When our university campus and simulation center closed because of COVID-19 in March 2020, I had zero online teaching experience. I was scheduled to teach a favorite occupational therapy course that had been centered on in-person standardized patient (SP) simulations. Students were tasked to interview a patient to obtain their occupational profile. Shifting my attention to finding the best replacement activity, I discovered the option of online SP encounters via web conferencing. Intriguingly, I loved the idea of still incorporating SPs. However, would students find an online encounter believable? Despite my doubts, I was very curious to see how this could work.
Over the next several weeks, I was immersed in simulation planning. Already overwhelmed grappling with the inevitable unstable Internet connections and technology glitches of the online landscape, I dreaded the many planning meetings that were required to tackle the logistical details for online simulations. However, after each meeting, I was glad it happened. I felt reassured. The online environment provides less room for troubleshooting on the spot. For example, we decided to forgo faculty giving SPs impromptu stage directions during the simulation. Instead, we scheduled extra SP training to ensure that the SPs were strong in their role portrayals.
An unexpected bonus from the planning meetings was connecting more deeply with the SPs. During a rehearsal, I complimented an SP on the emotional depth of his performance. He then shared that he drew upon his recent personal experience with mental illness to realistically portray a depressed mood. On another occasion, SPs expressed appreciation for a private online space (a breakout room) immediately before and after each encounter. They explained that the private space would allow SPs to “get into character” without distractions and without being affected by the students' “nervous energy.” I also learned that after encounter, SPs needed and desired space to recover emotionally from demanding or intense roles. One SP shared that she drinks a cup of tea and even curls up under a favorite blanket between rounds if needed. I had been working with SPs for over a decade but never considered the emotional energy required for them to perform their roles until then. It was eye-opening and moving to realize how much SPs were willing to give of themselves emotionally.
On the first online simulation day, I “arrived” with calmness and mental clarity despite having many logistical details on my mind. I was mostly eager to see how the students would respond, like a child about to reveal a surprise that they had been planning. During the presimulation briefing with my students, even through my Zoom screen, I could feel their nervous anticipation, very much like in-person. The scenario unfolded with the occupational therapy students introducing themselves to Mark, a 21-year-old college student who just sustained paraplegia. Mark now needs to complete all activities while seated and to use a wheelchair for mobility, most likely for the rest of his life. I witnessed simulation magic at work as students attempted to move through their prepared checklist to gather information about Mark's valued activities and life context to design a patient-centered rehabilitation program. This magic manifests through the looks on the students' faces. The look of confusion and panic as Mark expressed sudden anger when asked about his previous daily activities—running had been Mark's passion, or the look of profound realization when students put down their scripted list of questions and started to really listen to Mark. I was thrilled that the students seemed fully engaged and that this familiar magic seemed to work on Zoom. Viewing the encounter, I was moved to tears. I do not cry easily. My emotional reaction came as a complete surprise and had never happened before. What was different? When in-person, my attention would have been focused on directing the scenario and considering whether I needed to prompt the SP through their earpiece. I was fully immersed in the scenario for the first time online.
After simulation, I sought to learn about the student experience. Given my initial doubts about believability, it was a big relief to hear that students felt the encounters were realistic. They reported that the SPs were “entirely convincing.” “The online simulation captured the emotions that I would have felt with a real client,” one student reported. “I felt in-the-moment and connected with the client.” Recalling my own experience of being moved to tears, I completely understood their perspectives. During planning, I had assumed that environmental fidelity would be an important aspect of believability; I sent hospital gowns to the SPs and emailed them a virtual background of a hospital room. However, much to my surprise, the simulated context did not seem to matter much for this scenario. As one student explained, “I don't think my mind even went there… I was not thinking that we're in the hospital at the time. I was just trying to talk to the patient.”
The biggest surprise from the student feedback was that some students were actually glad this simulation was online instead of in-person. I had initially viewed online simulations as a contingency plan, the next best thing because in-person simulations were not available. I never imagined that any student would actually prefer it. One student explained, “The online simulations were a good leeway… to be in the comfort of my own home our first time as active learners. I now feel more comfortable going into the simulation labs.” She shared that for this first encounter, trying to make a connection with a patient who just had a life-changing injury was already “a lot to handle.” The student's explanation resonated deeply with me as an occupational therapist. One of the cornerstones of occupational therapy practice is designing the demands of any activity to be the just-right level of challenge for an individual's current abilities. It dawned on me that for some students, online simulations were the just-right level of challenge, a perfect introduction to SP encounters.
Now in 2022, our university simulation center has finally resumed “normal” operations and full capacity for in-person simulations. When completing simulation request forms for the first simulation of the school year, I am asked to indicate whether SPs will be in-person or online. I click online.