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This research paper provides an overview of simulation – an active, experiential teaching-learning method that has been effectively employed in the bioethics education of healthcare students and professionals. Bioethics simulation is a technique used to imitate or represent essential individuals, relationships, conditions, and clinical elements of an ethical issue to evoke a genuine experience for teaching, assessment, or evaluation. The paper reviews the value and effectiveness of simulation in meeting the goals of bioethics education. It summarizes the characteristics and structure of simulation, various forms of simulations, beneﬁts of ethics simulation, and ethical reasons for its incorporation in bioethics education.
Simulation is an active, experiential teaching learning method that has been effectively employed in the bioethics education of healthcare students and professionals. Bioethics simulation is used to create an authentic representation or depiction of an ethical problem or situation by mimicking the individuals, relationships, conditions, and setting of the ethical issue for the purpose of teaching, assessment, or evaluation. This research paper highlights the value and efﬁcacy of using simulation-based instruction and provides background support for its incorporation in ethics curricula to better meet the goals of bioethics education. It describes the characteristics of simulation, the types of simulation that may be employed in bioethics education, the basic structure of simulation, and the beneﬁts of using this educational approach. It concludes with a discussion of the ethical reasons to use simulation in bioethics education.
History And Development Of Simulation-based Ethics Education
Background Support For The Use Of An Experiential Teaching Method In Bioethics
The role of bioethics education in the healthcare professions has increased considerably in the past decades. Rapidly expanding medical knowledge and technology, complexity of patient care, changes in healthcare delivery, limitations on resources, and cultural considerations in healthcare produce signiﬁcant ethical issues and challenges to which ethics educators must respond. For example, healthcare providers may feel pressure to discharge patients earlier than recommended, struggle to ﬁnd adequate resources for patients, or experience tension between professional and institutional goals.
Ethical issues also frequently occur in routine interactions between the patient and his or her healthcare provider, such that most patient-nurse and patient-physician interactions have an underlying ethical dimension or raise pressing ethical considerations. Healthcare practitioners strive to provide beneﬁcent care in a practice environment that is respectful of patients’ autonomy and requires balancing and weighing of ethical principles on a routine basis. The ethical issues that emerge from the healthcare environment challenge the novice and experienced practitioner alike.
The goal of ethics teaching, therefore, is to develop clinical ethics competency – the cognitive, affective, and behavioral skills of the healthcare practitioner – in order to prevent, identify, and manage the ethical problems that arise in professional practice. Professional competency standards in medicine and nursing stress that ethics education should include professional virtues and ethical decision-making skills. Various worldwide codes of ethics in medicine and nursing also reﬂect the need for ethics competency. The Institute for International Medical Education has also established minimal global requirements for medical education to include competency in ethics (Wojtczak and Schwarz 2003). Of note, the Accreditation Council for Graduate Medical Education (2013) speciﬁes that preparation in ethics should ideally occur prior to caring for patients.
Despite the requirements for ethics teaching in nursing and medicine programs around the globe, the literature of ethics education reveals inconsistent attention to these skills. Moreover, some programs emphasize the development of professional virtues while others stress decision-making skills. Educators must strive, therefore, to develop curricula that foster the attitudes, behaviors, and skills for ethical practice and to assist students to successfully manage the ethical problems that arise in professional practice.
Ethics educators face a particular challenge known as the hidden curriculum – the informal, implicit teaching that is often associated with the clinical environment. As Hafferty and Franks (1994) note in their classic article on the hidden curriculum and medical education, students are affected by the practices and habits – positive and negative – of their role models. This unplanned teaching may exert a strong inﬂuence in the moral development of the student, even more so than the formal ethics curriculum (Hafferty and Franks 1994). Educators are advised, therefore, to develop educational approaches that counteract the negative effects of the hidden curriculum.
Traditional And Nontraditional Educational Approaches To Ethics Education
Educators are challenged with the task to develop ethics curricula with holistic, comprehensive learning approaches that bridge the gap between formal theory and clinical practice and help to ensure the development of the skills needed for ethics competency. It is also critical to assist healthcare students to develop these skills, as much as possible, prior to caring for patients. Different educational strategies have been used to meet speciﬁc learning objectives, with each approach having its advantages. While there is not one method of teaching that emerges as the best, educators must select the methods that are best suited to achieving particular goals. Traditional methods typically include lecture, small group discussion, and case study analysis. Nontraditional methods include literature, poetry, media, portfolios, reﬂective writing, games, panels, interactive computer programs, ethics grand rounds, role-play, and use of standardized patients or actors.
