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Adding the Human Dimension to Simulation Scenarios

Szauter, Karen MD, FACP

doi: 10.1097/SIH.0000000000000035

From the Department of Internal Medicine and Office of Educational Development, University of Texas Medical Branch, Galveston, TX.

Reprints: Karen Szauter, MD, FACP, Department of Internal Medicine and Office of Educational Development, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0420 (e-mail:

The author declares no conflict of interest.

The relatively recent widespread acceptance of simulation methodology has stimulated creative development of simulation-based activities across health care disciplines. Descriptions of educational programs, projects, and research using simulation have appeared in hundreds of journals. Historically, simulation-based activities have been grouped in 2 broad categories: model-based simulation (technology-enhanced simulation) and simulation programs employing actual people (simulated or standardized patients or participants). The divide between these 2 simulation applications remains evident in our administrative structures, with many facilities sustaining 2 geographically separate simulation centers supported by staff specifically dedicated to either technology-based simulation or simulated patient (SP)–based activities. Until recently, much of our literature has been separate, and experts working in one area had a limited understanding of the potential educational contributions of the other.1 The added benefit blending of technology-based simulations with people (participating in roles from patients or family members to health care providers) is increasingly recognized as a valuable educational tool. Each simulation methodology requires careful planning, preparation, and refinement. Now more than ever, sharing descriptions of best practices and innovations is essential to keep simulation methodology moving forward.

Two articles in the August 2013 and April 2014 issues of Simulation in Healthcare address issues related to the inclusion of SPs in technology-based simulation activities.2,3 These articles share the authors’ experiences and practical recommendations regarding recruitment and training of SPs. Both articles contribute interesting perspectives to the limited literature on how to choose and train the human participants for their roles in simulations.

Dr Pascucci et al posit that professional actors provide important dimensions to simulations and that formal theatrical training is essential for SPs participating in complex, emotionally charged scenarios. The article describes their program, supported by a performing arts consultant, to select and prepare their SPs. Their processes involve techniques familiar to the acting community: audition, casting, rehearsal, performance, and critique. The authors strongly support the need for formal acting training to ensure that the SP can quickly and realistically adapt during evolving scenarios. The article by Ms Sanko et al provides a more theory-based approach to preparing participants for their role as a health care provider during a simulation scenario. They describe a variety of formal theatrical techniques, which can be applied during the training of SPs. Their article also touches on the contributions of the visual cues of the scenarios—the costumes, props, and setting—and how purposeful inclusion adds realism to the scenario.

Although simulated patient methodology has a long history, optimal techniques for recruitment and training of SPs remains open for discussion. Published recommendations have largely served as guidelines to individual programs, with processes being created locally based on available resources.4,5 Recommendation on how to integrate SPs into scenarios into technology-based simulations have been limited.6 The current articles serve as a reminder that the addition of SPs to a simulation scenario requires careful preparation and planning to ensure that the SP enhances, rather than derails, the scenario.

Is an acting background essential for simulated patients or participants in complex scenarios? The benefits of employing actors are highlighted by Pascucci et al and Sanko et al. Characteristics including the ability to effectively portray the emotional depth of the role, skills in improvisation, and the ability to separate from the role at the end of the scenario are a few issues cited. However, it is also important to recognize that a lack of access to a pool of actors should not negate plans to include SPs in simulations. Standardized patient programs exist throughout the world and typically draw participants from the local community. Persons without acting or health care backgrounds have been successfully employed as SPs in a wide range of teaching and assessment activities, from simple classroom exercises to licensing examinations. When there are specific needs for particularly challenging roles, the literature includes descriptions of employing students from theater or communication programs or even health care professionals with insight into the behaviors of a targeted population.7–9 What seems primary in all of the discussions about SP selection is that the person chosen for a role in simulation is dedicated to the process and is provided with adequate information and training to allow for an effective portrayal.

Both articles provide rich discussions of relevant steps in the training process. Whether in the role of a patient or part of the health care team, an understanding of the educational objectives of the scenario is essential. This requires that the SP is fully prepared to understand not only his or her character but also the place and purpose of everything and everyone in the scenario and the goals for the learners. Pascucci et al provide some helpful tools to guide the development of the character backgrounds. Specific techniques that may aid the SPs in role development are outlined by Sanko et al. These practical suggestions provide helpful guidelines for less experienced simulation trainers to incorporate human participants in scenarios. The articles also highlight the roles that SPs can play in providing feedback to the learners and in further development of the scenario through feedback to the staff. It is important to recognize that no matter who is selected for the SP role (layperson to health care professional), training on providing feedback is essential. Focusing on the educational objectives that the SP needs to understand is key in the selection of the person who will participate in the scenario.

As we continue to recognize the complimentary contributions of blending human and technology-based simulation activities, it is important to share the lessons learned from each perspective. Capitalizing on skills from professions outside medicine, which serves to enrich our learning opportunities, is essential. We must continue to bring together professionals who work with all types of simulation, share our expertise, and work collaboratively to expand the possibilities of simulation training in health care.

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