The survey was completed by 41 participants (19 nurses, 19 residents and fellows, and 3 respiratory therapists). Median clinician experience was 3 years (range, 1–42 years) and each had experienced a median of 1 mannequin death (range, 1–10 with 1 outlier stating they had experienced 20 deaths). Survey data are presented later by theme.
Learner Preparation and Suspension of Disbelief
Sixty-nine percent of learners agreed or strongly agreed that they felt prepared to engage in the session before participation and 66% of learners agreed or strongly agreed that they were able to suspend disbelief. Comments indicated that mannequin appearance, case structure, environmental fidelity, personal perception of the stressfulness of the situation, and engagement of other learners facilitated each learner’s ability to maintain this suspension.
Differences in Emotional Response Between Real and Simulated Death
Although learners were divided on the question of whether mannequin death generates an emotional response (Fig. 1), 80% of respondents reported that mannequin death did not evoke the same emotional response as real patient death. Although learners reported feelings of frustration, disappointment, or embarrassment with mannequin death, they linked this more closely with perceived knowledge or skill deficits than with an emotional identification with the hypothetical patient. One respondent stated “A real death is on a completely different emotional level than the death of a mannequin. When a mannequin dies, I just have a feeling of failure in my clinical skills.” Another respondent stated “A real patient hurts worse. A mannequin elicits similar emotions on a smaller scale. I have difficulty believing anyone could feel the same for a mannequin as they do an actual patient.”
Effects of Simulated Death on Future Emotional Engagement in Learning Activities
Learners were also divided on whether knowledge that mannequin death may occur increases their anxiety about participation before simulation sessions (Fig. 1). This distribution was modestly correlated with the emotional reaction to simulation death (rs = 0.46; P < 0.001; Fig. 2), supporting the possibility of a more emotionally sensitive subpopulation. Eighty-nine percent of participants disagreed or were neutral, however, with the statement that mannequin death made them reluctant to participate in future simulations. However, one learner stated “I felt that I will be more hesitant to take a leadership role in this kind of scenario because I felt a loss of confidence,” suggesting that some carryover of negative emotion to future simulations does occur.
Learner Self-Perception and Perception by Team
Eighty-eight percent of learners had a neutral or positive response toward the team during the simulation, regardless of mannequin death. Similarly, 92% of learners had either neutral or positive perceptions of the team’s response toward them during the simulation.
Impact of Debriefing on Emotive Response to the Simulation
Learners perceived that debriefing significantly altered postsession emotions, with a reduction in frustration (49%–22%, P = 0.02), disappointment (68%–44%, P = 0.045), and embarrassment (49%–19%, P = 0.02). In addition, debriefing was associated with a perceived increase in satisfaction (5%–31%, P = 0.003; Fig. 3). One learner stated “The debriefing is where the mystery gets unraveled. I get to find out where we went wrong, what could have been done differently, and how it was supposed to happen. It’s what makes the experience worthwhile. I think I learn the most during the debriefings after a mannequin death.” Another opined that after the debriefing, “The disappointment was still there, but the experience felt like a learning experience instead of a failure.”
Impact of Debriefing on Knowledge and Skills Learned
Ninety-seven percent of learners agreed or strongly agreed that the debriefing positively impacted their knowledge base. Sixty-six percent of learners agreed or strongly agreed that the death of the mannequin enhanced the learning occurring during debriefing, whereas 25% were neutral regarding this.
Perceived Effect of Mannequin Death in Knowledge Retention and Practice Changes
Ninety-two percent of learners reported that they would use the knowledge gained during these simulations. Similarly, 69% of respondents reported that mannequin death enhanced or significantly enhanced their learning retention, whereas 31% reported that the effect of mannequin death was neutral in terms of their learning retention. Several learners made this link explicit in comments such as “The mannequin dying certainly made me remember hyperkalemia and managing arrhythmias” and “If they can’t die, it’s akin to taking a test you can’t fail. When death is a possibility, it enhances the fidelity of the whole experience.”
The model was further refined on the basis of these results. The final model is presented in Figure 4.
