Q: I am the director of a large university-based simulation program. Because of sheer numbers, I often work with groups of eight learners during simulation cases. Eight is too many learners to have participating in care, so I usually have four providing care, while the other four observe the simulation. I’m never sure that the observers get much out of the experience; sometimes they just check out. I’m also not sure where to put them — in the control room? In an adjacent room with live streaming? In the sim room? All of those places have their pros and cons.

A: This is an excellent question and one that can help many others. My thinking on observers in simulation has evolved over the years. At first, I just saw them as “extra” people that I’d have to figure out something to do with while the “real” learners were in the simulation providing care.  How wrong I was….

The change came when I noticed the valuable input the observers had during debriefing discussions. They had such a unique perspective: they were at the same level as the learners providing care, yet their view allowed them to see the events of the simulation without the cognitive load of having to perform tasks. I became much more purposeful about inviting their perspective during debriefing. To be sure that they were tracking the simulation’s events, which we’d be talking about in debriefing, I developed an Observation Sheet with broad categories that they were asked to take notes about. Categories included: team communication, patient safety behaviors, frequency of monitoring, and so on.

Where should these observers be? There is no data to guide this decision, so I will tell you my personal preference: in the simulation room. I believe when the watchers are in the room, they are more likely to become emotionally activated by the simulation, and we know that emotional activation is important to learning. A remote room with live streaming is not quite as activating, and usually requires a faculty proctor. I generally don’t have learners in the control room. My concern is that seeing the man behind the curtain may affect their perception of realism.

In a systematic review of observers in simulation, O’Regan, Molloy, Watterson, & Nestel (2016) conclude that outcomes in observers are equal to (or better than) active participants in simulation. Positive learning outcomes were tied to observer tools, learning engagement, role clarity and contribution to the debrief.

It is of the utmost importance that the observers be oriented to their role during the prebrief. They primarily need to know that their observations will be a key part of debriefing. If they are to be in the same room with the participants during the sim, they should be positioned in such a way that they don’t interfere with the simulation and should be instructed not to engage with the care providers. Then be sure to involve them in the debriefing discussion, where they will become valuable and valued partners in the learning!

-Mary Fey, Associate Director, CMS-ALPS

Reference:  O’Regan, S., Molloy, E., Watterson, L., & Nestel, D. (2016). Observer roles that optimise learning in healthcare simulation education: a systematic review. Advances in Simulation, 1(1), 4.