Preparing learners for simulation-based education – more important than we think?

By: Victoria Brazil (@SocraticEM)

The emergency medicine team were just starting their simulation – caring for an elderly man who had fallen and hit his head. As the scenario unfolds, he becomes unconscious and needs endotracheal intubation.

But one of the nurses is giggling, and the team are slow to make the decision about intubation – they seem uncertain about his GCS. The team is smaller than they need, because two of the nurses called in sick when they learnt they were allocated to sim today.

Simulation faculty are often frustrated by learners who fail to immerse themselves in simulation-based education (SBE), perform poorly, or simply don’t turn up. Learners may perceive that simulation lacks realism, fear being unfairly judged, or feel they are joining a ‘game’ that bears little resemblance to actual practice.

Effective solutions are thoughtful design and delivery of simulation-based education, and careful pre-briefing of the participants just before the sim commences. These strategies can help establish a ‘fiction contract’ with participants, improve realism and functional task alignment, and establish psychological safety.

But can we achieve more through better learner preparation even before coming to simulation? Can we do better than simply writing simulation events into learner schedules?

Yes. By considering both content preparation and process preparation.

Content Preparation

Any preparation for simulation learners is better than none. Simulation faculty may worry that pre-reading will be ignored by learners, but the anticipation of performing in front of peers may serve as a motivator 😊. This pre-reading is often focused on the content of the simulation (e.g. head injury or geriatric trauma in the example above). This is an excellent strategy for supporting participants to apply this ‘cognitive domain’ knowledge to the complex interactions and environment of the simulation. It can avoid wasted time spent teaching content that can be more efficiently learned elsewhere. Ideally this material is contemporary, peer reviewed and presented in appealing multi-media formats – like this excellent example for an SVT scenario from the STRORK team at Queensland Children’s Hospital.

Process Preparation

But content preparation is probably not enough. We also know that psychological safety (and performance) is threatened by unclear expectations – are we in our own ED? Is it night shift? Am I playing myself? Can I call the attending? Do we really inject the drugs? Are there tricks? 

Cognitive load theory is relevant. If learners are overwhelmed thinking about what’s ‘allowed’ in the sim, or how the mannikin works, they won’t be doing their best at the actual clinical task. Faculty can significantly underestimate this cognitive load on learners, because – of course – we planned the sim!

So perhaps we also need to be preparing learners for the process of the sim?


Some options….

  1. Short pre-reading on the ‘how’ of the sim – clearly describing the purpose, the timeline and some detail of the environment, equipment, team and process.
  2. Videos (medical student example here) can enable participants to ‘see’ themselves in the scenario environment and engaging with sim process. Deconstruction and seeing what’s ‘behind the curtain’ can help remove the extraneous cognitive load created by uncertainty.
  3. Combining content and process preparation through multimedia software – allowing learners to step through/ mentally rehearse their simulation experience such as in this excellent example of caring for a woman with a post partum haemorrhage, using Articulate Rise 360 (nb Nil disclosures – there are lots of software options).  Guidance for these strategies can also be found in the literature on flipped classrooms.
  4. Learner courses – online multimedia or face to face. We spend a lot of time on simulation faculty development – focused on simulation design, delivery and debriefing.  But maybe we need courses/ workshops focused on helping learners get the most out of their simulation? Training for the training?
  5. Having learners participate as simulation faculty – either through rotations into simulation based education, simulation Fellowships, or through peer assisted learning’ simulation sessions.

Selection of approach will depend on context, faculty skills and available resources. Keen to hear others’ examples or principles!

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