The goal of this study was the development of a pilot model describing the educational and psychological aspects of mannequin death due to learner action or inaction. In this discussion, we explore the findings contributing most to the final model, offer a description of the model itself, explore linkages to the current literature, and address the intersection of our model with issues of psychological safety and adult learning.
The focus groups and subsequent survey uncovered a number of interesting findings that were critical in the development of the final model. First, it seemed that most learners make a sincere attempt to suspend disbelief but nevertheless do not perceive that mannequin death possesses the same emotional valence as that of a real patient. Although learners may engage with us in the “fiction contract,” it seems that the distinction between reality and the “as-if” of the simulation remains clearly in view.17,18 Second, the bimodal distributions with respect to emotions invoked by mannequin death and the effect of possible mannequin death on anticipatory learner anxiety are moderately correlated, suggesting that the same learners potentially experience both reactions. This may represent a particularly sensitive subpopulation, although the nature of that sensitivity is at present unclear and will require further exploration.
Learner perception of the team seemed generally positive despite the death of the mannequin. Indeed, both focus group and survey data suggest that learners are more likely to judge themselves than others. This is reassuring given our initial concerns about the possible negative effects of distress and ill will within the learner group.5 Given the limitations of our sample size, however, we cannot necessarily conclude that such effects never occur.
Perhaps, the most significant finding was the perceived positive effect of debriefing on emotional state. The ability of debriefing to mitigate learner emotion and create psychological safety has long been accepted by the psychology and simulation communities, and these results support this.18–24 These debriefings, however, were conducted by experienced faculty, which is likely reflected in these results. Most also felt that mannequin death positively or neutrally impacted knowledge acquisition during the debriefing process. Although this is a largely reassuring response, it was not completely uniform, because 9% felt that mannequin death detracted from learning. Although small, we do not wish to ignore the significance of this group, because its existence again raised the possibility of a “more sensitive” subpopulation with characteristics requiring further study. Finally, the vast majority of respondents perceived mannequin death to have a positive impact on long-term practice and knowledge. Respondents explicitly stated that the opportunity to experience the consequences of their actions was highly valued and emphasized the learning points of the case.
Explanation of the Model
When developing the model, we strove to maintain a clear focus on learner perceptions, and thus, after much discussion, we chose to use the temporal organization of a typical simulation session as a framing device. By doing this, we hoped to arrange the themes in the sequence that would make the most intuitive sense to learners. The model begins with the recognition of a number of “emotional modulators” that potentially impact the response of learners to an instance of mannequin death. Relevant themes here include theme 1, which addresses the preparatory approaches used by learners to ready themselves for the simulated environment; theme 2, which encapsulates the individual differences that exist in emotional responsiveness; and theme 3, which addresses the possibility of anticipatory anxiety. Arrows delineate the ways in which these themes interact. A linkage of particular note exists between themes 2 and 3, where bidirectional arrows represent the possible subpopulation of emotionally sensitive learners (which bridge these 2 themes) noted in our analysis.
Once the event of mannequin death is experienced, the flow of the model proceeds to the effect of that experience on self and team perception (theme 4). This is linked to the debriefing process, because unaddressed tension within the team could potentially have a significant effect on the debriefing, requiring a degree of facilitator skill to mitigate.1,2,20,25 Because our survey results suggested that this was not a significant issue among our population, we depicted the links between theme 4 and those related to the debriefing using dashed lines to indicate its questionable strength. Study of other populations and institutions will be needed to clarify the strength of this theme. The event of mannequin death also impinges directly upon the emotional and educational aspects of the debriefing, represented in the 5th and 6th themes. These, in turn, influence how the experience affects long-term knowledge and practice (theme 7).
Finally, the entire model is itself situated within the context of previous and subsequent simulation-based educational experiences as represented by the clear boxes framing the model. The influence of previous experiences is envisioned as occurring primarily via interactions with the differing emotional responses and anxiety levels represented by themes 2 and 3. As the vast majority of our survey respondents indicated that the experience of mannequin death did not adversely affect their desire to participate in future educational activities, the link to theme 3 link was also depicted as a dashed line. The influence of these themes on future simulations is represented by the arrows continuing to the right of the diagram.
