Interprofessional simulations that use simulated participants (SPs, professional actors who have been trained to play a patient, family member, or clinician) and technology to recreate clinical scenarios and include facilitated debriefing have been shown to improve individual learning outcomes for health professionals who care for patients with co-occurring physical and mental illnesses.1 Empirical evidence for how interprofessional simulation activities translate to participants' clinical practices is, however, currently lacking.2–4 Reviews of studies in the broader simulation literature have emphasized the need for a richer, theory-based understanding of the relationship between instructional design and simulation effectiveness.5,6
Fidelity, the degree to which a simulation technology or scenario matches a “real” practice context, is an important instructional design consideration. Fidelity has been previously described in the literature as having physical and psychological dimensions.7Physical fidelity refers to the look and feel of the simulation technology and environment, whereas psychological fidelity pertains to whether the simulation faithfully replicates the critical elements of the task such that participants feel that they can engage in it authentically as they would in clinical practice.7 An example of reduced psychological fidelity would be when clinically necessary steps (eg, adopting sterile technique for a surgical procedure) are skipped, often for logistical or cost reasons. In the domain of interprofessional simulation, Sharma et al8 introduced the term sociological fidelity to represent the degree to which a simulation scenario addresses the reality of the interprofessional care context, including issues of power, hierarchy, and professional boundaries.9 An example of reduced sociologically fidelity would be a crisis intervention scenario where roles for a physician and a nurse were interchangeable, instead of acknowledging the power imbalance that typically exists between these professions.
Significant costs are often incurred to increase the fidelity of a simulation activity, with the implicit assumption that it will enhance participant engagement and learning. There is, however, growing evidence to suggest that the degree of physical fidelity is independent of educational effectiveness,10–13 whereas empirical evidence of the roles of psychological and sociological fidelity in achieving learning outcomes remains limited.14 Hence, there is a need to better understand the dimensions of fidelity which influence learning in interprofessional simulation. In this study, we explore the dimensions of fidelity that participants of an interprofessional mental health simulation course perceive as influential for promoting meaningful learning and practice change.
We conducted an interview-based qualitative study to explore the relationship between learning and the different dimensions of fidelity from the perspective of interprofessional simulation course participants. We obtained research ethics board approval from the Centre for Addiction and Mental Health (CAMH) and The Hospital for Sick Children (SickKids) in Toronto, Canada. All participants provided written informed consent.
The specific focus of our study was the Interprofessional Simulations of Patient Experiences Across the Care Continuum - Child and Youth (iSPEACC-CY) course. This 1-day simulation course is aimed at health care professionals who work with adolescents with co-occurring physical and mental illnesses. The curriculum builds on a previous course that was delivered at the CAMH in 2016. In each of 3 two-part scenarios, the same simulated patient presents in two different healthcare settings (see Table A-1, Supplemental Digital Content 1, for an example scenario, http://links.lww.com/SIH/A491). Specific practice settings were selected to represent 3 partner institutions in the Greater Toronto Area: CAMH, SickKids, and Trillium Health Partners. Each scenario was followed by a structured group debriefing session led by two experienced facilitators to encourage reflection and learning related to specific scenario objectives. Topics related to interprofessional collaboration, such as role clarification and effective team functioning, were incorporated into the debriefing discussions where possible.
In response to participant feedback that the 2016 course did not adequately reflect the Canadian health care context,15 significant efforts were made to increase the physical, psychological, and sociological fidelity of the scenarios. The physical set designs were intended to resemble participants' actual practice settings as closely as possible, for example, by changing the signage on the walls to be institution-specific and including specialized props such as the headwall above a hospital bed. To enhance psychological fidelity, adult SPs were extensively trained to realistically portray adolescent patients and their parents. Specific care processes and protocols from each institution were identified and incorporated into the scenario design. Sociological fidelity was addressed by adapting scenarios to accurately reflect the institution, professional role, and expertise of each participant. Participants were always expected to act within their professional scopes of practice. For example, a scenario involving a nurse and a psychiatrist expected that the psychiatrist would have the decision-making authority, as per the governing mental health regulations. One of the planned topics of the debriefing discussion was the hypothetical situation of a team member disagreeing with a decision the physician has made. Scenarios were deliberately ordered to reflect the ways patients access the Canadian healthcare system, with participant roles for each scenario chosen to represent how diverse interprofessional teams operate within this context. All scenarios built in explicit interprofessional interaction by having one or two participants meet with the patient, then leave the room to consult with another participant, and subsequently return together. In some scenarios, these pathways were selectively constructed as not to reinforce stereotypical hierarchies of nurses and social workers always requiring assistance from physicians. For example, one scenario involved a family physician seeing a 16-year-old adolescent girl with disordered eating and anxiety first and then consulting with a social worker, who both returned to see the patient together to discuss a management plan. As the more typical pathway would be for the social worker to consult the physician, this represents one area where sociological fidelity was reduced.
