Friday, 4 March 2016

Response to 'Living dolls and nurses without empathy'

Re: Dean, S., Williams, C., Balnaves, M. (2016) Living dolls and nurses without empathy

Michelle Kelly

The editorial by Dean et al(2016) in JAN raises several valid points but does not incorporate many others which have been raised or already addressed in the rapidly maturing area of healthcare simulation.

Like other ‘new technologies’ the initial 'wow' factor over time moves to more considered wider application of the initiative and so too with simulation-based education. While Dean et al. (2016) focus on the use of manikins in simulation, other modalities feature strongly in this space – simulation role-plays often with peers or simulated patients (Nestel & Bearman 2015), a hybrid approach (task trainer or mask and person as in MaskEd™(MaskEd™ - KRS Simulation)) and virtual or augmented reality. Such fit-for-purpose approaches, which address the current limitations of manikins, have been cited in the literature for over a decade (Bryans & McIntosh 2000, Hardoff & Schonmann 2001, Kelly & Gallagher 2014, Kneebone & ApSimon 2001, Kneebone et al. 2004). Another exciting area of growth is emotional expressive screen-based simulation such as Baby X (Auckland Bioengineering Institute, 2016) demonstrated at the 2015 SimTecT/SimHealth conference in Adelaide. These types of interactive experiences are a game changing new dimension in simulation for health professions education, and can certainly elicit the affective aspects of learning.  

A strong imperative for using simulation-based education is patient safety - to rehearse clinical procedures or enact commonplace scenarios prior to practice experiences. For undergraduate students these are the main foci of simulation embedded within curricula, and incorporate engaging and communicating with ‘patients’ and ‘relatives’. Unlike in the clinical setting, simulation scenarios can be sped up or slowed down to cater for participants’ expertise or learning needs. As such, cognitive load can be managed and specific skills sets and context can be combined within sequential simulations.

When contemporary simulation ‘appeared on the stage’, the context of scenarios tended to focus on acute medical situations, such as the chest pain vignette described in the editorial. There is now a plethora of literature which features innovative and diverse scenario topics and approaches to simulation-based education to ensure students understand and develop a holistic approach to clinical practice, including empathy (Bearman et al. 2015, Chaffin & Adams 2012, Everson et al. 2015, Orr et al. 2013). Common feedback from nursing students is that simulation ‘glues things together’ – that theoretical aspects make sense as they draw on tacit knowledge and apply it to a realistic unfolding scenario. This does not discount the benefits of other educational strategies to contextualise theory with practice, but simulation scenarios enables students to 'walk in the shoes' of the Registered Nurse, the ‘patient’ (as the voice of the manikin) or the ‘relative’ and appreciate the impact and importance of how interactions amongst the recipients and providers of healthcare impact on patient care and outcomes.

A benefit of this editorial is to remind those who facilitate learning through simulation to engage the wider community in discussions about the contribution of simulation-based education to the health professions. Empathy is certainly an important aspect of professional practice as much as other domains - dexterity in clinical procedures, effective teamwork and communication, and clinical reasoning, judgement and decision making. One reason why simulation appeals to many is that all these components of practice can be incorporated into a well-planned and facilitated scenario to trigger the affective features of learning – to help participants reflect on their values and professional behaviours – inclusive of empathy.

Michelle Kelly  PhD MN BSc RN
Associate Professor
Director: Community of Practice
School of Nursing, Midwifery & Paramedicine | Faculty of Health Sciences

Curtin University
Kent St, Bentley WA 6102 Australia


Auckland Bioengineering Institute. (2016). Laboratory for Animate Technologies. Retrieved 16 February, 2016, from

Bearman, M., Palermo, C., Allen, L. M., & Williams, B. (2015). Learning Empathy Through Simulation: A Systematic Literature Review. Simulation in Healthcare, 10(5), 308-319. doi: 10.1097/sih.0000000000000113

Bryans, A., & McIntosh, J. (2000). The use of simulation and post-simulation interview to examine the knowledge involved in community nursing assessment practice. Journal of Advanced Nursing, 31(5), 1244-1251. doi: doi:10.1046/j.1365-2648.2000.01382.x

Chaffin, A. J., & Adams, C. (2012). Creating Empathy Through Use of a Hearing Voices Simulation. Clinical Simulation in Nursing, 9(8), e293-e304. doi: 10.1016/j.ecns.2012.04.004

Dean, S., Williams, C., Balnaves, M. (2016). Living dolls and nurses without empathy. Journal of Advanced Nursing, 1-3, e-publication ahead of print.

Everson, N., Levett‐Jones, T., Lapkin, S., Pitt, V., Riet, P., Rossiter, R., . . . Courtney‐Pratt, H. (2015). Measuring the impact of a 3D simulation experience on nursing students' cultural empathy using a modified version of the Kiersma‐Chen Empathy Scale. Journal of Clinical Nursing, 24(19-20), 2849-2858.

Hardoff, D., & Schonmann, S. (2001). Training physicians in communication skills with adolescents using teenage actors as simulated patients. Medical Education, 35(3), 206-210. doi: 10.1111/j.1365-2923.2001.00764.x

Kelly, M. A., Hager, P., & Gallagher, R. (2014). What matters most? Students' rankings of simulation components which contribute to clinical judgement. Journal of Nursing Education, 53(2), 97-101. doi: 10.3928/01484834-20140122-08

Kneebone, R., & ApSimon, D. (2001). Surgical skills training: simulation and multimedia combined. Medical Education, 35(9), 909-915. doi: 10.1046/j.1365-2923.2001.00997.x

Kneebone, R., Scott, W., Darzi, A., & Horrocks, M. (2004). Simulation and clinical practice: Strengthening the relationship. Medical Education, 38(10), 1095-1102. doi: 10.1111/j.1365-2929.2004.01959.x

MaskEd™ - KRS Simulation. What is MaskEd™? Retrieved 10 February, 2016, from

Nestel, D., & Bearman, M. (Eds.). (2015). Simulated patient methodology: Theory, evidence and practice. Chichester, UK: Wiley Blackwell.

Orr, F., Kellehear, K., Armari, E., Pearson, A., & Holmers, D. (2013). The distress of voice-hearing: The use of simulation for awareness, understanding and communication skill development in undergraduate nursing education. Nurse Education in Practice, 13(6), 529-535. doi: 10.1016/j.nepr.2013.03.023

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