Creating a Safe Remote Learning Healthcare Simulation Environment

Guest author Candace “Candy” A Campbell, DNP, RN, CNL, CEP, LNC, FNAP, Healthcare Consultant, Leadership Coach, Academic at Peripatetic Productions and Candy Campbell & Co. shows us how to decrease student performance anxiety by creating a safe remote learning environment. Combining her experiences with clinical education, acting, aviation flight attendant simulation training and innovative spirit, Candy shares with us how to better prepare students in distance-based classrooms with the practice of applied improvisational exercises in pre- sim lab and in-situ Clinical Simulation debriefing. Candy writes us…

History

The use of role-play or simulated learning is not a new concept. This method has been utilized in medicine since the use of the earliest simulated manikins in the 1700s, by Madame du Coudray, a midwife in the court of King Louis XV, who used childbirth simulators for training lay-midwives. Since then, the practice has evolved to a much more complicated use of sophisticated manikins and/or surrogate patients who help enact certain case study scenarios. Interestingly, the research shows that no matter how experienced the clinician, no matter whether the industry is aviation, military, or healthcare, learners often complain that they suffer physiological and psychological symptoms of anxiety (a kind of stage fright) before, during, and after simulations.

As a trained actor, this author and educator recognized the learner problem and sought to mitigate the anxiety by utilizing applied experiential exercises from principles of improvisational theatre arts during in-person simulations.  The object was to create a safe environment for learning in two phases: 1) during the pre sim lab, and 2) during the actual simulated scenes, to alleviate or decrease much of the anxiety and increase learning. The process outlined here has been used successfully with in-person simulations. Remote or online simulations require a slightly different approach, as the hands-on deliberate practice element is missing, but have been used successfully.

Pre-Lab Process

The practice of the flipped classroom works well to save time and prepare students for the class. (Faculty assigns video and discussion questions to be addressed during the class). Before the class begins, is the time to make sure students are familiar with the technical aspects of the remote system.

To begin the first simulation class pre-lab orientation, include a discussion about the real-world challenge and necessity to form-storm-norm-and perform as a team with persons we may not have met before. In terms of practice, often the same individuals will have infrequent opportunity to engage with others. However, cognitive research about the ability to form a trusting professional relationship has shown the ability to quickly relate to another person is necessary to communicate effectively.  Therefore, the Pre-lab includes a 2-minute ice-breaker exercise meant to demonstrate how we can establish a collegial relationship quickly. This exercise can be duplicated in a remote classroom by placing students into break-out rooms and then coming back together and sharing with the group.

The next pre-lab exercise includes practice recognizing non-verbal communication. This can easily be adapted to a remote environment, also. Then, a review of the expected in-person policies/procedures should be discussed and questions answered. Use of the Socratic method is helpful to keep the conversation going and ensure all students have completed the required preparatory work, including how-to videos and discussion questions assigned. This may take 30-40 minutes, depending upon the experience of the non-licensed learner.

Lastly, provide an orientation to the remote work and how it well be different from in-person simulations. Notably, the person playing the role of the patient can be a predetermined/hired Standardized Patient (SP) confidant or one selected from the student group. [Note: Because of small or dwindling university budgets for SPs, this author has had success by allowing students to rotate through the roles of patient and/or family members.] Faculty should divide the case into scenes, dependent upon the time allotted and the number of students. Simulated learning works well with smaller groups, so everyone has a chance to be directly involved. Equally as important, each student should also have the opportunity to be an objective observer and add to the final discussions.

Students should be assured that the main outcomes goal of simulated learning is to make the simulation more like rehearsal and less like testing, so that real learning will commence. The idea of practice vs. evaluative learning should be discussed during this time. The faculty will retain the posture of ‘coach’ vs ‘critic.’ Similarly, all students are encouraged to be supportive of fellow students, whether they play a role or are observers; no shaming and/or blaming allowed. This is a place to make mistakes and leave having learned best practices.