Course attendees included nurses, social workers, and physicians from CAMH, SickKids, and Trillium Health Partners. The course was delivered twice: course 1 at CAMH in June 2017 and course 2 at SickKids in November 2017. All healthcare practitioners (N = 22) who attended either course were eligible to participate in the study.
Data Collection and Analysis
Participants were invited for individual semistructured interviews 3 months after their course participation. This time frame was chosen to enable the exploration of the impact of the course on participants' clinical practice. Because of participants' time constraints, the actual interviews took place between 4 and 6 months after their course participation. The interview questions are presented in Table 1. The interviews lasted up to 1 hour and were conducted by a single researcher (L.M.N.) who was not involved in course design or delivery. Data analysis began alongside our interviews and the results of the ongoing data analysis informed subsequent data collection.16 We met as a team iteratively during the data collection phase to refine our interview guide, probe for emerging ideas, and determine theoretical saturation, which occurred after 10 interviews.17
We analyzed the interview transcripts using an iterative, constant comparative approach, drawing on a grounded theory framework.18 Three team members (L.M.N., S.S., C.M.W.) reviewed the first group of 3 transcripts to identify preliminary codes related to fidelity, learning, engagement, and practice change. Two team members (L.M.N., C.M.W.) then conducted an inductive analysis with codes emerging from the data rather than a pre-existing coding scheme. In regular meetings, we met to compare interpretations, review, refine, and merge codes to create a coding structure and reconcile different viewpoints through team discussion. Throughout this process, data were compared within and across transcripts. Theoretical saturation was determined to have been achieved at the point at which no new insights or conceptual categories were observed in the data.17 Confirmability was ensured by maintaining an audit trail of all analytical memos, meeting minutes, and coding structure revisions. Final coding was then conducted by L.M.N. using Dedoose (Version 8.0.42; SocioCultural Research Consultants), which facilitated data organization and cross-referencing.19
Our research group included clinicians with experience participating in and facilitating simulation-based education and nonclinician education researchers who brought outsider perspectives.20 During the data collection and analysis phases, we engaged in a dialog to question and challenge one another's assumptions and recorded memos as coding proceeded.21
Study participants were representative of course participants. Of the 10 participants who provided data, 5 were from course 1 and 5 were from course 2. Participants included 4 nurses, 4 social workers, and 2 physicians and 60% were female. Four were from CAMH, 4 were from SickKids, and 2 were from Trillium Health Partners. None had previously participated in an interprofessional simulation course. Interviews lasted between 13 and 47 minutes (mean = 36 minutes) and generated 115 pages of data for analysis. The selected quotes presented in Table 2 illustrate the themes and supporting concepts of the final analysis.
Participants generally reported that they found the physical appearance of the simulation rooms and equipment to be realistic (Quote 1a). Although it was important to some participants that the environment realistically represent a generic clinical setting (Quote 1b), the efforts to accurately recreate the participants' own clinical settings (eg, by using institution-specific signage and props) went largely unnoticed (Quote 1c). Interestingly, participants did not comment on the physical appearance of the adult SPs who portrayed the adolescent patients. Overall, participants did not view the physical fidelity of the simulation as having a significant impact on their learning experience (Quotes 1d and 1e).
Most participants reported that the simulation scenarios were believable surrogates for real clinical encounters. In particular, the SPs' realistic portrayals were seen as critical for engagement in the learning process. Participants made frequent references to the SPs as “patients” and repeatedly said that the scenarios “felt real.” They made a link between this aspect of fidelity and their abilities to overcome their anxiety related to being observed (Quotes 2a and 2b) and inhabit their own professional roles in the scenario (Quotes 2c and 2d). At times, however, participants pointed out discrepancies between the information they received in the scenario brief and how the encounter would typically unfold in their clinical practice (Quotes 2e and 2f). Participants felt that scenarios that closely matched their own clinical experiences made it possible to easily access their current knowledge and skills (Quote 2g), but also that they sometimes limited opportunities for new learning (Quote 2h).
