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Assertiveness Training during a Crisis Resource Management (CRM) Session Using a Full Human Simulator in a Realistic Simulated Environment
W. Bosseau Murray, MB, ChB, Jody L. Henry, B.S.
Simulation Development and Cognitive Science Laboratory, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, United States.

Residents and medical practitioners with excellent clinical knowledge and skills may not have had the opportunity to fully develop their communication skills. For instance, they may be non-assertive: unwilling to initiate tasks, speak softly, and not follow through on a task they know should be done. It is very difficult for residents to change such non-assertive behaviors until they “see” themselves in a different light, e.g. on a videotape recording. They also need a venue (opportunity) to repeatedly practice the positive behaviors.

It is not practical to perform videotaping in the clinical arena where the occurrence of a crisis is unpredictable. It is also not possible to debrief in a busy clinical environment.

We have developed two pathways to provide opportunities for assertiveness training.


The Simulation Development and Cognitive Science Laboratory offers weekly Crisis Resource Management (CRM) sessions (Gaba 1988) during which principles of leadership, communication, calling for help, using all available resources, avoiding fixations, etc. are taught in a realistic simulated environment using a full human simulator (M.E.T.I., Sarasota, Fl.)

A. During the first (“null”) scenario, the participants are introduced to the environment and the simulator. As part of the demonstration, the “patient” requires treatment. This affords an opportunity for the non-assertive resident to take control of the team and direct the other participants to perform specific tasks.

B. Our CRM sessions typically require sequential entry of trainees (Murray 1999): the nurses “discover” the problem and initiate treatment. They call the primary care physician (residents from surgery, cardiology, internal medicine, pediatrics, etc.) who have to take over the leadership and continue therapy. Lastly, an anesthesia resident is called to assist with the intubation. Inserting a non-assertive trainee at any of these points affords the opportunity to practice the required assertive behaviors.


The resident repeatedly practices assertiveness behaviors during a familiar crisis scenario. Knowing exactly what is going to happen to the patient, as well as knowing the correct medical management, enables the resident to concentrate on the higher levels of management skills (i.e. practice leadership and assertiveness skills.)

A. Debriefing of the “null” scenario occurs in a private, one-on-one session. This is useful for the first few practice sessions. Residents can comment on their own behaviors, and compare their progress and improvement using the videotaped sessions.

B. Once the non-assertive resident has progressed (built up self confidence) to function in the second (“real”) crisis scenario, the behavior is debriefed in a group setting. The peer evaluation and acceptance of their leadership role by their co-workers encourages further assertive behavior in this supportive, non-threatening environment.


Gaba DM et al., Anesthesiology 1988;69:387-94

Murray WB, Proctor L, Henry J, et al. Increasing the "hot seats" for crisis resource management (CRM) training: planned sequential participant entry. Anesthesia Education 1999;17(2):6.

Anesthesiology 2003; 99: A1329