The educational value of improvisational actors to teach communication and relational skills: perspectives of interprofessional learners, faculty, and actors

Everyday Clinical Ethics: Essential Skills and Educational Case Scenarios

Bioethics conjures images of dramatic healthcare challenges, yet everyday clinical ethics issues unfold regularly. Without sufficient ethical awareness and a relevant working skillset, clinicians can feel ill-equipped to respond to the ethical dimensions of everyday care. Bioethicists were interviewed to identify the essential skills associated with everyday clinical ethics and to identify educational case scenarios to illustrate everyday clinical ethics. Individual, semi-structured interviews were conducted with a convenience sample of bioethicists. Bioethicists were asked: (1) What are the essential skills required for everyday clinical ethics? And (2) What are potential educational case scenarios to illustrate and teach everyday clinical ethics? Participant interviews were analyzed using qualitative content analysis. Twenty-five (25) bioethicists completed interviews (64% female; mean 14.76 years bioethics experience; 80% white). Five categories of general skills and three categories of ethics-specific skills essential for everyday clinical ethics were identified. General skills included: (1) Awareness of Core Values and Self-Reflective Capacity; (2) Perspective-Taking and Empathic Presence; (3) Communication and Relational Skills; (4) Cultural Humility and Respect; and (5) Organizational Understanding and Know-How. Ethics-specific skills included: (1) Ethical Awareness; (2) Ethical Knowledge and Literacy; and (3) Ethical Analysis and Interaction. Collectively, these skills comprise a Toolbox of Everyday Clinical Ethics Skills. Educational case scenarios were identified to promote everyday ethics. Bioethicists identified skills essential to everyday clinical ethics. Educational case scenarios were identified for the purpose of promoting proficiency in this domain. Future research could explore the impact of integrating educational case scenarios on clinicians' ethical competencies.

Integrating real-world skills and diabetes lifestyle coach training into a revised health promotion and communications course

BACKGROUND AND PURPOSE

Effective communication skills are essential for all pharmacists, regardless of practice setting. An implicit need in pharmacy education is to emphasize direct application of these skills to future healthcare practice prior to experiential rotations. The aim of this article is to describe how we revised a required first professional year (P1) doctor of pharmacy course to achieve two main goals: 1) improve the course relevance by connecting content to real-world skills; and 2) qualify all pharmacy students at our institution as certified National Diabetes Prevention Program (DPP) lifestyle coaches upon course completion.

EDUCATIONAL ACTIVITY AND SETTING

Lifestyle coach training approved by the Centers for Disease Control and Prevention (CDC) was integrated into a P1 communications course consisting of 14 modules that include: review of diabetes pathophysiology, group facilitation skills, social determinants of health, food tracking, action planning, participant retention and program administration. This content serves as a direct application of pre-existing course objectives related to knowledge (evidence-based theory) and skills (technical and counseling) required for effective communication with patients, families, and health professionals.

FINDINGS

Between 2019 and 2022, the redesigned course was offered to 373 P1 students. Course evaluations during this time were consistently positive. The average evaluation score since DPP activities were integrated into the course was 3.41 (on a 4-point scale). Based upon course evaluations, students appreciated three main benefits of incorporating lifestyle coach certification into the pharmacy curriculum: 1) a certified skill that can differentiate them in the job market; 2) practice of skills on real patients under faculty supervision in the community setting; 3) early exposure to pharmacy patient care topics, thus contributing to professional identity.

SUMMARY

Integration of lifestyle coach training into an existing core P1 pharmacy course increased application and assessment of communications skills and allowed wider availability of trained coaches to deliver DPP in the community.

Three perspectives on learning in a simulated patient scenario: a qualitative interview study with student, simulated patient, and teacher

INTRODUCTION

Patient simulation can be useful for medical students in developing communication skills for vulnerable situations. Three participants are primarily involved in the patient simulation activities: the student, the simulated patient (SP), and the teacher. We here aimed to explore these participants' perceptions of learning in a patient simulation scenario.

METHODS

We conducted individual interviews with eight students, three teachers, and one SP at a psychiatry placement of a Medical Doctor Program (5th year). During the interviews we asked the participants to watch a video of their participation in a patient simulation session. Thus, we obtained three perspectives on each of the eight recordings. We analysed our data with qualitative content analysis.

RESULTS

Three themes were generated: identity formation, collaborative learning, and learning intentions. This highly emotional scenario forced students out of their comfort zone, to the intersection of their roles as private person and professional. The SP perceived the collaborative creation of the scenario as significant learning. The teacher took a professional position and perceived the learning in the perspective of a future colleague.

CONCLUSIONS

The mutually created emotionally loaded scenario was found to be important from all three perspectives, forcing the students to identify unexpected ways of communicating. This possibly enhanced their professional identity development. Implications for future research can be to explore the process of skills transfer.

Medical students' experiences of working with simulated patients in challenging communication training

BACKGROUND

Physicians' communication skills are important for patient-centered care. Although working with simulated patients (SPs) in case simulations is common for training communication skills, studies seldom include a wide range of challenging behaviors or explore students' own experiences of learning communication skills with SPs. Therefore, this study was aimed at investigating how medical students perceive communication training involving challenging consultations with SPs and the impact on their learning experiences.

METHODS

Twenty-three medical students from the same class were interviewed in focus groups about their experiences of simulation training with actors as SPs. In the simulation training, the students were instructed to deliver bad news, manage negative patient reactions, and encourage behavioral changes in reluctant patients. This was followed by feedback and a debriefing exercise. The interviews were analyzed with content analysis.

RESULTS

Students reported that actors as SPs made the simulations more realistic and enabled them to practice various communication skills for challenging consultations in a safe way and manage their own feelings, thereby promoting new learning experiences. Elements such as actors' flexibility in changing behaviors during role-play and exposure to different challenging behaviors, like negative emotions, were regarded as valuable. The importance of an accepting and permissive climate for the debriefing exercise was highlighted, though without taking too much time from the simulation training. Feedback directly from the SP was appreciated.

