Q: I read your recent column on observers in simulation, and I was surprised to see that the most recent research cited was from 2016. I have a similar issue with having more students than can reasonably care for the patient, but our issues are due to how our lab scheduling and enrollment have changed post-COVID. Do you have any advice that takes into account all the ways the world has changed in the last ten years?

A: Yes, absolutely– but the core principles remain. I used to think that having extra people was a problem I had to solve by making some of them observers, and I definitely saw the observer role as inferior to the active participant role. In the past ten years, I have come to see the observer role as a powerful learning opportunity in its own right. Luckily, new research has given us quite a bit of direction on the topic of observers in simulation.

That research tells us that observers can learn just as much as active participants as long as they are actively involved in doing something during the simulation and participate in the debriefing. Whether your participant numbers are from enrollment changes or pandemic policies, the question remains: what do we have them do?

Some general guidelines to support learning for observers include:

• Design a prebriefing specifically for observers so that they understand their roles, what will be expected of them and how they can get the most out of the experience.
• Give each observer something different to track and take notes on (e.g. communication, safety, frequency of vital signs/monitoring).
• Provide observers with a tool to follow along with the simulation and note their observations (e.g. time of onset of symptoms, vital signs, communication).
• Include observers in the debriefing.
• If there will be multiple simulations run during the session, have learners alternate being active participants and observers.

Another question that often comes up is “where should they observe from?” I have tried observers in the control room, in a distant room watching via live stream, and in the room with the active participants. Without question, my favorite is to have observers in the sim room with the active participants (as space allows). I believe that when they are in the same room, they become emotionally activated in the same way as the active participants, and learning in the presence of emotional activation is more likely to “stick”. This also requires specific prebriefing so that they understand how to observe without interference. Here are few papers on the topic, both before and after COVID-19:

Johnson, B. K., & Fey, M. (2023). Setting observers up for success in simulation. Nurse Educator, 48(6), 321-325.

Johnson, B. K. (2019). Simulation observers learn the same as participants: The evidence. Clinical Simulation in Nursing, 33, 26-34.

Leigh, G., Miller, L. B., & Ardoin, K. B. (2017). Enhancing observers’ learning during simulations. The Journal of Continuing Education in Nursing, 48(10), 454-457.

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.

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