Complexity and the simulation-based education paradigm

In terms of pedagogical frameworks, there is a need to build on work that helps prepare students to navigate and manage ethical quandaries in clinical practice. Simulation-based learning (SBL) methods are widely used to advance students’ clinical skills and behaviours before they transfer into clinical practice. SBL can provide learning opportunities for large cohorts of medical students that are not readily available in workplace environments [5, 6]. Additionally, SBL may offer an immersive and embodied experience that introduces learners to complex ethical dilemmas.

Clinical workplaces are often dynamic and challenging environments in which to work. Often, healthcare professionals will encounter uncertainty, unpredictability and risk whilst carrying out their duties. Exposure to clinical uncertainty in medical curricula may better prepare students to manage complexity and explore the boundaries of professional competence and so improve their preparation for practice [7]. SBL has an established evidence base for developing technical and procedural abilities in idealised settings [8]. The fidelity of SBL in mirroring authentic real-life uncertainty and complexity is much less clearly defined [9–11]. The use of theorised research is thus central in helping to understand and improve such methods of learning in these settings [12].

Few published studies to date have used complex SBL to teach ethics or explore student experience in depth [13–16]. Evidence is emerging that increasing the complexity and realism of such scenarios has a positive effect on learning [17]. Realistic SBL can provide a safe environment for students to develop moral imagination and more effectively engage with ethical dilemmas [18]. Moral imagination is that capacity which allows individuals to identify with others, exercise empathy, imagine future possibilities and consequences as a result of a course of moral action and respond appropriately [18].

Our study aimed to understand the fine-grained nuances of medical students’ lived experiences in coping with the dynamic clinical, social and emotional challenges of managing ethical dilemmas within a SBL environment. We also aimed to gain potential teaching insights.

Epistemological position and conceptual orientation

This qualitative study was underpinned by an interpretivist epistemology given the nature of the research aims and the complex social dimensions that occur within a high authenticity ward-based simulation teaching activity. Existential phenomenology focuses on the description and interpretation of lived experiences in order to truly understand a phenomenon as it exists in the consciousness of an individual [19]. Therefore, phenomenology was used as a conceptual framework for this study due to its appropriate theoretical fit for examining and interpreting the richness of student experience [20, 21].

Setting and context

The study was performed in Queen’s University Belfast (QUB), Northern Ireland. The medical degree programme at QUB follows a 5-year integrated curricular model, with increasing clinical exposure through years 3 to 5. Students are exposed to SBL activities throughout the entire curriculum.

Recruitment and sampling

Description of the ward-based SBL activity

An interprofessional SBL ward-based activity was developed by a multidisciplinary team incorporating practitioners from medicine, nursing, ethics and law, psychiatry, drama and simulation, as well as simulated patients and medical students. The aim was to create a naturalistic, immersive environment that allowed participants to have an embodied and reactive learning experience, without risk of patient harm. The SBL setting was framed as a typical hospital ward. Participants were asked to assume the role of a first year junior doctor who had been assigned to this ‘ward’. They were asked to perform a range of clinical duties but were not briefed about the specifics of any ethical issues that would emerge. The ethical dilemmas incorporated into the SBL activity have been identified as key issues for which medical students and junior doctors express the need for more guidance [24]. These included dealing with end-of-life issues, family conflict, breaches of confidentiality, raising concerns about a colleague’s unprofessional behaviour and appropriate use of social media.

Both scenarios (see below) were run simultaneously and adjacent to each other in a bespoke simulated ward environment in the Clinical Skills Education Centre at QUB. The scenarios lasted for up to 15 min. Several individuals wearing scrubs or wearing stethoscopes were present along with simulated patients and relatives. All interacted with each other and the participant in a naturalistic manner as if they were in a busy hospital ward. Realistic medical equipment, including fixtures such as hand-washing stations, patient charts, observation machines, oxygen and IV fluid equipment were all present (see Additional file 1).

