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Healthcare professionals will always have a first patient. Students must be trained properly prior to that first "real" experience in order to provide safe care (Smith & Lammers, 2014). In the past ten years, research regarding simulation has inundated nursing literature. Themes such as increases in knowledge, problem-solving, task performance, and critical thinking skills have been associated with simulation use in nursing students (Hayden et al., 2014; Lapkin, Levett-Jones, Bellchambers, & Fernandez, 2010; Lee & Oh, 2015). Simulation can be delivered in numerous fashions including low- to high-fidelity mannequins, standardized patients, and virtual reality (Smith & Lammers, 2014). Settings for simulations can include highly technological simulation centers, classrooms, and clinical environments (Smith & Lammers, 2014).

Simulation delivery is dependent upon the goals and objectives of the nursing program as well as the resources available. While simulation has been associated with positive learning outcomes, high costs and limited resources lead to dilemmas regarding the use of simulation as a teaching strategy (Hayden et al., 2014). Using high priced simulators, mannequins, and equipment is not always the best or most effective method to provide learning and assessment (Smith & Lammers, 2014). Choosing appropriate teaching modalities and learning scenarios while keeping ethical considerations and costs in mind should be considered when developing educational activities for the student.

Ethical Considerations

Simulation offers the unique ability for students to acquire and develop skills prior to practicing on real patients, thus shortening the learning curve and reducing the risk of harmful errors in the clinical setting (Miller, 2010). This is an example of beneficence, or doing good for the patient; and nonmaleficence, which is preventing harm (Smith & Lammers, 2014). It is important to prevent harm, not only to the patient, but to all individuals involved with simulation. This includes students, faculty, and standardized patients. Those responsible for developing simulations should adhere to the ethical principles of doing good and preventing harm, as well as having an awareness of the psychological effects simulations pose to the learner.

Potential Negative Effects

As simulation continues to expand into multiple aspects of nontechnical healthcare education, it is important for educators to evaluate ethical standards for dealing with emotions surrounding the simulation (Park et al., 2018). Examples of emotionally charged situations include learning how to deal with death and dying and practicing end-of-life care. While simulation can prepare students to more effectively deal with emotions accompanying a death and dying experience, controversy exists regarding possible psychological harm incurred by the learner (Park et al., 2018). Undue stress from the death and dying simulation may detract from learning objectives and leave the student with feelings of guilt and a lasting negative impression of the experience in general (Park et al., 2018). Negative simulation experiences may result in overwhelming stress, limited learning, and result in students leaving the program (Park et al, 2018). Two perspectives regarding death and dying in the simulated environment exist. One perspective is that the mannequin should never be allowed to die, while the other perspective sees allowing mannequin death as an opportunity for enhanced participant learning and improved performance (Park et al., 2018).

Simulations without a death experience.

From the perspective of simulated patients not being allowed to die, goals of the simulation are to assess how teams manage and intervene during a learning scenario. If students miss a critical intervention, a time-out is called to discuss what was missed and how it could affect the patient (Smith & Lammers, 2014). During such scenarios, students recognize that action, or inaction, will have an effect on patients, families, and other healthcare providers without the possible risk of psychological harm from the simulated patient "dying" (Smith & Lammers, 2014).

Simulations with a death experience.

This perspective believes the actual death of the mannequin better prepares learners for the emotional shock that accompanies the experience of patient demise despite best efforts at resuscitation (Park et al., 2018). Evidence in the literature shows increased stress can enhance learning and is associated with powerful memory creation (Calhoun & Gaba, 2017; Goldberg et al., 2017; Smith & Lammers, 2014). While some stress is good, it is very important that learners are not placed in a position in which the level of stress is too high and negatively affects outcomes.


Students who experience death during a simulation are more likely to have increased stress levels (Park et al., 2018). While stress has been found to increase student performance during simulations, other studies suggest students experiencing death during simulation can lead to negative emotional responses and reduced learning outcomes (Smith & Lammers, 2014). It is imperative for the simulation environment to promote trust and safety. Clearly, students who are beginners and new to healthcare experiences should not be exposed to emotionally charged simulations without advanced preparation and guidance (Gaba, 2013).

