2011. Vol.2, No.3, 316-320
Copyright © 2011 SciRes. DOI:10.4236/ce.2011.23044
Creating Scenarios and Guiding Learning in a Medical
Gregorio Mañeru Zunzarren1, Alfredo Rodriguez-Sedano2
1Simulation Center, Faculty of Medicine, University of Navarre, Pamplona, Spain;
2Department of Education, University of Navarre, Pamplona, Spain.
Email: firstname.lastname@example.org, email@example.com
Received July 1st, 2011; revised July 15th, 2011; accepted July 20th, 2011.
In this article we propose to address the importance of learning scenarios in a simulation center in graduate
studies in Medicine. We will describe in detail the context in which this learning is developed. To do this, we
need to reflect briefly on the contents that permit the configuration of these scenarios as teaching units, the ob-
jectives which should be commensurate with the level of training and experience of the students, the activities to
develop and the means by which these are arranged, and, finally, the evaluation of the process. The development
of this learning would not be possibl e without an activity guide, as a well as an evolution and debriefing stage.
Keywords: Scenarios, Competencies, Simulation, Debriefing, Innovation
Creation of Learning Scenarios in Medical
From the educational context in the teaching of medicine and
nursing, simulation can be defined as “the technique by which
to manipulate and control a virtual reality, fulfilling the steps
and sequences necessary to stabilize, modify and reverse a
phenomenon that directly and indirectly affects the normality of
a biological, psychological and social being such as the human
being.” (Lopez, 2007).
There a different classifications and methods of simulation,
but as Vázquez-Mata y Guillamet-Lloveras (2009: p. 153) in-
dicate, they should be distinguished by their practicality and
complexity (see Table 1).
The effectiveness of learning environments depends less on
the simulators or the facilities themselves than it does on the
preparation of these and the guidance offered by the teacher.
The effectiveness of simulation as a teaching methodology is
demonstrated in numerous studies, more or less extensive, both
in undergraduate education as in the period of residency
training (Weller, 2004; Midik & Kartal, 2010).
According to Özgür Tatli and Zeynep Tatli (2010: p. 1826)
there are several benefits of using simulation in medicine edu-
cation. The comparison of these benefits from the point of view
of students, patients, education and institution is given in Table
There are scenarios recreating traffic accidents, high-mountain
rescues, responses to fires or medical assistance during cata-
strophes, to name a few examples. Learning scenarios that
manage to re-create real or likely situations have a learning
potential and the ability to achieve difficult goals that make
them a very attractive means for the education and training in a
student’s personal, professional and social skills. They allow us
to place ourselves in situations that we may never or very
seldom find ourselves in, appealing to our knowledge and
capacities for responding, taking action and making decisions
Practical classification of simulation-based training.
Low complexi ty: based on simple models that permit
the practice of isolated, basic skills (from learning
anatomy to practicing basic skills such as the intu-
bation of the airway).
Intermediate complexity: brings together skills and
require a certain level of integration between them.
The paradigm is the acquisition of clinical skills,
such as patient history and clinical examination,
formulation of diagnostic approaches and writing
High complexity: is based on the use of highly
interactive technologies, i.e., ones that simulate
reality, offer information and require active responses
from the professional; allow training in difficult-to-
acquire psychomotor skills, such as virtual reality
equipment f or the simulation of endoscopies or lapa-
roscopic surgery, or the management and treatment
Low complexity: non-interactive or passive human
mannequins that permit training in all methods of
cardiopulmonary resuscitation, both in isolation and
in conjunction with the mannequin; another example
could be the initial exercises in extractions and the
stabilization of injured patients.
Intermediate complexity: workshops based on role
playing to analyze situations, adverse events and
medical e rrors , as well as situations of improvement.
