, like aviation, is driven
by safety, more specifically patient safety.
As the link between simulation and patient
safety becomes increasingly apparent,
simulation will be adopted as the education
and training method of choice for such
critical behaviors as communication and
teamwork skills.
Keywords: simulation, patient safety,
education, history
Simulation in Aviation
Historical Perspective
The first successful use of simulation in
aviation began in the late 1920s with the
development of the Link trainer. This early
flight simulator was developed by Edwin Link
and consisted of a small wooden airplane with
a fuselage and wings mounted on a universal
joint. The cockpit had the standard aircraft
controls of that era, and it was driven by an
electric pump that made the trainer pitch and
roll as the pilot worked the controls, simulat-
ing the motion of flying. Enhancements were
added later, and in the 1930s, the Link Flying
School opened, where individuals could learn
Michelle Aebersold is a Clinical Associate Professor,
University of Michigan School of Nursing, 426 North Ingalls,
Ann Arbor, MI 48109 (mabersol@umich.edu).
The author declares no conflicts of interest.
DOI: http://dx.doi.org/10.4037/aacnacc2016436
VOLU ME 27 • N U MB ER 1 • JANUARY-M ARCH 2016 H ISTORY OF SIM ULAT ION
how to fly by using the Link trainer.1 One of
the distinct advantages of the Link trainer was
its ability to teach pilots how to fly using
instruments; in this way, pilots could practice
their skills in flying “blind” or in instrument
training. The importance of this type of train-
ing was soon recognized by the US Army Air
Corps, after pilots were killed in hazardous
weather; their training methods of flying by
viewing the ground did not work in poor
weather conditions. The Link trainer was the
beginning of the commercial use of simulators
for training in aviation, and thus an industry
was born.2 The next evolution in aviation
training occurred during World War II, when
the need arose for training large numbers of
individuals in team skills to carry out proce-
dures involved in flying large aircraft (eg, bomb-
ers flying long complex missions). Large-scale
simulators/trainers were built to accommodate
the pilot, navigator, and bomber. The trainer
included all the components needed for each
of these roles so that team members could
practice their individual responsibilities as well
as work together to meet mission objectives.3
In 1979, simulation in aviation had reached
its 50-year anniversary, and the majority of
pilot training was now done in simulators.
The industry, as a result of pressure from
airlines and simulator maintenance organiza-
tions, developed simulator standards and
paved the way for the movement of training
from airplanes to simulators. Today, pilots
are trained in simulators; the first time a
pilot lands a commercial airplane, he/she
does it with a check pilot next to him/her
and a full load of passengers on board.2
In this brief overview of the types of simu-
lator-based training, many parallels to nursing
training using simulators are apparent. Nurses
are educated using simulation to achieve many
learning objectives, many of which ultimately
affect patient safety (just as a pilot’s training
affects the safety of the crew and passengers).
Pilots learn technical skills in trainers such
as the Link trainer and learn team skills in
the large-scale trainers. Standards were imple-
mented in aviation to create consistency in
training and evaluation, making it possible to
move to use of a predominately simulator-
based training method. Today in nursing,
simulation methods are being used to train
for technical skills, teamwork skills, and criti-
cal thinking and decision making. However,
we are using simulation-based methods for
57
only a small portion of our learning and train-
ing needs. Health care has not even caught up
to where aviation was in 1979. Standards put
forth by the International Nursing Associa-
tion for Clinical Simulation and Learning4-9
have been supported by the National Council
on State Boards of Nursing (NCSBN) and the
National League for Nursing.