CONCLUSIONS

Actors as SPs were perceived as a valuable part of challenging communication training and added elements to the learning process. Future studies should include a wider range of challenging behaviors in training with SPs and evaluate the effects of such training on students' use of communication skills.

Overcoming language barriers, enhancing collaboration with interpreters - an interprofessional learning intervention (Interpret2Improve)

BACKGROUND

Language barriers (LB) are common in patient care. They can negatively impact the quality of care, and increase costs. LB can be overcome by using interpreters. However, collaboration with interpreters is a professional activity which can and needs to be learnt. Interpret2Improve is an innovative educational intervention where medical and nursing students learn together how to address LB and effectively collaborate with interpreters.

METHODS

The three-hour course has two parts: After a short introduction on the relevance of LB and resulting issues of patient safety etc., students in interprofessional teams of two practice conversations with non-German-speaking simulated patients and professional interpreters. The course is evaluated in a pre-post format with the Freiburg Questionnaire for Interprofessional Learning Evaluation which has been validated in prior studies.

RESULTS

Fifty-one students (thirty of the participants were medical students, 21 participants were students in nursing care) participated from 11/2016-07/2018. Overall, the course was very well received (mean 1.73 (SD 0.85) on a five point scale: 1 = very good, 5 = insufficient). The evaluation by medical and nursing students differed significantly. Fourteen out of twenty-one items show a self-assessed increase in interprofessional knowledge or skills.

CONCLUSIONS

Students felt that their skills in addressing LB by effectively collaborating with interpreters increased during this interprofessional format. Further studies are needed to obtain further evidence beyond self-assessment and regarding the long-term outcomes.

Advancing communication skills in intensive care: Caring for relatives of critically ill patients

OBJECTIVE

The aim of this study was to explore critical care nursing students' experiences with simulation-based communication skills training focusing on relatives.

METHODS

Two complex scenarios were developed using professional actors in the role as relatives. A survey was conducted with critical care nursing students from 2017 to 2020. We performed descriptive and correlational analysis of the quantitative data and thematic analysis of the open-ended questions.

RESULTS

The total learning outcome was 4.10 (SD = 0.79, N = 98) on a Likert scale from 1 to 5. The learning outcome with the use of a professional actor was 4.65 (SD = 0.6, N = 118), and the experience of realism was 4.16 (SD = 0.85, N = 67). The students rated the debriefing as 4.38 (SD = 0.73, N = 118), and they experienced more positive emotions than negative during the simulation.

CONCLUSION

High learning outcomes were reported. The use of professional actors with fine-tuned improvisational skills enhanced the sense of realism in the scenarios. However, the impact of emotions on learning outcomes should be further investigated.

PRACTICE IMPLICATIONS

By obtaining advanced communication skills focusing on relatives during their nursing education, critical care nursing students can improve the care they give.

Aligning Family-Clinician Expectations During Pediatric Surgical Informed Consent: Development and Implementation of an Innovative Communication Skills Workshop

INTRODUCTION

Aligning expectations during the informed consent process before a child's surgery is an important element of good communication that benefits both surgical staff and families. We developed and evaluated a 2-hour pilot interprofessional workshop to improve the communication and relational skills of pediatric surgeons and nurse practitioners.

METHODS

Focus groups with families identified key challenges in the process of informed consent. An interprofessional team, including parents whose children had experienced complex surgeries, developed the workshop collaboratively. A realistic simulation with professional actors portraying parents allowed surgical staff to practice communication skills and receive feedback about the parent perspective. Participants completed a postworkshop evaluation to determine whether the workshop met its objectives and whether they would change practice.

RESULTS

Five key themes identified for the workshop included customize communication; align expectations; share clinical uncertainty; recognize/attend to emotions; and identify team members. Thirty-five clinicians participated in a workshop, and 89% completed evaluations. Three-quarters reported the learning to be valuable, and 64% were likely to change practice. Eighty-seven percent would recommend the workshop to other colleagues, and 58 to 74% felt more prepared to achieve each of eight specific skills.

DISCUSSION

An innovative workshop for pediatric surgical practitioners to align family-clinician expectations can help improve clinician communication skills and comfort with informed consent. Keys to workshop development included involving parents to identify themes and participate as workshop co-faculty; enlisting leadership and recruiting surgical champions; and using pre-existing meetings to ease scheduling challenges of busy practitioners. Booster sessions may facilitate the desired cultural changes.

'Difficult Conversations with Patients'-A Modified Group Objective Structured Clinical Experience for Medical Students

This study presents a modified Group Objective Structured Clinical Experience (GOSCE) focused on difficult conversations, in which, due to limited time and financial resources, only some students could actively participate in scenarios. We aimed to evaluate the intervention, including differences between them and observers. The intervention was organized for sixth-year medical students at a Polish medical university. The study protocol assumed a pre-post analysis of students' attitudes and self-efficacy of communication skills and their opinions about the intervention. Complete questionnaire pairs were returned by 126 students. The pre-post analysis revealed a significant improvement in their self-efficacy levels of almost all skills as well as their affective attitudes and belief in outcomes of communication learning. The improvement was significant among both the active participants and observers. It also showed a decrease in the motivation score, significant only in females. Regardless of their roles, students had positive opinions about the course and its particular aspects. The modified GOSCE may be an enjoyable and effective learning experience for students, especially in the light of limited resources. However, changes in their motivation score suggest the necessity to increase the importance of communication learning in the curriculum.

Twelve Years of the Italian Program to Enhance Relational and Communication Skills (PERCS)

To describe the experience of the Italian Program to Enhance Relations and Communication Skills (PERCS-Italy) for difficult healthcare conversations. PERCS-Italy has been offered in two different hospitals in Milan since 2008. Each workshop lasts 5 h, enrolls 10–15 interdisciplinary participants, and is organized around simulations and debriefing of two difficult conversations. Before and after the workshops, participants rate their preparation, communication, relational skills, confidence, and anxiety on 5-point Likert scales. Usefulness, quality, and recommendation of the program are also assessed. Descriptive statistics, t-tests, repeated-measures ANOVA, and Chi-square were performed. A total of 72 workshops have been offered, involving 830 interdisciplinary participants. Participants reported improvements in all the dimensions (p < 0.001) without differences across the two hospitals. Nurses and other professionals reported a greater improvement in preparation, communication skills, and confidence, compared to physicians and psychosocial professionals. Usefulness, quality, and recommendation of PERCS programs were highly rated, without differences by discipline. PERCS-Italy proved to be adaptable to different hospital settings, public and private. After the workshops, clinicians reported improvements in self-reported competencies when facing difficult conversations. PERCS-Italy’s sustainability is based on the flexible format combined with a solid learner-centered approach. Future directions include implementation of booster sessions to maintain learning and the assessment of behavioral changes.