High complexity: Have two variants. The first focuses
on team training in crisis situations (traumatic shock,
myocardial infarction, intraoperative myocardia) and
uses highly interactive human mannequins that
reproduce cardiovascular and breathing functions
with great fidelity, and all within a realistic scenario;
in these simulations intensivists, emergency physicians,
nurses, anesthesiologists and surgeons can participate
simultaneously. The second option focuses on advanced
surgical training requiring the full involvement of the
surgical team, such as remote robotic surgery, which
modifies all the classic surgical pro tocols.
G. M. ZUNZARREN ET AL. 317
The Benefits of using simulations.
From Student’s Point
Reduces S train of Students
Repeatin g Opportunity
Increasing Clinical Experience
Opportunity of Using without Any Worry
Opportunity of Testing all Possible C ases.
Making Students Think about His/Her
Minimization of the Possible Punishment
as a Result of Faulty Applications
Equality of Opportunity in Educati on
Learning by Doing
Opportunity of Trainin g a Group
It can be Integrated to Curriculum
Mechanism for Repeated Applications
Opportunity of Practicing Applications
Related t o Rare Diseases
From Patient’s Point
Reducing Complication Rate
High Quality Service Complying with
Patient Centred Approach
From Education and
Trainer’s Point of View
Reduces Complication Rate
Providing Training of High Attributions
to Larger N umber of Peopl e in Shorter
Consolidating Theoretical Knowledge
with Instant P ractical Applications
Educational Environment Students Ac-
tively Particip ate
Offering Related Opportunities for Stu-
dent Field C o mpetences
From Institution’s Point
Low Cost (Rentability)
Lower Complication Rate
Education a nd Servic e of Higher Q uality
Making Institution More Preferable
Labour Force of Higher Quality
under stress, preparing in some way in our subconscious a more
or less automatic response should we find ourselves in similar
situations in the future. Okuda (2009: p. 333) offers a decalogue
of the features and applications that make the methodology of
teaching via simulation scenarios effective (Table 3).
In general, medical scenarios are set in the context of a case
study, or rather the model of competence-based learning (Mar-
tínez-Clares et al., 2008), and limited to a core activity of no
more than 10 minutes. This is because there are so many
parameters to be controlled in real-time situations that require
extensive preparation and a countless number of evaluators that
can meet all the variables. Limiting time helps to focus and
sequence the activity in order to objectify and evaluate it. It
should first be explained to the small group of four to six
students what it is that will be done, what role each participant
must assume, for which purposes and how the activity is going
to develop. This will involve at least 10 minutes.
Finally, a debriefing or reflection should be conducted by the
members of the group and the teacher at the end of the activity.
The activity should be assesse d in light of the stated objectives,
in order to correct errors and evaluate the successes.
There are many questions to ask the teacher in shaping the
scenario; for this reason it makes sense to be very specific
Features and uses of high-fidelity medical simulations that lead to
1. Mechanism for Repetitive Practice
2. Ability to Integrate into a Curriculum
3. Ability to Alter the Degree of Difficulty
4. Ability to Capture Clinical Variation
5. Ability to Practice in a Controlled Environment
6. Individua lized, Active Learning
7. Adaptability to Multiple Learning Strategies
8. Existence of Tangible/Measurable Outc omes
9. Use of Intra-Experience Feedback
10. Validity of Simulati on as an Approximat ion of Clinic al Practice
Note: The material for this table was taken from Issenberg et al. (2005) and
Mc Gaghie et al. (2006).
about what it is you want to teach.
As in any training activity, four key elements must be dis-
tinguished in order to configure a learning scenario as a
teaching unit. The first is the element that leads us to consider
and reflect on what content you teach, what the degree of
difficulty is, who is directing the activity and what previous
knowledge the participants have. This also defines the kind of
scenario to be created. All of the effort to ensure the student’s
learning and understanding the activity in order to develop
particular skills and expertise that can afterwards be used
independently, is pursues by contextual-izing it in scenarios
that make it meaningful to the student. According to Delors
(1996: p. 95), “it is no longer enough that each individual
accumulates early in life a reservoir of knowledge which he
may endlessly draw upon later. They must be able to take and
use during life of every opportunity that presents itself to
update, deepen and enrich the knowledge first learned and
adapt it to a changing world”.