As a test of the final model, we re-examined existing studies of mannequin death, as we would expect the subjects of these articles to correlate with aspects of the model if it is complete. This comparison is depicted in Table 4. Of the 6 current studies that report empirical data, 5 attempted in some way to assess theme 7.10,11,27,28 Each of these 5 articles also focused on 1 other theme.10,11,26–28 The sixth article addressed theme 2 only.26 Themes 1 (learner preparation and suspension of disbelief) and 4 (learner self-perception and perception by team) were unaddressed. This comparison both supports the applicability of the model and demonstrates how its use could suggest aspects of mannequin death requiring further study.
Exploring External Connections
Although the model was created on the basis solely of learner data, it is helpful to explore parallels between it and other published models of adult education and psychological safety. Indeed, significant parallels exist to the work by David Kolb.29 Kolb’s Cycle depicts adult education as a 4-step process beginning with a concrete experience that then proceeds through active reflection and observation and abstract conceptualization as learners attempt to alter their understanding of that experience. This is completed by a time of active experimentation in which they enact what they have learned, which in turn generates new experiences that begin the cycle anew. With regard to our model, the preparation for (theme 1) and the experience of mannequin death forms the fundamental experience, with reflection on both self and team occurring as part of theme 4. This naturally leads to the conceptual modification that occurs in the debriefing (themes 5 and 6). Active experimentation can be envisioned as occurring during theme 7. The iterative nature of Kolb’s Cycle is captured by themes 2 and 3, which serve to modify the nature of the next experience, as well as the explicit links to past and future sessions.
Aspects of our model also coincide with other recently published frameworks and discussions addressing psychologically difficult simulations.1,4,5,30 One recent model suggests an approach to the ethically difficult simulation in which educators actively consider aspects of the session facilitator, learner, case, educational goal, and institution that might impinge on the psychological safety of learners.30 Although our model has a somewhat different purpose, these considerations are somewhat reflected in themes 2 and 3, where learner-specific differences and their relationship to previous experiences are invoked, and in themes 5 and 6, in which facilitator experience with debriefing plays a crucial role.30
Perhaps the most significant limitation of this study is the initial focus group sample size and its possible effect on saturation. The largely homogenous distribution of initial, independently coded themes among the transcripts, however, suggests that despite the small size, adequate saturation was reached for the purposes of our pilot.
A second cluster of limitations centers on the potential for bias. Given the retrospective nature of the study, a degree of recall bias is possible in the identification of subjects and collection of data. Potential bias also exists in the study population, which consisted of experienced physicians and nurses in pediatric acute care environments, many of whom have experienced real patient death, and among investigators, because our program is one that supports the use of mannequin death. In addition, our faculty primarily uses an “advocacy-inquiry” approach, which may limit the generalizability of our findings if other debriefing models are used (though this seems unlikely).21,22 Although care was taken to minimize these potential biases, the nature of our investigator and study populations render our model a pilot at best, and further study in less experienced populations, at sites where mannequin death is not allowed, and in nonpediatric settings may result in significant modifications or new themes.14,15
In addition, the survey referred to learner emotions in an intentionally ambiguous way. This approach was deliberate, because we did not wish to drive subjects toward specific emotional responses. No preliminary cognitive testing was performed on the survey, however, and thus, we cannot be sure if this achieved the desired effect. Finally, limitations in our program’s demographic databases (which does not record the dates at which learners experience mannequin death) prevent us from calculating true survey response rates or commenting on the effect of the time interval between experiencing mannequin death and study participation.
We report on the creation and exploration of a pilot model addressing the effect of mannequin death due to learner action or inaction. By exploring this issue among learners who have experienced it, we were able to generate themes that encapsulated the psychological and educational effects of this technique. Although the model stems from a limited population, it is our hope that it can serve as scaffolding for future qualitative work with a more diverse population, as well as a means of hypothesis generation for quantitative studies.
The authors thank Michele Morison for her invaluable work in transcribing the focus group recordings.
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Mannequin death; Simulation; Qualitative; Theoretical framework; Theory; Simulation-based medical education; Ethics; Cognitive load; Debriefing; Learning; Stress
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