The more commonly employed teaching methods have their merits but lack the ability to more fully assist students to develop particular virtues and skills. Methods such as lecture, group discussion, and case study analysis are appropriate for teaching foundational knowledge, ethical analysis, and developing sensitivity to ethical issues and, importantly, provide opportunities for dialogue, reﬂection, and application of ethical theory. Other methods, such as incorporating the humanities in the form of narrative, plays, and poetry, are effective in developing sensitivity and empathy to patients’ situations. Nontraditional approaches such as role-play, interactive computer programs, and games offer active, experiential learning. Clinical experience, an important component of ethics education for healthcare professionals, provides immersive learning, but this is often unpredictable and may not provide sufﬁcient opportunities for reﬂection. Furthermore, if not well addressed and supervised, the hidden curriculum associated with clinical experience may contribute to negative learning.
History Of Bioethics Simulation
The use of simulation to teach bioethics has a long history in medicine. Examples of bioethics simulations can be found in medical education programs in the late 1980s with the work of Arnold et al. (1988). This early ethics simulation was conducted to raise medical students’ and residents’ ethical awareness and skills in managing clinical ethics issues, such as informed consent, conﬁdentiality, and resource allocation. Shortly thereafter, ethics simulations were initiated to evaluate the bioethics skills of medical students and residents. The Ethics Objective Structured Clinical Examination (OSCE) was introduced to evaluate clinical ethics skills (Singer et al. 1993) using standardized patient-based simulation. Simulation continues to be applied in medical education to enhance bioethics knowledge and develop the behavioral and affective skills required to manage the ethical issues that arise in clinical settings on topics such as patient autonomy, informed consent, truth-telling, withdrawing and withholding care, value conﬂicts, and physician-assisted suicide (Wilt 2012).
Bioethics simulation has only recently been introduced in nursing curricula and less often is it conducted using standardized patients, as is common in medicine (Wilt 2012). Examples of bioethics simulation with nursing students and nurses include participation in mock ethics committees, computer-based instruction, and mannequin-based simulation to enhance ethical awareness, bioethics knowledge, communication skills, and ethical decision making. Vanlaere et al. (2010) designed an innovative immersive care-ethics lab experience that was conducted to develop ethical awareness, ethical reﬂection, and empathy in nursing students, nurses, and allied health professionals. Recently, bioethics simulation using standardized patients has been conducted to enhance ethical awareness and clinical ethics skills of staff nurses in situations dealing with patients who refuse recommended treatment and problems concerning premature transfer of patients (Wilt 2014).
Simulation As A Teaching-Learning Method In Bioethics Education
Definition Of Simulation
Simulation is an innovative, experiential teaching-learning method or technique that has emerged as an effective way to teach ethics to healthcare students and professionals. It allows for engaged, immersive, and interactive learning in an environment that imitates or represents essential clinical elements in order to evoke a genuine experience. Although simulation-based learning may involve technology to help achieve the educational goals (e.g., computer-based programs or mannequin-based simulators), the emphasis is on the process of learning. Simulation has been used extensively in nursing and medical programs to teach psychomotor and cognitive skills, such as critical thinking, physical assessment, communication, and simple to complex procedural skills. It has been implemented less consistently, however, to teach ethics in the healthcare professions. While it has been used more often in medical programs to teach ethics and professionalism, it is only recently being introduced into ethics curricula in nursing programs. Yet, by its nature, simulation is well suited for teaching ethics concepts and skills. Its characteristics illustrate its applicability to bioethics issues and problems, which beneﬁt from nuanced teaching approaches that allow for discovery. The structure of simulation is open-ended; open to change and controlled by the learner, while being guided by the educator or facilitator. Simulation is a method that allows educators to create and implement experiential learning about common everyday ethical issues in healthcare as well as more complicated, weighty ethical dilemmas and provides practice opportunities in identifying and managing ethical problems. The following sections describe the characteristics or traits of simulation, types of simulation relevant to ethics instruction, fundamental components of simulation, and the beneﬁts of implementing simulation based ethics education.
