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SP safety, autonomy and healthcare simulation practice in the COVID-19 era
  1. Lou Clark1,
  2. Anne Woll2,
  3. Tamara L Owens3,
  4. Deltonia Shropshire4,
  5. Bob Kiser5,
  6. Grace Gephardt6,
  7. Christine S Park7
  1. 1 M Simulation and General Division of Medicine, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
  2. 2 M Simulation, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
  3. 3 Clinical Skills and Simulation Centers, Howard University College of Medicine, Washington, DC, USA
  4. 4 Clinical Skills and Simulation Centers, Howard University, Washington, DC, USA
  5. 5 Simulation and Integrative Learning Institute, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
  6. 6 Simulation Education, Arkansas Children s Hospital, Little Rock, Arkansas, USA
  7. 7 Department of Medical Education and Anesthesiology, University of Illinois College of Medicine, Chicago, Illinois, USA
  1. Correspondence to Dr Lou Clark, M Simulation and General Division of Medicine, University of Minnesota Twin Cities, Minneapolis, USA; louclark{at}


This letter expands upon the three tenets of the Healthcare Simulation Manifesto—comprehensive safety, collaborative advocacy, and ethical leadership. To do this, we will discuss two key terms: ‘essential’ and ‘autonomy’ in relation to safety for standardized/simulated patients (SPs). In this time of crisis, simulationists must move the boundary of skills training previously accepted as safe for human beings, and leverage technology to ensure the highest level of safety achievable for our SPs.

  • standardised patients (actors)
  • simulated patient
  • safety
  • COVID-19
  • simulation centre operations / administration

This article is made freely available for use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

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This response to Griswold et al 1 expands on the three tenets of the Healthcare Simulation Manifesto—comprehensive safety, collaborative advocacy and ethical leadership. To do this, we will discuss two key terms: ‘essential’ and ‘autonomy’. Specifically, we will focus on human simulation and standardized or simulated patients (SPs) within the USA.

First, in relation to term “essential”, the manifesto describes the importance of understanding the term ‘essential worker’ as a labour perspective versus as a value proposition.1 To reiterate, “essential” from a labour perspective includes those workers ‘who conduct a range of operations and services that are typically essential to continued critical infrastructure viability’.2 In this sense, SPs are not essential labour. However, even essential workers have not always received adequate personal protective equipment and are suffering illness and dying as a result.3

The manifesto makes clear that all simulationists—including SPs—are essential, or integral, in terms of the value they bring to our teams. As SPs are integral team members, the health and well-being and safety of SPs must have equal priority to learners and other stakeholders. As such, many leaders managing SP programs committed great effort to re-engineer programming, including remote work, to meet educational objectives.4 As a result of this forced shift due to the pandemic, these leaders are innovating and expanding healthcare simulation practices more rapidly than ever before. SPs are integral collaborators in this ongoing effort.

While SPs are integral collaborators who routinely enjoy educational agency with learners, educational agency is not synonymous with autonomy. Educational agency for SPs has been championed by SP educators over decades.4 5 Educational agency in human simulation may be defined as the entrusted independence of trained SPs to teach and engage with learners. By contrast, autonomy may be defined as freedom from external control or influence.6 As one of our author team members learned through surveying SPs at their institution, more than 80% of the SPs prefer to remain working remotely until a vaccine is widely implemented. The following quotes from SPs provide evidence that working onsite is not being experienced as autonomy:

It feels like some of us are more expendable than others, and I think we’ve just accepted it. It’s not a matter of if, just when.

I have worked now 2x at another school and they were doing long days. Wearing the mask became difficult; being stuck in a small room and seeing lots of students became difficult. I was surprised at how anxious I felt and how much it affected me.

I am very grateful to this university in particular for being the most conservative school I work for. Having worked in-person a few times (with physical exam), the fear of exposure/having to be on high alert to watch for the student touching their face makes it harder for me to focus on the communication and checklist skills.

