Thursday, 3 March 2016

Response to 'Living dolls and nurses without empathy

Re: Dean, S., Williams, C., Balnaves, M. (2016) Living dolls and nurses without empathy

Judy AK Bornais
Karyn Taplay
Timothy Willett
Elizabeth Horsley

As Canadian educators who have worked with simulation-based pedagogy for many years we read with interest the editorial 'Living dolls and nurses withoutempathy.' The authors of the article expressed a concern that all of us working in simulation have encountered: namely that a manikin - or any simulator, for that matter - cannot possibly accurately represent, and certainly cannot replace, a real person.

We absolutely agree!

However, we have three arguments in response:

1.      Simulation is commonly misunderstood: specifically, the belief that simulation is a technology, and that simulation is synonymous with manikins. 'Simulation is a technique, not a technology' (Gaba 2007, p. 126). The field of simulation has evolved into a pedagogy of teaching and learning.   
2.      Traditional clinical experiences do not guarantee that all students will experience or gain an understanding of empathy.
3.      A well planned manikin based simulation can, in fact, expose all students to the construct of empathy.  We hope to make this clear through an example.  

Simulation is NOT synonymous with manikins  

First, we will clarify some definitions of simulation and offer some context. The first documented use of a simulator as a teaching strategy was in 1911 (Hyland & Hawkins 2009) when 'Mrs. Chase', the first human sized manikin (Herrmann 2008) was created for the purpose of clinical skill acquisition and refinement (Poole 1948).  While 'Mrs. Chase' was a low fidelity simulator, high-level simulators have evolved to mirror many medical conditions and can be programmed to respond to interventions (Nehring & Lashley 2004, Issenberg et al. 2001).

Simulation is the technique of emulating something real for the sake of education or quality improvement. What is critically important to realize is that simulation as a pedagogy is far broader than simply using high-fidelity manikins. Standardized patients, role-playing, computer-based/virtual simulations, videos, task trainers, and mock environments - alone or in combination - are some other modalities that may be employed. Sometimes using technology (e.g. a high-fidelity manikin) is the best way to achieve this, and sometimes it is not. Choice of an appropriate simulation modality is based on the learning objectives and desired outcomes of the educational activity.

Clinical experiences do not guarantee that all students will experience or gain an understanding of empathy

It is not simply the opportunity to be in a clinical setting that helps to establish empathy, caring and compassion in our students and healthcare practitioners. For decades we have taught students who have had wonderful clinical placements and sadly some have graduated lacking empathy. We are in complete agreement that, 'Empathy is, at its simplest, an understanding of and identification with someone else’s feelings. It involves compassion, responsiveness and understanding. It can be learned in a variety of ways...'  (Dean et al. 2016, p.1). We would emphasize that it can be learned in a variety of ways. What the authors of 'Living Dolls' fail to consider is the multitude of other ways that a simulated learning environment can indeed provide students with opportunities to establish therapeutic communication and learn empathy. The use of simulation allows manipulation of the environment to strategically introduce and facilitate the learning of empathy for all learners. This allows them to be challenged and reflect on their own feelings and beliefs; to move along a continuum to internalize values; and think about their future behaviours when dealing with patients. The reality is that the clinical setting cannot be altered thereby limiting such experiences. In addition, it cannot be standardized to ensure that all students have the same experience.

Scholarship around simulation has grown exponentially over the last decade. There are a myriad of studies that conclude that simulation, employed properly, leads to significant and meaningful gains in knowledge, skills and attitudes, and that simulation is more effective than other approaches for achievement of skill, attitude and behavioural learning outcomes (Cook et al. 2011, Cook et al. 2012, Shin et al. 2015). There is established evidence that the simulation-based learning of technical and non-technical skills translates into improved clinical practice (McGaghie et al. 2014, Griswold-Theodorson et al. 2015, Weaver et al. 2012).  

Further, simulation educators realize that no one modality can recreate a person or the holistic clinical encounter. But this is not a limitation. Using a scaffolding approach, educators can help learners to build and master the various foundational competencies needed for integration into an effective, empathic, and meaningful clinical learning experience in the real setting (Vygotsky 1978). In fact, there is emerging evidence that simulation-based preparation before on-site clinical placements improves the educational effectiveness of clinical placements (Struksnes & Engelien 2016).