The European Qualifications Framework (EQF) European
Council (2005) model appears to respond to some of the re-
commendations of the 1996 Delors Report. According to this
report, learning throughout life makes it possible to organize
the various stages of education to provide for a passage from
one stage to another, and to diversify the paths through the
system, while enhancing the value of each. “The concept of
learning throughout life is the key that gives access to the
twenty first century. It goes beyond the traditional distinction
between initial and continuing education. It links up with an-
other concept often put forward, that of the learning society, in
which everything affords an opportunity of learning and fulfil-
ing one’s potential” (Delors, 1996: p. 36).
The “lifelong learning” approach is in accordance with the
widely accepted view that links each level and cycle of the
education process with the achievement of objectives that the
knowledge society demands (Kelly & Morder, 2001; Mc-
Laughlin, 2005; Schriewer, 2000). Bently (1998) argues that
the key resources for the generation of wealth for the future will
be ideas, knowledge and creativity, not the land, labour, and
physical materials of the past. In this perspective, the task is to
increase individual responsibility for learning, with the aim of
developing the competences that will allow each citizen to
achieve lifelong employability in a dynamic and changing
world (Cheetham & Chivers, 1996; Kwiek, 2004; Smith &
G. M. ZUNZARREN ET AL.
Spurling 1999; Spencer & Spencer, 1993). According to Guillén,
Fontrodona, and Rodríguez (2007: p. 410), “ethical training
may be considered as a key element in terms of individual re-
sponsibility development for a lifelong employability and its
This premise is already of great importance with respect to
education and student motivation, since in the activities carried
out in the Simulation Center the motivational factor is achieved
by constantly involving the students in an active way in an
environment that is attractive for its semblance to reality. As a
result, the teacher has a tool that permits placing demands on
the students in order to help them achieve ambitious goals.
The second element is very important because we need to
establish what goals we intend to achieve, from what level we
are starting and how we will have to plan scenarios in order to
sequence our goals, as well as in what period of time we
foresee completing them. Formal Learning Objectives for the
course in September Must Be In Accordance with level of
training and prior experience (Wyte et al., 1995; Ende et al.,
Which errors are common to learning in each particular
activity should be taken into account, which ones are most
frequently committed in professional practice and why, what
difficulties arise as students integrate and consolidate learning
(how the student perceives the degree of difficulty and whether
or not there are significant differences in the assessment of
teaching with regard to these problems) and how the degree of
acquisition of the desired objectives will be assessed.
According to Hofmann (2009: p. 2) “there appear to be many
good reasons why simulations can be effective and efficient, e.g.
that simulation provides the opportunity to do practice situa-
tions that seldom occur in practice or that expose the patient to
unacceptable hazard. Some of these reasons are theoretical,
hypothetical, or argumentative, as there is little empirical evi-
dence of their importance”. Issenberg (2007) the literature on
empirical studies on the outcome of simulation and have identi-
fied the features and uses of high-fidelity medical simulations
that can lead to effective learning.
Activities to Develop and Resources
A third element is the one in which we evaluate what
resources we have at our disposal to carry out the activity. The
adequacy and timeliness of the activity to be developed is key;
there must be no doubt that simulators will influence and guide
the development of the scenario. We can create scenarios which,
using standardized patients, basic simulators or even advanced
simulators offer better feedback and allow us to manipulate
different variables and parameters. It is not the same if we are
able to rely on audiovisual recording media or if we do not have
access to them. The instructor should have a high level of
expertise in the use of simulators and the recording system so
that he or she can focus on the principal activity of the scenario.
