Monday, 15 February 2016

Commentary on Dean et al. (2016) 'Living dolls and nurses without empathy'

Commentary on: Dean, S., Williams, C. and Balnaves, M. (2016), Living dolls and nurses without empathy. Journal of Advanced Nursing. doi: 10.1111/jan.12891

We read with delight and great interest your editorial on dolls and nurses without empathy (Dean et al. 2016) in JAN and feel compelled to reply in unity, as board members and leaders of the healthcare simulation community that spans multiple professions. Manikin based simulation was relatively new to nursing in the USA in 2010 when the National Council of State Boards of Nursing survey was completed (Kardong-Edgren et al. 2012). Few programs or faculty had the training or money to develop truly robust simulation or standardized patient programs then. Simulation however was present well before the newer ‘high feature’ manikins became fiscally accessible. Simulation is a methodology (Gaba 2007) and as such, limiting it to manikin-based simulation would be a very narrow interpretation. We freely acknowledge the short-comings of manikins to adequately teach empathy; skilled simulation educators teach care and elements of communication.

In 2016, the ‘methodology of simulation’ has replaced the manikins (living dolls) as the main focal point of simulation research. Often that pedagogy includes empathetic communication. See: Donovan and Forster (2015); Jack, Gerolamo et al. (2014); McIntosh et al. (2015); Pastor, Cunningham and Kuipper (2015); Weekes and Phillips (2015).  Recently, clinicians at Northwestern University implemented an innovative simulation-based empathy curriculum (Bauchat 2016) using a hybrid simulation model of technology and standardized patients so trainees could empathize with their patients using a simulated environment. In simulation, the learning happens during the scenario but also in the debriefing after the scenario. In fact, the debriefing phase is often twice as long as the scenario itself. Communication and empathy are increasingly discussed at length during debriefing. Often, students have an opportunity to repeat a scenario, with a chance to try new communication and phrasing with a patient, something that cannot happen in the real patient care setting.

Dean et al. (2016) cite the statistic that one third of the respondents to the 2010 NCSBN survey said they did not think communication could be learned using simulation. The more important statistic is that two-thirds of respondents in 2010 thought communication could be learned in simulation. The debriefing process developed for use in simulation is considered so important in teaching such things as empathy and understanding, that it has been endorsed by the National League for Nursing as a pedagogy to be used across the nursing curriculum, in lecture, clinical, and simulation.

The problem of nursing and other healthcare provider students not developing or exhibiting empathy for their patients existed long before contemporary manikin based simulation and was well documented in the literature (Benner et al. 2010).  Simulation experts and researchers can clearly see this lack of empathy and ability to communicate effectively in their students, however we see it in a controlled environment, away from patients. We ‘acknowledge the limitations of manikin simulation’ (Dean et al. 2016, p. 2). The authors may be unaware of the breadth of simulation methodologies and strategies available today. A simulated learning environment is not predicated on the use of a manikin. Standardized patients, embedded actors, and hybrid simulation are but a few examples of the richness of the methodology. Many of these modalities may be far superior for imparting true empathy learning compared to the actual clinical environment (Kelm et al. 2014). Kelm et al. (2014) published a systematic review with eight randomized controlled trials that demonstrated increased empathy with interventions such as ‘role playing’, ‘communication skills training’ and other interventions. Seropian (2003), whom the Dean et al. cited, specifically spoke to the need to use the right form of simulation strategy, trained instructors, and to account for the important role of debriefing. The debriefing process further enhances the experience and likelihood of true learning and retention.

The 2015 research article of the year in Clinical Simulation in Nursing was just awarded to authors who developed of a tool for measuring caring and empathetic behaviors in nursing students (Pagano, O’Shea, Campbell, Currie, Chamberlain, & Pates, 2015). They were able to do this by reviewing hours of archived tapes from simulation scenarios, something that would not have been possible in the traditional clinical environment.

Simulation is becoming and will remain a major force in nursing and other healthcare provider education not because of the manikins themselves but because simulation and the pedagogy developing around it provides one solution to the growing problem of dwindling robust clinical sites and experiences for students and increasing restrictions on what students are allowed to do in those environments. Standardized patient programs are emerging in pre-licensure nursing programs to address Dean et al.’s, very real concern about the ‘lack of a real human being in the bed’ for human interaction. However, the facilitator, not the manikin, is in charge of the learning experience. We encourage you to broaden your interpretation of simulation as a doll and join us in working to make the pedagogy of simulation as robust as it can be for our learners.