Crew Resource Management
Developed by the National Aeronautics and
Space Administration in 1979 and initially
called cockpit resource management (CRM),
this team training method was introduced in
the 1980s in the airline industry with the
goal of correcting deficiencies in the lack of
assertiveness of junior pilots and authoritar-
ian behavior by captains. The communication
failures in the cockpit were found by the
National Transportation Safety Board to be
causal factors in several airline disasters in
the 1970s, which further underscored the
need for such training. The early generation
of CRM was focused on classroom exercises
and was aimed at assisting pilots to practice
interpersonal skills without risk. There was
general acceptance; however, some pilots were
resistant, and the exercises used in the early
courses were not aviation focused.10
In the early 1990s, CRM expanded to
include flight attendants and others who were
part of the flight crew. The content of the train-
ing included more human factors topics, such
as situation awareness, team building, and
stress management. In the late 1990s, CRM
had changed its focus to error management
based in part on the work of James Reason.11,12
This shift reinforced the focus on human factors
and the effects of fatigue, work overload, and
stress on performance; it also created systems
for reporting incidents and safety concerns in a
confidential manner.10
Crew resource management has moved into
health care training. Gaba pioneered early work
in the transfer of CRM into health care by the
development of the anesthesia crisis resource
management curriculum, in which aviation CRM
principles were used to develop a simulation-
based program aimed at improving the ability
of anesthesiologists to manage crises.13
Principles of CRM translate well into the
needs of team training, particularly in special-
ized teams such as staff in operating rooms
and intensive care units (ICUs), trauma
teams, emergency response teams, and other
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groups that work together. The Department
of Veterans Affairs implemented a nursing-
focused CRM that is based on the aviation
principles of CRM (eg, situation awareness,
fatigue management, assertive communication,
team briefings, and debriefings). The training
included didactic sessions, high-fidelity simu-
lation, and a unit-level CRM project. The
overall project was successful.14
Intensive care units are an environment
that would potentially benefit from CRM
training. Much like aviation and anesthesia,
ICUs are complex environments where a
significant emphasis is placed on technical
training, yet the need for teamwork and
communication skills is critical.15 Studies are
now underway to determine the effectiveness
of CRM in ICUs.16
Simulation in the Military
History of War Games
Simulation and war games have long been
used in the military to engage in battle strate-
gies. A war game is a simulated battle or cam-
paign to test military concepts and uses.17 Sand
tables were used by the Roman commanders to
plan battle strategies using miniature soldiers
representing different armies. Sun Tzu has been
credited with creating the first actual war game,
Wei Hai, in which colored stones were used to
represent different armies.17 In 1664, Weikmann
created a board game called Koenigspiel (or
“War Chess”). This game was developed specif-
ically to train military personnel in communica-
tion skills and the basics of military art and
science. Kriegsspiel, another board game devel-
oped in 1811 for the military, focused on
improving military thinking and strategy. In
comparing war games to health care simula-
tions, the elements are similar. A good war
game needs objectives, a scenario, a database,
models, rules, players, and an analysis.17
There are many different types or levels
of war games, and there still remains a com-
mercial market producing war games that
are used by hobbyists and the military. Hobby
games are those that usually recreate a par-
ticular battle, such as the Battle of Gettysburg.
Professional war games focus on 3 levels:
global/strategic, theater/operational, and local/
tactical. Each level has different goals and
objectives and provides different information.
The Global War Game series conducted at
the Naval War College improves strategic
thinking in the Navy.17
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Future of War Games/Virtual
Simulations
The computer age saw the move from
board games to computer games, and the
ability to incorporate more complex mathe-
matical formulas and complexity into the
games allowed greater expansion in training
capabilities. Initially, the simulations and war
games were developed on large computer sys-
tems that were specifically designed for mili-
tary applications.
Today, the military uses simulations and
war games for training in many areas and is
very advanced in this area. With the explosion
of personal computers, tablets, smartphones,
console gaming devices (eg, Xbox, Nintendo),
and the commercial gaming industry, the
military is able to take advantage by using
commercially available games and reworking
them for military use. The US Army negoti-
ated a deal with Epic Games to use Unreal
Engine, which is a game engine or set of tools
to design a game. Epic uses Unreal Engine to
design commercial games that are popular with
gamers. The US Army used it to develop Ameri-
ca’s Army (http://www.americasarmy.com/), a
game in which adults can learn about soldier-
ing and also a game in which soldiers can learn
skills ranging from lifesaving skills to manag-
ing threats from terrorism. The Army also uses
the game engine to design other training sim-
ulations for use with current military personnel.18
The virtual environment for training simu-
lations on personal computers and other devices
has become a large industry, and companies such
as Virtual Heroes (http://www.virtualheroes
.com/#) develop training solutions for mili-
tary and health care, among others. The use
of the virtual environment to run simulations
for either war games or training is gaining
popularity. Virtual environments are a
3-dimensional computer-​generated represen-
tation of a training environment or other
space in which people can interact. These
virtual environments can either be web-based
or developed and sold as a stand-alone vir-
tual game that is loaded on to a computer
via a digital video disk (DVD) or downloaded
from a site. The virtual environment does not
require physical space to conduct the training;
however, there is cost involved in developing
and maintaining or updating the virtual space.
