The stuff of life – the reality of ethical simulation

In this blog, Gareth Lewis & Gerry Gormley discuss their research investigating how simulation can be used to navigate ethical issues.

Junior doctors feel unprepared to deal with many of the human aspects of ethical and professional dilemmas. Equipping doctors to understand and navigate the emotion, stress, drama and uncertainties associated with moral decision making in these areas is critical.

There is an important gap in our understanding of how simulation can best prepare medical students and doctors for real life ethical encounters. Such simulation should layer on many of the essential human dimensions and move learners from textbook theory to a transformative embodied learning experience. It should provide a safe space for students and doctors to understand their emotions, thinking patterns and responses.

We therefore wanted to investigate how simulation could be used to unlock the moral and emotional landscapes that doctors need to navigate ethical issues. How do medical students cope when confronted with ‘real-life’ ethics problems? What factors have an impact on their ethical and professional reasoning in these settings? How do they react upon seeing unprofessional behaviours?

Unlocking reality

We designed a realistic hospital ward in which a simulation based exercise (SBE) was conducted. This environment incorporated a variety of participants and included multisensory reality cues such as professional dress, equipment, and background noise. Individuals from within this ward had been trained in drama improvisation techniques to faithfully recreate the dynamic emotional person to person interaction needed to create an authentic setting. This moved the simulation away from the constraints of a scripted set of responses.

Eight fourth year medical students participated in one of two scenarios. One scenario featured the relatives of a dying patient arguing over the validity of her advanced directive while she lay unresponsive [Video one]. Another had a patient making inappropriate remarks to the student as they carried out urinalysis at the bedside. The student was then greeted by a friendly nurse who suggested they post comments on a social media site.

Through their eyesSimulationGlasses

To surface student experiences  we asked participants to wear digital video glasses which captured Point-of-View (PoV) film footage of the SBE. Immediately after the SBE had concluded, we held minimally structured interviews with each student during which the PoV footage was played back to them as they provided commentary. We used phenomenology – a qualitative research method which aims to unearth the core of what a person is really experiencing.

An example of the value of the PoV footage in revealing lived experiences was capturing ‘Phoebe’ saying that she was “overwhelmed” by the end of the SBE. Up to that point in the interview she had closely guarded her real feelings. When she viewed and relived this moment we were able to expose her real feelings at that point in time, not her mediated or sanitised memory of them.

Feelings and Failures

The SBE felt realistic to the students in different ways and at different times. Participants remarked the SBE was most authentic when seeing a real human person, not an instrumentalized plastic manikin, in the bed during the end of life scenario. The range of emotion felt by all participants testified to the fact that they were experiencing something close to reality. They weren’t having to fake concern or empathy – it was being generated by the situation they faced. They were beginning not just to think or do, but feel like real doctors.

Even though participants recognised ethical and professional boundaries in the SBE, when they witnessed examples of unprofessional behaviours they could “clam up and not say anything”. One participant, in the heat of the moment, told a falsehood about not having a social media page [Video two].

The SBE uncovered some challenging perceptions of other healthcare professions and the workplace. The presence of nursing staff and a senior doctor is viewed with suspicion and anxiety. The ward environment is one in which students feel like “little children” and “ghosts” with no credibility to make suggestions or speak up if they see something wrong. Students are primed from early on in their training to view other colleagues and the workplace negatively. These perceptions transitioned seamlessly into this simulated environment and were only brought to the surface through the video-assisted interview.

What next?

We demonstrated in our study that a realistic ethics simulation, augmented with PoV footage and appropriate debrief can be effective in embodying the complexity and human factors associated with ethical decision making. The emotional colouring and stress associated with this environment hindered students raising concerns and challenging unprofessional behaviour.

This type of simulation training can uncover for learners where their moral and professional fault lines lie. It is our anticipation that such simulations will assist in the development of moral courage and resilience. Such approaches to medical education can be effective in preparing doctors for clinical and professional practice.

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