Characteristics Of Simulation
There are four essential characteristics to simulation: ﬁdelity, participant roles, a deﬁned set of data, and feedback (Gredler 2004). Fidelity refers to the level of realism in the learning activity, which can range from low (less realistic) to high (a more authentic experience). Although a high level of ﬁdelity is not always possible or required, in general, a higher level of realism allows the learner to suspend disbelief and become engaged and immersed in resolving the problems presented in the case study or learning scenario. The property of ﬁdelity can be applied to the physical conditions, relationships, equipment, technology, environment, functionality, or psychological states involved in the learning activity. Simulation also includes a data set or database. Participants in the simulation require information about the case that is credible and accurate to allow the learners to control the action and outcome. Valid data also guards against confusion or negative outcomes. Participants are also provided roles for the scenario, which closely represent their future professional role. Having deﬁned positions that represent the learner’s actual responsibilities sets simulation apart from role-play, in which participants are encouraged to “play act.” Genuine functional roles support the transfer of learning to the work setting. Simulation also includes feedback, which the learner receives during the experience or following the experience in a debrieﬁng and reﬂection session.
Types Of Simulation
Several types of simulation are suitable for ethics teaching – standardized patient-based, mannequin-based, computer and/or virtual reality-based, and hybrid forms that combine two types of simulation. Standardized patients, also referred to as patient actors or simulated patients, are individuals who have been trained to portray the physical, psychological, and behavioral characteristics of a patient or family member. Barrows (Wallace 1997) initiated the use of standardized patients for evaluating the physical assessment skills of medical students. In addition to the patient or family member role, individuals can also be trained to portray healthcare professionals or other persons, such as administrators, who are integral to the case or scenario. These additional roles are used to add realism and provide additional information to the scenario. Standardized patient-based simulation provides a high level of ﬁdelity, allowing learners to readily become engaged and immersed in their professional role as they interact with the acting patient and/or family member to navigate an ethical issue or situation. Standardized patients may also be trained to assess the learner and provide oral or written feedback on the learner’s performance.
With its high level of ﬁdelity, immersive nature, and immediate feedback, this form of simulation is well suited to teaching bioethics concepts, the application of professional virtues, professionalism, communication techniques, and ethical decision making. Standardized patient-based ethics simulation has been conducted to enhance knowledge, skills, and attitudes on such topics as ethical reﬂection, empathy, honesty, professional values, end-of-life care, advance directives, informed consent, patient autonomy, and ethics consultation (Wilt 2012).
Mannequin-based simulation can also be used to teach bioethics concepts and skills. It involves the use of a full or partial body mannequin (or manikin), also referred to as a human patient simulator. The mannequin typically has an integrated computer system that can be controlled or preprogrammed to produce patient manifestations and responses to participants’ actions. Human patient simulators may be simple or complex with low to high ﬁdelity. Mannequin-based simulation scenarios are typically designed to resolve medical, nursing, or other healthcare problems and have a long history of use in healthcare to teach and assess physical skills, health assessment, critical thinking, and team training. This type of simulation can also be used to teach and assess clinical ethics skills. Scenarios can be designed to solely teach ethical issues or ethical problems, or ethical issues can be integrated into a mannequin-based simulation that is primarily medically oriented (Wilt 2012).
Computer (screen)-based and virtual reality based simulation feature interactive programs that incorporate bioethics theory and practice of clinical ethics skills. This type of simulation may be used to teach and assess ethics knowledge, critical reasoning, professionalism, ethical decision making, and communication skills. Learners can participate in computer-based simulation independently or in groups. Examples include computer-based programs on assisted suicide and conﬁdentiality used with medical students in a bioethics course (Fleetwood et al. 2000). Virtual programs such as Second Life have been adapted to teach ethical theories (Houser et al. 2011). DecisionSim™, a cloud-based and mobile education program that enables educators to develop custom training programs, can be designed to teach bioethics concepts and enhance decision-making skills. Computer-based programs vary in the level of sophistication. Those incorporating high-level technology or virtual reality, such as three-dimensional graphics, avatars, and virtual patients, better assist in producing a sense of immersion in the learning environment.
Hybrid forms of simulation use more than one type of simulation in a case study or scenario. For example, a trained actor may be included in a scenario that uses a human patient simulator (mannequin) as a way to enhance the authenticity of the experience for the learner and provide opportunities for participants to practice interactional skills and apply professional attributes. In a scenario constructed to initially reinforce and assess physical assessment skills and management of a patient’s discharge to home from the hospital setting, a high-ﬁdelity mannequin can be used to represent a confused, elderly patient, and an actor can portray the patient’s daughter. Following the physical assessment portion of the scenario, the daughter can question the learner’s decision about the patient’s discharge, requesting continued hospitalization and more aggressive treatment. This development in the scenario can evolve into consideration of surrogate decision making, advocacy, beneﬁcence and nonmaleﬁcence, and the virtues required of the healthcare professional in this situation.