Simulated patient and role play methodologies for communication skills and empathy training of undergraduate medical students

BACKGROUND

Verbal and non-verbal communication, as well as empathy are central to patient-doctor interactions and have been associated with patients' satisfaction. Non-verbal communication tends to override verbal messages. The aim of this study was to analyze how medical students use verbal and non-verbal communication using two different educational approaches, student role play (SRP) and actor simulated patient (ASP), and whether the non-verbal behaviour is different in the two different poses.

METHODS

Three raters evaluated 20 students playing the doctor role, 10 in the SRP group and 10 in the ASP group. The videos were analyzed with the Calgary-Cambridge Referenced Observation Guide (CCG) and, for a more accurate evaluation of non-verbal communication, we also evaluated signs of nervousness, and posture. Empathy was rated with the CARE questionnaire. Independent Mann Whitney U tests and Qhi square tests were performed for statistical analysis.

RESULTS

From the 6 main tasks of the CCG score, we obtained higher scores in the ASP group for the task 'Gathering information' (p = 0.0008). Concerning the 17 descriptors of the CCG, the ASP group obtained significantly better scores for 'Exploration of the patients' problems to discover the biomedical perspective' (p = 0.007), 'Exploration of the patients' problems to discover background information and context' (p = 0.0004) and for 'Closing the session - Forward planning' (p = 0.02). With respect to non-verbal behaviour items, nervousness was significantly higher in the ASP group compared to the SRP group (p < 0.0001). Concerning empathy, no differences were found between the SRP and ASP groups.

CONCLUSIONS

Medical students displayed differentiated verbal and non-verbal communication behaviour during the two communication skills training methodologies. These results show that both methodologies have certain advantages and that more explicit non-verbal communication training might be necessary in order to raise students' awareness for this type of communication and increase doctor-patient interaction effectiveness.

Improving paediatric advance care planning: Results of a learning needs analysis and simulation-based education programme

AIM

To assess clinicians' experience, attitudes and confidence with advance care planning (ACP) at a quaternary paediatric referral centre using a learning-needs survey, and then apply this information to develop and examine the feasibility of simulation-based education for this topic.

METHODS

An electronic learning-needs survey was distributed to medical, nursing and allied health clinicians from departments who provide primary care for children with life-limiting conditions. Results were incorporated into the design of a simulation-based education session which was piloted with the Royal Children's Hospital Oncology Department.

RESULTS

A total of 157 learning-needs surveys were included in analysis, and included quantitative and qualitative responses from nursing, allied health, senior and junior medical staff from intensive care, general and subspecialty medical teams. Most (75.0%) participants had participated in ACP discussions previously. Only 40.1% of participants felt confident to assess appropriate timing of, and 45.2% felt adequately prepared to participate in ACP discussions. Barriers identified were both clinician and patient/parent related, including clinicians not knowing when to address issues (43.9%) or what to say (21.0%). Participants indicated that ACP discussions are most frequently initiated when death is clearly imminent. Following a pilot of simulation-based education with the oncology department, 90% of participants expressed confidence to participate in ACP discussions.

CONCLUSIONS

Barriers to paediatric ACP, including lack of clinician training, continue to contribute to delayed conversations. Simulation-based education is a valuable and feasible educational tool that can increase clinicians' understanding and confidence in this area.

Using Forum Theater as a Teaching Tool to Combat Patient Bias Directed Toward Health Care Professionals

INTRODUCTION

Health care professionals who identify as members of underrepresented and racial minority groups may experience bias from patients and patient families. These occurrences disrupt the educational and therapeutic environments, distress the targeted individuals and allies, and create potential legal liability. Yet there are few educational opportunities for individuals to brainstorm and implement strategies for responding professionally during such instances.

METHODS

Presented first as a grand rounds, then an invited workshop, and finally an invited series, this educational activity was developed in a stepwise manner over the course of a year. Each format was sequentially modified based on feedback from participants-more than 200 physicians and other health care professionals-using evaluation forms that were voluntary and anonymous. The educational activity used an adaptation of forum theater, in which participants role-played an instance of oppression with a goal of altering the ultimate outcome. This approach provided participants with the opportunity to develop and rehearse responses to workplace bias in a way that preserved the provider-patient relationship.

RESULTS

Feedback for these educational sessions was overwhelmingly positive. Participants noted the importance of acknowledging and addressing bias in the workplace and encouraged facilitators to expand the sessions in length, frequency, and scope.

DISCUSSION

Forum theater is a methodology that can be employed in health care to teach appropriate and authentic responses to expressed patient bias while maintaining the therapeutic relationship. The positive reception from participants in our preliminary sessions established a strong foundation for future improvements to this work.

Preparing the clinicians of tomorrow: Weaving integrated care across doctor of nursing practice education

In today's changing landscape of health care, integrated health care is essential for best patient outcomes. The number of people with psychiatric conditions in the United States today is staggering, but only half of these people will receive treatment for their condition. By effectively integrating psychiatric and primary health care patients can be connected to appropriate and necessary services that meet the Triple Aim of enhancing patient experience of care while achieving population health goals in a cost-effective manner. Incorporating integrated health care experiences in a DNP program can position future practice leaders to take on these challenges. Guided by DNP essentials and the National Organization of Nurse Practitioner Faculty competencies, integrated health care concepts were weaved across the DNP curriculum. Including robust academic experiences treating mental health conditions in primary care and integrated settings can increase the confidence and effectiveness of clinicians who identify, manage, and refer patients with mental health concerns. Increasing the number of doctorally prepared nurses who are educated in integrated health care helps improve clinical outcomes while transforming the health care landscape.