A well planned simulation can, in fact, expose students to the construct of empathy

The healthcare educator’s goal should be to use the modality whose aspects of realism (physical, cognitive, social, etc.; (see Grierson 2014) best match the real-life task and that can best achieve the desired learning outcome. Simulation, when used correctly, is not simply a replacement of clinical time with a 'living doll.' It requires careful consideration of the purpose of the learning and the anticipated learning outcomes and only then should a decisions be made about which modality best provides the students with the most meaningful learning. While simulation is often used to teach psychomotor skills (cognitive & behavioural domains), as authors of this resposne, we strongly believe that simulation can tap into the affective domain and be used to teach empathy.  Simulation modalities, such as standardized patient experiences and immersive role play, have demonstrated an increased awareness of empathy in health professional students (Bearman et al. 2015, Maruca et al. 2015, Schweller et al. 2014). A recent article by Power et al. (2016), reported that through the use of vignettes followed by working with manikins in the lab the theme of connecting and caring emerged and participants discussed, 'the patient [manikin] as if they were actual patients advocating for them and expressing relief when their conditions improved or sadness when they deteriorated' (p. 129). Additionally, Maruca et al. (2015) had nursing students wear an ostomy appliance, with simulated fecal matter and urine for 48 hours. The results of the study indicated an increase in the awareness of empathy as a necessary skill for nurses. This type of immersive role-play simulation could be modified for a variety of health conditions. Schweller et al. (2014) studied the empathetic responses of medical students before and after simulated consultations with standardized patients. The consultations were followed by in-depth debriefing sessions where issues such as the patient’s feelings towards the condition, student’s feelings towards the patient and the concept of empathy were thoroughly explored. The combination of a well planned simulation activity and a facilitated debriefing - focusing on the emotions and reflections of the students - can yield rich and robust learning around empathy.

The authors of 'Living Dolls' have chosen manikin based simulation as their barometer for what simulation learning entails. We are responding by presenting, as an example, a manikin based end-of-life simulation scenario. This scenario was used with a group of undergraduate nursing students. It provided students with an emotionally charged experience in which, after the scenario, they articulated an understanding and identification of another's perspective: essentially they experienced empathy.  

This end-of-life scenario entails a standardized patient as the son and a dying father (high-fidelity manikin) who has stage four mesothelioma lung cancer. The father is being cared for by homecare nurses (nursing students) who must attend to his psychosocial, emotional and physical needs. When his condition deteriorates, he is transferred from his home to the emergency department (ED). He arrives in the hospital hemodynamically unstable, goes into ventricular tachycardia and progresses quickly to asystole. A full code is called and advanced cardiovascular life support is initiated. The son arrives in the ED. Resuscitation efforts are stopped after discussion between the son, nursing students and the physician. The family member remains at the bedside requiring empathetic care and direction with funeral arrangements. At the completion of this scenario students are given the opportunity to provide post mortem care for the deceased body. All participants engage in debriefing including the standardized patient (Bornais & Rickeard 2014). A full version of this scenario can be found at this link.

Students who have experienced this simulation stated that:
·         'The son [standardized patient] being present was good, it helped make the situation real. I feel better prepared while dealing with family members of a dying patient.'
·         'The scenario was extremely realistic. The [standardized patient] who played the son helped greatly with dealing with family in end-of-life scenario.'
·         '...I learned a lot about my own feelings (about death). This was very important.' (Rickeard & Bornais 2015).

Unfortunately the authors of 'Living Dolls' portray their perception of simulators as merely ineffective, uncommunicative, static objects. This may have been an example of simulation being done poorly or the wrong modality being used. As with any teaching strategy, simulation can be done ineffectively. It can be used at the wrong time, for the wrong learners. It can be poorly designed, facilitated and debriefed. This may have been the case for the authors of 'Living Dolls.'  All of this underscores the importance of understanding that simulation is an evolving specialized field of knowledge with experts and faculty development and facilitator training being essential for the effective use of this pedagogy.

In summary, Dean et al.’s (2016) editorial illustrates three important misconceptions about simulation. First, the understanding of what constitutes simulation can be confusing. Simulation is a teaching pedagogy, not just static technology. It is dependent on the integration of clearly planned learning objectives, scenario development, matching and using the appropriate modality and facilitating meaningful debriefing. Secondly, clinical experiences do not ensure that a student will experience empathy nor does it guarantee that students will have the opportunity to reflect on their own feelings or those of others. Furthermore, a clinical experience does not ensure empathy will be discussed or valued by students. Lastly, through the end-of-life example, we hope to have provided Dean et al. (2016) with an approach to use simulation to teach empathy: one which uses learning objectives, appropriate modality, a well planned out simulation scenario and meaningful debriefing.

Judy AK Bornais  RN, BA, BScN, MSc, CDE; Experiential Learning Specialist, Teaching Leadership Chair, Faculty of Nursing, University of Windsor, Windsor, Ontario

Karyn Taplay  RN, PhD; Assistant Professor, Department of Nursing, Brock University, St. Catharines, Ontario

Timothy Willett  MD, MMEd; Interim President, SIM-one Healthcare Simulation Network

Elizabeth Horsley  RN, MEd, CHSE; Clinical Simulation Coordinator, Department of Nursing, Brock University, St. Catharines, Ontario


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