Structure Of Simulation
Ethics simulations may be conducted using any of the above forms. Successful simulation, however, requires carefully attending to its four fundamental components or structured phases: preparation, scenario implementation (the active experience), debrieﬁng/reﬂection session, and evaluation. The preparation phase addresses the appropriateness of experiential learning to meet the learning objectives and the development of the simulation materials to best achieve the educational goals. During the preparation phase, the educator identiﬁes the learning objectives and develops the case study, referred to as a scenario, and additional materials to best meet the needs of the learner. Educators may write original cases, use existing cases, or adapt cases. Texts of case studies in medicine, nursing, research ethics, and global bioethics can offer ideas. Educators may also develop scenarios that reﬂect the learners’ current experiences with bioethical issues. In addition to the case study, it is important to determine the participants’ roles, facilitator role, data for the case, equipment needed, focus of feedback to the learner, the degree of ﬁdelity desired, and the means of evaluation. Learners also need to understand the goal of the simulation and be adequately prepared to actively participate. In some cases, learners may need a review of ethical theory and principles, professional values and virtues, communication strategies, and so forth, prior to simulation. Participants will also require orientation to the simulation experience. Other considerations in this phase are scheduling and the available resources – time, faculty, physical space, and budget.
The implementation phase is the active participation of the learners in the scenario as they work to identify and manage the bioethical issue. Depending on the design of the simulation, learners engage with a standardized patient, human patient simulator, or computer-based program, either individually or in groups. The activity is learner-centered and learner-directed as students attempt to resolve an issue. Students may receive immediate feedback as they interact with the patient, family, or other healthcare professionals. During this phase, students reﬂect on their actions as they move through the scenario and respond to immediate feedback. The facilitator directly observes the moral comportment of the learner, characteristics of the patient-learner relationship, communication, identiﬁcation of ethical issues, and the way in which the learner works through ethical problems.
The third phase is debrieﬁng, during which participants are guided to review and reﬂect upon their performance and connect theory to practical application. It is essential that debrieﬁng facilitators create a supportive, safe environment for exploring of emotions and reactions, sharing of observations, and receiving constructive feedback. This phase promotes self-awareness of strengths and weaknesses. Using open-ended questioning, the facilitator coaches learners to critically self-reﬂect on their actions and engage in a discussion that examines the learning objectives of the scenario. Simulation often creates emotional feelings and stress; therefore, the early phase of debrieﬁng is often a time for participants to release their emotional responses or “decompress.” The facilitator should explore the emotional responses of the learners. Facilitators are encouraged to stress positive behaviors and constructively correct misconceptions and errors. During debrieﬁng, the facilitator also examines deﬁciencies in knowledge and performance and suggests strategies to overcome them.
The ﬁnal phase, evaluation, is planned during the preparation phase of simulation. Simulation is most often conducted for teaching and assessment; however, it may be used for formative or summative evaluation. Following simulations, participants may complete a self-evaluation and also evaluate the activity’s effectiveness and value. In simulations using standardized patients, learners have the opportunity to receive rich and highly valued feedback directly from the standardized patient. The facilitator may also choose to have the standardized patient participate in the debrieﬁng. Educators may evaluate the effectiveness of the simulation activity to meet educational goals, such as gains in bioethics knowledge and clinical ethics skills.
Benefits Of Incorporating Simulation In Bioethics Education
The advantages of simulation-based learning are well known in healthcare education, and its beneﬁts are appreciated in bioethics education as well. Simulation allows educators to create learning situations that may be difﬁcult to identify and observe in clinical settings. It provides standardized and consistent learning experiences among the participants. Scenarios can be repeated as needed to attempt to ensure a minimum level of clinical ethics competency. Opportunities for repeated practice help to form habits and professional virtues and, for healthcare students in particular may aid in overcoming the negative effects of the hidden curriculum.
