Simulation pedagogies are uncanny. For centuries, medical students, nurses and midwives have learned about caring for the humans by studying with an uncanny double of the human body: simulated bodies that replicate the human form in wood, stone, ivory, wax, cloth or plastic.
Recently, however, the focus on simulated learning in healthcare professions is placed on making the simulated scenario more ‘authentic’, with higher ‘fidelity’ (Abrandt Dahlgren et al. 2016). Medical and nursing schools have invested heavily to provide simulated clinical spaces that closely resemble the clinical spaces students are likely to encounter in the ‘real’ world.
The purpose of simulation pedagogies has always been built on the assumption that students can develop the confidence to interact with real bodies without harming any real people. However, as digital technology has progressed and simulated clinical spaces have become more ‘authentic’, the role of technology in simulation pedagogies has become more complex, causing a shift in the ways in which knowledge is mobilised within this space.
The simulated clinical space is uncanny: the space looks familiar – a double of any other clinical space in which the students will have practised before – but at the same time, strangely unfamiliar. When confronted with the simulation labs, students are filled with this sense of uncertainty: What is real? What is simulated? Their uncertainty is directly related to the “peculiar comingling of the familiar and unfamiliar” (Royle 2003, p. 1) that greets them.
The uncanny has to do with making things uncertain: it has to do with the sense that things are not as they have come to appear through habit and familiarity, that they may challenge all rationality and logic. (Bennett and Royle 1999, p. 37)
While most of the artefacts within these labs are real, it is usually the actor who is most ‘human’ in practice, the human patient, who is the most simulated and thus, a paradox is created: the central positioning of the human patient within professional healthcare practice is pushed to the periphery of authenticity, shifting the locus of patient care from the human to the technological. This shift also contributes to the uncanny sense of repetition (or doubling) of the clinical world, but one that is not ‘quite right’.
The mannequin takes centre stage, a digital hybrid of the human body and digital technologies; a cyborg. This adds a further layer to the sense of the uncanny: what is perceived as human is in fact mechanical. For many students, here is where the threshold of the “uncanny valley” (Mori, 2012/1970) is breached. Often, when asked to consider the cyborg as a real human, the overwhelming uncanniness creates such a disturbance in the students that they are incapable of engaging in the training session.
The technological element makes the teaching task extremely complex: the educators must simultaneously operate the software to control the mannequins, provide an imaginary narrative relating to the scenario and the patient’s history, provide the voice of the patient, take on the role of other healthcare professionals who might enter the scene, all while monitoring and evaluating the students’ progress, and correcting any glitches with the technology. By the end of the lesson, however, students are so fully absorbed in the simulated performance of their skills, even those who had refused to touch the mannequins have developed an emotional bond with these “lumps of plastic” and relate to the mannequins as though they were real human patients.
The educators achieve this shift by constantly reinforcing idea that the mannequin is not a real person, but, at the same time, reminding the students that what they are learning is genuinely serious. They allow the mannequins to straddle both the real and the imagined by paying equal attention to the difficulties in practising in the uncanny world and the repercussions of these imaginings in the real world. By exploiting the uncanniness of the situation, the educators continually acknowledge that these assemblages are not ‘real’, while at the same time ‘performing’ the very real consequences of what might go wrong.
In my research, the issue of authenticity in simulating clinical practice does not seem to be the most important concern. Instead, the educators manage to disrupt the authenticity of the simulation to facilitate learning how to care for humans in the real world (Ireland 2016). They fully acknowledge the power that the uncanny has within these learning spaces, drawing attention to it and deflecting the disturbances away from the mannequin itself, incorporating “both the look back and the look forward” (Turkle 2005, p. 290) of the uncanny to mobilise practice learning. While nascent, these observations raise important questions about the practices of simulated human patients in professional education, many of which I continue to explore in my doctoral studies.
References
Abrandt Dahlgren, M., Fenwick, T. and Hopwood, N. (2016) Theorising simulation in higher education: difficulty for learners as an emergent phenomenon. Teaching in Higher Education, 21 (6), pp. 613–627.
Bennett, A. and Royle, N. (1999) Introduction to Literature, Criticism and Theory, 2nd edn. Harlow: Pearson Education Limited.
Ireland, A.V. (2016) Simulated human patients and patient-centredness: The uncanny hybridity of nursing education, technology, and learning to care. Nursing Philosophy, Early view online. doi: 10.1111/nup.12157
Mori, M. (2012/1970) The uncanny valley. Trs by Karl F. MacDorman and Norri Kageki. IEEE Robotics & Automation Magazine, June, pp. 98–100.
Royle, N. (2003) The uncanny. Manchester: Manchester University Press.
Turkle, S. (2005) The Second Self: Computers and the Human Spirit, Twentieth Anniversary Edition. London: The MIT Press.
