Simulation is now widely used in healthcare for pedagogical and practice-based objectives. Both the ethics of simulation and how it may be used to explore, train and assess ethical issues in a clinical context have received growing interest in recent years. The literature that considers the ethics of simulation discusses a range of issues, from the use of vulnerable standardized patients (
Using children as standardised patients for assessing clinical competence in paediatrics.
), psychological safety of the simulation participants (
) to debating the use of simulated death (
Goldberg et al., 2017
- Goldberg A.T.
- Heller B.J.
- Hochkeppel J.
- Levine A.I.
- Demaria S.
Simulated mortality - We can do more.
), and even the extent to which simulation should be used to train healthcare professionals to mitigate risk of harm to patients (
). There is now a code of ethics for simulation, which seeks to “promote, strengthen, and support an ethical culture among all individuals and organizations engaged in healthcare simulation” (
Beyond discussions about the ethics of the simulation activity itself, there is an emerging literature that outlines how simulation has been utilized to train and explore a range of ethical issues in healthcare. For healthcare professionals and those in training, knowledge of ethical concepts and how to apply these are essential to providing safe and competent care (
). In the UK alone, there is a standard of conduct, performance and ethics code for nurses and midwives (
), ethical guidance consisting of 32 pieces and 11 categories for medical doctors (
), and a different standards of conduct, performance and ethics for allied healthcare professionals (
). This is mirrored across other countries that have healthcare professional regulatory bodies (
The literature suggests that ethics instruction varies, and there is little consensus on the best practice for achieving ethical awareness/competence amongst learners (
When is the best time to teach medical ethics?.
). Beyond this, several concerns can be found throughout the literature related to the challenges of including ethics content into curriculums (
), learner engagement (
) and in assisting learners to translate ethical concepts into action in clinical situations (
). Simulation has been proposed as a means to remedy some of these problems and as an aide to training and maintaining ethical competence for healthcare professionals. Simulation, as it has been used to teach other skills has been shown to improve knowledge, skills, confidence, critical thinking, competence, and well-being (
Alanazi, Nicholson and Thomas, 2017
- Alanazi A.A.
- Nicholson N.
- Thomas S.
The use of simulation training to improve knowledge, skills, and confidence among healthcare students: a systematic review.
Fuglsang, Bloch and Selberg, 2022
- Fuglsang S.
- Bloch C.W.
- Selberg H.
Simulation training and professional self-confidence: A large-scale study of third year nursing students.
Evaluating competence and confidence using simulation technology.
Ethical concerns permeate almost every element of simulation. That is, while simulation could, for example, focus specifically on ethical issues like beneficence or non-maleficence or explore specific ‘dilemma’ scenarios, the normative elements of simulation are far more expansive. Ethical issues arise in the design of simulated scenarios and within these scenarios, even if not explicitly exploring ethical issues. Perhaps most fundamentally, every decision or event in simulation has a normative element where we can evaluate whether it was good or desirable, or bad or undesirable. Beyond these normative considerations, the design of simulated scenarios themselves also entail a range of ethical concerns, most notably on this point, there has been a growing literature of psychological safety (
). At least partly for these reasons, this emerging field remains relatively fragmented, lacking a common vocabulary or standardized practice and methodology.
Given this, the primary aim of this paper was to systematically map the literature related to ethics in healthcare simulation, guided by the research question, ‘how is ethics in healthcare simulation recorded in current literature?’. This included studies that utilized or discussed simulation in relation to clinical or practical ethical problems or papers that discussed the ethics of simulation itself. Both were included as it would be impossible to separate them at this stage due to the same terminology used. It was also anticipated that most papers referring to the ethics of simulation participants would use the term ‘psychological safety’. However, this term wasn't included in the search as it is a specific field in its own right and this review was more interested in ethics and simulation more generally, and how it is being considered and incorporated into simulation activities. We were foremost interested in exploring the year and place published, the amount and type of papers that had been published and the samples/professions involved in the outputs, keyword co-occurrence and co-authorship. This would give us a broad sense of how and if ethics is considered through simulation, where and why, ultimately leading to a more focused and refined understanding post review.
Our secondary aim was to explore the feasibility of conducting a systematic mapping review within a diffuse field such as the healthcare simulation literature, as this would potentially generate a useful methodology for delineating many other areas of interest. To our knowledge, such a review has not been carried out in the simulation literature previously.
