HealthSeptember 24, 2018

Moulage magic - it's not just for the simulation lab

Author: Jacqueline Semaan, MSN,/ BA, RNC-LRN

Moulage, the use of makeup to enhance clinical simulation can strike fear into the hearts of novice nurse educators. When we hear the word “moulage,” we conjure up images of simulation specialists working frantically to create the realistic wound or patient condition using different makeup color wheels, latex, hairpieces, putty, and much more. Sometimes the decision is made to forgo the use of moulage on the manikin or standardized patient because creating effective, realistic moulage is too daunting of a task.

Moulage is an essential part of the simulation experience because it is a vehicle in which to tell a story. We know that the more realistic the situation, the more likely the participants will believe that the situation is real. The more realistic the experience, the more likely the participants will react as if they are truly experiencing the simulated situation. Simulated events provide participants with the opportunity to suspend belief and act in the manner they would if faced with the situation in the “real world". It is then that we can evaluate whether the actions of the participants are appropriate or need further remediation. Moulage is a vehicle to suspending belief and enhancing fidelity as it activates the participants” sense of smell, touch, and sight

Active learning activities are used to develop the critical thinking and clinical reasoning abilities of nursing students. Educators are bringing simulation into the classroom and implementing simulated clinical experiences that allow the students to feel they are in the clinical setting. They are actively engaged in the experience as they apply their newly acquired knowledge. Creating a clinical environment in the classroom provides the students with the opportunity to rehearse nursing care of a variety of different patient conditions, thus preparing them for future clinical experiences and closing the gap between theory and clinical practice. Therefore, moulage is a vital component in the creation of the classroom clinical experience. Imagine using moulage on a manikin or human actor in your classroom to bring the clinical experience of a hypoglycemic patient into the classroom. Envision students learning how to suction a tracheostomy or provide tracheostomy stoma care on manikins who have tenacious, yellow-green mucous secretions in their trachea and around the stoma and faceplate. Moulage provides the link between the physiology of the situation and how it is interpreted by the participants.

Does moulage have to be complex and time intensive? Of course not! Simple moulage techniques have the capability to elevate and enrich the fidelity of the learning experience. So how and where to begin? Luckily there is a vast amount of instructional information related to moulage use available to nurse educators.

