Developing Simulated Learning Experiences

Picture of Amy Hamilton
Students Taking Simulatons Seriously
by Amy Hamilton - Wednesday, April 16, 2014, 8:51 PM
I am occasionally having trouble with students taking Simulation seriously. Most students love simulation, and feel like they learn so much. However, other students can't (or won't) talk to the mannequins like real people. I am currently not grading simulation, but I am highly considering it. I feel like this would hold the students more accountable. What are your thoughts? Anyone had the same experience? How did you handle it?

Just a little background on our sim lab (We do have a control room so I am able to talk through the mannikin. They also have a monitor to look at for vital signs, they have a computer on wheels, and they use an EHR to chart). I try to make it as realistic as possible (using moulage, decorations, make-up, wigs, etc. etc.)

Thank you for any information that you can provide.
Picture of Diana Breed
Re: Students Taking Simulatons Seriously
by Diana Breed - Thursday, April 17, 2014, 12:01 PM
Hi Amy,
We have that every once in a while. More often I hear, "I would do it better, if it was a REAL person". Studio Code has been extremely helpful when this happens. This way they are able to see themselves and view how their comments and expressions change the interaction. For example I had a student who was loud and in the face of the patient. During debriefing he said well if the patient was real he would have noticed that she was cringing and changed. During the third video playback he looked up and everyone and asked, "Am I really that much louder than everyone else". You can't put a price on that type of self-awareness.
Picture of Jeff Carmack
Re: Students Taking Simulatons Seriously
by Jeff Carmack - Tuesday, April 22, 2014, 9:58 AM
I think Diana hit upon a valuable point, video playback through whatever means you have is very valuable. But as to the grading or evaluation of the simulation-based learning experiences (SBLE), I feel you need something in place to hold your participants to a standard. Through the use of a simulation rubric, you can set an expectation for your participants. Like your experience, if students do not sense they are earning points, I feel they may not give their all.

I think the approach has to be multifaceted. One, simulation integration across the curriculum helps develop a sense of what is expected. Think of it as an extended orientations. If your participants only attend and SBLE once in their training, they may not have had sufficient orientation. In early SBLE, there will be a period of adjusting to the manikin and learning how to interact with the trainer and the environment. As the student grows, they should show growth in the lab as well. Secondly, I am sure you already have a confidentiality agreement in place with the participants, after all what happens in sim stay in sim. Consider including at least a few sentences, like a manikin's bill of rights, that the participants sign that indicate they will engage and treat the patients as patients. This way in the debriefing it can be referred back to as needed. We have a line in ours that also tells the participants that manikins are allergic to ink pens and that they may refuse care from any provider that uses them at the bedside (it is a handy place to slip in reinforcement of expectations). Finally, we have a rubric to evaluate the SBLE, it is not about what was done right or what was done wrong. Our rubric looks more at topics related to professionalism and interaction within the SBLE. We have evaluation points on ours like "Fully participates in simulated scenarios", "Display positive professional attitudes, behaviors, and speech", "Accepts responsibility for own actions during the debriefing period" and another item that addresses prior learning.

With the integration of multiple types of patients from the mid-fidelity to the standardized patient, respecting all patients for "their" differences is just part of the day in the life of our participants. Video playback in conjunction with orientation and clear communication of expectations may be all you need to address your concerns.
Picture of patti hill
Re: Students Taking Simulatons Seriously
by patti hill - Friday, May 9, 2014, 8:42 AM

Greetings Jeff,

This issues has come up several times with our students during the simulation encounter as well as in debriefing and your suggestions clearly make sense.

Are you willing to share your rubric to evaluate the SBLE. If so, I would greatly appreciate it.

My email address is:

Thank you for your insight and support,


Picture of Jo-Ann Cole
Re: Students Taking Simulatons Seriously
by Jo-Ann Cole - Tuesday, May 13, 2014, 4:39 PM
Hi Jeff.
I absolutely agree that you need something in place to hold the students to a standard expectation. Overall, our students do a pretty good job but I hear the same comments regarding "I can't talk to a manikin ..." or "I do better with real patients ..." etc. I also see all levels of preparation and participation.

You offered several interesting suggestions. I particularly liked incorporating a "manikin's bill of rights" into the Confidentiality Agreement and hope to implement this change in the fall semester. I also liked the focus of your rubric for evaluating SBLE. Although we have used a rubric in some of the upper level classes, we haven't implemented a rubric in the first year nursing classes.

As a relatively new Simulation Manager trying to incorporate simulation into the curriculum, I've struggled with the evaluative component of simulation but incorporated it into my strategic plan for this academic year. I like the focus of your rubric and think it may be a good way for us to start an evaluative process in the Fundamentals course. Do you use the same rubric throughout your nursing curriculum? If you would be willing to share your rubric, please forward to
Thank you for sharing.
Picture of Cathy Miller
Re: Students Taking Simulatons Seriously
by Cathy Miller - Wednesday, June 18, 2014, 11:25 AM
Hi Jeff,

As the newest member of the education staff, I too would like to know if you would be interested in sharing your rubrics? My new position of simulation coordinator is exciting but also a blank slate for me to establish. Anything you could share would be greatly appreciated. Thank you for sharing your process!
Picture of Donna Gloe
Re: Students Taking Simulatons Seriously
by Donna Gloe - Wednesday, June 18, 2014, 12:07 PM
I also would like your rubric. Thanks
Thanks for sharing as I would like to see your rubric as well. My email:
Picture of Marilyn Stoner
A couple of thoughts
by Marilyn Stoner - Wednesday, July 2, 2014, 11:41 AM
Good morning all.