Participants varied in their assessment of the degree to which the scenarios accurately replicated their interprofessional practice contexts. Similar to their views of the SPs, interprofessional interactions that were realistic supported participant engagement (Quotes 3a and 3b). The structured interprofessional interactions and patient flow of the scenarios did not, however, always align with participants' clinical experiences (Quotes 3c and 3d). Although this sometimes impacted learning negatively (Quote 3e), more often participants noted that these discrepancies presented valuable learning opportunities (Quotes 3f and 3g).
To our knowledge, our study is the first to explore participant perspectives of the relationship between physical, psychological, and sociological fidelity and learning in the context of an interprofessional simulation course. Our findings suggest that participants differentially valued the various dimensions of fidelity as impacting their learning experience.
Overall, participants viewed the iSPEACC-CY course as a close approximation of their clinical practice contexts. Beyond realistically representing a generic clinical setting, participants seemed to derive little added learning value from the efforts that were put toward accurately recreating institution-specific settings. Their views on the relative unimportance of the appearance of the simulation environment echo findings from the procedural simulation literature on the minimal relationship between physical fidelity and learning.10–13 Importantly, however, Rudolph et al22 note that the importance of physical fidelity is likely to vary according to the simulation context. For example, they identify high physical fidelity as desirable in procedural simulations for developing kinesthetic awareness and muscle memory. In teamwork and crisis resource management simulations, however, lower physical fidelity may be sufficient as long as it does not interrupt participants' emotional or experiential engagement.
Study participants highly valued psychological fidelity. The SPs' realistic portrayals of the adolescent patients and their parents allowed participants to immerse themselves in the scenarios in the context of their professional roles. Most research on SPs in psychiatry has focused on their use in communication-oriented scenarios.23,24 Our findings suggest that SPs can additionally be used to address knowledge and skill-based learning outcomes to improve integrated care for patients with co-occurring mental and physical illnesses. Using adult SPs can help mitigate ethical concerns related to working with adolescent SPs.25 Costs incurred in recruiting and training SPs to authentically evoke a variety of psychiatric conditions seem to be justified.26
Despite repeated calls to attend to sociological fidelity in the design of interprofessional simulation,8,9,13 we only found one study that reported empirical data.14 In that study, the determination that the sociological fidelity of a mass casualty simulation was sufficient for learner engagement was based on an analysis of observer notes. Our results challenge the implicit assumption that higher sociological fidelity is always better, by suggesting that the structure of interprofessional collaborative practice does not have to be authentically recreated in a clinical simulation scenario to promote meaningful learning. In particular, the deliberate variation in assigning how participants in different clinical roles would consult with each other seemed to support learning objectives related to understanding and appreciating the roles and responsibilities of other health professionals. We hypothesize that challenging set working practices in the context of a simulation scenario may support learning by providing an opportunity to surface some of the hidden discourses that underlie interprofessional practice in the debriefing session.27
Our study has several limitations. Our decision to conduct the interviews several months after course participation was intended to permit participants to reflect on how fidelity impacted both their immediate learning and subsequent practice change. We acknowledge, however, that this delay may have limited their ability to recall some of the specific details of the scenarios. This study was conducted in the context of a single simulation-based course, and all participants had limited previous interprofessional simulation experience. Although our findings illustrate the varied perceptions of interprofessional participants with respect to the relationship between learning and the different dimensions of fidelity, they cannot be directly generalized to other simulation-based contexts. We strongly encourage future research to measure learning in interprofessional simulations where physical, psychological, and sociological fidelity are systematically varied, and to explore both educators' and learners' perspectives on the impact of these design decisions. In particular, the tension between having adequate fidelity to promote learner engagement and selective manipulations to promote new learning is an area for further exploration.
In summary, we found evidence to suggest that participants of an interprofessional mental health simulation course highly valued psychological and sociological fidelity as critical elements to promote meaningful learning, although physical fidelity was less essential. Selective manipulations of these fidelity dimensions may be appropriate depending on the scenario and course learning objectives. Our findings also suggest that financial costs incurred in recruiting and training SPs for mental health scenarios are justified, whereas those related to increasing the realism of the clinical environment and equipment should be considered carefully.
The authors thank the members of the iSPEACC-CY curriculum design and implementation team for their support of this work.
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