If he or she does not, there should at least have staff that can be
relied upon to assist in this task. Whether or not the center has
facilities such as clinic rooms or operating rooms that permit
the simulation of reality also influences the activity. The
physical environment is a factor that helps to improve the
intensity and realism of the scenario. “The High-fidelity simu-
lations provide a controlled environment where learners can
make, detect and correct errors without adverse consequences”
(Hofmann, 2009: p. 2).
Among the preparatory work of the teacher, and it should not
be regarded as being of lesser importance, is the essential
responsibility of checking beforehand to ensure that each
simulator to be used in the scenario and the recording system
are functioning properly. It should also be verified that that are
enough connections in the room and that all the consumables
required by the scenario—gowns, gloves, masks, syringes,
bag-masks, etc.—are present and in good supply:
Once the content, objectives, activities and media to be
employed have been established, how the extent to which they
reach each of the goals will measured or evaluated should be
defined and specified, as well as what means will be available
to those who do not pass so that they can also achieve them.
Evaluation is the fourth element of the teaching process and
for that reason we try to assess each student during the
scenarios, so that the individual assessment is relative to
achieving the objectives of the group, and should be clearly
distinguished and differentiated. The scenarios allow the instructo r
to assess not only the students’ competence relating to the
technical and practical dimensions, it also permits the o bs er va ti o n
of personal skills such as communication style, interpersonal
relationships, and leadership initiatives, ethical behavior and
spontaneous reactions to the difficulties or successes of their
peers or themselves, and so on. The instructor guiding the
scenario should explain in advance what skills are being
assessed and how they will be evaluated. It is also useful to
have some well-defined indicators of the goals and stipulate in
advance the system to be used in the evaluation, so as not to be
influenced or conditioned by the subjective perception of the
outcome of the scenario. The assessment should also be based
on a framework different from traditional evaluation. Irigoin
and Vargas (2002) graphically detail in Table 4 the difference
between traditional assessment and the kind of competency-
based assessment that this type of learning is based on.
Adapted from irigoin and varg a s (2002).
TRADITIONAL EVALUATION COMPETENCY-BASED
Final Product Continuous Process
Transmission of Knowledge Knowledge Managem ent
Periodic Planned, Coordinated and
Objective te st i ng Focuses on evidence of actual job
The evaluator plays a passive role as
the administrator of the t est. The evaluator plays an active role,
even as a trainer.
Focuses on parts of the curriculum
and takes place at the end of it. Does not take the curriculum into
Does not inc l ude knowledge beyond
Includes evaluation of previously
acquired kn o wledge from
G. M. ZUNZARREN ET AL. 319
The teacher should also assess his or her own performance
and any events that influenced its development, the level of
commitment and participation that has been achieved, the
objectives that were not achieved as expected, etc., as this will
significantly influence the desired quality of subsequent sce-
narios. We learn from experience if we reflect on it, not from
the passage of time. Instructors will become guides and
effectively aid students if they evaluate their own performance
and ask themselves how they can improve as guides.
Guiding the Activity
As an observer, it is important to acquire the skill of making
notes about and recording everything that occurs during the
scenario and not to rely on one’s memory, because this will
speed up and significantly enrich the debriefing afterwards by
allowing the reviewing and repetition of the key points or
objectives of the activity. It is a good idea to have a rubric for
each participant and a “check list” for each activity or objective.
If it is possible to do it privately, students will be grateful as
this is better than correction done anonymously or in a group.