I am old so I have a couple of suggestions, based on evidence and practical strategies.
Maybe we can start doing Google Hangouts to help each other, I'm happy to help anyone.

Anyway, use Jeffries model to increase the degree of difficulty.
1. Have the simulator refuse to have the student care for them
2. Put the simulator on the floor
3. Run multiple simultaneous simulations--I never do just 1 anymore.
4. Start having family members call the sim center and ask for patient updates--do not tell the students this will happen.
5. Have a primary care provider call and ask for a clinical update.

NEVER USE actors (faculty or other students) as actors, always beg, borrow and steal from friends and campus people to be the actors, people the students don't know. Single biggest and most most effective intervention to bump up the challenge of simulations is to introduce strangers.
Combine sim with research class to find and evidenced based way to improve care.

We have a librarian who is kind of in charge of nursing material in the library. She was a GREAT actor and really feel she knows more about nursing now.

I think we do not challenge students enough. They are used to the sims now so they blow them off like so much of the work they are used to.
All of my end of life simulation is on my website

I will be uploading a list of more suggestions this summer to my nurse educator website

Don't let students make the simulation a test of how they can test you.

Picture of carol odinzoff
Re: A couple of thoughts
by carol odinzoff - Tuesday, August 12, 2014, 8:31 PM

The more sims I do, the more I agree that the students either are intimidated by the idea of talking to the mannequin or just blow it off. And the more I do of this, the more I am convinced that having real people to interact with makes a difference.

The sims are good for things like cpr and recognizing cardiac dysrhythmias and the more technical criteria but not for practicing personal communication skills or determining disease processes.



I absolutely love your idea of the maniken's "Bill of Rights". I think that is very clever and a way for people to kind of break the ice with the discomfort of treating the simulator like a real patient. Is there any way you can elaborate on this topic and maybe give some other examples of what is on your Bill of Rights? Thank you so much for your time and assistance with this!


Nichole Shockley

Picture of Jeff Carmack
Re: Students Taking Simulatons Seriously
by Jeff Carmack - Tuesday, March 8, 2016, 9:57 PM

Nicole and Katherine,

I am going to try and hit the high points in a single post.  It always catches me off guard when these posts takes on new life years later.  However, despite the changes I have made and been a part of in this time, the relevance is still clear.  There is a Manikin Bill Rights out there somewhere.  One of the big South Carolina simulation centers had a good one.  But maybe you want something a bit more personal.  

Many of our local medical facilities have a patient bill of rights.  This is an excellent starting point, as you read through the document, how would the manikin feel?  I agree, it is a strange question.  As an example, Manikins have a right to understand treatment options and take part in decisions about their health care.  We are saying that you have to listen to the manikin to know these things, they should expect the caregiver to explain procedures, and if the manikin says no, then no is the answer.  This is just one way to frame the experience.  It seems less "because I said so".   

You could simply place a line in the rubric that addresses calling the manikin a "dummy" for example, or cover it with your professional behavior standards and the points associated with this evaluation point. If you want a more direct approach.  

One major thing has changed, and ironically enough this was the conversation in a meeting today.  In our program we are discussing reducing the points earned in simulation.  We are considering this for several reasons.  First, and foremost, our students have recognized the value of the simulation setting. We see it on evaluations, we hear it anecdotally, and we are all working hard to measure it empirically.  If the product (simulation in this case) has value in the eyes of the participants, they will do it for the experience.  Our labs have been doing simulation since 2008, and in 2010 we felt the students were not taking it seriously.  So we decided to make simulation worth the same points as a clinical day. It worked, we got buy in and engagement.  

At the same time we invested heavily in faculty.  Immersion training and faculty support is a major factor.  We started slowly, sending one person when we could, it took years to get funding, but last year we sent our second group of two.  When we talk about manikins in the briefing covering the limitations, we deliberately refer to them as simulators and call them by the brand name (SimMan Classic, SimMan essentials...).  As we end this section, we remind our participants that "There are no dummies in simulation. The simulators know a lot, just as you came prepared...". 

Debriefings have to move from plus/Delta.  This was our approved model from 2007- 2012.  It leads to lecturing, failing to understand or to uncover the gaps, and we can all cite the known failures.  The last thing that I think changed our students perception was the fact that we flipped the pre-briefing (I know this is not what we need to call them, but we do a pre-briefing where we cover meds, disease process, and teaching before me move to the labs where we hold a faculty lead briefing).  Our faculty often walk into a room of 30 participants, and just start by going down the line, "So I have just been told I have X, what do I need to know...".  We have points in our rubric that cover preparation, and this is where points will be deducted. Word spread like wildfire.  

I am sure you do most if not all of these exact same things, and as students become better consumers of simulation, I hope your efforts pay off and you see a more positive understanding of the value of simulation by your learners. It took time, but simulation is a pedagogy for engaged learning. 

Katherine, I will send you a rubric, let me know if it helps or if there are question I can help with.  



I have run in to this same issue. Students fail to prepare as they know they are not technically being graded. If you would be willing to share your rubric, that would be great. 

Thank you.