Design of simulation scenarios (2023)

A guide to designing simulation scenarios for clinicians engaged in simulation-based education.


The ultimate goal of simulation is to create an authentic learning experience (P. Dieckmann et al., 2007) and this starts with scenario design. However, scenario design is an underappreciated area in the field of health simulation. A scenario is an event designed to stimulate discussion (the report), generate research data, or provide an opportunity for evaluation. Robust scenario design is critical to ensure that objectives are met in a way that is meaningful and valid for participants, trainers, and researchers. The scenarios have been called "Theatre with a Purpose" (P. Dieckmann, Gaba & Rall, 2007) or "Trojan horses" to stimulate discussion in health education and as such are only a means to an end. In developing an effective scenario, the purpose of running the scenario is the starting point. In other words, rather than the initial discussion being “Let's create a scenario about disease X”, a more structured process begins with a rationale and outcome measure of a scenario's success.

The simulation episode is the center of scenario design, although this phase is usually brief, perhaps as little as ten minutes. More time is devoted to debriefing when the “Trojan Horse” is revealed for what it is and reflective learning begins. However, for there to be a story to discuss, the story must first be told. Running the simulation tells the story.

This article examines how to define purpose and design a scenario to achieve that purpose. In most cases we will approach the simulation as a teaching tool; with a focus on mannequin-based simulation, the authors' area of ​​expertise and possibly the most common form of simulation in healthcare. However, these basic principles can be applied to other simulation methods, such as B. simulated patients (Nestel, Fleishman & Bearman, 2015) or virtual reality, and for other simulation purposes, such as. B. Research and translational simulation (Brasil, 2017).

A standardized template is useful for scenario design. An example is the one used by the Alfred Hospital Intensive Care Unit, available at this URL: The templates serve as a checklist to ensure all factors affecting simulation deployment are addressed, including configuration requirements.


The purpose of the simulation is often self-evident. Usually the aim is to fill gaps in knowledge or skills identified in clinical practice or to add a practical element to an existing curriculum. These knowledge or skill gaps can be identified through the learner's needs assessment (see below) or through clinical events or incident reports. Occasionally there is a change in practice or process that needs to be communicated or explored before it is accepted in the work environment (Brasil, 2017).

An important aspect of education to consider is the balance between technical and non-technical skills that need to be addressed. Technical skills are often first addressed outside of a highly immersive realistic simulation through the use of procedural trainers or through prior reading and discussion of factual information. This allows students to implement skills with progression to more complex and realistic simulated situations and ultimately to compatible clinical environments. Non-technical skills such as teamwork and communication are increasingly recognized as important in clinical care.

Important design decisions

Once the learning goals are identified, it is important to ask yourself, “Is simulation the best way to achieve these goals?” For example, a mannequin-based simulation scenario is not the best way to convey the details of kidney physiology. In terms of learning outcomes for a simulation teaching session, simulation fits into the higher levels of Bloom's taxonomy, particularly those associated with the application of knowledge and skills in the clinical setting (Bloom, 1956).

Important design decisions need to be made once it has been decided that a simulation-based learning experience is the best way to achieve the chosen learning objectives. These decisions include the choice of simulation modality, the level of realism or authenticity required, and feasibility.

There are always scenario design limitations in terms of equipment, environment and even the time it takes to design and run the scenario. For example, it may be difficult to create an on-site scenario that uses critical equipment needed for patient care while the scenario is running, or have a scenario that develops realistically slowly in real time and due to the weather running over longer periods of time. Clinical area limitations or staff availability.

Numerous other factors affect the course of a simulation and must be taken into account when designing the scenario. These include the needs and background of the students, the number of teachers available and their experience, the complexity of the equipment used, the space available and the preferred approach to debriefing. For example, a single faculty member with a portable monitor controller (e.g. iSimulate, SimMon) can stand in the room with the participants and "pause and discuss" with the beginners. On the other hand, advanced students participating in team training can participate in a highly immersive, seamless simulation with the help of a confederate. Meanwhile, in another room with video cameras and a one-way mirror, a technician and two informants observe everything that happens before reporting back after the simulation ends. The availability of resources and the feasibility of scenario design should be checked with the designated teachers and simulation engineers and coordinators early in the design process.