Included in the pre-lab directions should be some general information about the planned scenes for that session, e.g., that there will be X number of scenes and that each scene might involve 1, 2, or more players, and how images will be projected on part of the screen to trigger the activities needed. If, for instance, the topic is Postpartum Hemorrhage and faculty has planned three scenes, you might say: “The topic today is, what?  Yes, PPH. What do you think will happen to the patient in scene 3? A hemorrhage, yes. Who do you think you will need to call? “(Etc.) Having these general discussions in advance helps learners prepare and decreases anxiety.

Lastly, students should be assigned their roles in advance of the scenes. If using students to also play patient or family roles, learners might vote on whether they want to volunteer or be randomly assigned to each scene and their role within it.

During this preparation, the Rules of Engagement for In-Sim Debriefing are Explained:

• Because patient/manikin images are used and hands-on learning is not available, learners should preface their needed actions in the present tense, “as if”, e.g.,” And now I am placing the BP cuff on the patient’s right arm because there is a PIV in her left arm…”
• Anyone is allowed to stop the action with a Timeout during the simulation, a so-called, Pause for Information, if they have a question. Only the students playing the part of clinicians are allowed to pause the scene, either by raising a hand or a verbal request.
• Faculty also may signal a Timeout, dubbed a Pause for Information or Contemplation, to dialogue with learners about the reaction of certain actions or words/phrases.
• After a Timeout discussion, faculty will signal a continuation of the scene with a command to “Rewind from the place where _____ happened.” Learners begin again from that point, with new knowledge and understanding of their words and actions.
• Action continues until the next Timeout or faculty states, “End of scene.”
• All learners convene for a communal debriefing so that everyone can share their thoughts and insights. Players should speak first. Generally, these questions should be answered:
  • How did it feel to be in that scene?
  • What worked well?
  • What surprised you / didn’t work well?
  • What would you do differently / what did you learn?

Observers should all be supportive and add to the discussion. Based on this practice, the end debriefings will be shorter. Learners should be congratulated for completing the class and encouraged that learning occurs incrementally.

Conclusion: The Reality

Now that COVID19 has emerged globally, we must adapt to the change. Some university Simulation Center were able to pivot quickly because the staff had already been considering ways to adapt to assist learners who may have been out of class and needed to make-up a lesson remotely or in a virtual environment. This proven method of In-Sim Debriefing may be utilized as a mechanism to improve performance and competency of non-licensed learners in simulation training. Intro Exercises for remote learning include:

Exercise #1:

• Learner outcomes: Learners practice listening skills. Introducing another person validates that person and begins the process of relationship building and trust.
• Instructions:
• Students will be randomly assigned to breakout rooms (2-3 students max)
• In break-out rooms, students will have 2 minutes each to answer the questions with NO interruption. Listeners will NOT take notes, but commit the details to memory to introduce the other person to the class.
  • What is your name? What do you like to be called? (nickname)
  • Where do you call home? Where are you right now?
  • What healthcare experience, if any, do you bring to the program? (As a volunteer, patient, caregiver, other?)
  • What is the reason you chose this major?
  • What do you do for fun?
• After the allotted time, learners can share common thoughts, then re-join the main room.
• When called upon, students take turns introducing another person in their

Exercise #2:

• Learner Outcomes: Learners practice recognizing subtle non-verbal cues to assist the clinician in establishing a therapeutic, trusting relationship.
• Instructions: Faculty prepares one slide with a list of at least 12 emotions (more is better) and a randomized, non-alphabetical, list of learners in the class.
  • Number the list of students. (Each student is told their number prior to Exercise #1.)
  • Faculty asks for a student volunteer assistant. (If no one volunteers, pick someone.)
  • Faculty presents the list of emotions
  • The volunteer is asked to choose an emotion from the list, then strike a pose (waist-up) to model the emotion and maintain it. Faculty thanks the volunteer for the pose
  • In the open mic or the CHAT box, the group comments about what emotion they think the person is trying to convey.After several people have commented, Faculty asks the student what word/concept they intended to convey and leads the ensuing discussion about what the modeled expression/pose says to each person.
  • Faculty encourages everyone to thank the volunteer, then calls out another random number (or just go around the circle) until everyone has modeled an emotion, including faculty.
  • Discussion: Ask the group what they learned from this exercise? What surprised them about one or more posed emotions?