Data capture

In order to augment data gathering, participants wore digital video glasses (SunnyCam™ HD) to capture point-of-view (PoV) film footage of their SBL experience (see Fig. 1). This footage recorded a trace through participants’ experiences in the complex simulation environment. Such video methods of capturing data have been used in a wide range of settings, including healthcare, to capture the perspective of subjects in order to understand more closely their actual experiences [28, 29]. Immediately following the scenarios, participants were interviewed individually by one of two researchers (GL or GG). Interviews were exploratory and open-ended in nature, deriving from the content of what participants were sharing in order to remain as true as possible to their experiences. As the interview proceeded, issues were probed in more depth and reference was made to PoV footage. This helped in unearthing each participant’s embodied experiences in an attempt to uncover perceptual knowledge that usually remains tacit [30]. Interviews were audio-recorded and transcribed verbatim including paralanguage. Participants were assigned pseudonyms (see Table 1) and quotations below use the nomenclature: I—investigator, P—participant.

Analysis

A range of qualitative analyses was performed in this project. In this primary analysis, a phenomenological analysis using a template analysis approach was used to analyse the data [22]. A priori areas of interest were used to identify themes expected to be relevant to the analysis a number of weeks before data collection commenced. This promoted reflexivity by bringing to the surface researcher assumptions and presuppositions that were identified and noted. This aimed to mitigate the effects of unconscious bias on the part of researchers during participant interviews, for example, by ensuring that some areas were not favoured or pursued more intensively unless the participant had identified these as significant. Interviews were transcribed verbatim and analysed separately. Themes derived from the first two transcripts were coded independently by the researchers, and each subsequent transcript was analysed without reference to the analysis of previous transcripts. Themes derived from the first two transcripts were entered into an initial template and compared with the a priori areas of interest previously identified. Subsequent themes from the remaining six transcripts were entered into another template which was then applied to the entire dataset. Once the final template was agreed, all transcripts were coded against it and used to illuminate the interpretation of the dataset.

Consistent with a phenomenological methodology, reflexive diaries before, during and after analysis were kept and referred to. As both researchers had been closely involved in the design and running of the SBL scenarios, by fostering dialogue, cross-checking of transcript analysis and discussing complementary and divergent interpretations, hidden beliefs and biases could be surfaced in order to strengthen the validity of the findings.

Authentic on all levels?

Participants toggled between reality and simulation as the scenario unfolded and situations and emotions became more complex. The tone and paralanguage of those interviewed became more intense and colloquial when describing stressful or emotionally laden moments. During these times in the SBL exercise, participants reminded themselves they were in a simulation in order to control these emotions.

However, uncertainties in the environment, such as the identity of other individuals, drew participants into an internal dialogue in which they tried to deduce what was happening based on information gathered. Participants reported this as reinforcing their perception of dealing with a true to life situation, even though in their thinking they acknowledged, at points throughout the exercise, its simulated nature.

Craig illustrates that the SBL experience can be authentic on different levels, but not necessarily at the same time and in the same way. He felt the reality of worrying about the patient safety aspects of an incorrect prescription on the medication chart (kardex). Yet, he gained a measure of psychological safety in knowing the exercise was a simulation. A further psychological safety net is Craig's belief, when imagining (cf ‘at the same time') if this were not a simulation, that a real-life mistake would have been ‘picked up on’. In this case, both his own safety and that of the patient would be maintained.

Alongside participants’ authentic experiences were a range of physiological responses to increased stress. These included ‘warmth’, ‘sweating’, a ‘fight or flight’ response, an ‘adrenaline’ rush, ‘heart going a dinger’ and a distorted perception of time. Some of these were quantitatively expressed with resolution of difficulties leading to a ‘dipping’ in anxiety ‘levels’. Despite uncertainties and anxieties in the scenarios, all participants felt safe to explore the boundaries of ethical practice in the SBL setting. Whilst participants recognised the potential real-world implications of error, being able to recall this was a simulation provided a psychological safety net that errors would not result in actual harm. Additionally, though participants had been briefed that they could withdraw from the SBL exercise at any time, none chose to exercise this option. Whilst participants felt ‘pushed’, none were pressed beyond their tolerable limits. All commented that they would like to re-engage with similar SBL scenarios at a later date, articulating a greater confidence in handling them.

