Exclusives, Training

Standardization of EMS Simulation Activities Improves the Learning Experience

Standardization may sound like a simple notion. To suggest that simulation has some uniformity, at least presumed uniformity, is fascinating to ponder. Just like a medical or trauma condition isn’t uniform in its presentation, simulation may also present itself in myriad fashion, creating challenges for educators.

For the purposes of this article, standardization shall be understood by its definition in Merriam-Webster, “to bring into conformity with a standard.” The goal is to discuss appropriate structure and methodology, yet still allow that simulation to be delivered creatively.


There are many standards that exist that describe the framework for appropriate simulation. Each set has a unique perspective that can help to capture what is needed to design, develop, deliver and debrief simulation activities. For instance:

Each of these standards has been developed to support quality healthcare simulation. They’re grounded in research and/or data and were developed with input from subject matter experts worldwide. They have varying levels of specificity and each supports the standardization that’s desirable in simulation.

Applications in Simulation

Standardization has been utilized in EMS education programs for decades. Establishing a set standard way to complete each clinical skill can reduce the confusion for learners while improving the quality of assessment. Applying a similar approach to EMS simulation activities will allow learners to function to their maximum ability, and it will improve the quality of the learning activity. Here are some examples of how standardization impacts simulation.


Simulation activities should have a number of components that frame the activities within the “standards” of how patients and environments present themselves to enhance validity. For instance, there are choices about setting, as well as how realistic to make the activity. It can be argued that the farther the activity is from the real world, the less value there is for the participant.

For a construction worker who’s fallen and become impaled on rebar, how can that be simulated to make it more realistic, and thus support transfer to practice? The more “pretending within the  simulation” we do (e.g., telling the participants to pretend there’s a piece of rebar sticking out of the patient), the less the simulation is standardized compared to real life.

Adding realistic cues to an EMS simulation adds to the standardization expected by learners when they enter a live patient experience. Do they scan the environment for risks or clues that help them determine the attributing factors of the situation? These variations from the standards of real life can have negative educational impacts—because it’s no longer valid to real life.

Adherence to Objectives

Designing a simulation activity should always begin with the development of learning objectives. Facilitators must understand the purpose educationally for completing the activity. To maintain a valid and reliable learner assessment, every participant needs to receive the same information related to the scenario with the same progression within the case, providing the same cues or feedback at the same time and with the same inflection or importance.

Utilizing a written script, with timed triggers, as well as providing facilitator briefing prior to each simulation activity, can help overcome the inherent urge of many facilitators to be helpful and freelance within an activity. The case result may differ based on the decisions of the participant, but the standardization in presenting the case the same way for each learner is paramount for accuracy related to skill competence. Equally important is assessment and feedback to the facilitators for quality improvement. 


Due to the number of participants requiring training at a specific time, most simulation opportunities require numerous facilitators. For standardization to occur, a realistic script must be followed by both the facilitator and participant.

Allowing facilitators to run simulations “on the fly” allows significant variability and prevents adherence to the learning objectives. Although programming a scenario can be difficult and may require specialized training, a detailed map can easily be created. The facilitator script should contain the learning objectives, a brief synopsis of the case, starting vital signs, and trends that can be manually adjusted throughout the scenario that allows a standard reaction to specific treatments initiated by the learner. The script should also have basic debriefing points tying back to the written learning objectives as well as cited material that the facilitator can reference during the debriefing session.

In the absence of information, the facilitators will utilize their personal knowledge and feelings leading to variability and possibly wrong information.

Standardized Patient Training

The key frames of standardized patient (SP) methodology were discussed in a recent JEMS article, Considerations When Using Standardized Patients in EMS Simulation. There are many ways to ensure that the SPs are actually performing in a standardized way.

Certainly, when SPs are used for summative (and formative) assessments, their scripts and behaviors must be precise, consistent and fair. This is a very rigid standardization that’s essential when performing assessments. But even when using SPs, they must be prepared by the educator to stay within a designated area of the activity to provide a learner-centric experience.

Imagine allowing SPs to make up signs and symptoms as the activity progresses without guidelines. It’s easy to envision that the learners at the end of the experience will have very different experiences! Standardized patients must be vetted to be standardized and must be trained for the role and activity.

Inter-/Intra-Rater Reliability

A similar notion to preparing your SPs is the concept of standardizing your evaluators for any simulation activity. Every participant deserves to be evaluated fairly for any simulation activity—and this isn’t just inter-rater reliability, but also intra-rater reliability. It’s too easy to have variation over time between individuals and within ourselves.

Using established tools like the Sweeney-Clark Evaluation Rubric supports standardization of evaluation and also standardization of the understanding of the simulation activity.1 Have you chosen your tools, prepared your faculty, and tested your simulation activity so that your ratings can be reliable?


There are many standard methods for conducting a debriefing. Beyond choosing a style or method, there are standards that help prepare for an effective debriefing session.

Developing standardized debriefing questions related to the learning objectives assists in streamlining the session. Debriefing immediately following the activity is a standard that enhances the reflective learning and improves the quality of the debriefing. Ensuring a psychologically safe, non-punitive, non-judgmental environment is a standard that’s paramount to shift the EMS culture of safety and improve learning from the simulation activity.


Standardization is an essential consideration for any simulation activity. The level of standardization must be specifically chosen and incorporated into the design to ensure that each simulation is appropriate and useful.

It’s not acceptable to simply place the manikin on a table, or throw the manikin down into the mud and recreate a patient encounter that was “cool” from the last shift. Standardization within simulation activities improves quality and the experience for learners. It also enhances the efforts of proper simulation design, execution and debriefing making the effort of evidence-based practice worth it.


  1. Gantt LT. Using the Clark Simulation Evaluation Rubric with associate degree and baccalaureate nursing students. Nurs Educ Perspect. 2010;31(2):101–105.