Exercise #3: (Round Two of #2 Above)

• Learner Outcomes: Learners practice recognizing subtle non-verbal cues and beginning/extending a conversation with therapeutic, open-ended questions.
• Instructions: Faculty prepares a list of open-ended conversation-starters (see below)
  • Faculty asks for another student volunteer assistant to play the patient. (If no one volunteers, pick someone.)
  • Faculty presents the list of emotions.
  • The volunteer patient is asked to choose an emotion from the list, then strike a pose (waist-up) to model the emotion and maintain it. Faculty thanks the volunteer for the pose
  • Faculty asks for yet another student volunteer to play the clinician. (If no one volunteers, pick someone.)
  • Faculty asks the 2^nd volunteer to have a short conversation with the patient, beginning with one of the suggested open-ended questions/statements from the list.
  • After a short exchange, Faculty thanks the players and begins the debriefing discussion with the players.
  • Faculty may ask several questions to each player re: assumptions, what worked, what didn’t work, what they would change/ lessons learned.
  • Open the discussion to the group and learn of their observations.

Exercise #4

• Learner Outcomes: Learners write about their lessons learned both as playing a patient/family member and as a clinician.
• Preparation: Faculty will ask students to come to class with ability to write in their class journal.
• Instructions: Allow 5 minutes
• Faculty allows students to write down their reactions to the class exercises so far. Encourage them to keep the journals private.
  • “What are your take-aways from playing the role of a patient/family member so far?”
  • “What are your take-aways from playing the role of the clinician so far?”
  • “What surprised you about what happened in these exercises?”

More About Candace 

Candace (Candy) Campbell, DNP, RN, CNL, CEP, LNC, FNAP is an international speaker, award-winning actor, author, filmmaker, and healthcare academic. Her research includes work with Vietnam War veterans and familes of micropremature babies who suffer from PTSD, elective cesarean outcomes and implications for maternal-child health, and the history of the nursing profession. As a professional actor, she has worked on stage, screen, and radio. Candy co-founded an improv and stand-up comedy troupe in the San Francisco area and has taught both improv and clinical simulation to intra- and inter-professional groups. Her third solo show is, “An Evening with Florence Nightingale: A Reluctant Celebrity.”

Visit Candy Campbells’ Website to Learn More!

References

1. Gardner, R., & Raemer, D., (2008). Simulation in Obstetrics and Gynecology, Obstetrics and Gynecology Clinics of North America. 35(1), pp 97-127 https://doi.org/10.1016/j.ogc.2007.12.008
2. Iacono, C.S., & Weisband, S. Developing trust in virtual teams, Proceedings of the Thirtieth Hawaii International Conference on System Sciences, Wailea, HI, USA, 1997, pp. 412-420 vol.2, doi: 10.1109/HICSS.1997.665615.
3. Al-Ghareeb, A., McKenna, L., Cooper, S. (2019). The influence of anxiety on student nurse performance in a simulated clinical setting: A mixed-methods design, International Journal of Nursing Studies, 98, pp 57-66.
4. Ericsson, A., & Poll, R.  (2017). Peak: Secrets from the New Science of Expertise. Boston: Houghton Mifflin Harcourt.
5. Tuckman, B. (1965). Developmental sequence in small groups.Psychological Bulletin. 63 (6): 384–399. doi:1037/h0022100. PMID 14314073.
6. Campbell, C. (2018). Improv to Improve Healthcare A System for Creative Problem-Solving. San Francisco: Peripatetic Productions.