Letting the emotions flow

Emotions featured prominently in participants’ interviews, and each recalled unpleasant negative feelings such as fear, anxiety, awkwardness, loneliness and regret, through to embarrassment and feeling silly. Less often, more positive feelings of humour and relief were present. All participants had to navigate a rapidly shifting emotional landscape as the scenario unfolded.

The role of previous life experiences assisted in real-time processing of feelings. Drawing on similar experiences of encountering inappropriate behaviour, participants were primed with a repertoire of coping strategies such as maintaining distance and being ‘very professional, nice and pleasant’. This permitted them to regulate their feelings of awkwardness.

Ethical alarm bells

Participants readily perceived the explicit ethical dilemmas relating to autonomy and confidentiality present within the two SBL scenarios. Recognising the implicit ethical considerations for truth-telling and raising concerns when confronted with an unprofessional nursing colleague in the ‘maintaining professional boundaries’ scenario was more challenging for some. Of interest were further, emergent ethical dimensions. A urinalysis specimen bottle was unintentionally mislabelled during one iteration of the above scenario. This was recognised by the participant who resolutely refused to accept the validity of the results and insisted on such to the simulated nurse.

There was less clarity when other ethical boundaries were approached. The specific legal status of the advance directive in the ‘end-of-life care’ scenario was unknown by participants. Duncan felt an unease ‘at the back of [his] mind’ when discussing confidential patient information with a person who ‘appeared to be a nice guy’ at the relative’s bedside. The smiling and supportive nurse made it more difficult for participants to challenge her unprofessional behaviour. Cheryl tells a falsehood about not having a Facebook page when asked by the nurse, describing subsequent regret she told a lie when viewing the PoV footage (see Additional file 2). Others displayed avoidant behaviour by not rebutting the nurse’s insistence that it was ‘ok’ to post patient-identifiable comments on social media.

The approach of these ethical boundaries could be masked by ignorance of the legislative backgrounds in one case and the context-dependent nature in which they arose. In the latter cases, a friendly person or smiling face disguised the request to compromise confidentiality and subsequently made it more difficult for participants to challenge unprofessional behaviour.

Voices of children and ghosts

Participants described anxiety at the presence of a consultant in the scenario. This inhibited their performance of the urinalysis as they were worried about being asked something they did not know. Descriptions of ward attachments in which the participants suggested some areas for improvement that were not taken seriously reinforced a passive and disempowering stance towards the workplace. These feelings of passivity spill over into how interprofessional relationships with nursing staff are viewed. Nursing staff have to be ‘appeased’, they can ‘make or break’ a junior doctor’s working life and one has to be ‘careful’ when dealing with the nurses. An example of nursing staff gossiping about another student went unaddressed by one participant who avoided challenging or reporting unprofessional behaviour. Another recounted being shouted at by a theatre nurse and the negative effect this had on their views of nurses more generally.

Authenticity unlocking learning spaces

SBL in which a highly faithful representation of an ideal procedure or scenario exists is useful in the development of basic technical skills. It could be assumed therefore that SBL activities will only achieve their full pedagogical potential when all components are as lifelike as possible. However, this may not necessarily be the case. Whilst it is evident that SBL experiences should not be overly simplistic, reductionist or predictable, recreating closely a complex, real-life ethical dilemma may not require all parts to be fully authentic at all times and in all ways for participants. Reality and fiction cues in SBL may not be perceived in the same way by participants [33]. In our study, inserting interruptions to mimic reality during the end-of-life care scenario actually reduced immersion for Duncan. The real requirement in this SBL exercise was to create authenticity in the uncertain ethical complexities faced by participants whilst ensuring that the supporting environment and actors did not overly detract from immersion or the perception of authenticity.

