Playing the Simulation Game

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Simulation is becoming a popular education modality attracting an increasing amount of research and discussion.   Fidelity is a heavily debated subject which involves a crafted combination of appropriate props, confederates and skilled instruction.  A lack of visual or verbal cues, and unnatural or stilted interactions are some features that may contribute to the lack of realism and result in an unhelpful preoccupation with the artificiality instead of the task at hand.  If not managed properly, this may detract from potential learning opportunities.  Here are some tips for participants on how to engage with simulation and optimise their experience.  These comments mainly refer to acute care and team-based sims.

Interact only with the mannequin and your team

But don’t interact with the instructor even though they seem to be interacting with you.  A key component of the play-acting is whilst the participants and mannequin are expected to only engage with one another, an outside observer regularly interacts and responds to the activity in the centre to give momentum and flow to the scenario.   Unless you have an exceptionally high fidelity mannequin, during assessment and treatment the instructor will generally narrate the findings or the clinical response within the room.  To maintain a degree of realism, the ‘fourth wall’ should not be broken by trying to elicit information directly from the instructor.  It is important to remain in character by patiently interacting with the mannequin (see below) and trust that the instructor will provide the appropriate responses in a timely manner

Verbal prompts are inevitable but unpredictable

At times there will be periods in which there may be extended stretches of silence where nothing happens (including a lack of an improvement in the patient’s condition).   The irregular nature of these moments can disturb the rhythm of how one one would normally approach these clinical situations (see below – The Passage of Time is not constant).  This apparent lack of feedback from the instructor can be disconcerting, confusing or even demoralising and may be interpreted in several ways:

  1. They are waiting for you to conduct a crucial part of assessment before offering further information
  2. They are waiting for you to commence a specific intervention so that a change in the patient’s condition can be observed
  3. They simply failed to observe what you said or did leading to a stall in proceedings or an incongruous or ambiguous situation
  4. A natural amount of time needs to elapse before a change is expected and you should continue your routine assessment before possibly commencing and escalating therapy e.g. waiting for status epipleticus to respond to first line benzodiazepines (see below – The passage of time is not constant)

It is important not to obsess about which of these is occurring.  The best solution is to  demonstrate that you are constantly monitoring and re-evaluating the situation until a change is perceived or a suitable time has passed before the next prompt occurs

Script your responses

Particularly for subconscious actions that are important but aren’t normally verbalised, learn to articulate and narrate your actions in detail clearly e.g. ‘I’m checking if there is any danger,  ‘I am going to feel for a pulse’.  This reassures the instructor you are completing or re-establishing fundamental safety checks before you move onto more detailed assessment or treatment.

Exaggerate your performance

In additional to verbal scripting, it is helpful to make a deliberate and exaggerated show during particular parts of the assessment or clinical procedures to demonstrate that you have completed certain key steps e.g. bending over the patient and listening to the breathing or watching the chest rise, flourishing your stethoscope and carefully auscultating the mannequin’s life-less torso, feeling down the ribs for the 5th intercostal space before inserting a chest drain, looking around the room to ensure everyone is clear before defibrillation.  

Think out loud

Particularly when faced with a dilemma or a difficult situation, it is useful to indicate to people in the room that you are taking pause because you are considering additional possibilities or have recognised the challenging issues.  These include facing a diagnostic challenge, waiting to see if the patient first responds to initial treatment or deciding to prioritise between two urgent interventions. Often these situations are deliberately crafted for discussion later, other times they are inadvertently created due to errors in scenario set-up, design or conduct.  Either way, verbalising this assists the instructor on providing further prompts that assist with the flow of the session.    A useful technique of managing this is explaining the reasons you have chosen one route and the additional contingencies you might take e.g.  I think this is just asthma so I am going to start salbutamol nebs but I will continue to look for evidence of anaphylaxis such as angiodema, rash or hypotension to see if we need to give IM adrenaline.

The passage of time is not constant

Although all sims are remarkable in that a great number of events can occur in a short period of time, each passing moment is not equal in length or proportional to the same elapsed period in real-life.   Symptoms and signs can rapidly wax and wane depending on the decisions made.  Interventions are miraculously completed in record time.   Sequence is more important than time.  As a result it is difficult to get a cadence of when to act or when to ‘watch and wait’.  A useful technique to gain some control over this is by prefacing all your decisions with the amount of time you expect to elapse for a treatment to be completed, when you expect a response to normally occur and when you expect to proceed to the next intervention. e.g. “as long as the patient isn’t deteriorating let’s continue to give three rounds of rescue puffs over the next 30 minutes and see if they settle.  If that doesn’t work we may have to consider magnesium.  In the off-chance they significantly worsen we may need to intervene with intubation but let’s not consider that at the moment”.   The instructor can then choose how quickly they wish to accelerate events


As can be seen, successful simulation is not only an intricate dance between participants and the mannequin, it is also a highly dynamic performance that simultaneously involves an impartial yet heavily engaged observer.  Although every Simulation needs to establish a ‘fiction contract’ that allow participants to suspend belief over reality, learning the ‘simulation game’ can help maximise the practical benefit of this educational technique.

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