Bioethics simulation provides comprehensive, holistic learning across the educational domains and complements other teaching methods. An ethics simulation, for example, may be developed to strengthen cognitive learning, such as critical thinking and the ability to justify ethical decisions; promote behavioral learning, such as therapeutic communication skills and relationship building; and foster affective learning, such as increasing ethical awareness and developing professional virtues. The structure of simulation allows students to prepare for a particular learning experience and receive feedback on their actions and decision-making process from standardized patients, educators, and other participants. Moreover, ethics simulations provide a safe learning environment for the participants. Learners are able to explore their weaknesses and strengths in a supportive environment and also practice clinical ethics skills without fear of harming patients.
Furthermore, by enhancing ethics competency in realistic learning settings prior to working with actual patients, ethics simulation may potentially prevent and mitigate harm to patients and enhance the quality of patient care. Novice training is known to be associated with an increased risk of injury. Harm to patients is most often conceived of as physical, and yet it may also be realized as psychological, socioeconomic, and moral harm (UNESCO 2008). Moral injury may include disrespect, indifference, insensitivity, unfairness, and social stigmatization, among others. Clinical examples of moral harm include lapses in protecting patient autonomy and conﬁdentiality, failing to advocate for a patient’s rights, or failing to recognize ethical issues. With simulation-based learning, educators can observe errors or weaknesses in clinical ethics skills that would contribute to lower quality care for patients and provide remediation.
Importantly, simulation is effective, and participants value simulation-based learning. Simulation in medicine and nursing education reveals gains in conﬁdence, knowledge, critical thinking, communication, interpersonal skills, counseling, satisfaction, procedural skills, and affective skills. Ethics simulations have been shown to improve conﬁdence and comfort in applying professional virtues, improve communication techniques and relationship-building skills, enhance ethical decision making, nurture empathy, ethical sensitivity, and ethical reﬂection, and aid in self-awareness of personal values and bias (Wilt 2012).
The Ethical Obligation To Conduct Simulation-Based Ethics Education In The Healthcare Professions
The incorporation of simulation-based teaching in bioethics education is warranted by its efﬁcacy and value in nurturing the virtues and skills required to provide quality patient care. Even more, in their seminal article, Ziv et al. (2006) argue compellingly that there is an ethical imperative for medical educators to provide simulation based education when possible. The authors base their conclusion on the results of simulation training used primarily for communication skills, procedural skills, physical examination, and obtaining informed consent. This requirement is based on the moral tension between the need for students to learn by working directly with patients and the duty to provide the best care while reducing patient harm. Likewise, this imperative is equally relevant in developing bioethics competency. The authors defend their position by addressing four factors: maintaining best standards, error management and patient safety, patient autonomy, and social justice and resource allocation. The use of simulation improves the level of competency of the trainee in early encounters with actual patients, reducing risk and dependency on actual patients for learning. The authors assert that the risks or harm associated with novice training are only warranted if training that minimizes such risks has been optimized, underscoring the principle of nonmaleﬁcence or “ﬁrst do no harm.” As noted above, harm may be understood as physical, psychological, socioeconomic, or moral. They stress also that simulation-based learning guards against viewing patients as resources for learning. Moreover, Ziv et al. maintain that educators have a moral responsibility to students to utilize the best practices in education. Simulation permits educators to expand the learning opportunities of students by introducing case scenarios on problems that they might rarely experience. Simulation also provides learner-centered training – need-based education that can be structured to allow self-paced learning and provision of constructive feedback with the opportunity to repeat skills. Importantly, while educators and trainees work to prevent errors in the clinical setting, during simulation, errors are expected and reviewed as a learning experience with the hope of fostering a culture of safety and openness. Simulation-based education also supports patient autonomy and protects patients by offering an alternative to novice training. Finally, the authors argue that simulation based training may serve to reduce the disproportionate amount of novice training that poor and disadvantaged patients receive based on the larger numbers of trainees in academic hospitals, which serve greater numbers of vulnerable patients.
Bioethics simulation is an interactive, experiential method of ethics instruction that offers a holistic approach to ethics teaching. While other teaching methods have their beneﬁts, simulation-based learning promotes learning across the educational domains. It provides practice opportunities in bioethics to enable the formation of habits and skills essential for ethics competency in healthcare, consistent with the goals of ethics education. Bioethics simulations present standardized and consistent learning experiences for healthcare students and professionals. Importantly, they allow practice opportunities to develop competency in clinical ethics skills and in the application of professional virtues. Bioethics simulation may provide learning opportunities to raise the minimal skill level of healthcare students to reduce the risk to patients – moral, psychological, socioeconomic, and physical – with a real potential, therefore, to improve the quality of patient care.
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