I truly believe everyone at this simulation program and other schools should be working remotely until there is a good covid treatment or cure.

Now, more than ever, we must remain steadfast in establishing, reviewing, and upholding safety protocols for SPs. Since the online publication of the Manifesto there have been more than 1.1 million additional deaths and more than 68 million new COVID-19 infections worldwide.7 During this same timeframe, there are many accounts of simulationists— including those who manage SP programs—being compelled to work with SPs onsite in the pandemic prior to availability of the vaccine. In one example, an SP educator, feeling left with no other choice, personally chose to undergo all of the physical exams for a class of students rather than bring SPs onsite. In other instances, simulationists have been pressured to bring SPs back onsite without sufficient PPE and/or an adequate safety plan, and now without the tested protection of the COVID-19 vaccine.

Rather than and before compelling SP Educators to bring SPs onsite prior to having the opportunity to receive the vaccine, stakeholders with influence must advocate for SPs to receive the vaccine as part of the CDC specified 1b group “…and those who work in the education sector (teachers and support staff members)”.8 Using their own bodies in face to face settings, SPs serve as teachers for health sciences students and therefore meet the criteria for inclusion with 1b educators for the COVID-19 vaccine. Numerous SP educators in this pandemic, including program leaders, are facing the increasing tension between protecting their workers and professional retribution, even including potential job loss. So, stakeholders with influence must also advocate for the professional safety of SP Educators as they raise their voices to advocate for the safety of SPs in the pandemic.

As simulationists continue to adapt curricula for remote learning, this expanded healthcare simulation practice (HSP) also expands the autonomy of SPs. Upholding autonomy includes not enticing SPs back to work onsite under the premise of educational agency. Upholding autonomy also includes not appealing to their senses of altruism to entice SPs to return to work onsite. While a minority of SPs may be willing to work onsite in the pandemic prior to receiving the COVID-19 vaccine, employers must not sidestep their responsibility to pursue the highest possible levels of occupational safety and protection from hazards.

PPE is the last and least effective stopgap between COVID-19 and all workers, including SPs.1 This means that interventions like isolating people from the hazard is a far superior protective strategy than PPE as visualised by the National Institute for Occupational Safety and Health (NIOSH) pyramid.9 As Griswold et al noted: ‘Social distancing—keeping six feet apart, wearing high-quality medical masks, or face shields when distancing is not possible—minimizes the spread of SARS-CoV-2’.10 This very act of apparent minimisation continues to result in surging infections, illnesses and deaths. All in-person simulated encounters involving physical exam skills will violate the required six feet social distancing work safety guideline. So, while this choice may benefit learners in the short term, SPs may become very real patients, and programmes and learners may suffer long-term damage.

Human simulation has changed the landscape of healthcare broadly and, more specifically, of medical training. The field of medicine has a dark and often unspoken history in which patients’ bodies have been used and discarded for the sake of education. As recently as the early 20th century, consensual and non-consensual use of real patients’ bodies was a common, acceptable practice in medical training. Standardised patient methodology has evolved over the past 60 years so that learners work with SPs, who employ their bodies in service of this training, as a necessary and safe complement to working with real patients. SP educators consistently uphold safety as a critical component of their best practices.5 11

In this time of crisis, we—simulationists—must again move the boundary of skills training previously accepted as safe for human beings, and leverage technology to ensure the highest level of safety achievable for our SPs. While it may be a difficult choice for some stakeholders, it is the ethical choice. Every human life is essential. The Manifesto invites all simulationists to heed this call together, in partnership, for our collective physical and psychological autonomy, well-being and professional success.

Ethics statements



  • Twitter @LouClarkartist, @cpark_stories

  • Contributors LC took the lead on writing and revising this letter. CSP made substantial contributions to the writing and revising of this paper. AW, TLO, DS and GG provided substantive feedback on this letter. BK implemented the COVID-19 Wellness Survey and provided data from the survey for the letter with CSP.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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