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Does Appearance Matter? Current Issues and Formulation of a Research Agenda for Moulage in Simulation

Stokes-Parish, Jessica B. M. Nurs (Adv Prac); Duvivier, Robbert MD, PhD; Jolly, Brian PhD

doi: 10.1097/SIH.0000000000000211
Concepts & Commentary

Summary Statement The use of moulage is assumed to add realism and authentic context in simulation. Despite the expense required to utilize moulage effectively, there is little exploration in the literature as to both its necessity and its accuracy of portrayal. We explore engagement, authenticity, and realism theories in the context of moulage and highlight the need for more evidence on moulage in simulation-based education, including suggestions for future research. In particular, we urge the simulation community to move beyond descriptive papers to investigate moulage in terms of justification and clarification.

From the School of Medicine and Public Health (J.B.S.P., R.D., B.J.), Chameleon Simulation Centre School of Medicine and Public Health (J.B.S.P.), University of Newcastle, Callaghan, New South Wales, Australia.

Reprints: Jessica B. Stokes-Parish, M. Nurs (Adv Prac), Chameleon Simulation Centre Level 1, Clinical Skills Training Centre, Hunter Region Mail Centre, NSW, 2300, Australia (e-mail:

The authors declare no conflict of interest.

Simulation-based education (SBE) is commonly used in both undergraduate and postgraduate education. Often used as a primer before clinical placement or when clinical activity is infrequent, the level of realism required in SBE is frequently questioned in the literature.1–3 Typically, in SBE staff “set the scene” using equipment that matches the clinical environment to increase the illusion of “the real thing,” using techniques such as moulage to simulate wounds and other effects.4–6

Moulage dates back to the ancient Egyptians, when embalming and preservation of the dead were reserved for the Pharaohs of the time. Although historical accounts are sketchy, this mummification was linked to the traditional moulage process used for building models for anatomical and medical teaching in the late 16th century.7–9 Using the process of casting, artists created anatomical moulds from cadavers and then used wax to fill the moulds. After completing the moulding and casting process, the models were painted to enhance the realism of the replicas.7,10 With these models now housed in musea across the world, the term moulage currently refers to the application of special effects or makeup techniques to manikins and simulated or standardized patients.11,12 Common examples of moulage include bruises, wounds, burns and other signs of trauma, and illness effects such as sepsis, jaundice, and rashes. Simulation staff rely on training resources such as books, home recipes, web-based instructions (eg, YouTube), and their attendance at special training courses. Such training courses can be expensive, with costings for a basic course US $450.00 to 600.00. In addition to this, the outlay for using moulage in every day simulation practice is estimated to be at least US $300.00.13 This figure covers tools, specialty, and theatrical makeup supplies.

Considering the significant cost to simulation that moulage requires, we need to reflect on the necessity of moulage in simulation. With the theoretical concepts of engagement, realism, and authenticity in mind, we sought to identify the place of moulage in simulation. This Concepts and Commentary will explore the evidence base, with a view to developing a research agenda that will allow the field to move beyond “show&tell” or descriptive research toward clarification studies.14 We will identify areas of investigation that are currently underdeveloped, which would benefit from studies seeking to answer “how and why does it work?” rather than “what did we do?” We argue that our collective effort should focus on deepening our understanding to advance the science of simulation. We hope that this C&C will stimulate the simulation community to reflect on the purpose of moulage in their teaching and to strive to ask more appropriate research questions.

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How do Moulage, Engagement, Realism, and Authenticity Relate?

Learner engagement is essential for deepening the learning experience.15–17 Components of engagement critical to the success of simulation involve the learners' perception of the activity, including how realistically it is portrayed.18–21 If you were to reflect on a film you watched recently, think on the scenes portrayed. How realistic did it appear to you? If it was an action or horror film, did the makeup portrayed look real or artificial? Did the surrounding scene props fit the picture, or were they out of place—that is, did it feel authentic?

Authenticity, “quality of being real or genuine, not fake” or “quality of accurately recording or reflecting something” is dependent on participant interaction and perception.22–24 Further exploration of the term authenticity or authentic identifies two core characteristics: context and the process in learning. Context refers to how closely the “whole experience” mimics real life. Authentic learning in education is complex, and it has been described as “a pedagogical approach […that] situates learning […] in the context of real‐world situations.”25 Authenticity in simulation is noted as increasingly important24; however, it is sometimes dismissed by simulation facilitators as unimportant.24,26,27 For learners, however, their “perceptions of authenticity are critical because learning is embedded in our everyday experience of the world […] Information and problems perceived to be authentic entail social contextualization […] which influence all subsequent mental processing.”28 Although contextual authenticity in simulation and authentic learning process are separate concepts, they are intertwined.22,23,25 A literature review discovered the following four key themes of authentic learning experiences: “real worldness,” open-ended inquiry, discourse among learners, and choice.29 When this framework of authenticity was applied to a pilot simulation, it was found that the gap widens between real world and simulation when there is a lack of real worldness.23 Furthermore, authenticity of simulation is dependent on multiple, combined factors, with the detail contributing to authenticity underresearched27; to what level is real worldness (perhaps this is realism) and elements of authenticity required? Even small disruptions to authenticity can cause the participant to dismiss it and subsequently the clinical relevance of simulation.