Suggestions for using moulage to enhance the classroom learning experience

  • Identify Available Resources - The Who, What, Where, and How!
    • Review the simulations you are creating for the classroom. How complex are the scenarios? Make a list of what you need for each scenario created. Do you need stage makeup, fake blood, clothing, a manikin versus human actor, props, family members, monitoring equipment, IV arms, medications, and EHR, etc.? Use this as your checklist to ensure you don"t forget something.
    • Resources available to assist educators in learning more about simulation use in nursing, simulation design, and the art of moulage include the following:
      • NLN - Simulation Innovation Resource Center (SIRC) at
      • Laerdal at
      • Healthy Simulation at
      • Society for Simulation in Healthcare at
      • International Nursing Association for Clinical Simulation and Learning at
      • Moulage Sciences Training at
    • Moulage materials are available from a variety of retail sources. When purchasing moulage makeup, check to see if it is manikin friendly or not. You do not want to permanently discolor your manikin because you used a product that is not compatible with your manikin's skin. Some vendors of stage makeup, moulage kits, and other moulage supplies include:
      • Ben Nye at
      • Moulage Concepts at
      • Healthy Simulation at
      • Moulage Sciences Training at
  • KISS-Keep it Simple and Straightforward-Learn the basics first before attempting something more complicated. 
    • Practice making secretions such as sweat, vomit, clear sputum, yellow phlegm, blood and urine. The mixing of glycerin and water in a spray bottle can be used to create the diaphoresis associated with hypoglycemia. Lemon juice, water, and parmesan cheese mixed together create vomit that looks and smells like vomit.
    • Practice creating simple “fresh” bruises before tackling more complex bruises. The combination of red, blue, and purple stage makeup blotted together create the appearance of a fresh bruise.
    • Scrapes and abrasions are as simple as a dipping a rough sponge into stage blood and dragging it across the skin surface.
    • Yellow water-based paint mixed with water simulates urine. Placed in a spray bottle, you can simulate incontinence by spraying it across bed linens or diapers. It can also be placed in a Foley catheter bag to simulate urine output.
    • Stage blood or red water-based paint with water can be used to simulate blood. Placed on a gauze 4 X 4 creates wound drainage for assessment.
    • Molding wax spread on the skin creates wounds and lacerations. Simply drag a toothpick or cotton-tipped applicator across the wax to create the edges of a laceration. Dust it with skin-toned powder and add thickened blood to create a fresh wound. Try using the wax before moving on to silicone and latex molds.
    • Remember that sometimes LESS IS MORE.
  • Identify a Starting Point
    • Review your course schedule. Think about how many classroom simulations you wish to implement within the semester. Start with 2 to 3 and implement more if you desire in further semesters.
    • What content speaks to the integration of classroom simulation? What topics are you most comfortable with? Start with content that is familiar and less complex. Over time, you can develop in-class simulations that cover more complex topics/content.
    • Know your audience. What level of nursing student are you teaching? The in-class simulation should be designed around the level of the student as well as the level of the content. The actions desired within the simulation must match the level of the student and the content.
    • Utilize your academic health record patient case library to develop your simulated activity.    
      • Lippincott® DocuCare contains over 200 pre-populated cases that you can edit (or not) to assist you in bringing the clinical environment into your classroom. 
      • Choose a patient based on the content topic for that classroom session. 
      • You can incorporate barcode scanning for medication administration, if desired.
      • DocuCare allows for interdisciplinary care to be documented. Maybe you want to invite other disciplines to participate in your in-class experience
      • Preview mode allows students to view a “read-only” version of the chart, so they are familiar with the patient prior to class.
      • Create 3 to 4 student learner objectives for the simulation activity based on your weekly chapter objectives, course objective, and end of program student-learner outcomes. When creating the assignment in DocuCare, using the chosen patient case, copy and paste the objectives into the assignment so they are available to the student as they work through the simulation.
      • Determine what you want the students to complete during the simulated activity.
        • What is the problem they are presented with and what are the acceptable solutions?
        • What roles do you want the students to fulfill? RN, LPN, CNA, Case Manager, Safety, etc.”
      • Identify the resources you need for the simulation-talk with your nursing lab or simulation coordinator about the supplies you need. Make a checklist so that you have the proper manikin, equipment, medications, point of care supplies etc.
      • Do a dry run of the in-class simulation. This allows you to become familiar with how it will flow and to identify areas that need fixing.
      • Share your in-class simulation with other faculty in your program. Your simulation could encourage them to incorporate in-class simulation in their courses.
      • Take the concept presented in the lowest-leveled simulation and thread it through the curriculum, creating more complex in-class simulations based on the fundamental content.
  • Know Your Manikin or Actor
  • What are the capabilities of your manikin? Is it considered a low-, mid-, or high-fidelity simulator? Can the participants auscultate lung and heart sounds? Can they feel peripheral pulses? Do the eyes blink? Does the chest rise and fall? Knowing the capabilities allows the facilitators to create a simulated experience that matches the capabilities of the simulator.
  • What resources are needed to operate the manikin: electricity, speaker, webcam, tablet, or computer?
  • If applying moulage to the simulator, do you need a barrier to prevent damage to the manikin's skin?. Barriers may include applying petroleum jelly prior to the makeup, or the use of plastic wrap, tin foil, tape, baby oil, or other barrier-like products.
  • If using a human actor, does the individual have any allergies to topical agents such as the barrier products listed above, or to latex?
  • Has the actor been adequately prepared for the simulation? Provide the human actor with all the relevant information regarding the patient condition. Discuss expectations for the simulation and their performance. The actor needs to know exactly what they are to do and how they are to respond. Provide information related to all questions that could be asked by the participants. The actor should have all necessary patient data available for review. Ideally, the actor should have this information well in advance of the simulated experience.
  • What props are needed to enhance the fidelity of the manikin or human actor (for example: glasses: a walker, bed pan, wig, clothing items, or slippers)?

Moulage is a wonderful vehicle to bring your in-class activities to life. It provides the realism we need to assist the students in treating the simulated situation as if it were real. By identifying your resources and what additional support you require, keeping it simple, identifying a starting point, and knowing your manikin or human actor, you can begin to utilize in-class simulations. These activities will engage the students in applying the concepts they have learned and further develop their critical thinking and clinical reasoning abilities.

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