Errors are never the fault of a group of people or a team; they
are personal, but the responsibility is shared. Depending on
how the scenario unfolds and the group’s participation, it may
be interesting to include problems that require changes in
leadership or result in increased participation of a student with
one role or another. Naturally, the degree of knowledge of
students to determine their ability to respond to problems that
arise during development of activity, and our experience, we
believe that the following pattern is useful as a guide to
advanced students, a limited amount of data for decision-
making, however, with student’s early career, offer more data
to help you succeed in making decisions. The degree of difficulty
in the cases can be changed during the course of their deve-
lopment, provided this does not alter the objectives or create an
unrealistic situation. Leading an activity is not exactly passive,
but to avoid directing the activity, the instructor should be in
the background: adapting to the students’ in dications and helpi ng
to maintain their attention, reporting unexpected d eve lop ment or
modifications to the activity being conducted, because they
provide information so that the students participating in the
activity can make better decisions. Therefore, when creating
scenarios teachers should assess the potential degree of difficulty
in the use of simulators, and the programmed activities should
always adapt to the participants’ real possibilities of handling
them, as well as the possible improvement and increase in
knowledge and skills depending on time or the academic level
of students. According to Issenberg (1999: p. 865), “The key
element in the successful use of simulators is that they become
integrated throughout the entire curriculum so that deliberate
practice to acquire expertise over time is possible”.
The Role of the Instructor
Since learning scenarios place students in the role of
protagonist, the instructor will try to assume a non-intrusive
role as a facilitator of learning, and to promote the involvement
and initiative in students (Dieckmann, 2008). Is an important
objective that the students achieve critical thinking and
management skills (Wendy, 2004). This will therefore require
some resources and relational skills so that the instructor’s
profile appears to be that of a close associate, cooperating and
engaging in dialogue if needed, and not that of an evaluator or
In the event that the instructor’s intervention becomes ne-
cessary, it is best to do so by asking open questions that refresh
prior knowledge, or, if necessary, brief explanations to remind
the students of the key objectives, and to clarify each par-
ticipant’s role. It is not the time to solve problems, or even to
Evaluation and Debriefing of the Scenario
Finally, it is time to evaluate and correct, once the activity
concerned has been concluded, utilizing the recording of the
activity made to prepare the debriefing (Mort, 2004; Rall, 2000).
It’s part of learning environments that has great value and
perhaps its most important feature is as a means of training, as
it aims to make the students self-assess and constructively
critique the performance of their colleagues, the group as a
whole and even the instructor. This requires an intense effort by
the instructor to organize and plan his or her group’s reflection
on the activity being viewed once more in order to note and
highlight the instructions, ideas or contributions that arose
during the development of the activity. The physical orientation
of the group is also important; the participants should all be
able to see one another’s faces. Once the group is seated, the
guide should clarify with a brief explanation how the debriefing
will take place and the time devoted to activity. It starts with a
question to each component so that everyone feels challenged,
asking them to present their views, suggestions or ideas on how
to act according to their own roles and their assessment of the
development, constraints and completion of the activity. Once
the group has expounded upon its performance, it is time to
offer food for thought as annotations and corrections collected
by the instructor during the case, trying to highlight the suc-
cesses and clarify doubts mistakes. The objectives and the
extent of their achievement will be the assessment criteria both
of the group and of each of its members. The model proposed
for learning scenarios for pilots may be of interest (it is not for
no reason that they are pioneers in the use of simulation as a
teaching methodology), and their experiences can help to shed
light on how to organize, conduct and complete a good de-
briefing (McDonnell, 1997). Closer to the context of edu-
cation and medical training, Dieckmann’s proposal can be very
attractive for us (Dieckmann, 2009).
Students expect to receive the most comprehensive training
possible, updated and adapted to their real needs as pro-
fessionals, by means of scenarios that are both accessible and
safe, while being as close as possible to real-life situations as
possible. The scenarios allow the instructor to modulate or
control the level of difficulty, and to assess individual and team
participation. To the extent that we see a patient behind each
disease, we find ourselves in an ethical context that cannot be
renounced. It is an extraordinary way of ensuring that students
have no doubts about the importance of always being attentive
to patient safety, and in order to achieve this, the instructor
must train them with great care and personal responsibility. The
deeper question that arises is whether or not the methodology
G. M. ZUNZARREN ET AL.
outlined in this paper may contain some of the keys to reducing
the errors that occur in medical intervention To the extent that
learning scenarios are a valid teaching methodology, they can
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