Death of a Simulator: Pro and Con

By: Alaina Herrington and Sabrina Beroz

Pro side

There is little literature on the death of a simulator. However, literature exists on the lack of preparation students and practicing nurses feel when caring for patient death. Anxiety, personal inadequacy, and shock have been identified as common themes (Leighton, 2009). The NLN Jeffries Simulation Theory defines outcomes at three levels (participant, patient, and system) with the goal of simulation being patient safety (Jeffries, Rodgers, & Adamson, 2015). Moreover, in simulation, students can experience the consequences of wrong actions and repeat the simulation with a favorable outcome. But we must ask: How do we educate health professionals about the realities of care decisions? When using patient death scenarios, can facilitators maintain psychological safety in the service of learning?

The Nurse Executive Center conducted a nationwide survey with frontline nurse leaders on new-graduate proficiency across 36 competencies deemed essential for safe and effective care (Berkow, Virksitis, Stewart, & Conway, 2009). The skill sets ranking lowest in proficiency include recognition of changes in patient status, ability to take initiative, interpretation of assessment data, ability to prioritize, and ability to anticipate risk. We argue, where better to learn the impact of these limitations than in simulation?

Let’s look at three types of patient death scenarios: expected, unexpected, and result of action or inaction (Leighton, 2009). In expected death, the simulations are planned with pre-work, objectives, prebriefing, and orientation to the scenario. The death is a result of a predicted cause rather than a crisis. In an unexpected death, students prepare with knowledge of potential patient death such as a code blue scenario. Patient death due to wrong action or inaction carries risk of psychological harm as the possibility of a poor outcome is not expected. With this type of simulation, the key is to repeat the scenario with a positive outcome. Time must be planned to rerun the scenario.

In consideration of the pro side of simulator death, please remember the number of patient deaths that happen each year from medical mistakes and our oath, to do no harm.

For scenarios on expected and unexpected simulation death, see the link to the Montgomery College Nursing Simulation Scenario Library: link.

Con side

Simulation education should provide a safe environment for the learner to practice skills before working on a patient. However, many faculty members use simulation to teach their learners a lesson and punish them for not preparing for the experience. There are also faculty who do have good intentions, who want their learners to learn from a simulated death, but have never been trained in psychology to help a learner through this emotional state. Why do you think the Society for Simulation in Healthcare requires applicants to have a mechanism to protect the psychological safety of individuals involved in simulation (2016)?

The current literature does not have enough information on the psychological effects of a simulated death on learners. Health care workers have to act fast and rely heavily on their confidence in a critical event. Is it possible that experience in a simulated death as a learner could cause a nurse to provide worse patient care because actions in the simulation led to diminished feelings of self-esteem?

Nickerson and Pollard (2009) steered a survey where 28 percent of respondents had emotional distress during an unexpected simulated death. Current literature does not reflect how many deaths are prevented by conducting simulated deaths. Does the possibility of saving lives outweigh the possibility of destroying the psychological safety of a learner? How much benefit does the learner actually receive from taking part in a simulated death? Andrew and colleagues (2017) found repeated exposure to simulated mortality may unnecessarily increase the learner’s anxiety level. Until research can show benefits, let’s follow our oath and do no harm.


In this blog, we present the extreme side of each argument, pro and con. We believe arming simulation facilitators with both sides of the discussion will allow them to consider the best method of education for their learners. As it often happens, the answer may lie somewhere in the middle. If you find yourself wanting to integrate a simulated death in your curriculum, we recommend you review Corvetto and Taekman’s (2013) recommendations specific to death scenarios:

  1. Assess the disposition of the instructor.
  2. Prepare an adequate prebriefing session.
  3. Do not allow death with early learners.
  4. Allow simulator death for more advanced learners.
  5. Do not use simulated death punitively.
  6. Balance emotions.
  7. Perform a detailed and careful debriefing.


Andrew, G., Stefan, S., Yury, K., Daniel, K., Alan, W., Adam, L., & Samuel, D. (2017). Exposure to simulated mortality affects resident performance during assessment scenarios. Simulation in Healthcare: Journal of the Society for Simulation in Healthcare, 12(5), 282-288. doi:10.1097/SIH.0000000000000257

Berkow, S., Virksitis, K., Stewart, J., & Conway, L. (2009). Assessing new graduate nurse performance. Nurse Educator, 34, 17-22.

Corvetto, M. A., & Taekman, J. M. (2013). To die or not to die? A review of simulated death. Simulation in Healthcare8(1), 8. doi:10.1097/SIH.0b013e3182689aff

Jeffries, P., Rodgers, B., & Adamson, K. (2015). NLN Jeffries Simulation Theory: Brief narrative and description. Nursing Education Perspectives, 36, 292-293.

Leighton, K. (2009). Death of a simulator. Clinical Simulation in Nursing, 5(2), 59-62. doi:10.1016/j.ecns.2009.01.001.

Nickerson, M., & Pollard, M. (2009). Simulation philosophy and practice: Simulator patient death versus survival. Clinical Simulation in Nursing, 5, 147.

Society for Simulation in Healthcare (2016). Core standards and measurement criteria.

One thought

  1. Love that this is being talked about From another angle, could ill-intentioned faculty who choose to place students in high-anxiety, demoralizing simulation situations be considered incivility…I say yes. Consider how this act of “I’ll show them” permanently impacts the culture of your program.

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