Assessing the Effects of a Paired TBL Session and Patient Simulation on Pharmacy Student HIV Treatment Knowledge

Description of the Problem

Pharmacists can play a crucial role in monitoring, counseling, and providing adherence checks across practice pharmacy settings; but they may not gain experience in this area until after graduating from pharmacy school.

Statement of Innovation

Students participated in an intentionally aligned team-based learning session followed by completion of an HIV patient treatment worksheet and an HIV patient care simulation. This sequence was assessed using the HIV Treatment Knowledge Scale.

Description of the Innovation

Second-year pharmacy students (N=48, 98% response rate) participated in a baseline knowledge assessment before a four-hour HIV team-based learning (TBL) session, which included the use of an online HIV Patient Management Simulator. Students were administered the scale again post-session. Three days before the simulation, students had access to an HIV patient treatment worksheet that was required to be completed before the simulation. Ten days after the initial assessment, students participated in an HIV patient simulation where they proposed a new antiretroviral plan while also addressing monitoring, barriers, and maximizing adherence for the patient. Post-simulation, students were again administered the scale. Data were analyzed using descriptive statistics, Wilcoxon and paired t-tests, as appropriate.

Critical Analysis

A total of 48 second-year pharmacy students participated. HIV knowledge increased significantly post-TBL (p < 0.001). Post-simulation, scores improved, but not significantly (p = 0.291). Knowledge on 15 of the 21 items on the HIV Treatment Knowledge Scale significantly improved from pre-TBL to post-simulation (p ≤ 0.025).

Next Steps

Future investigation should focus on the impact that HIV simulation training has on skills, abilities, confidence, and empathy.

Caring for Critically Ill Patients: Clinicians' Empathy Promotes Job Satisfaction and Does Not Predict Moral Distress

Background

Several studies have highlighted the benefits of empathy in healthcare settings. A correlation between clinicians' empathy and patients' adherence and satisfaction, as well as the ability for the clinician to accurately assess family members' needs, has been found. However, empathy is often seen by clinicians as a risk factor for their wellbeing. This study aims to assess whether the level of empathy of clinicians working in critical care settings may expose them to moral distress, poor job satisfaction, and intention to quit their job.

Methods

Italian clinicians who attended the 2016 "Smart Meeting Anesthesia Resuscitation in Intensive Care" completed the Empathy Quotient questionnaire, the Moral Distress Scale-Revised, and two questions assessing job satisfaction and intention to quit the job. Multiple linear and logistic regressions were performed to determine if clinicians' empathy influences moral distress, job satisfaction, and intention to quit. Age, gender, and profession were used as control variables.

Results

Out of 927 questionnaires distributed, 216 were returned (23% response rate) and 210 were used in the analyses. Respondents were 56% physicians, 24% nurses, and 20% residents. Over half of the clinicians (58%) were female. Empathy resulted the only significant predictor of job satisfaction (β = 0.193; p < 0.05). None of the variables included in the model predicted moral distress.

Conclusion

Empathy determined neither moral distress nor intention to quit. Findings suggest that empathy is not a risk factor for critical care clinicians in developing moral distress and the intention to quit their job. On the contrary, empathy was found to enhance clinicians' job satisfaction.

The use of actor-based immersive health and safety inductions: Lessons from the Thames Tideway Tunnel megaproject

Health and safety inductions are ubiquitous in construction but tend to be poorly designed and suffer low levels of worker engagement. In this paper we report on the evaluation of an innovative, full day, actor-based health and safety induction called EPIC, currently being used on London's Thames Tideway Tunnel megaproject. As of March 2019, more than 14,000 individuals had attended EPIC. This evaluation examines the impact of EPIC from the perspective of participants and other stakeholders, and considers the utility of actor-based immersive health and safety inductions for use more widely, in both construction and other sectors. Using a mixed-method, longitudinal approach to data collection, EPIC is evaluated against Kirkpatrick's (1959) 'four levels' framework of reactions, learning, behaviour change and results. This paper discusses factors which support and hinder actor-based inductions, and the challenges involved in assessing the impact of inductions on subsequent behaviour and health and safety outcomes.

Compassionate and Clinical Behavior of Residents in a Simulated Informed Consent Encounter

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Background

Compassionate behavior in clinicians is described as seeking to understand patients’ psychosocial, physical and medical needs, timely attending to these needs, and involving patients as they desire. The goal of our study was to evaluate compassionate behavior in patient interactions, pain management, and the informed consent process of anesthesia residents in a simulated preoperative evaluation of a patient in pain scheduled for urgent surgery.

Methods

Forty-nine Clinical Anesthesia residents in year 1 and 16 Clinical Anesthesia residents in year 3 from three residency programs individually obtained informed consent for anesthesia for an urgent laparotomy from a standardized patient complaining of pain. Encounters were assessed for ordering pain medication, for patient-resident interactions by using the Empathic Communication Coding System to code responses to pain and nausea cues, and for the content of the informed consent discussion.

Results

Of the 65 residents, 56 (86%) ordered pain medication, at an average of 4.2 min (95% CI, 3.2 to 5.1) into the encounter; 9 (14%) did not order pain medication. Resident responses to the cues averaged between perfunctory recognition and implicit recognition (mean, 1.7 [95% CI, 1.6 to 1.9]) in the 0 (less empathic) to 6 (more empathic) system. Responses were lower for residents who did not order pain medication (mean, 1.2 [95% CI, 0.8 to 1.6]) and similar for those who ordered medication before informed consent signing (mean, 1.9 [95% CI, 1.6 to 2.1]) and after signing (mean, 1.9 [95% CI, 1.6 to 2.0]; F (2, 62) = 4.21; P = 0.019; partial η2 = 0.120). There were significant differences between residents who ordered pain medication before informed consent and those who did not order pain medication and between residents who ordered pain medication after informed consent signing and those who did not.

Conclusions

In a simulated preoperative evaluation, anesthesia residents have variable and, at times, flawed recognition of patient cues, responsiveness to patient cues, pain management, and patient interactions.