What is a Systematic Mapping Review?
A systematic mapping review provides a means to broadly map an area of research, focusing on the features of the literature search and allowing for a range of descriptive figures and tables to be produced in relation to the characteristics of the literature, such as the methods used, and temporal, spatial and thematic trends. The focus of a mapping review is thus far broader than traditional systematic and scoping reviews and may even be conducted prior to conducting a more focused search. How broad or focused a review is will at least partially depend on the literature available. A mapping review, in comparison to other forms of systematic and scoping reviews, is far more flexible in its application, search, inclusion criteria and how data is analyzed. Rather than analyze data contained in the full text of papers, systematic mapping reviews are generally concerned with bibliographic data, that is, years of publication, keywords, authors, journals, citations and countries in which the research was conducted. Mapping reviews may also draw on data contained in the abstract or full text of the paper; a number of reviewers ‘code’ elements of the paper (i.e., methodology, type of intervention) depending on their research questions (
identify three reasons for mapping a research field. Firstly, mapping can be useful in clarifying the type and nature of the research that has been undertaken to date. Secondly, mapping can be a useful precursor to more focused synthesis, that is, mapping may be useful in clarifying a research question and/or refining the scope of a more focused review. Thirdly, mapping can provide useful contextual information to inform future syntheses.
EVIDENT Guidance for Reviewing the Evidence: a compendium of methodological literature and websites.
add that where there is an abundant but diverse area of research, mapping reviews are able to help create a visual synthesis of trends, patterns and themes in evidence.
The scope and research questions explored in mapping reviews are typically broader than those in traditional systematic or scoping reviews. Mapping reviews can contain anywhere from hundreds to thousands of included papers. In this case, after a series of preliminary searches and discussions amongst the authors, we concluded a mapping review was appropriate to map the healthcare simulation ethics literature, as it firstly brings two literatures (i.e., healthcare simulation and bioethics) together that are often disparate. Secondly, a mapping review provides a means to include papers (other than research) that would not be included in more focused systematic or scoping reviews, such as letters, opinions, analysis and normative articles (although these sometimes are included in scoping reviews). This was important, as we wanted a wider understanding of what is being practiced as well as what is known. We therefore felt a mapping review would be appropriate to provide a broad overview of an emerging area in simulation and bioethics and identify gaps and direction for future research, practice and discussion.
Systematic mapping reviews broadly follow the process of other systematic reviews, in that a search is conducted, papers are screened/reduced and then analyzed. Each step however is somewhat different, perhaps most notable in how data is extracted from papers and how this is then analyzed. Each stage such as sample reduction, coding to perform visualizations such as clustering and further analyses will be broadly outlined below. As systematic mapping reviews aim to map out (or visualize) the type and kind of the research that has been undertaken to date, but does not go into the detail of synthesizing the content of the literature found - as it would with a focused systematic review or scoping review - the step of critical appraisal has been omitted.
How is ethics in healthcare simulation recorded in current literature?
A search was conducted on 08/19/21 using Scopus, Medline, CINAHL and PsycInfo. The search terms were broad and reflected key concepts related to our research question addressing simulation, ethics and healthcare. The search terms utilized were: simulat* AND ethic* AND doctor OR physician OR clinician OR "medical practitioner" OR nurs* OR "health profession*" OR healthcare OR "healthcare" OR pharmac* OR dentist OR midwi* OR dieti* OR therap* OR paramed* OR physiotherap* OR radiograph* OR psycholog* OR "health worker" OR hospital. No date or language limitations were applied. Search results were transferred to Endnote; there were 1856 results after duplicates were removed.
In a mapping review, sample reduction (or a first screen) involves cleaning up the data, generally scanning titles and abstracts. This step can apply broad criteria, simply just removing clearly irrelevant results or a more stricter eligibility criteria. Two authors <redacted> carried out this screen and excluded irrelevant papers. A broad inclusion and exclusion criteria guided this process. Papers were included if they had a substantive focus on ethics or an ethical issue either related to simulated clinical/medical ethics or the ethics of simulation. Papers were only excluded where ethics was not a substantive focus of the paper, where simulation was used in a treatment or therapeutic context, or where the paper was not available in English. After sample reduction, 104 papers were left.
