Tips to Use Clinical Simulation to Address Conformity Behaviors
In order to conform to cultural norms and/or hierarchies, healthcare professionals and learners may make clinical decisions which they know to be incorrect or for which they have insufficient knowledge to determine a safe intervention. A recent article titled, “Twelve tips for using simulation to teach about conformity behaviors in medical education,” by Ghazwan Altabbaa, Tanya N Beran, Michelle Arlene Drefs, and Elizabeth Oddone Paolucci, offers 12 tips for educators in the use of clinical simulation to help healthcare learners understand how social influences such as conforming to cultural or social norms can affect their clinical decision making behaviors.
Tip 1: First, the authors note that conformity is only one element of social influence and its meaning should be clearly defined. For example, an individual’s response may be based on obedience such as obeying a senior member of staff, compliance such as following a direction from a person of similar/lower status, or conformity when the learner follows what others do even though the learner knows their action is incorrect. Altabbaa et al. note creating scenarios that address these issues is difficult. All scenario development should include careful planning to protect the psychological safety of the learners.
Tip 2: Design a scenario with a clear learning objective related to conformity behaviors which matches the learner’s level. Altabbaa et al. chose Diabetic Ketoacidosis (DKA), Community Acquired Pneumonia (CAP), Upper GI Bleeding (UGIB), and Clostridium Difficile Infection (CDI) for their simulation. All scenarios included standard diagnostics and prescriber orders as well as typical assessment findings. Learners were expected to be familiar with, although not necessarily experienced with, all the clinical parameters and interventions.
By choosing a relative clinical situation with which the learner should be familiar, the learners would be able to focus on the effects of social influences on their behaviors. Appropriate clinical learning outcomes were identified for each scenario. For example, for the DKA scenario, the social influence learning outcome was “Manage the risk of conformity even when the learner has prior knowledge but has little experience”. The learner is required to differentiate between DKA and HHS.
A senior resident gives a verbal report which includes a diagnosis of Hyperosmolar Hyperglycemic Syndrome (HHS) although labs clearly indicate DKA. The learner is later provided an opportunity to give a report to another staff member and may or may not “conform” to the resident’s diagnosis, rather than report the correct diagnosis (DKA).
Tip 3: Select a stimulus or trigger for the scenario. For example, consider using a team situation where an individual might “conform” because of their desire to become one of the group. Another example of a stimulus might include a clinical situation in which the learner has some knowledge of a clinical situation but lacks sufficient experience to make correct interventions. Clinicians may feel pressure to intervene even though they know they lack the necessary experience.
Tip 4: Once the event trigger has been developed, the actual mechanism for the trigger should be created. Altabbaa et al. identified four components in this step: give learners adequate time to review and manage medical information, allow learners to proceed with their knowledge and skills, match clinical skills to the appropriate discipline and create specific detailed steps (a timeline) for the scenario. Well-rehearsed confederates are key for this step.
Tip 5: Specific and measurable outcomes must be included. For example, the learner must state the correct diagnosis or intervention, or exhibit a certain behavior which does or does not conform to the stimulus. A framework for both types of behavior may be created to facilitate correct evaluation of the responses by educators.
Tip 6: Ensure the psychological safety of learners. Consider that during the scenario, a learner’s desire to conform may have led them to make an unsafe clinical decision or intervention. This is a potentially harmful situation for the learner particularly during debriefing. The authors stress the importance of psychological safety following nationally identified standards for simulation ethics; however, they also recognize the need for alerting learners to possible errors due to conformity behaviors.
One strategy identified in the article is to provide prompts to learners during the prebriefing. Prebriefing always includes a review of all learning objectives. The following statement is typically used during debriefing. “In today’s scenario, we will be sharing a clinical situation where uncertainty and different kinds of pressure might affect our decision making. The purpose is to recognize areas for improvement and become aware of some communication strategies to manage such situations”.
Tip 7: Learners may either conform or not. Both responses may induce positive and negative emotions. Educators should be prepared for this to happen and have some strategies on hand to convert the situation to a learning experience. The article includes detailed information for educators. The authors recommend that only experienced simulation educators attempt “conformity behaviors” simulation scenarios.
Tip 8: Beta-test the scenario with different learners or groups and experienced educators. Use phone calls or confederates etc. to offer prompts where necessary. Do not hesitate to end a scenario if a learner appears to be distressed.
Tip 9: Use a debriefing method that focuses on reflection and frames of reference. All debriefers should hold the learners in high regard. The educator themselves may reflect on their experiences and consider sharing about similar situations they have faced. Silence, eye contact, humor, facial expression and body language of both earner and educator, all play a part in a thoughtful and supportive debriefing.
Tip 10: Use additional resources from literature. For example, information on interpersonal working relationships and collaboration, and visual representations such as concept maps, may be helpful.
Tip 11: Recognize that conformity and compliance in healthcare is necessary. Following national resuscitation guidelines and infection control are two examples where conformity is beneficial. Altabbaa et al. suggest conformity and nonconformity should be balanced but primarily driven by patient safety concerns. Having learners share their inner thoughts can be helpful, as is a discussion of various communication tools.
Tip 12: Typically at the end of a simulation, educators should summarize the learning points (take-home points). During the closing phase, educators should be careful to identify any learner that is stressed or confused, and intervene as needed. In addition, the final debriefing phase offers educators a time to assess whether the learning outcomes have been met in a safe and constructive learning environment. Identification of potential gaps in the learning experience should be noted and addressed for future simulations.
Altabbaa et al.’s article is full of helpful advice and tips for simulation educators on the design and implementation of healthcare simulation specifically related to the impact of social influence and conforming behaviors on clinical practice.
Altabbaa, et al., 2021. Twelve Tips For Using Simulation to Teach About Conformity Behaviors in Medical Education. Medical Teacher, 2021 Feb 23;1-15. Doi: 10.1080/0142159X.2021.1879375).
Dr. Kim Baily, MSN, PhD, RN, CNE has had a passion for healthcare simulation since she pulled her first sim man out of the closet and into the light in 2002. She has been a full-time educator and director of nursing and was responsible for building and implementing two nursing simulation programs at El Camino College and Pasadena City College in Southern California. Dr. Baily is a member of both INACSL and SSH. She serves as a consultant for emerging clinical simulation programs and has previously chaired Southern California Simulation Collaborative, which supports healthcare professionals working in healthcare simulation in both hospitals and academic institutions throughout Southern California. Dr. Baily has taught a variety of nursing and medical simulation-related courses in a variety of forums, such as on-site simulation in healthcare debriefing workshops and online courses. Since retiring from full time teaching, she has written over 100 healthcare simulation educational articles for HealthySimulation.com while traveling around the country via her RV out of California.