Inspiration: Real Clinical Cases

Simulation scenarios can be created from real clinical cases. The advantages of real cases are relevance, motivation, peer review and teaching, and the availability of realistic props. Disadvantages include risks to participants, potential breaches of patient or staff confidentiality, and lack of connection to well-defined goals, e.g. H. the simulation is an opportunity based on the clinical case and not adapted to a goal or a planned study plan. .

Fall 1
Sam, an anesthetist, was called in to assist a senior trainee shortly after induction of anesthesia on a patient scheduled to undergo an emergency craniotomy. The patient was hypotensive and anaphylaxis was quickly diagnosed. A cognitive aid used to initiate treatment and perform surgery. Communication between team members was clear and effective, and a post-incident report indicated that the team was satisfied with the handling of the case. Learning points from the case inspired a simulation session the following week on a patient's deterioration under general anesthesia.

Case 1 has a clear overlap with the goals of the planned future worsening under anesthesia session. It has a combination of technical and non-technical factors related to the issue and is likely psychologically safe, but it would be wise to consult with the staff involved. Patient confidentiality is a potential concern, but patient demographics can be easily altered and patient data used as props (e.g., an electrocardiogram or a radiological image) can be anonymized. Consideration should be given to how signs of anaphylaxis are presented and how strongly the diagnosis or required treatment is signaled to participants.

Fall 2
As in Case 1, the diagnosis of anaphylaxis was delayed and epinephrine was discontinued due to concerns about increased intracranial pressure. The patient had an adverse outcome due to persistent hypotension, and clinicians were criticized by peers that day and in a subsequent review of morbidity and mortality. The trainee concerned was dismayed by the incident and felt guilty. Both the anesthetist involved and the department head request that the simulation center run the case to show the others how it "should have been handled".

Case 2 concerns a recent emotionally charged event and harm was done to the patient. The doctors involved are "second casualty" and the incident can be recognized by the team members present at the simulation. Themes from this session may be used with or without reference to the original case (e.g., undifferentiated hypotension), and the appropriateness of the case will depend in part on the level of trust between Sim staff and participants. It would be unwise to use this case as it is.

Design Considerations for Time Shift

The flow of time in simulation scenarios can be deliberately manipulated in different ways. The “pause and discussion” debriefing during simulation execution (brief recap, rephrase, redirection) is commonly used by relatively young teams or for those facing simulation challenges outside of their comfort zone. Allow a redirect and set yourself up for success. "Pause and rewind" allows students to go back and "correct" mistakes. Gamification with level progression (“live, die, repeat”) has the potential for students to face a challenge without a satisfactory end solution, but it is higher risk and requires experienced facilitation (Sunga, Sandefur, Asirvatham, and Cabrera, 2016). In general, we should aim for a scenario that feels inherently fair and that the participant group can realistically encounter in their clinical setting.

Interprofessional and interdisciplinary simulation

These should be co-authored, or at least reviewed, by members of the various "tribes" (ie relevant sub-specialties and interdisciplinary groups). This should include input and target agreements. Avoid the trap that participating nurses are used as "props" for medical participants and that a tribal view dominates. Avoid stereotypes, especially about poor employee performance or professionalism issues related to a particular tribe. Write these roles for confederates instead of participants and explicitly remove the role during reporting.

Student needs and background

The needs of the students and their background should be at the forefront of the scenario designer. Students' needs and abilities can usually be determined to some extent by observing performance in previous clinical and simulation-based interactions, awareness of their level of education, and knowledge of their curriculum. 'Learning needs assessment' questionnaires can be helpful, but they do not identify the learner's 'unknown unknown' needs. Similarly, formal exams ("pre-tests") still have limitations in the scope and depth of the knowledge they test. Both strategies require a higher logistical and time effort on the part of employees and students.

The knowledge, skills and attitudes of the students can never be fully known to the scenario designer and will vary from student to student. This increases the challenge for simulation specialists, how to expand learners beyond what they could originally do themselves. According to Vygotsky, reaching this “zone of proximal development” is critical to learning (Vygotsky, 1978). Similarly, Ericsson has emphasized that students must perform “outside their comfort zone” in order to gain experience through conscious practice (Ericsson, 2008).