Papers that had a substantive focus on ethics or an ethical issue either related to clinical/medical ethics of the ethics of simulation.
Papers that utilized or discussed simulation.
Papers with a focus on health or healthcare training or education.
Empirical research, theoretical papers, commentaries and editorials.
Coding is also a common step in mapping reviews and allows for analysis that would otherwise not be possible on information contained in the abstract and bibliographic information alone. Seven authors coded the papers (n = 104) which were subsequently checked by RE and SMW. Papers were coded on several variables:
whether the focus of the paper was on the ethics of simulation or simulation to explore/assess or train ethical issues as applied to healthcare;
whether the paper was empirical research (or not), that is where it had a sample and reported data from the sample (e.g., many studies reported a simulation implementation/process/innovation and reported that this simulation had been validated, however provided no data on this).
If the paper was empirical research, further variables were coded:
the methodology employed by the study;
whether the sample included students and;
the profession of the sample, for example nurses, doctors of an interdisciplinary sample.
Several analyses were carried out to map the literature. Specifically, (a) the year and country of publication, (b) the nature and type of research, this included analyzing how many studies were empirical research, the methodology they employed and their sample characteristics, and (c) co-occurrence analysis of keywords and co-authorship analysis. Data was explored and analyzed in Excel, SPSS (
IBM Corp 2020
Released 2013. IBM SPSS Statistics for Windows, Version 27.0.
) and VOSviewer (
). VOSviewer is a program designed for visualizing bibliometric networks and can map bibliometric data such as co-authorship and co-occurrence of keywords.
Summary of Findings
This study sought to map the literature related to ethics in healthcare simulation and to explore the feasibility of a systematic mapping review as applied to simulation and ethics. In relation to our first aim, there are several notable findings. The above literature is a relatively small, but rapidly growing field. The majority of publications included here were published after 2010 and prior to 2000 there were few studies that discussed ethics in simulation. While this increase may of course be reflective of the increasing volume of simulation research more generally it may also reflect a growing interest in ethics and simulation. Prior to 2011 there were limited standards.
highlighted the need to develop standards to help simulation reach its full potential. In 2011 the International Nursing Association for Clinical Simulation and Learning (INACSL) set their first standards which were revised in 2016 (
Extra! extra! read all about it! INACSL standards of best practice: simulation have been revised.
) and again in 2022. Also in 2016, the Association for Simulated Practice in Healthcare (ASPiH) standards were published (
The literature was also geographically concentrated, with the overwhelming majority of papers coming from the US. This analysis also suggests limited co-authorship in the papers included. While these could be seen as shortcomings, they are also likely attributable to the fact that this field is in its infancy.
When looking more closely at the type of research conducted, qualitative, mixed methods and quantitative methodologies were utilized, across studies that included doctors (or medical students), nurses (or nursing students) and interdisciplinary samples. Notably there were few studies that included other allied health professionals found in this review. This could be for a range of reasons, but may at least partially be due to the fact that many allied health professionals have more traditionally acted on referrals rather than being a ‘first-contact’ group (
Greenhalgh, Selfe and Yeowell, 2020
- Greenhalgh S.
- Selfe J.
- Yeowell G.
A qualitative study to explore the experiences of first contact physiotherapy practitioners in the NHS and their experiences of their first contact roles.
). There are likely several other reasons, but regardless there appears to be substantial opportunity to expand research int his area.
Research involving samples of nurses relied more heavily on qualitative methods and students in their samples than that of medical doctors or other professions. More generally almost double the number of studies included students in their sample, as opposed to qualified healthcare professionals. Keyword co-occurrence suggests that studies utilized simulation overwhelmingly in an educational context, with keywords such as teaching, education, medical education and curriculum heavily weighted in these analyzes. In this respect there is the potential for significant growth in this area; future studies should consider research with more diverse allied health professionals (and students) and look to sample outside of North America. There also appears to be the potential for substantially more collaboration.
While we are aware of no other mapping reviews as they relate to the healthcare simulation literature, it is worth offering some reflections on our findings in light of the broader literature on simulation. We found a range of papers that examined the ethics of simulation itself. Clearly there is a need for more focused reviews and attempts to organize and categorize this literature to better identify common issues, approaches and more generally, the intersections of ethics and simulation. On this, there appears to be a case for greater standardization across the literature and a broader focus on research questions related to ‘ethics.’ One example relates to the training of healthcare professionals in relation to ethics and ethical decision making (
Sedgwick, Yanicki, Harder and Scott, 2021
- Sedgwick M.