Simulations of this nature may be more appropriate for students with considerable experience in realistic clinical simulations who are reaching the end of the academic program (Gaba, 2013). In addition, instructors must consider the ethical and psychological aspects of each simulation and the goals and objectives of the learner population. Disclosure of relevant psychologically challenging aspects of the simulation should be discussed with students during pre-briefing to prepare students and prevent adverse affects in learning. Debriefing should offer clarification and discussion of strong emotions evoked from participating in the simulation (Gaba, 2013). Follow-up with participants following a death and dying simulation should be conducted to identify any significant psychological impacts from the experience as well as refer students to professionals who can evaluate and treat individuals troubled by the simulation (Gaba, 2013).


Simulation in healthcare education is a powerful tool that provides an opportunity for students to increase safety and improve client outcomes. It is the responsibility of those who develop and use simulation in nursing education to be aware of the ethical implications impacting this teaching modality. It is important for simulations to adhere to the principles of beneficence and nonmaleficence for patients, students, and faculty. Answering the question of whether mannequin death can be used in a context that furthers a sense of trust and psychological safety for the student is difficult. As in real life, if death is surrounded by blame, criticism, or humiliation it is likely to be regarded as a degrading and potentially devastating experience. Conversely, if death is a realistic consequence of action, or inaction, and occurs in an environment of support, it then can be a positive experience that results in personal growth.

Special considerations should be taken regarding death and dying and student cognitive level. Early learners may not be prepared to handle death and dying experiences, while more experienced learners are better able to address the psychological distress that more advanced scenarios invoke. Simulation actively engages students and opens the learner up to a variety of emotions, including stress, shame, stimulation, and empowerment (Gaba, 2013). By using ethical considerations when developing simulations, students are able to practice in an environment that promotes self-directed learning and safety. Simulation provides students with the opportunity to experience specifically directed situations, such as death and dying, which may not be available during regular clinical experiences (Miller, 2010). This, in turn, enhances the student's learning experience and provides the opportunity for personal reflection and self-growth. Professional organizations, such as the National League for Nursing and the Institute for Medicine, call for nursing educators to train the next generation of nurses in a safe and efficient manner. By using simulation in an ethical manner, this call is answered.

Sue Hudson, BSN, RN


Calhoun, A. W. & Gaba, D. M. (2017). Live or let die: New developments in the ongoing debate over mannequin death. Simulation in Healthcare, 12(5), p. 279-281. doi:10.1097/ SIH.0000000000000256

Gaba, D. M. (2013). Simulations that are challenging to the psyche of participants: How much should we worry about what? Simulation in Healthcare, 8(1), p. 4-7. doi: 10.1097/ SIH.0b013e3182845a6f

Hayden, J. K., Smiley, R. A., Alexander, M., Kardong-Edgren, S., & Jeffries, P. R. (2014). The NCSBN national simulation study: A longitudinal, randomized, controlled study replacing clinical hours with simulation in prelicensure nursing education. Journal of Nursing Regulation, 5(2), S2-S64. Retrieved from Supplement.pdf

Lapkin, S., Levett-Jones, T., Bellchambers, H., & Fernandez, R. (2010). Effectiveness of patient simulation mannequins in teaching clinical reasoning skills to undergraduate nursing students: A systematic review. Clinical Simulation in Nursing, 6(6), e207-e222.

Lee, J., & Oh, P. J. (2015). Effects of the use of high-fidelity human simulation in nursing education: A meta-analysis. Journal of Nursing Education, 54(9), 501-507. doi: 10.3928/0148483420150814-04

Miller, S. (2010). Implications for incorporating simulation in nursing education. Journal of Practical Nursing, 60(3), p. 2-5. Retrieved from articles/21175101/

Park, C. H., Wemore, D., Katz, D., DeMaria, S., Levine, A. & Goldberg, A. (2018). Simulated death enhances learner attitudes regarding simulation. BMJ, 4, p. 23-26. doi: 10.1136/ bmjstel-2017-000215

Smith, A. B. & Lammers, S. E. (2014). The ethics of simulation: Defining excellence in simulation programs. Philadelphia, PA: Wolters Kluwer.
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Title Annotation:Peer Reviewed
Author:Hudson, Sue
Publication:Missouri Nurse
Date:Dec 22, 2018
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