Adverse Event Disclosure Training for Nursing Students: Peer Role-Play and Simulated Patients

Background Simulation has proven valuable in nursing communication training, but there are limited studies comparing the effectiveness of different training methods, especially in the area of adverse event disclosure (AED) training. Therefore, this study aimed to examine the impact of two training methods, peer role-play (PRP) and simulated patients (SP) on the self-efficacy and performance of nursing students in AED in a simulated environment. Methods Forty-four nursing students participated. Students' self-efficacy toward AED was assessed using the pre/post-test method. Also, students' performance was evaluated after the simulation encounter. Results It showed a significant difference in self-efficacy between the groups. However, no significant difference emerged between the groups in performance. Conclusion This study provides a basis for comparison of these two methods in patient communication training. Educators should consider their resources and expected learning outcomes in designing the emotionally draining adverse event disclosure training.

Evaluation of a sepsis teaching rounds simulation for pharmacy students

BACKGROUND AND PURPOSE

The goal of this prospective, observational cohort study was to determine if simulated interdisciplinary teaching rounds improved student perceptions of confidence and attitudes towards working as part of a team. The secondary objective of this study was to investigate changes in student knowledge of the management of sepsis.

EDUCATIONAL ACTIVITY AND SETTING

Students participated in a traditional sepsis lecture followed by a simulated interdisciplinary rounding experience. Confidence and collaborative attitudes were assessed using a 5-point Likert scale (1=strongly disagree, 5=strongly agree). Changes in knowledge were measured using multiple choice questions. Students completed these tools at three points in time: pre-lecture, post-lecture, and post-simulation.

FINDINGS

Student confidence and attitudes related to interdisciplinary rounds improved following the simulation (2 of 4 items, p=0.003; 2 of 5 items, p<0.05). Also, most students agreed or strongly-agreed that the simulation reinforced knowledge gained from lecture (94.7%), that lecture followed by a simulation was the most effective way to learn about sepsis (94.7%), and that the simulation helped reinforce critical-thinking skills (94.7%). Knowledge improved between the didactic lecture and the simulation, but these differences were not found to be statistically significant.

SUMMARY

A simulated interdisciplinary rounding experience may increase student confidence during teaching rounds and improve attitudes towards working alongside other healthcare professionals. Incorporating rounding simulations into pharmacy curricula may be beneficial towards student success on rounds.

Common Ground: Frameworks for Teaching Improvisational Ability in Medical Education

Issue: The practice of medicine is intrinsically unpredictable. Clinicians must respond skillfully to this uncertainty; therefore, medical educators are using improvisational theater training methods to teach improvisational ability in areas such as communication and professionalism. This teaching approach is called "medical improv." Although early reports of medical improv suggest promise, the collective descriptions of curricular content lack consistency. This ambiguity creates impediments for further implementation and research of this new educational technique. To address this challenge, the author presents two unifying conceptual frameworks for medical improv curricula. Evidence: Medical improv evolved from previous work done in improvisational (improv) theater and "applied improv," which is the broader category of improv-based training in nontheater environments. The author synthesized curricular elements from all three fields of improv into two conceptual frameworks: core curricular components (skills, principles, and exercises) and core skill groups (attunement, affirmation, and advancement). The curricular component framework simplifies terminology and clarifies a previously vague distinction between skills and principles. The skill group framework harnesses a redundant and wide-ranging list of improv skills into three categories. Together, the frameworks provide a simple structure that encompasses and organizes the core concepts of medical improv. Implications: These curricular frameworks enable educators and learners to more easily understand the scope and depth of medical improv concepts and to identify areas where medical improv could enhance existing medical education strategies. For example, there is substantial overlap between improvisation skills and current curricular objectives for communication skills, as outlined by Accreditation Council for Graduate Medical Education benchmarks (e.g., Milestones, Competencies, Entrustable Professional Activities). Medical improv courses could be an efficient way to achieve many of these objectives. In addition, improv-based exercises represent an experiential learning modality that is underutilized in communication skills training; therefore, exercises could be integrated into existing coursework to bridge the learning pathway between texts and simulation. Furthermore, the deliberate cultivation of affirmation skills could enhance resilience and wellness in clinical and learning environments. In summary, through their conceptual simplicity, these curricular frameworks for medical improv can help educators understand, study, and optimize teaching of improvisation in medical education.

An Observational Study of a Simulation-Based Cross-Discipline Learning Activity Between Theater Arts and Physical Therapy Students

INTRODUCTION

Professional actors are often used to portray simulated patients during healthcare professional training. This study aimed to create an activity where physical therapy (PT) and theater arts (TA) students could address discrete learning outcomes in a common setting with mutual benefit.

METHODS

Mixed methods observational study of 246 university students (201 PT, 45 TA) undertaking a scenario involving the provision of a clinical history. All students completed a 5-question qualitative survey relating to the activity, and each group scored themselves and each other using an observer rubric rating performance from 1 (do not agree) to 10 (agree).

RESULTS

For PT students, the range of means (SDs) across the five questions were significantly different (P < 0.001) with 6.2 (1.6) to 6.8 (1.4) for self-assessment and 8.2 (1.4) to 8.7 (1.1) for TA assessment of PT. For TA students, across all repetitions and all questions, the mean (SD) was 7.6 (1.5) for self-assessment and 7.9 (1.2) for PT assessment of TA, representing a significant difference (P < 0.001). After initial enactment, there was a significant improvement in TA self-assessment of performance (P = 0.002), but thereafter, there was no significant difference over time (P = 0.114).Qualitative data analysis revealed the following three themes common to both groups: worthiness, authenticity/realism, and anxiety/confidence. The PT students also identified history-taking skills and the importance of patient/PT relationships. The TA students identified learning around character portrayal, improvisation, and concentration.

CONCLUSIONS

This study describes a simulation-based learning activity undertaken within existing infrastructure with complementary learning objectives for both TA and PT students that was realistic and engaging.