- Yanicki S.
- Harder N.
- Scott D.
A scoping review of the integration of ethics education in undergraduate nursing high-fidelity human simulation-based learning.
Simulation appears to have enormous potential when compared to traditional approaches that rely on traditional teaching methods. In the broader bioethics literature for example, codes of ethics and other ethical guidance has been long disputed, an alternative that has proposed is a more reflexive approach, that is, training health care workers to respond as ethically as possible to unforeseen situations, rather than simply being knowledgeable in ethical principles which may not help in such a situation (
Professional codes of practice and ethical conduct.
). Simulation in this sense has the advantage that it can simulate conflicts and issues not otherwise found in codes of ethics, helping learners to resolve conflicts in an applied, rather than abstract fashion. In saying this, pragmatic limiations mean that simulation could not possibly recreate the spectrum of ethical issues faced by healthcare professionals throughout their careers, so a question that naturally follows relates to how might we utilize simulation to its potential to train healthcare professionals to be ethical decision makers? Such a research focus will require collaboration across disciplines, discussions about effective methods or means and it will also raise fundamental questions about what we are trying to achieve if exploring ethics within simulation. In short, while focused questions about specific ethical dilemmas are warranted, if we are to realize the potential of simulation in this domain we will also need a broader focus with questions in mind about what simulation and ethics can bring to one another.
On this final point, the relationship between simulation and ethics should not be seen as unidirectional, there is clearly scope for greater theoretical work in this area that examines the contribution that each could make in informing the other, in comparison to the vast literature on clinical/medical and nursing ethics (in the context of clinical practice) for example and the vast literature that critiques the normative aspects of research methodologies, this review found a relatively small number of papers that discussed the ethics of simulation itself.
Our second aim was to explore the feasibility of a mapping review as applied to ethics in healthcare simulation. To our knowledge, this form of review has not yet been carried out in this area of interest. While it could be applied to a larger body of literature, we felt in this case it would be appropriate to apply this method to an emerging literature, such as the one included in this paper. While such an approach comes at the cost of more specific details that would otherwise be seen in more traditional systematic and scoping reviews, this review allowed us to apply a broader lens to the literature, noting its broad strengths and limitations, among other things. We feel that such reviews have merit for further application in simulation and ethics research and could be applied to better understand the literature in these areas. Furthermore, we also feel that such reviews could provide valuable direction for more focused scoping and systematic reviews in this area.
One limitation of this review relates to the nature of the concept of ethics itself, that is, it is a concept with relatively diffuse boundaries which often makes it difficult to study in a systematic fashion; this has been well documented in methodological papers related to literature reviews in the bioethics literature for example (
Reviewing literature in bioethics research: Increasing rigour in non-systematic reviews.
). In practicality this means that when it comes to simulation and clinical practice more generally, there is no clear line where ‘ethics’ starts and ends. For this reason there may be a number of other studies not included here that are relevant. Additionally, although no language restrictions were placed on the search, language barriers may mean we don't have a full picture of what is being done globally. The other major issue raised by this review, already alluded to above was that the focus of review was relatively broad, this was not a limitation in itself as we sought to map the literature, it does however mean we can only say so much about certain things, like the types of research questions asked in empirical studies or the major arguments made in the theoretical literature.
Recommendations for Future Practice and Studies
This review identifies several key directions and opportunities for practice and future research. Firstly, there were relatively few papers that included healthcare professionals and few studies that utilized interdisciplinary participants outside of nursing and medicine, therefore more studies and practice incorporating multi/interdisciplinary teams should be conducted. Secondly, the methodology employed by studies appeared to largely correlate with the participant population, for example studies with nurse participants relied more heavily on qualitative methods. While we can only speculate why this is the case, this may be due to differences in research approaches across disciplines (i.e., medicine and nursing), there is therefore an opportunity for greater methodological diversity. Thirdly, there also appears to be scope to utilize simulation more broadly (in clinical practice), and not just educational contexts to explore ethical issues more generally. Finally, and more generally there was very little collaboration in this area. Again, this may be because this is a generally emerging area of scholarship, it is however something to keep in mind in future studies.