Monday, 7 March 2016

Response to 'Living dolls and nurses without empathy'

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

Tamara Power
Carolyn Hayes

Having recently published a paper that discussed increasing student engagement with manikins (Power et al. 2016), it was with great interest that we read the editorial by Dean et al. (2016), discussing their impression of a one-off demonstration of a simulation scenario. We welcome this opportunity to provide insight into the use of manikins and the development of empathy in nursing students.

Dean et al. (2016) are correct in stating that manikins are increasingly being used in nursing education. They are incredibly useful for students to practice a wide range of nursing skills (including communication), in an environment that is safe for them and removed from the patient. Unlike humans, manikins can tolerate multiple repetitions of the same clinical procedure with no detrimental or lasting effect. Students can make verbal faux pas, with no risk of offending or upsetting an already vulnerable person. They can learn from making life threatening errors, without endangering an actual patient. Dean et al.s’ (2016, p. 2) statement that “artificial intelligence has found its limits in trying to replicate empathy” does not reflect current investigations. Researchers are actively engaged in developing manikins who have lifelike skin, can emulate facial expressions, move their heads, whose eyes can track faces, read text and have their pupils dilate in response to light (Baldrighi et al. 2014). The primary goal of these researchers is in fact “eliciting a more powerful emotional connection between student and simulator” (Baldrighi et al. 2014, p. 563). Others are experimenting with humanising simulation equipment through retro-projecting expressive human faces onto manikins with translucent face masks (Delaunay, de Greef & Belpaeme 2009). As science fiction rapidly becomes reality, can the future of simulation where manikins are barely distinguishable from humans be that far away?

While we wait for these advances in technology, we agree with Dean et al. (2016) that manikins are currently limited in their emotional range. Those working in simulation have long acknowledged this limitation. It is for this reason that other simulation modalities are employed instead of, or in conjunction with the use of manikins. In our own recently published study, the combination of case study audio-visual vignettes using paid actors, and transferring props from the actors in the vignettes to the manikins, was found to increase student nurses’ empathy in a simulated setting using manikins (Power et al. 2016). Students reported being grateful for an opportunity to witness nurse-patient interactions portrayed in the vignettes. They described repeating phrases that had been used by the nurse actors in the films when practicing skills with the manikins. Despite their current limitations, being able to practice communication with a manikin, while mastering unfamiliar psychomotor skills, has to be preferable to practicing the skill devoid of a patient.

“…Knowing what to say was helpful as we could practice holistic nursing and not just focus on the skills e.g. giving a needle but also focusing on the patients other needs” (Power et al. 2016, p. 129).

Simulation is not limited to manikins. Others academics have successfully used a variety of simulation modalities to develop empathy including paid actors working with students (Ward 2016); providing students with experiential opportunities such as wearing an ostomy bag for 48 hours or engaging in an ageing simulation game (Chen et al. 2015). Cultural empathy has been cultivated through the use of 3D video to simulate the experience of being admitted to hospital in a developing country (Everson et al. 2015).

Additionally, in Australia, it is mandated by accrediting bodies that all undergraduate nursing programs provide a minimum of 800 hours of clinical placements (ANMAC 2012). These placements involve engaging with intra and inter-disciplinary teams and patients who do display non-verbal body language and facial expressions. There are a minimum of 800 hours to engage in ‘embodied practices’. Any simulation experiences offered are in addition to clinical placement. If in the future, as Dean et al. (2016, p. 1) citing Jeffries (2009) reported, clinical learning does move more into the simulated space, it will be in response to “mounting evidence” that the experience is equitable.

Blaming the use of manikins for a decline in empathy, fails to take into account the multiple modern stressors on nursing curricula. As Sheehan et al. (2013, p. 457) highlighted, nurses are operating in an increasingly regulated, policy driven, complex environment. “With nursing faculty attempting to teach the ever expanding list of essential nursing concepts, the time to teach caring, comfort and affective skills is narrowing” (Sheehan et al. 2013, p. 460). These researchers also point to generational factors, highlighting that today’s nursing students are increasingly isolated from human interaction through engagement with personal devices, computers and the internet.

In their own words, “empathy is a multi-determined response that results from the integration of experiences” (Dean et al. 2016, p. 1). However, Dean et al. (2016) have not considered any alternative reasons for a decline in nurse empathy beyond the hypothesised use of manikins. Certainly increasing empathy in nursing students is an admirable goal, and it is heartening that so many recent studies, as referenced here, are pursuing that goal. However, we disagree that any decline in empathy can be laid at manikins’ plastic feet.

Tamara Power | PhD RN
Senior LecturerDirector, Health Simulation
Faculty of Health | University of Technology Sydney

Carolyn Hayes | BHSc RN
Manager, Simulation and Laboratories
Faculty of Health | University of Technology Sydney


ANMAC 2012, 'Registered nurse accreditation standards', accessed 1st December, 2014 at

Baldrighi, E, Thayer, N, Stevens, M, Ranson Echols, S & Priya, S 2014, 'Design and implementation of the bio-inspired facial expressions for medical mannequin', International Journal of Social Robotics, vol. 6, no. 4, pp. 555-74.

Chen, AMH, Kiersma, ME, Yehle, KS & Plake, KS 2015, 'Impact of the Geriatric Medication Game on nursing student's empathy and attitudes toward older adults', Nurse Education Today, vol. 35, no. 1, pp. 38-43.

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

Delaunay, F, de Greef, J & Belpaeme, T 2009, 'Towards retro-projected faces: An alternative to mechatronic and android faces', paper presented to The 18th IEEE International Symposium on Robot and Human Interactive Communication, Toyama, Japan.

Everson, N, Levett-Jones, T, Lapkin, S, Pitt, V, van der Riet, P, Rossiter, R, Jones, D, Gilligan, C & Courtney-Pratt, H 2015, 'Measuring the impact of a 3D simulation experience on nursing student's cultural empathy using a modified version of the Kiersma-Chen empathy scale', Journal of Clinical Nursing. 24: 2849–2858. doi: 10.1111/jocn.12893

Jeffries, PR 2009, 'Guest editorial: Dreams for the future of clinical simulation', Nursing Education Perspectives, vol. 30, no. 2, pp. 71-.

Power, T, Virdun, C, White, H, Hayes, C, Parker, N, Kelly, M, Disler, R & Cottle, A 2016, 'Plastic with personality: Increasing student engagement with manikins', Nurse Education Today, vol. 38, pp. 126-31.

Sheehan, CA, Perrin, KO, Potter, ML, Kazanowski, MK & Bennett, LA 2013, 'Engendering empathy in baccalaureate nursing students', International Journal of Caring Sciences, vol. 6, no. 3, pp. 456-64.

Ward, J 2016, 'The empathy enigma: Does it still exist? Comparison of empathy using students and standardized actors', Nurse Educator, vol. e-publication ahead of press, pp. 1-5.

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