Anatomy of a simulation case
A complete case gives the facilitator enough structure to run the same learning experience reliably: target learners, objectives, initial state, expected actions, case progression, triggers, vital-sign changes, embedded participant roles, equipment needs, and debrief priorities.
The goal is not to script every sentence. The goal is to make the educational design visible enough that another facilitator can understand what matters.
Signal, noise, and distractors
Signal is the information learners need to meet the objective. Noise is everything else. Good cases usually include some noise, because real clinical work is not sterile, but the noise should be purposeful.
A distractor works best when it represents a real cognitive trap. In the pediatric drowning exemplar, airway foam is useful because it can pull the team toward repeated suctioning even though the case is designed to teach ventilation, oxygenation, and a structured approach to post-intubation hypoxemia.
Stepwise progression and escalation
The case should move in steps that give learners a fair chance to recognize the problem, act, and see consequences. Escalation can be physiologic, interpersonal, logistical, or systems-based, depending on the objective.
Write the progression so the facilitator knows what changes when learners act, what changes when they delay, and when the scenario should be advanced for teaching value rather than realism.
Designing for accurate learner assessment
Assessment is part of case design because the case determines what performance the facilitator can actually observe. Before choosing a checklist or rating scale, decide whether the case is meant to support formative assessment, summative assessment, or both.
Formative assessment helps the learner close a performance gap. In simulation, that usually means noticing a behavior tied to a predetermined objective, describing the gap, exploring the learner’s frame, and using the debrief to coach toward better future performance. Summative assessment is different: it uses predetermined criteria to make a defensible judgment about competence, such as pass/fail, advancement, remediation, or credentialing. Most resident-authored rotation cases should be written primarily for formative assessment unless the program has built a more formal testing process around them.
Use the objective to decide what counts as evidence. A knowledge objective may not need simulation at all. Simulation is most useful when the objective lives near the “shows how” or “does” levels of Miller’s pyramid: learners must demonstrate clinical decision making, technical performance, communication, leadership, or team behavior in context.
When writing the case, define three things:
- Observable behaviors: What should the learner do or say if they meet the objective?
- Assessment method: Is this best captured by a checklist, a global rating scale, a behaviorally anchored scale, direct narrative feedback, or a team performance tool?
- Fairness controls: What must be standardized so the observation is fair: cues, timing, confederate behavior, equipment, expected vital sign changes, and rater expectations?
Checklists work well for concrete actions where the important question is whether the learner did the step: called for epinephrine, placed the patient on the monitor, used ultrasound before cannulation, or verbalized a backup plan. Rating scales work better when quality matters: leadership, prioritization, closed-loop communication, procedural fluency, or crisis resource management. Behaviorally anchored rating scales are stronger than vague numerical scores because they define what different performance levels look like.
For a low-stakes teaching case, you may not need a psychometrically validated tool. You still need alignment. Do not assess behaviors the case never gives the learner a fair opportunity to show, and do not turn every possible action into a score. Select a small number of assessment targets that map directly to the objective and that will also make the debrief more focused.
Designing the debrief before the case runs
The debrief begins during case design. Decide in advance which moments are worth returning to, what learner frames they may reveal, and which objective each moment supports. Strong cases create a small number of clear debrief hooks rather than a long list of possible teaching points.
Sources Used
- Course-authored content synthesized from the local simulation case-writing framework and exemplar cases in this repository.
- Local exemplar cases:
pediatric-drowningandstemi-on-the-ward. Used for examples of decision points, distractors, progression, and debrief hooks. - Anson W. Assessment in healthcare simulation. In: Palaganas et al., Defining Excellence in Simulation Programs. Used for the formative versus summative assessment distinction, Miller’s pyramid framing, assessment tool selection, and fairness/reliability considerations.