Following the framework of ecological validity, and taking into account the social character of simulation, we investigated how six anesthesiologists each experienced three patient simulation scenarios. Using content analysis, we describe factors mentioned in the 18 half-structured interviews that were relevant for the perceived realism of the scenarios: overall impression and medical plausibility, participants' own actions, role play of the simulator team, workload, technical aspects, group dynamics, and anticipations. Further, we describe the circumstances under which these relevant elements were experienced as fiction cues (emphasizing differences between scenarios and clinical cases) or as reality cues (emphasizing similarities between scenarios and clinical cases). The experience of the scenarios among the anesthesiologists was dynamic over time and differed among participants. Considering the described elements and their character as either fiction or reality cues improves the understanding of the still-unanswered question of why simulators and simulations “work.” Simulators and simulations help in designing, optimizing, conducting, and analyzing patient simulation scenarios in a goal-oriented fashion.
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