Using forum theatre to teach communication skills within an undergraduate pharmacy curriculum: A qualitative evaluation of students' feedback

BACKGROUND AND PURPOSE

Pharmacists need to learn communication styles which adopt a more consultative model. The objectives of this paper are to describe the use of forum theatre facilitated by actors to teach communication skills to pharmacy students and to highlight perceptions of the workshops.

EDUCATIONAL ACTIVITY AND SETTING

During the actor-led forum theatre, students redirected scenes depicting pharmacist-patient consultations. Students also learned about their own communication styles and role-played consultations and interview situations with actors. Pharmacy undergraduate students enrolled in years 2, 3, and 4 answered open-ended questions online at the end of workshops. All responses were coded to identify themes.

FINDINGS

Five themes emerged from 752 comments: (1) workshops were useful in facilitating communication skills development, (2) workshops encouraged reflection, (3) appreciation of feedback provided, (4) the live, interactive nature of the workshop enhanced learning, and (5) suggestions for improvement. There were requests for more varied scenarios involving different patient groups and more opportunities to participate in the role-plays. Students also requested smaller groups, which would encourage participation from those who were reticent and allow more personal feedback.

SUMMARY

The use of forum theatre employing role-play, small group coaching on consultation and interview skills, and emphasizing feedback was perceived as an effective and engaging method to teach communication skills.

Comparison of Mental Health Nursing Student Academic Achievement and Satisfaction: Classroom Versus Online Education in Teaching Therapeutic Crisis Management Techniques

BACKGROUND

Mental health nurse educators use online education in an effort to offer students the ability to practice varying skills in a safe environment.

PURPOSE

The purpose of this study was to compare the effectiveness and student satisfaction of live classroom versus online education in delivering therapeutic crisis management skills content to pre-licensure nursing students as measured by overall grade point average (GPA), test scores, class grade, and student satisfaction survey results.

METHODS

This quasi-experimental, post-hoc comparative study had a two-group post-test design. The participants were pre-licensure psychiatric mental health nursing students who were presented a 30-min lecture followed by group work with case studies and interventions.

RESULTS

There were no statistically significant differences between the live classroom and online education group.

CONCLUSIONS

This study indicates that therapeutic crisis management techniques can be taught a variety of ways for academic success and may validate the feasibility of online education within mental health nursing curricula.

Active Learning on Center Stage: Theater as a Tool for Medical Education

INTRODUCTION

Knowledge and skill development related to communication must incorporate both affective and behavioral components, which are often difficult to deliver in a learning activity. Using theater techniques and principles can provide medical educators with tools to teach communication concepts.

METHODS

This 75-minute faculty development workshop presents a variety of techniques from theater and adapts them for use in medical education. Using examples related to diversity and inclusion, this session addresses general educational and theater principles, role-play, sociodrama, applied improvisation, and practical aspects of involving theater partners. The session materials include a PowerPoint presentation with facilitator notes, interactive activities to demonstrate each modality, and an evaluation. The sessions can be extended to longer formats as needed.

RESULTS

Forty-five participants at Learn Serve Lead 2016: The AAMC Annual Meeting attended the 75-minute session. We emailed 32 participants 5 months after the conference, and eight responded. Participants reported that their confidence level in using theater techniques as a tool for medical education increased from low-to-medium confidence presession to high confidence postsession. All survey respondents who were actively teaching said they had made changes to their teaching based on the workshop. All commented that they appreciated the active learning in the session. Many indicated they would appreciate video or other follow-up resources.

DISCUSSION

Principles and techniques from theater are effective tools to convey difficult-to-teach concepts related to communication. This workshop presents tools to implement activities in teaching these difficult concepts.

Interprofessional Learning to Improve Communication in Challenging Healthcare Conversations: What Clinicians Learn From Each Other

INTRODUCTION

Although contemporary health care involves complex interactions among clinicians of varying professions, opportunities to learn together are relatively few. The authors assessed participants' views about the educational value of learning with colleagues of mixed health care professions in communication and relational skills training focused on challenging conversations.

METHODS

Between 2010 and 2013, 783 participants enrolled in 46 workshops hosted by the Institute for Professionalism and Ethical Practice at Boston Children's Hospital, Boston, USA. Participants received pre-, post-, and 3-month follow-up questionnaires with quantitative and qualitative questions about their experiences learning with clinicians of varying professions ("interprofessional learning"). Descriptive statistics and chi-square tests were used to compare participant groups. Responses to open-ended questions were coded according to standard principles of content analysis.

RESULTS

Seven hundred twenty-two (92%) participants completed surveys. Previous interprofessional learning was reported by 60% of respondents, but generally comprised <30% of their education. Clinicians with <3 years of work experience were least likely to have previous interprofessional learning. Nearly all (96%) participants reported interprofessional colleagues contributed valuably to their learning. Asked specifically what they learned, participants described five themes: Stronger Teamwork, Patient-Centered Focus, Specific Communication Skills, Content-Specific Knowledge, and Shared Global Values. After 3 months, 64% of respondents reported that workshop participation helped make their interactions with interprofessional colleagues more collaborative.

DISCUSSION

Communication skills training for challenging health care conversations is a valuable opportunity for interprofessional learning and generates sustained positive attitudes about collaboration. Clinicians learn from their colleagues a deeper understanding of each other's professional roles, challenges, and unique contributions; specific communication approaches; and a sense of belonging to a collaborative community reinforcing the patient at the center of care.

Care for Dying Children and Their Families in the PICU: Promoting Clinician Education, Support, and Resilience

OBJECTIVES

To describe the consequences of workplace stressors on healthcare clinicians in PICU, and strategies for personal well-being, and professional effectiveness in providing high-quality end-of-life care.

DATA SOURCES

Literature review, clinical experience, and expert opinion.

STUDY SELECTION

A sampling of foundational and current evidence was accessed.

DATA SYNTHESIS

Narrative review and experiential reflection.