One method of dealing with this challenge is to create scenarios that can be increased or decreased in difficulty. Within the scenario design there can be different options that will be activated depending on the progress of the students. Progress can be judged by task completion, time spent, and whether mistakes are made. The simulation then becomes a game of "snakes and ladders", with various challenges and props provided to balance and enhance the learning experience. An important principle is to vary the "signal-to-noise ratio" according to the performance level of the students. For example, beginners learning to recognize a tension pneumothorax need obvious clinical signs without distractions. Whereas more competent students are expected to diagnose more subtle presentations even amid distracting and competing priorities (Dreyfus & Dreyfus, 1980). Scenario difficulty can be rated by assessing the complexity (e.g., additional problems or patients), the standard of performance required, the circumstances (e.g., unusual presentations or difficult environments, e.g., confinement in a bathroom), and the degree, time pressures (e.g. rate of deterioration) and the addition of distractors (e.g. environmental noise or actors distracting students from their assignments) or stressors such as B. interpersonal conflicts.

By anticipating potential knowledge gaps, the scenario designer can incorporate supports that help learners to meet the challenge at hand. It makes the most sense to integrate an accomplice into the simulation (see below). The scenario can also be designed to include resources for students to 'read' in preparation for the simulation episode and additional resources for further learning and reflection after the report ('reading').

Resources: staff, simulators, equipment and environment

To create an authentic learning experience, simulationists must strive to help participants maintain a state of engagement using available resources: staff, simulators, equipment, and the environment. These resources must be considered in scenario design.

Various personnel roles are required to carry out a simulation, which must be taken into account when designing the scenario. Hesimulation engineeroperates the simulator and ensures that it responds appropriately to the actions of the participants. HeInformantcarefully monitors the scenario to identify notable events and behaviors and facilitates their discussion during debriefing. Heallyis an embedded faculty member who works with participants but is skilled in scenario design and can provide clues through team interactions, confirm findings (especially those that are difficult to simulate, such as a seizure) and help redirect the team, when they do so unexpectedly (Nestel, Mobley, Hunt & Eppich, 2014). Depending on the complexity of the scenario, other patients, accomplices and/or simulated actors may also be required. It is possible to run simulations with a single faculty member performing all of these roles. However, it is far preferable to have a separate accomplice as this allows the interrogator/technician to be completely outside of the simulation. Separate specific information to inform the various faculty roles may be provided in different sections of the scenario design template (e.g., Confederate information information, a worksheet for the technician, and a debriefing guide).

Surprisingly, the "realism" of the simulator and the equipment and accessories used (their "physical fidelity") are often less important than ensuring that, however basic they may be, they are capable of performing the functions required to achievement of certain learning objectives are required. (a concept called “functional task alignment”) (Hamstra, Brydges, Hatala, Zendejas & Cook, 2014). For example, straws and a styrofoam cup can be used to teach uroscopic procedures just as well as an expensive simulator (Matsumoto, Hamstra, Radomski, & Cusimano, 2002). However, a useful rule of thumb when simulating a clinical task is to aim for a high level of realism for the body part to be instrumented and the equipment to be used, and less realism is required to represent the larger environment according to the model. "of the participant". Focus Circle” (Kneebone, 2010). When authentic patient interaction is required, a scenario should be designed with a standardized patient or “hybrid” simulation in mind (e.g., a patient wearing a prosthesis that allows safe intravenous cannulation) rather than a dummy. It also makes sense for students to complete assignments using the same devices they will actually be using in the workplace. An extension of this is the simulationand the Ort, so that the participants learn to function in the most authentic possible work environment (Petrosoniak, Auerbach, Wong & Hicks, 2017). However, on-site simulation poses additional challenges for scenario design, including the need to be able to set up and take down the scenario quickly, the risk of contaminating the work environment with “fake” devices and drugs, and time constraints and privacy for observation and debriefing (Raemer, 2014). Regardless of the equipment used, the teacher conducting the simulation must be fully conversant with it and able to troubleshoot on the fly.

Video can also be integrated into the stage design in a number of ways. For example, playing a video of a patient in distress before interacting with a mannequin can prepare participants and increase authenticity. The video can also be used by employees for monitoring and reporting. Although evidence supporting the benefits of video-assisted debriefing is lacking (Cheng et al., 2014), there are many practical benefits. This includes allowing additional observers to see the simulation without being in the room, observing events that may be difficult to see through a crowd (e.g. with an overhead camera), and showing participants exactly what happened as part of the simulation .a report.