Note: Additional valuable resources exist that expand in the understanding and development of simulation based education. Please refer to the INACSL Standards of Best Practice: SimulationSM published in 2011 and revised in 2013 by INACSL. The standards are evidence-based and heavily referenced. These standards were reviewed and endorsed by 17 international simulation and healthcare provider education organizations. (


Jeanette R. Bauchat MD
Northwestern Feinberg School of Medicine, USA

Jeff Carmack, DNP, RN, CHSE
University of Arkansas at Little Rock, USA/ INACSL Board

Carol F. Durham, EdD, RN, ANEF, FAAN
University of North Carolina at Chapel Hill, USA, INACSL Past President

Chad Epps MD
University of Alabama at Birmingham, USA

Susan Gross Forneris, PhD, RN, CNE, CHSE-A
Excelsior Deputy Director Center for Innovation in Simulation and Technology, National League for Nursing, USA

Laura Gonzalez PhD, ARNP, CNE, CHSE
University of Central Florida, USA/INACSL Board

Teresa Gore, PhD, DNP, FNP-BC, NP-C, CHSE-A
University of South Florida, USA/INACSL President

Nicole Harder RN, MPH, PhD
University of Manitoba, CA/INACSL Board

Martina S. Harris, EdD, RN
Chattanooga State Community College, USA/INACSL Board

Pamela Jeffries PhD, RN, FAAN
Dean, George Washington University, USA/Past President SSH

Suzan Kardong-Edgren, PhD, RN, ANEF, CHSE, FAAN
Robert Morris University, USA/INACSL Board

Ralf Krage, MD, PhD
VU University Medical Center, The Netherlands/SESAM Past President

University of Alabama in Huntsville, USA/ INACSL Board

Grace Lim MD
University of Pittsburgh Medical Center, USA

Robert P. O’Brien, EdD, MEd, BA, BTeach, CHSE
Belridge Park Consulting, Melbourne, AUS/ASSH

Mary Anne Rizzolo, EdD, RN, FAAN, ANEF
National League for Nursing, USA

Michael Seropian MD, FRCPC
Oregon Health Sciences Center, USA/Past President SSH

Elaine Tagliareni, EdD, RN, CNE, FAAN
Chief Program Officer, National League for Nursing, USA


Bauchat J, R, (2016) Simulation Curriculum for Anesthesiology Residents Improves Empathy as Measured by the Jefferson Scale of Physician Empathy; Abstract International Society for Simulation in Healthcare 2016, San Diego, California

Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses. Stanford, CA., Jossey-Bass.

Donovan, H., & Forster, E. (2015, October). Communication adaption in challenging simulations for student nurse midwives. Clinical Simulation in Nursing, 11(10), 450-457. j.ecns.2015.08.004.

Dean, S., Williams, C., Balnaves, M. (2016). Living dolls and nurses without empathy. Journal of Advanced Nursing, DOI: 10.1111/jan.12891

Gaba DM, (2007). The future vision of simulation in healthcare. Simulation in Healthcare, 2(2), 126-35. doi: 10.1097/01.SIH.0000258411.38212.32.

Jack, D., Gerolamo, A. M., Frederick, D., Szajna, A., & Muccitelli, J. (2014, October). Using a trained actor to model mental health nursing care. Clinical Simulation in Nursing, 10(10), 515-520. http://

Kardong-Edgren, S., Willhaus, J., Bennett, D., Hayden, J. (2012, January). Results of the National Council of State Boards of Nursing National Simulation Study: Part II. Clinical Simulation in Nursing 8(4), e117-e123. doi: 10.1016/j.ecns.2012.01.003.

Kelm, Z., Womer, J., Walter, J.K., Feudtner, C. (2014, October) Interventions to cultivate physician empathy: A systematic review. BMC Medical Education, 14, 219. doi: 10.1186/1472-6920-14-219.
McIntosh, C. E., Thomas, C. M., Allen, R. A., & Edwards, J. A. (2015, March). Using a combination of teaching and learning strategies and standardized patient for a successful autism simulation. Clinical Simulation in Nursing, 11(3), 143-152.

Pagano, M. P., O’Shea, E. R., Campbell, S. H., Currie, L. M., Chamberlin, E., & Pates, C. A. (2015, September). Validating the health communication assessment tool (HCAT). Clinical Simulation in Nursing, 11(9), 402-410.

Pastor, D. K., Cunningham, R. P., & Kuiper, R.A. (2015, February). Gray matters: Teaching geriatric assessment for family nurse practitioners using standardized patients. Clinical Simulation in Nursing, 11(2), 120-125.

Seropian M.A. (2003) General concepts in full scale simulation: getting started. Anesthesia and Analgesia 97(6), 1695–1705.

Weekes, C. V.N., & Phillips, T. M. (2015, November). A mile in my patients’ shoes: A health literacy simulation for baccalaureate nursing students. Clinical Simulation in Nursing, 11(11), 464-468.

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