November 1, 2023By Erin Carn Bennett

How to Handle a “Difficult” Participant in Healthcare Simulation

Occasionally, as a healthcare simulation facilitator, a “difficult” or disruptive participant may be present in a clinical simulation scenario or course. A key question for new clinical simulation debriefers is how to manage this situation professionally and effectively. Important to consider is that one terrible experience for a learner when first engaging with medical simulation training may be extremely difficult to overcome later on, and so careful consideration on this topic should be encouraged to clinical faculty early in the adoption of the adult learning methodology. This article by Erin Carn-Bennett, MSN, RN, will explore the thoughts behind why a participant may display “difficult” behavior in a healthcare simulation and considerations for the management of the situation.

Assumptions Must Be Discussed Early

A clinical simulation participant may be considered difficult for displays of behavior such as derailment of the scenario due to a lack of participation, abrasive communication style in scenario or debrief, and inappropriate comments and tone that impact the clinical simulation experience of other participants present. Often, there can be a tendency for others to make assumptions about why these behaviors have occurred.

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Many clinical simulation programs will read out loud a “Basic Assumption” statement to participants before the scenario. A basic assumption usually includes that the clinical simulation faculty members believe that participants present in the clinical simulation are here to do their best and are well-trained professionals in their jobs. During these disruptive encounters, facilitators can lean on the basic assumption with kindness and curiosity and remove judgment of any difficult behavior displayed by participants. The reality is that unless shared, the facilitator and other participants will not know why the participant behaved in what was considered difficult.

Difficult behavior in a clinical simulation may be displayed by some clinical simulation participants for many reasons. Some reasons include stress, a lack of confidence, and personal reasons from home that may have been bought into work. No one is able to perform at their best every day, and everyone has bad days. People are often much harder on themselves than facilitators or peers after a suboptimal performance in a clinical simulation.

Andragogy Has Many Components Which Must Be Considered

Many learning theories are used in clinical simulation. In the 1980s, Malcolm Knowles first described Adult Learning Theory and the seven principles of andragogy, or learning as an adult. The adult learning theory is described as the art and science to teach adults. Adult learning theory is commonly woven and referred to throughout the structures of most clinical simulation programs. The seven principles include self-direction, transformation, experience, mentorship, mental orientation, motivation, and readiness to learn. To motivate and engage adult learners in clinical simulation, these principles are the essential foundations used to engage adult learners.

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When a participant struggles in the clinical simulation environment, this can be an opportunity to review how faculty have not met the participant’s needs. Although behavior may be from external factors, this can not be assumed. The behavior may also be a sign of frustration by the adult learner not having their learning needs met as per the seven principles of adult learning. The best way to discover the reason for the behavior is to have a one-on-one conversation with the participant.

Adult Learners in Simulation Must Be Respected

Healthcare simulation is set up well for the adult learner, but the technology is new and unique to contemporary education and practice. In a clinical simulation environment, the adult learner is able to translate self-directed learning into a hands-on educational experience. Participants are generally internally motivated and are able to draw on prior experiences and situations from real life to translate into hands-on learning in clinical simulation. If ready to learn, the clinical simulation participant can have a transformative experience, particularly in the debrief, while mentored to reflect on their own and the team’s performance. Learning does not cease at the end of the scenario and may continue for some time for the adult learner. This may be from either a positive or perceived negative experience. As such, one must be careful to recognize the challenges inherent with the methodologies and especially when using innovative technologies never experienced before.

Curiosity Should Not Be Crushed

Some learners may be frustrated if difficult behavior is not addressed directly with the participants involved. As faculty, there is great importance to remain neutral and unbiased in the approach toward participants in the clinical simulation scenario. Curiosity is a wonderful approach in debriefing to unpack any events that may appear to confuse or cause frustration for participants.

The facilitation should notice non-verbal communication from participants within the clinical scenario and the debrief. With all previously mentioned above, consider how to respond in the debrief. If the participant considered difficult has no eye contact, and has a low affect in the debrief, consider the decision to honor their lack of participation in the moment. If there is a contribution of one word answers in the initial phase of the debrief, consider a prompt for expansion so that more of their frame of mind is shared. For example: “awful” may be expanded with a prompt for more information to “felt awful as didn’t perform at best today. The morning at home was full of challenges that have continued into the scenario today.”

Genuine curiosity and the ability to meet participants where they are and encourage their progression can be incredibly powerful. With gentle persuasion, even the most irate of participants can move through emotions via reflections on their actions. This can be a powerful moment for participants to realize the impact of their behaviors and adapt for next time.

Confidentiality in Clinical Simulation is a Must

There is importance in an explicit description of confidentiality before the clinical simulation scenario. Assure participants that their individual performance within the scenario or debrief will not be shared with others external to the clinical simulation. Confidentiality is essential as it assists with clinical simulation participants’ ability to feel more psychologically safe to contribute to the clinical simulation and the debrief.

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Encourage Space for Concerns to Be Addressed

If there appears to be no disclosure or exploration of the perceived difficult performance in the debrief and concern remains afterward, have a process to support the participant. A simple check-in to ask if they are okay can be hugely impactful. The participant who has displayed difficult behavior may open up or have more insight in a one-on-one environment. Listen to all that is shared, and acknowledge and validate all emotions. Where required and appropriate, don’t be afraid to offer external support via mentorship, suggest seeing a counselor, or offer to follow up with a phone check-in within one to two days.

This article has explored when a participant has displayed difficult behavior in a clinical simulation. Particularly for new debriefers, this can be a thought that provokes overwhelm. However, as discussed, adult learners learn via several principles. A participant will turn up to clinical simulation and not participate or derail a clinical simulation for a number of reasons. As facilitators, we must trust our adult learners and manage this delicate situation in a sensitive and effective way to promote introspection and alterations in behavior.

Learn More About Difficult Conversations Skills in Clinical Simulation Debriefing?

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