The military has successfully used virtual
environments for training in many areas,
including aircraft maintenance. Using a
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virtual world application called Open Simula-
tor (www.opensimulator.org), maintenance
crews can be trained to install and maintain
engines on aircraft even when those aircraft
are not physically available. The virtual world
is designed to have planes in the hangers and
checklists for engine repairs and installations.19
All of the work in the virtual environment
has created opportunities for health care edu-
cation. Several companies are now making
virtual products to specifically train nursing
students by using virtual simulation, which
can be used in addition to in-person simula-
tion. Using a combination of simulation meth-
ods can be beneficial to learners, who often
learn in different ways. This area of simula-
tion is relatively new and the least studied.
A systematic literature review that was pub-
lished in the Journal of Medical Internet
Research featured a decade of research in
virtual environments and concluded that the
education category (ie, professional and aca-
demic) had the most publications.20
Simulation in
Health Care Education
Much has already been written on the
history of simulation in medicine and nursing
education,21-24 and key highlights are noted
here. In the area of nursing, it is important to
note that the first mannequin used to teach
nurses was a life-size doll called Mrs Chase.
She was built in 1911 by Martha Jenkins
Chase (a doll maker) for the Hartford Hospi-
tal to train nurses in how to dress, turn, and
transfer patients. In 1914 an upgraded ver-
sion, Arabella, allowed nurses to practice
injections.25 In the 1940s, a male version of
the mannequin was requisitioned by the US
Army to teach medical corpsmen the techniques
of hospital care.26 Laerdal Medical introduced
its first mannequin, Rescue Annie, in 1960 to
train people in mouth-to-mouth ventilation
and then later in manual chest compressions.
In medicine, anesthesia was the pioneer in
the field of what is now commonly thought
of as high-fidelity simulation. One of the ear-
liest anesthesia simulators was Sim One, which
was developed in the 1960s by the Sierra Engi-
neering Company. In 1986, Gaba and DeAnda
developed the Comprehensive Anesthesia
Simulation Environment (CASE) by modify-
ing a commercially available mannequin.
This product later become known as MedSim
Eagle Simulation through a partnership with
59
CAE-Link Corporation in the 1990s. Also in
the 1990s, Medical Education Technologies,
Inc developed a high-fidelity simulator; then
Laerdal Medical joined the group in the pro-
duction of SimMan in 2000, and an industry
was born.27 Today, several companies produce
high-fidelity mannequins that are very sophis-
ticated and that offer options that meet the
needs of health care students and practition-
ers. Trainers have been developed for other
applied professionals as well (eg, dentistry
and veterinary schools).
Simulation in Higher Education
and Leadership Training
To appreciate how simulations have been
used in the area of education, it is important
to understand how they are classified. Often,
many terms are used interchangeably and can
be confusing; the industry has not adopted a
single taxonomy. Some definitions here will
provide some background. Gaba and others
often state that simulations are a technique,
not a technology.28 Aldrich defines immersive
learning simulations as those simulations that
are used in formal programs (ie, both serious
games and educational simulations). They can
include case studies, role-play simulations,
branching stories, standardized patients, or
high-fidelity simulations. Serious games tend
to be more computer-based and make use of
the game elements found in commercial games.29
Immersive simulations and serious games
in education have been used in higher educa-
tion and leadership training for many years.