If you consider authenticity of a bruise painted on a manikin or simulated patient, ask yourself, is the bruise portrayed authentically? As simulation professionals,30,31 we often dismiss the authenticity of small details as unimportant.24 An example might clarify how authenticity can derail the purposed learning set for the participant. Consider a bruise, perhaps applied with too much makeup, making the appearance of the bruise too blotchy, which the learner incorrectly identifies as being external, thinking about active bleeding and seeking to stem the bleed, while in actual fact, it was meant to reflect an internal splenic bleed requiring urgent surgical attention. Although key factors of engagement in learning include participant briefing (inclusion of confidentiality agreements, acknowledgement of participant requirements, limitations of simulation and suspension of disbelief, and open discourse in simulation), can we underestimate the impact of the accuracy of visual cues portrayed?2,18,32 As educators and simulation designers, it is imperative that we question the authenticity of delivery and the presence of real worldness.22,23,29

Encompassed in this concept of authenticity is realism, a multidimensional aspect of instructional design. Key elements that contribute to the construction of realism in media are plausibility (the ability for it to occur in real life), typicality (the event could readily happen to the participant/observer), factuality (the event actually happened), involvement (how well the observer/participant can relate to the event and feel emotional involvement), narrative consistency (no contradictions), and perceptual persuasiveness (how well items or events are presented, persuading the individual that it could be real).33 The apparent reality (how authentic or real something appears to an individual) of film is directly associated with increased emotional arousal.17,34,35 We propose that these subcategories can also apply to the context of simulation and instructional design in portraying authenticity. This idea of identifying that the likeness of the setting and context contributes to engagement in simulation is not new.15,18,36,37 Based on the theoretical principles of reality in simulation, research on perceptions of participants has shown that the level of realism and its impact on learning is directly related to the learning objectives of the activity.19,23,36,38 However, it is important to note the distinction between transfer of learning and engagement; here, we are exploring authenticity and its impact on engagement. Unpacking the simulation literature on realism highlights multidimensional aspects already considered in Hall's (2003) hypothesis—engagement is more than physical (perceptual persuasiveness), and it is also semantic (conceptual—plausibility, typicality, and involvement) and phenomenal (emotional—involvement and perceptual persuasiveness).19,20,33

Scoping the literature on moulage and authenticity, there is a lack of clarity on its importance in moulage.27 Articles on moulage in general are few, with most focusing on recipes and “how-to” directions. The few articles that do explore moulage further provide some suggestion that moulage could increase the retention of knowledge (as opposed to using images). In an example of this, two-dimension (2D) images of melanoma were pitted against 3D-preprepared moulages in undergraduate dermatology education—over time, the knowledge of those in the 3D group remained unchanged, whereas those in the 2D group performance deteriorated.39 Moulage is most commonly associated, in the literature, with authenticity and its contribution to this.4,6,11 Despite this assumption, there seems to be no clear evidence of moulage inclusion being essential in simulation practice.40–47 Some authors refer to Wikipedia for the evidence,4 and others list passing comments from participants about “how real it was”; however, authenticity of moulage was not explored or at least not discussed in the literature.4,11 Most articles that explore moulage at greater depth are in the field of dermatology.39,48–51 Probably because of the niche it fits, moulage may provide a unique opportunity to educate individuals on various skin ailments that would be difficult to achieve in short clinical placements. In the example of melanomas, there would be a requirement for authenticity because of the opportunity for accidental misdiagnosis and the significance of observing its height, texture, and abnormality in shape and color. In one article, the authenticity of moulage was assumed to be high—the learners dismissed the moulage item as being the patient's own skin ailment.48 One could question whether this is due to the lack of previous experience on the part of the students or due to the highly authentic portrayal, and in this circumstance, authenticity might have unforeseen consequences. Frijda (1988)34 and Tan (2008)35 explored the psychology of authenticity and engagement in media, identifying the need to allow “dual awareness”—that is, clearly identify what is real and what is not to allow the observer to engage. Perhaps the boundaries of play were not set before engagement in the simulation. In any case, the authenticity of moulage seems to be largely ignored in the literature and commonly taken for granted.

