Simulation Moulage: Bang for buck?

By Victoria Brazil (@SocraticEM)

Simulation enthusiasts (including me) have been known to spend hours perfecting the most realistic vomit, or choosing exactly the right wig for the elderly fall case. But is this time well spent? How does moulage affect engagement (or disengagement) and learning from healthcare simulation?

This issue is brought into sharp focus in an article published recently in Simulation in Healthcare – Does Appearance Matter? Current Issues and Formulation of a Research Agenda for Moulage in Simulation by Jessica Stokes-Parish et al(1). The authors challenge us to reflect upon the impact of moulage efforts on our intended simulation aims and call for research specifically investigating the question.

Moulage is used to enhance physical realism of simulators, actors or the environment in healthcare simulation. The techniques range from simple makeup to complex creations mimicking procedures like a cardiac surgical ‘re-open’.(2). Simulation operations experts have sought lessons from performance arts, film and TV, robotics, engineering and 3D printing.

The scope of ‘moulage’?

Advances in materials science and computer animation have enabled significant progress Brazil_moulage workshop laceration with glass 1in industries like cinematography (think Shrek’s facial expressions) and pornography (don’t think too much :)). Healthcare simulation has been a beneficiary, with examples like Mask-EDTM and wearable trainers like the Surgical Cut Suit.

However, most simulation educators operate on a lower budget than Hollywood, and there are a multitude of low cost options for basic wounds and skin moulage, and simulated blood and vomit. For those seeking practical advice – courses and online resources are widely available, including blogs like TheSimTech, EM sim cases, and HealthySimulation, as well as from industry and simulation centres.  Manikin manufactures and others have moulage materials and kits for purchase. (NB nil disclosures)

What are we trying to achieve?

The term fidelity has been defined in the Healthcare Simulation Dictionary(3), and used in general simulation parlance to denote ‘how real’ is a simulation. Physical or ‘structural’ fidelity was described as ‘high’ or ‘low’, especially by manikin manufacturers, and many courses still specify ‘high fidelity simulators’ as a requirement. However, when considering engagement and learning impact, factors such as task and team fidelity may be just as important.  Experienced simulation educators have all seen effective scenarios run without any moulage, and high quality moulage is no guarantee of success if scenarios are implausible, the team participating contrived, or other educational aspects are ignored.

Hamstra and colleagues argue that the concept of fidelity is flawed, and prefer the terms physical resemblance and functional task alignment(4). This article further quotes Roger Kneebone “All too often it is the surface realism of the simulation that occupies the ingenuity of those who develop it, eclipsing key issues of teaching and learning …”(5) and suggests simulation educators should redirect their time and money away from efforts to improve physical resemblance.

Its probably not that simple…

Stokes Parish and colleagues also prefer a change in terminology and refer to engagement, realism and authenticity of learning and explore the latter term in some depth(1).

Simply put – it depends.

Physical realism is of variable importance to educational engagement and outcomes. Major trauma simulations would lose that ‘task fidelity’ if there were no wounds, injuries or internal bleeding to manage, while a CPR skills simulation only needs the chest wall resistance and recoil to be ‘real’ and even the absence of legs is unlikely to affect learning outcomes.

Brazil_Low physical realism but highly effective CPR training in South Sudan. Photo courtesy Dr Amy Neilsen
Low physicial realism but highly effective CPR training in South Sudan.       Photo courtesy Dr. Amy Neilson

The real question (and research challenge) becomes – how can we predict this in advance for more nuanced examples than mine? How can we judge ‘bang for buck’ in using moulage in our simulation programs? Both Hamstra and Stokes-Parish offer frameworks and potential methodologies, and delve into deeper questions of measuring simulation impact (engagement, learning and more) at individual and team levels.

 What should this mean for the practice of the everyday simulation educator?

I think it invites reflection, rather than a major change in practice for most. It should help those of us on limited equipment budgets realise that these limitations may not be fatal to learning outcomes.

I suggest: –

  1. Read the article Does Appearance Matter? Current Issues and Formulation of a Research Agenda for Moulage in Simulation(1)
  2. Reflect on whether our sim programs are ‘over specified’ with moulage, or whether we should be adding more physical realism, based on our best assessment of educational impact.
  3. Explore resources and simulation networks to see if there might be other ways of achieving the physical fidelity we require.
  4. Re-think our sim terminology 🙂 ( and check out more from the newly released Healthcare Simulation Dictionary)(3)
  5. Maybe get involved in research related to moulage, physical realism and educational outcomes.

I’m not giving up the quest for that perfect fake vomit recipe just yet. 🙂


  1. Stokes-Parish JB, Duvivier R, Jolly B. Does Appearance Matter? Current Issues and Formulation of a Research Agenda for Moulage in Simulation. Simulation in Healthcare. 2017;12(1):47-50.
  2. Campher D, Watson M, Hayden M, editors. Moulage In High-Fidelity Simulation: a Post-Cardiac Re-Open Model For Visual Realism and as an Education Tool. Simulation-Realising the Potential; 2008: Australian Society for Simulation in Healthcare.
  3. : Sociiety for Simulation in Healthcare; 2016. Healthcare Simulation Dictionary.
  4. Hamstra SJ, Brydges R, Hatala R, Zendejas B, Cook DA. Reconsidering fidelity in simulation-based training. Acad Med. 2014;89(3):387-92.
  5. Kneebone R. Evaluating clinical simulations for learning procedural skills: a theory-based approach. Acad Med. 2005;80(6):549-53.

Feature image courtesy of Ms Clare Scott, Simulation Educator, Gold Coast, Australia