Often those in health care do not think of
this as simulation; but it fits the definition,
and much can be learned from their use of
these techniques and applied to our simula-
tion activities. TeamSTEPPS (team strategies
and tools to enhance performance and patient
safety) makes effective use of immersive sim-
ulations such as role plays and case studies
in their training course, which is discussed in
more detail later. Educational simulations
focus on such goals as transfer of knowledge,
skill development, and application of both
knowledge and skill. These goals are very
similar to the goals that are seen in health
care simulations.
Educational simulations also are focused on
assisting students to acquire discipline-specific
knowledge that they can transfer into their
specific professional setting. Such simulations
have traditionally been carried out in the
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classroom and have been sequential decision-
making events with guidelines provided by the
instructor; they need to be based on reality,
with no predetermined solutions.30 For exam-
ple, lawyers engage in mock trial simulations to
learn how to be lawyers. Students in business
schools engage in simulations such as Eazy’s
Garage (Harvard Business Publishing) to learn
negotiation skills. Educational simulation can
be done in a short period of time during a class
period, or what education calls an “extended
simulation” can run for days or weeks. Infor-
mation is given to the students over time as
they need it to complete their tasks.30 Exam-
ples of extended simulation would include
(1) building a theme park for business students
and (2) an urban development project in which
engineering students would participate.
Traditionally, these projects have been pri-
marily classroom-based and included paper
case studies (or perhaps Excel spreadsheets
or emails) that were used to deliver “office
memos” to drive the simulation. Today—
similar to the growth in personal computers,
smartphones, and tablets—these simulations
in the educational industry have also grown
in options. Many great “tabletop” and paper-
based educational simulations are still
available, but there are also computer-based
simulations to add to that, such as Harvard
Business Publishing’s Simulation Everest V2
(https://cb.hbsp​.harvard​.edu/cbmp/product​
/7000-HTM-ENG). This is a team simulation
in which students participate to climb Mount
Everest. The learning objectives focus on
team leadership, decision making, and team
functioning. This simulation is completely
played online outside of class. Students can
either discuss or debrief in class or online
through blogs or discussion boards. This type
of simulation is essential for online and dis-
tance learning courses to support engaged
learning. The advantages to immersive simu-
lations are many: (1) they are similar to those
of any type of simulation experience; (2) they
allow knowledge transfer and inquiry-based
learning; and (3) they do require instructors
to put time and effort into preparation just
as they do for classroom-based simulation.
Bringing educational simulations into the
health care area has been modeled well by
the TeamSTEPPS program. Developed by
the Department of Defense and the Agency
for Healthcare Research and Quality, Team-
STEPPS is focused on integrating teamwork
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into practice by using educational simulations
as part of its curriculum. They use simple tab-
letop simulations and video exemplars to stim-
ulate discussions; they can also incorporate
high-fidelity simulations effectively throughout
the program to engage learners and deliver
the curriculum effectively.31
Conclusion
Simulation in health care is on the verge of
becoming the standard in both education and
training, and it may soon become the indus-
try standard in medicine/nursing as it did in
aviation in the late 1970s and early 1980s.
The key driver in aviation was safety. When
the clear link between simulation-based train-
ing and pilot/passenger safety became clear,
aviation adopted simulation as the standard
for pilot training. The effectiveness of simula-
tion-based education as replacement hours
for clinical experience in prelicensure nursing
students was demonstrated in a large study
conducted by the NCSBN.32 Many types of
simulation methods are available, and review-
ing the history of simulation in aviation, the
military, and education has shown that in
each industry, simulation training methods
were driven by educational needs and were
shaped by available technology.
As technology became more advanced,
training methods moved from tabletop games
to computer-based or virtual environments.
In health care, this trend is also occurring, as
the mannequins have advanced from simple
“dolls” to highly sophisticated computerized
mannequins. Health care, much like aviation,
is driven by safety, more specifically, patient
safety. As the link between simulation and
patient safety becomes apparent, simulation
will be adopted as the education and training
method of choice for such critical behaviors
as communication and teamwork skills. Sim-
ulation will also be an integrated part of every
prelicensure nursing student’s clinical educa-
tion and orientation for every new nurse.
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