If we drill down further to apply the theory of authenticity and realism to moulage, do we consider authenticity and realism in detail? Perhaps moulage is ignored as being only an abstract representation of reality; moulage is a physical element of realism, yet it crosses into the semantic and phenomenal spaces in various situations. Applied to moulage, the subcategories of realism33 suggest that moulage should be believable, relatable, and not contradictory. Imagine a wound that is applied to a manikin. Was the wound plausible—that is, is there a possibility it would occur in real life. Was it consistent with the scenario (narrative)? Were there aspects of the wound that could have “jarred” the participant—was it colored incorrectly or misshapen/inappropriately located, interrupting their engagement. This concept of jarring is supported in the literature, where episodes of disengagement occurred in simulations when the narrative or setting was not plausible or factual.24 This response, however, could change on the basis of the participants' level of expertise—that is, a novice learner may not pick up these anomalies because of their low level of knowledge in the area (although perhaps the authenticity replication is required for teaching purposes). To an expert in the field, the inaccuracies may be too distracting (conversely, perhaps they do not require the physical level of realism to engage). This jarring can significantly impact the purpose of the learning; instructional design of simulation is critical to its success.2,32 Applying the framework by Rule29 to moulage, one can hypothesize that it must have real worldness to facilitate authentic learning. What is not clear in literature is the level of authenticity in moulage required to achieve this within the design process. The issues discussed highlight the need to understand how the authenticity of moulage impacts on learner engagement at any level.

You will note that we (the authors) have not included the term “fidelity” in our discussion. This is due to the continued confusion and lack of clarity regarding its definitions and appropriate use. We agree with Hamstra et al's (2014)52 position of abandoning the term and as such have limited our discussion to the terms engagement, moulage, realism, and authenticity.

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Directions for Future Research

With these caveats in mind, we ask the reader to consider the application of moulage in simulation. Do we dismiss moulage as being so unimportant that we do not see the cause for exploration? There seems to be some mismatch in our thinking—we are willing to outlay thousands of dollars in expense to add this skill to our simulation expertise, and it is regularly included in the discussion of instructional design; however, there seem to be no goalposts in the literature with regard to its use and the accuracy of portrayal required. We questioned why this is the case. Is moulage actually not essential to the success of simulation or maximal learning outcomes? The theories outlined previously suggest that the accuracy of portrayal would be essential (in part), with each generation expecting better portrayal of authenticity than the previous.53 However, some research argues that complete authenticity is not required.54,55 Instead, they argue that the participant engages from the initial impression only. Some even go so far as to suggest that no similarity at all is required to establish a relationship of resemblance.55,56 Perhaps moulage is essential to some disciplines but not others (eg, dermatology but not obstetrics). Is the concept of authenticity too complex to fathom in any meaningful studies—that is, there are too many variables to explore? After a thorough search of the literature regarding moulage in simulation, there is little discussion on any of these concepts. Do they not apply?

We would argue the case that the relationship between moulage, authenticity, and engagement should be explored in future research to shape the design of simulation and maximize learner engagement. To achieve this, a framework for authenticity in visual cues should be developed. Moving beyond descriptive research,14 a framework would allow for benchmarking and comparison between modalities and authenticity of portrayal. A comparison study might look like Garg's (2010)39 design, rating the authenticity of moulage versus digital images and its impact on engagement (using a measure for engagement) or a study exploring a poorly represented (in-authentic) moulage versus a well-represented (authentic) moulage. Studies such as these would provide information such as quality of products used, level of training required, accuracy, and real worldness of portrayal required. Further research that might benefit the simulation community in understanding whether participants are influenced by authenticity of portrayal. Interviewing participants using a model of open-ended inquiry could provide insights as to how they value the accuracy of portrayal and its influence on their buy-in or engagement (ie, is the participants' value of simulation influenced by the authenticity of portrayal or how “well presented” the simulation is?). Furthermore, it would be useful to understand the impact of engagement in a novice versus expert learner. Such a study might compare the novice with expert's response to varied levels of authenticity. Referring to the instances where an expert may identify anomalies in design, would their engagement be “jarred” or do they engage beyond the physical level of realism? This could be explored through measuring their engagement via a number of methods. Information from these studies would inform practice at both an instructional design and delivery level.

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It seems that the validity and authenticity of moulage should be explored for use in simulation to provide clarity for future practice. We suggest moving on from the description of what is done to studies focusing on justification and clarification of why and how the approach worked.14 We call upon the simulation community to begin a discussion on moulage and commence exploring the potential for robust research to define whether authenticity in moulage really does matter.

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Moulage; Realism; Engagement; Authenticity; Fidelity; Simulation-based education; Instructional design

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