When learners are placed in an authentic real-life situation potentially demanding many competencies to be exercised, those areas in which the learner feels weaker may well cause the greatest anxiety for him or her. This was observed in the present study where, early on in these scenarios, it became clear where the fault lines lay for participants. Some were confident with technical tasks, others less so. A minority felt able and relished the challenge to engage with the human characters in the SBL activity whereas others on seeing nursing or senior medical staff immediately became suspicious or fearful. The value of these authentic and complex SBL environments is that learners’ particular issues and concerns readily rise to the surface as they face the complexity encountered by clinical practitioners. This permits more targeted and student-centred learning. For example, the specific issues uppermost in the minds of each student could be readily elicited during debrief interviews. The PoV footage unlocked aspects of student experience that were previously hidden behind layers of memory and the differences between recall versus actual experience [34]. The PoV footage captured Phoebe describing herself as being ‘overwhelmed’ immediately after the scenario. Throughout the interview, she had neither stated nor hinted at this. In phenomenological terms, by reviewing the footage, the ‘onion skin layers’ overlying her significant lived experience were peeled away [19]. The contours of her actual experience, rather than her mediated external projection of it, were exposed. In Phoebe’s case, the authentic emotions created by the SBL unlocked real learning; despite feeling ‘overwhelmed’, she did not feel able to reveal this to others.

Opening up the emotional dimension for learners

Emotions play an important role in the learning process as well as in the development of interpersonal skills and medical professionalism [35]. Nevertheless, the measurement, teaching and assessment of emotional awareness and intelligence in medical school curricula remain controversial and in need of further research [36]. In McNaughton’s work on how emotion is conceptualised within medical education, she presents three discourses on emotion: emotion as physiology, emotions as skills and emotion as a socio-cultural mediator [37]. Results in our study indicate that SBL can evoke emotion in all three domains described by McNaughton. This provides an opportunity to set our work within this theoretical framework and so to understand and harness the influence of emotion on the clinical learning environment. Participants described a broad range of emotion with associated physiological and autonomic accompaniments. The additional effects on cognition and behaviour reinforced to participants that what they were feeling was very real. Emotion as skills was demonstrated in the way some participants wanted to escape from a difficult situation and how they then rationalised and sublimated these initial feelings into providing patient-centred care. The third domain of emotion as socio-cultural mediator is appreciated when considering the SBL activity as furnishing students with a transformative learning experience. Here, they develop a deeper empathy and a greater emotional resilience and are changed in a foundational way by their experiences. This may assist learners in bridging the gap observed in the literature between stated moral intentions and actual moral actions in an emotionally fraught environment [38, 39]. By revealing those factors that lead to personal, ethical or moral compromise, learners may be more able to gain control of them on subsequent occasions.

Moral distress, courage and compromise in ethically complex narratives

Both moral distress and moral courage are attended by strong emotional colouring that can profoundly influence ethical decision-making [37, 40]. However, the influence of emotions on clinical professional development, learning processes and ethical decision-making remain substantially under-investigated.

In this present study, instances of both moral courage (refusal to credit the validity of an incorrectly labelled specimen) as well as moral compromise (telling an untruth about not having a Facebook page) were evident. These were nuanced by the particular emotional and professional contexts in which these occurred [41]. The clinical necessity of analysing a correct specimen superseded the reassurances from the simulated nurse. On another occasion, the friendliness and perceived emotional safety afforded by this same nurse after a difficult patient encounter weakened moral resolve to tell the truth and challenge unprofessional behaviour.

Significantly, participants viewed their situation regarding raising concerns when on clinical placements in diminutive and insubstantial terms—‘little children’ and ‘ghosts’. They expressed feeling unable to challenge the status quo and voice legitimate concerns. This is most concerning, in light of the findings from healthcare inquiries such as the Francis Report [42], that whilst trainees should be the ‘invaluable eyes and ears in a hospital setting’, there is for some an acclimatisation during undergraduate training to the acceptance of poor practice and unprofessional behaviour and a learned helplessness in being able to challenge this. Furthermore, participants described a seamless transition of interprofessional caricatures and prejudices into the SBL environment. Students default to the position that the presence of senior staff is stressful and uncomfortable and threatens to expose their ignorance. Nursing staff are viewed with suspicion. This ‘learning’ from previous clinical attachments went unquestioned and unanalysed. A hidden curriculum of negative interprofessional interactions and subsequent paralysis in raising concerns was brought to the surface by the SBL activity. What was previously latent became open to critique and modification.