Case vignette and scenario flow

The scenario design begins with a realistic case vignette. The case details are important as they must support the learning objectives, be representable in the simulation and contribute to an authentic learning experience. Participants may be briefed with a case history during the pre-simulation summary; Otherwise, they must collect this information as the scenario unfolds (e.g., during an unannounced scenario or a "guerrilla simulation").

The scenario flow is derived from the case vignette and begins with baseline parameters (eg, predetermined patient vital signs) that will evolve over time. The rate at which these parameters change should be as realistic as possible; However, there is permission to change the patient's rate of deterioration and assess the level of challenge according to the student's experience. Scenario design typically incorporates planned events and transitions into these parameters, along with realistic responses to anticipated interventions. This can usefully be presented in the form of tables or flowcharts in scenario templates. This is how an evolving story is outlined, and then it's up to the sim suppliers to make it happen! Transitions and responses to specific actions can be pre-programmed with many types of simulators (e.g., apnea following administration of a neuromuscular blocking drug). However, while running the simulation, staff must remain flexible and ensure that the simulator's responses match the participants' actions, even when the unexpected occurs. For example, if participants are given rocuronium instead of suxamethonium, the preprogrammed response to neuromuscular blockade should not involve fasciculations...

Stage Lifeguards are a key component to successful stage design. These are strategies to deal with participants' actions that were not anticipated and/or risk derailing the scenario and not achieving the learning objectives (P. Dieckmann, Lippert, Glavin & Rall, 2010). Despite the best plans and best intentions, participants may hit dead ends when they lose clinical signs, experience technical glitches, or behave unexpectedly, such as due to simulation-induced hypervigilance ("simulitis"). ). By assessing “signal noise” when designing and running scenarios (e.g. through clearer clinical signs), participants can be steered in the right direction. However, when such measures fail, stage lifeguards are required. Often the best option is to use an embedded shill to convey information that prompts or redirects participants. Alternative possibilities include introducing other actors (e.g. the friendly anesthetist who came to the rescue) or using a patient's voice (either a standardized patient or a dummy with a loudspeaker). Less ideal are instructions from a teacher standing in the room or speaking over a loudspeaker as "the voice of God." Such direct communication by personnel outside the simulation environment carries the risk that the participants "dive in" and lose authenticity.

Whenever possible, difficulties should be anticipated during scenario design and solutions provided. These should be part of the briefing for the Confederates, as should the engineer's run sheet. Iterative modifications can be made if new problems are discovered during subsequent use of the scenario.


Assessment of participant performance can be formally structured as part of a formative or summative assessment of the student, or it can be informal and feed into the reporting process. In accordance with good assessment practice, the rubric needs to be clear and related to the learning outcomes. Increasingly, the section is available to students prior to the simulation event or to observers watching their peers perform the simulation. As with any summative assessment, it is important to define the standard of expected performance through a standard setting exercise. Simulation-based exam design is beyond the scope of this article.


Debriefing is arguably the most important phase of a simulation-based learning experience and should be carefully considered in scenario design. It is important to document an information guide in the scenario plan. Brief notes on design goals, suggested topics, and effective questions to ask during the debrief are helpful. If the scenario is part of a course that includes multiple scenarios, the learning guide can help align the topics covered in each scenario. If the report pause and discussion are to be used, the suggested scenario progress points for a pause should be provided. However, the need for flexibility and the ability to react to individual scenario outcomes and participants is important. Where appropriate, the scenario notes should also include an intention to use video recordings and replays during the briefing.


A simulation scenario is rarely useful immediately after it is created. The initial design should be viewed simply as a prototype that can be iteratively improved. Colleague review of the scenario is essential to clarify the purpose and practical development of the event. It is even more useful to test the scenario with medical colleagues who have experience in simulation training. These essays provide valuable feedback on plausibility, authenticity, and alignment with intended learning outcomes. At this point, it is common to identify the deviation of the participants' actions from the actions anticipated by the scenario designers. Even if no educators can be found to test, simply going with another doctor as a story can provide crucial insight into the scenario's flaws.

