Clinical simulation with dramatization: gains perceived by students and health professionals

ABSTRACT Objective: to identify in the literature the gains health students and professionals perceive when using clinical simulation with dramatization resources. Method: integrative literature review, using the method proposed by the Joanna Briggs Institute (JBI). A search was undertaken in the following databases: Latin American and Caribbean Health Sciences Literature, Web of Science, National Library of Medicine, Cumulative Index to Nursing and Allied Health Literature, The Cochrane Library, Scopus, Scientific Electronic Library Online. Results: 53 studies were analyzed, which complied with the established inclusion criteria. Among the different gains obtained, satisfaction, self-confidence, knowledge, empathy, realism, reduced level of anxiety, comfort, communication, motivation, capacity for reflection and critical thinking and teamwork stand out. Conclusion: the evidence demonstrates the great possibilities to use dramatization in the context of clinical simulation, with gains in the different health areas, as well as interprofessional gains.


Introduction
As a result of the needs of a globalized society, immersed in Information and Communication Technologies (ICT) and going through a continuous process of scientific and technological modernization, teaching in health and nursing has undergone transformations, adapting competencies, critical thinking and decision making skills (1)(2)(3) .
To satisfy these needs, the professional education underwent restructuring, which has slowly provoked the evolution of knowledge and complex thinking, aiming to prepare more critical and reflexive professionals, capable of acting in a wide range of situations. In that context, the teaching institutions have reconsidered the educational practices and employed innovative strategies, with a view to stimulating competent professionals, which has highlighted the use of clinical simulation as a necessary and valued tool in the teaching-learning process (1)(2)(3)(4) .
The act of teaching through clinical simulation has frequently been part of the undergraduate curriculum, and also of health professionals' training. Nevertheless, as a result of the advances in the structuring of the strategy and the increased capacity to gain competencies, critical reasoning, decision making and teamwork and to strengthen the professionals' self-confidence, it has been increasingly valued and enhanced as a teaching strategy (5)(6)(7)(8) .
In simulated clinical practice, several resources can be used, ranging from dramatization to the use of inanimate anatomic pieces and/or advanced simulators, which incorporate high computer and robotic technology and lead to many interaction possibilities, with great variation in the costs involved. In the construction of the simulated scenarios, physical and material resources are employed that approach the actual activities of clinical practice involving patients with a high degree of realism. The resources are defined according to the learning objectives and are classified according to their technological potentials (6,9) .
Among the resources applied in this study, the dramatization technique will be highlighted.
Dramatization can be defined as a theatre representation, determined based on a focus or theme. This resource grants meanings and permits the contents taught to be experienced in a context similar to those experienced in the actual practice (10) . Dramatization allows the student to integrate theory and practice, it is flexible and adjustable to different contexts, permits experiencing different perspectives and viewpoints and offers the student the opportunity to explore the individual vulnerability in a safe environment (11) .
In dramatization, the techniques explored can be role play and the use of simulated patients, mixed models and standardized patients.
Role play is the situation in which the learner,   Satisfaction with the clinical simulation method has been increasingly valued at health institutions and is related to the motivation process for learning (30) . It is an indicator of best practices in the teaching-learning process and of good work conditions for the educators. The studies also demonstrated that the simulations made the learners more trusting, minimizing the fear to undertake the procedures with the patients (20,26,30) , mainly in the physical examination and communication processes (33,36,41,49,54) . Self-confidence also leads to the reduction of the anxiety level (26,44,47,63) and increased comfort (44,47) .
Anxiety is a natural reaction, produced in response to certain situations in which the person needs adaptive resources. When confronted with critical activities for which they do not feel prepared, the learners report anxiety, tension, mainly when the care targets children and patients in severe and/or terminal conditions (79) .
The stress and anxiety can negatively contribute and interfere in the teaching-learning process. The two main sources of anxiety in clinical practice are lack of knowledge and lack of skills (79) .
In the gains the learners perceived, the development of empathy could be observed, which involves the feeling of sensitization for the changes the other person feels and reflects moment by moment (80) . Empathy was a gain perceived in some studies analyzed (29,59,(66)(67)69) and measured during the role play strategy (69) .  (36) . It was also observed that dramatization was used to develop critical thinking in punctual (30,35,62,68) studies, perhaps due to the fact that the physiological outcomes cannot be controlled in simulated patients.

Conclusion
The large number of studies found in this research demonstrates that simulation with dramatization is a tool in the teaching-learning process, largely used in the education and qualification of health professionals.
In this process, in a wide range of health areas and also involving different professionals, different gains are