CONCLUSIONS

The well-being of healthcare clinicians in the PICU influences the day-to-day quality and effectiveness of patient care, team functioning, and the retention of skilled individuals in the PICU workforce. End-of-life care, including decision making, can be complicated. Both are major stressors for PICU staff that can lead to adverse personal and professional consequences. Overresponsiveness to routine stressors may be seen in those with moral distress, and underresponsiveness may be seen in those with compassion fatigue or burnout. Ideally, all healthcare professionals in PICU can rise to the day-to-day workplace challenges-responding in an adaptive, effective manner. Strategies to proactively increase resilience and well-being include self-awareness, self-care, situational awareness, and education to increase confidence and skills for providing end-of-life care. Reactive strategies include case conferences, prebriefings in ongoing preidentified situations, debriefings, and other postevent meetings. Nurturing a culture of practice that acknowledges the emotional impacts of pediatric critical care work and celebrates the shared experiences of families and clinicians to build resilient, effective, and professionally fulfilled healthcare professionals thus enabling the provision of high-quality end-of-life care for children and their families.

SimZones: An Organizational Innovation for Simulation Programs and Centers

The complexity and volume of simulation-based learning programs have increased dramatically over the last decade, presenting several major challenges for those who lead and manage simulation programs and centers. The authors present five major issues affecting the organization of simulation programs: (1) supporting both single- and double-loop learning experiences; (2) managing the training of simulation teaching faculty; (3) optimizing the participant mix, including individuals, professional groups, teams, and other role-players, to ensure learning; (4) balancing in situ, node-based, and center-based simulation delivery; and (5) organizing simulation research and measuring value. They then introduce the SimZones innovation, a system of organization for simulation-based learning, and explain how it can alleviate the problems associated with these five issues.Simulations are divided into four zones (Zones 0-3). Zone 0 simulations include autofeedback exercises typically practiced by solitary learners, often using virtual simulation technology. Zone 1 simulations include hands-on instruction of foundational clinical skills. Zone 2 simulations include acute situational instruction, such as clinical mock codes. Zone 3 simulations involve authentic, native teams of participants and facilitate team and system development.The authors also discuss the translation of debriefing methods from Zone 3 simulations to real patient care settings (Zone 4), and they illustrate how the SimZones approach can enable the development of longitudinal learning systems in both teaching and nonteaching hospitals. The SimZones approach was initially developed in the context of the Boston Children's Hospital Simulator Program, which the authors use to illustrate this innovation in action.

Grace Under Pressure: a drama-based approach to tackling mistreatment of medical students

A positive and respectful learning environment is fundamental to the development of professional identities in healthcare. Yet medical students report poor behaviour from healthcare professionals that contradict professionalism teaching. An interdisciplinary group designed and implemented a drama-based workshop series, based on applied theatre techniques, to help students develop positive professional qualities and interpersonal skills to deal with challenges in the healthcare setting. We piloted the workshops at the University of Sydney in 2015. Attendees completed evaluation questionnaires and participated in a focus group or interview. Of 30 workshop attendances, there were 29 completed questionnaires and three participants attended a focus group or interview. Workshop activities were rated as 'very good' or 'good' by 21/22 (95.5%). Thematic analysis of qualitative data highlighted the rationale for participation (to deal with bullying, prevent becoming a bully, learn social skills), workshop benefits (express emotions, learn about status dynamics and deconstructing personalities, empathy, fun), challenges (meeting participants' expectations, participants' need for further practice) and implications for medical education (need to develop awareness of others' perspectives). Our research has shown that there is momentum to challenge mistreatment in medical education. While a multipronged approach is needed to generate systemic change, this pilot offers a positive and creative innovation. It helps students improve their interpersonal skills and sense of self to deal with challenges in the healthcare setting, including mistreatment.

Compassionate Options for Pediatric EMS (COPE): Addressing Communication Skills

INTRODUCTION

Each year, 16,000 children suffer cardiopulmonary arrest, and in one urban study, 2% of pediatric EMS calls were attributed to pediatric arrests. This indicates a need for enhanced educational options for prehospital providers that address how to communicate to families in these difficult situations. In response, our team developed a cellular phone digital application (app) designed to assist EMS providers in self-debriefing these events, thereby improving their communication skills. The goal of this study was to pilot the app using a simulation-based investigative methodology.

METHODS

Video and didactic app content was generated using themes developed from a series of EMS focus groups and evaluated using volunteer EMS providers assessed during two identical nonaccidental trauma simulations. Intervention groups interacted with the app as a team between assessments, and control groups debriefed during that period as they normally would. Communication performance and gap analyses were measured using the Gap-Kalamazoo Consensus Statement Assessment Form.

RESULTS

A total of 148 subjects divided into 38 subject groups (18 intervention groups and 20 control groups) were assessed. Comparison of initial intervention group and control group scores showed no statistically significant difference in performance (2.9/5 vs. 3.0/5; p = 0.33). Comparisons made during the second assessment revealed a statistically significant improvement in the intervention group scores, with a moderate to large effect size (3.1/5 control vs. 4.0/5 intervention; p < 0.001, r = 0.69, absolute value). Gap analysis data showed a similar pattern, with gaps of -0.6 and -0.5 (values suggesting team self-over-appraisal of communication abilities) present in both control and intervention groups (p = 0.515) at the initial assessment. This gap persisted in the control group at the time of the second assessment (-0.8), but was significantly reduced (0.04) in the intervention group (p = 0.013, r = 0.41, absolute value).

CONCLUSION

These results suggest that an EMS-centric app containing guiding information regarding compassionate communication skills can be effectively used by EMS providers to self-debrief after difficult events in the absence of a live facilitator, significantly altering their near-term communication patterns. Gap analysis data further imply that engaging with the app in a group context positively impacts the accuracy of each team's self-perception.

Improving Communication and Resolution Following Adverse Events Using a Patient-Created Simulation Exercise

OBJECTIVE

The response to adverse events can lack patient-centeredness, perhaps because the involved institutions and other stakeholders misunderstand what patients and families go through after care breakdowns.

STUDY SETTING

Washington and Texas.

STUDY DESIGN

The HealthPact Patient and Family Advisory Council (PFAC) created and led a five-stage simulation exercise to help stakeholders understand what patients experience following an adverse event. The half-day exercise was presented twice.