Good scenarios "drift" into different interpretations over time. This is understandable when many educators use the same setting and have a slightly different focus on learning outcomes, or when clinical practice changes with new policies or technology. For example, as educators, the authors have observed that in some areas the skills of the participants have changed. Trainees at the same level as previous years who were unable to perform an emergency coniotomy are now prepared to do so due to changes in the broader training curriculum. Consequently, simulation needs to shift from applying skills (positioning, preparation, equipment) to event communication and team coordination. This is just one example of a proper scenario change, but failure to explicitly include these changes in the scenario documentation can result in a scenario becoming out of context with its intended purpose.

We recommend that each scenario is evaluated formally or informally at the end of each use: Did it serve its intended purpose? Did the participants need additional “life jackets” or challenges? Were there aspects of authenticity that influenced your engagement? Simply annotating the scenario printed on paper with a pen or pencil is not enough, as this creates multiple versions of the same scenario. Assessments should preferably be documented after each scenario run. If this is not possible, a change table or "version control" with the date and reason for the change must be attached and previous versions kept as electronic files.


Regardless of the source, scenarios must be consistent with the objectives and needs of the participants and be feasible and reported with the resources available, while ensuring appropriate challenge and psychological safety. A final fairness check makes sense. The scenario should be one that might happen to participants in their clinical setting, and the goals and objectives should overlap with learning relevant to that setting.

Scenario design is an often neglected area of ​​training for simulation educators. It requires careful attention to detail, especially to fit the purpose of the simulation and the intended learners. Even after the scenario has been created, it still needs to be re-evaluated and monitored to ensure that the content and the report are aligned.

Using a standard template helps designers remember key points and ensures that enough information is provided to share within the institution and beyond.

Even with a standardized template, a final check of the scenario is useful throughout the design process:

  • Is the scenario consistent with the goals?
  • Is it doable?
  • Is it suitably challenging?
  • Is it physically and mentally safe?




…more SMILE2

Chris Nickson

Chris is a Critical Care Physician and ECMO Specialist at theAlfred intensive care unitin Melbourne. He is one tooAssociate Clinical Associate Professor at Monash University.He is a co-founder of theAustralian and New Zealand Clinical Educator Network(ANZCEN) and is the head ofANZCEN Clinical Educator InkubatorProgram. He is on the board ofIntensive Care Foundationand is a first part examinerSchool of Intensive Care Medicine. He is an internationally recognized clinical educator with a passion for helping physicians learn and improve clinical performance of individuals and groups.

After completing his medical degree at the University of Auckland, he continued his postgraduate education in New Zealand, the Northern Territory of Australia, Perth and Melbourne. He has completed fellowship training in critical care medicine and emergency medicine, as well as postgraduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in using translational simulation to improve patient care and process and system design at Alfred Health. He coordinates Alfred ICU's educational and simulation programs and runs the unit's educational website.INTENSIVE. He created the Critical Illness Airway course and teaches numerous courses around the world. He is one of the founders ofFOAM(Free Open Access Medical Education) and is co-founder,IsRABIA-Podcast, Isrevivalof course, and theSMACCConference.

His only major achievement is being a father to three wonderful children.

It's him on Twitter@prerecordialthump.


ian Sommer

dr Ian Summers is an Emergency Medicine Physician and Instructor and Director of Simulation at Monash Health. He was director of emergency training at St. Vincent and helped recruit and set up the emergency response team at Casey Hospital as its initial assistant director. You can find him trekking through the bush with his family taking photos of sunsets or wildlife.

Stuart Marshall

Stuart is a practicing anesthesiologist, simulation educator and researcher with an interest in patient safety and human factors/ergonomics. He is Honorary Clinical Associate Professor, Medical Education, at the University of Melbourne and Principal Investigator, Department of AnAesthetic and Perioperative Medicine, at Monash University.

His research includes studying the impact of cognitive tools (checklists and algorithms) on device performance in emergencies and simulations as an educational method to teach patient safety and improve patient and healthcare worker outcomes. He has been involved in the development of several innovative patient safety courses for undergraduate and graduate students and has been closely associated with the MS in Perioperative Medicine, for which he co-administers a Unit on Human Factors and Patient Safety (POM5005). It also hosts the Clinical Human Factors Short Course (

Stuart is also coordinator of the 9th International Clinical Skills Conference in Prato, Italy in 2021 and founding director of the charity running the conference: The International Clinical Skills Foundation Inc.

He is a member of the International Advisory Panel for the Editorial Board of the journal "Anasthetic" and co-editor of the journal "Advances in Simulation" of the European Society for Simulation (SESAM).

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