DATA COLLECTION AND ANALYSIS

Lessons learned related to the development and conduct of the exercise were synthesized from planning notes, attendee evaluations, and exercise discussion notes.

PRINCIPAL FINDINGS

One hundred ninety-four individuals attended (86 Washington and 108 Texas). Take-homes from these exercises included the fact that the response to adverse events can be complex, siloed, and uncoordinated. Participating in this simulation exercise led stakeholders and patient advocates to express interest in continued collaboration.

CONCLUSIONS

A PFAC-designed simulation can help stakeholders understand patient and family experiences following adverse events and potentially improve their response to these events.

Clinicians' strategies for managing their emotions during difficult healthcare conversations

OBJECTIVES

To examine strategies employed by clinicians from different disciplines to manage their emotions during difficult healthcare conversations.

METHODS

Self-report questionnaires were collected prior to simulation-based Program to Enhance Relational and Communication Skills (PERCS) workshops for professionals representing a range of experience and specialties at a tertiary pediatric hospital. In response to an open-ended prompt, clinicians qualitatively described their own strategies for managing their emotions during difficult healthcare conversations.

RESULTS

126 respondents reported emotion management strategies. Respondents included physicians (42%), nurses (29%), medical interpreters (16%), psychosocial professionals (9%), and other (4%). Respondents identified 1-4 strategies. Five strategy categories were identified: Self-Care (51%), Preparatory and Relational Skills, (29%), Empathic Presence (28%), Team Approach (26%), and Professional Identity (20%).

CONCLUSIONS

Across disciplines and experience levels, clinicians have developed strategies to manage their emotions when holding difficult healthcare conversations. These strategies support clinicians before, during and after difficult conversations.

PRACTICE IMPLICATIONS

Understanding what strategies clinicians already employ to manage their emotions when holding difficult conversations has implications for educational planning and implementation. This study has potential to inform the development of education to support clinicians' awareness of their emotions and to enhance the range and effectiveness of emotion management during difficult healthcare conversations.

Teaching and assessing ethics in the newborn ICU

Ethics and professionalism education has become increasingly recognized as important and incorporated into graduate medical education. However, such education has remained largely unstructured and understudied in neonatology. Neonatal-perinatal fellowship training programs have generally grappled with how best to teach and assess ethics and professionalism knowledge, skills, and behavior in clinical practice, particularly in light of accreditation requirements, milestones, and competencies. This article reviews currently available teaching methods, pedagogy, and resources in medical ethics, professionalism, and communication, as well as assessment strategies and tools, to help medical educators and practicing clinicians ensure trainees achieve and maintain competency. The need for consensus and future research in these domains is also highlighted.

Development of a situational initiation training program for preceptors to retain new graduate nurses: Process and initial outcomes

BACKGROUND

Most preceptor training programs consist of classroom-based courses, and only a few programs are conducted using films. Preceptors have identified most training courses as inapplicable in various clinical situations.

OBJECTIVES

To describe the systematic development of a situational initiation training program (SITP) for preceptors and to evaluate its impacts on the stress levels of preceptors and new graduate nurses (NGNs), the preceptor-NGN relationship, support provided by preceptors to NGNs, and the intention to leave among NGNs during a 1-year preceptorship.

DESIGN

The conceptual framework of development, implementation, and evaluation was used for program completion.

PARTICIPANTS AND SETTINGS

Preceptors and NGNs working at a teaching medical center in Taipei participated.

METHODS

The 1-day SITP workshop comprised four films, reflection time, and four classroom-based courses. Training outcomes were evaluated using a questionnaire survey for preceptors and NGNs at months 3, 6, 9, and 12 after employing the NGNs. Data were analyzed using descriptive statistics and analysis of variance with repeated measures.

RESULTS

The annual turnover rate of NGNs was 10.5%. During the first preceptorship year, the NGNs reported moderate stress levels, good to excellent relationships with their preceptors, moderate to excellent support from their preceptors, and low intention to leave their current jobs. Similarly, preceptors reported moderate stress levels, except at month 12 (mean=4.8), and good to excellent relationships with their NGNs. The SITP considerably improved the preceptor-NGN relationship for both NGNs and preceptors, whereas no improvement was observed in the stress levels, except in the stress levels of preceptors.

CONCLUSIONS

The SITP is clinically effective for preceptors; thus, nurse educators may apply the SITP for redesigning the existing preceptor training programs to develop highly skilled preceptors and improve training outcomes.

Observer roles that optimise learning in healthcare simulation education: a systematic review

Background

Simulation is widely used in health professional education. The convention that learners are actively involved may limit access to this educational method. The aim of this paper is to review the evidence for learning methods that employ directed observation as an alternative to hands-on participation in scenario-based simulation training. We sought studies that included either direct comparison of the learning outcomes of observers with those of active participants or identified factors important for the engagement of observers in simulation. We systematically searched health and education databases and reviewed journals and bibliographies for studies investigating or referring to observer roles in simulation using mannequins, simulated patients or role play simulations. A quality framework was used to rate the studies.

Methods

We sought studies that included either direct comparison of the learning outcomes of observers with those of active participants or identified factors important for the engagement of observers in simulation. We systematically searched health and education databases and reviewed journals and bibliographies for studies investigating or referring to observer roles in simulation using mannequins, simulated patients or role play simulations. A quality framework was used to rate the studies.

Results

Nine studies met the inclusion criteria. Five studies suggest learning outcomes in observer roles are as good or better than hands-on roles in simulation. Four studies document learner satisfaction in observer roles. Five studies used a tool to guide observers. Eight studies involved observers in the debrief. Learning and satisfaction in observer roles is closely associated with observer tools, learner engagement, role clarity and contribution to the debrief. Learners that valued observer roles described them as affording an overarching view, examination of details from a distance, and meaningful feedback during the debrief. Learners who did not value observer roles described them as passive, or boring when compared to hands-on engagement in the simulation encounter.

Conclusions

Learning outcomes and role satisfaction for observers is improved through learner engagement and the use of observer tools. The value that students attach to observer roles appear contingent on role clarity, use of observer tools, and inclusion of observers’ perspectives in the debrief.