Guidelines for the Responsible Use of Deception in Simulation: Ethical and Educational Considerations.

STATEMENT: Many techniques and modifications commonly used by the simulation community have been identified as deceptive. Deception is an important issue addressed by both the newly adopted Healthcare Simulationist Code of Ethics and the American Psychological Association Code of Conduct. Some view these approaches as essential whereas others question their necessity as well as their untoward psychological effects. In an attempt to offer guidance to simulation-based healthcare educators, we explore educational practices commonly identified as deceptive along with their potential benefits and detriments. We then address important decision points and high-risk situations that should be avoided to uphold ethical boundaries and psychological safety among learners. These are subsequently analyzed in light of the Code of Ethics and used to formulate guidelines for educators that are intended to ensure that deception, when necessary, is implemented in as psychologically safe a manner as possible.

Techniques to Communicate Better With Parents During End-of-Life Scenarios in Neonatology.

BACKGROUND AND OBJECTIVES: Clinicians are urged to optimize communication with families, generally without empirical practical recommendations. The objective of this study was to identify core behaviors associated with good communication during and after an unsuccessful resuscitation, including parental perspectives. METHODS: Clinicians from different backgrounds participated in a standardized, videotaped, simulated neonatal resuscitation in the presence of parent actors. The infant remained pulseless; participants communicated with the parent actors before, during, and after discontinuing resuscitation. Twenty-one evaluators with varying expertise (including 6 bereaved parents) viewed the videos. They were asked to score clinician-parent communication and identify the top communicators. In open-ended questions, they were asked to describe 3 aspects that were well done and 3 that were not. Answers to open-ended questions were coded for easily reproducible behaviors. All the videos were then independently reviewed to evaluate whether these behaviors were present. RESULTS: Thirty-one participants' videos were examined by 21 evaluators (651 evaluations). Parents and actors agreed with clinicians 81% of the time about what constituted optimal communication. Good communicators were more likely to introduce themselves, use the infant's name, acknowledge parental presence, prepare the parents (for the resuscitation, then death), stop resuscitation without asking parents, clearly mention death, provide or enable proximity (clinician-parent, infant-parent, clinician-infant, mother-father), sit down, decrease guilt, permit silence, and have knowledge about procedures after death. Consistently, clinicians who displayed such behaviors had evaluations >9 out of 10 and were all ranked top 10 communicators. CONCLUSIONS: During a neonatal end-of-life scenario, many simple behaviors, identified by parents and providers, can optimize clinician-parent communication.

Ethical Reasoning Debriefing in Disaster Simulations.

BACKGROUND: With disasters occurring often, nurses must understand and ethically implement disaster management and patient care coordination. Yet these topics are often not discussed in nursing education curricula. Simulations are a potential solution to this ethical educational deficit, allowing students to act as professional nurses in a realistic scenario with minimal threat of harm to themselves or others. AIM: This study investigates the effect of a high fidelity, multiple-casualty disaster simulation followed by a structured faculty-led debriefing session on perceived ethical reasoning confidence on senior Bachelor of Science in Nursing (BSN) students. Additionally, the effect of the intervention on students' perceived importance of ethical reasoning and perceptions of such skills was explored. METHODS: Students were provided with preparatory materials on the START (Simple Triage and Rapid Treatment) System and The Madison Collaborative's Ethical Reasoning in Action Eight Key Questions (8KQ) frameworks one week before the simulation exercise. In total, 90 students worked in pairs during the 15-minute disaster simulation. Participants' ethical reasoning attitudes were measured before and after the exercise, employing the Survey of Ethical Reasoning (SER) to indicate the importance of each of the 8KQ in students' ethical reasoning process using a five-point Likert scale. The SER was administered electronically using Qualtrics and statistical analysis was completed using SPSS. The 8KQ was also used in the debriefing led by faculty. RESULTS: Comparative assessment of pre and post-results demonstrate significant growth in students' ethical reasoning confidence scores (t(89) = -6.609, p < 0.001). CONCLUSIONS: Simulations are shown to be effective educational approaches in developing ethical reasoning confidence and promoting the development of students' ethical preparedness.

Is live-tissue training ethically justified? An evidence-based ethical analysis.

Trauma training is a crucial element of medical education in the civilian sector, as well as in the military sector. Its aim is to prepare physicians, medics and nurses for stressful and demanding emergency situations. Training methods include live-tissue training (LTT) on animal models and simulation-based trauma education. For LTT, blast, gunshot or stab wounds are inflicted on anaesthetised animals, mostly goats and pigs, but sometimes non-human primates. This training method raises ethical concerns, especially in the light of increasingly sophisticated simulation-based methods. Despite these non-animal alternatives, LTT is still widely used due to its presumed educational benefits. In this paper, the question of whether LTT can still be justified, is discussed. We developed a normative framework based on the premise that LTT can only be ethically justified when it yields indispensable benefits, and when these benefits outweigh those of alternative training methods. A close examination of the evidence base for the presumed advantages of LTT showed that it is not superior to simulation-based methods in terms of educational benefit. Since credible alternatives that do not cause harm to animals are available, we conclude that LTT on animal models is ethically unjustified.

A simulação no ensino de enfermagem: reflexões e justificativas a luz da bioética e dos direitos humanos / La simulación en la enseñanza de enfermería: reflexiones y justificaciones a la luz de la bioética y de los derechos humanos / Simulation in training nurses: reflections and justifications based on bioethics and human rights approaches

Resumo: 18. Objetiva-se refletir sobre a simulação no ensino de enfermagem a luz da bioética e dos direitos humanos. Trata-se de ensaio reflexivo que parte da premissa que o contexto formativo atual em saúde e enfermagem deve contemplar, em seus processos, estratégias de ensino e aprendizagem que levem em consideração as diversas questões éticas e bioéticas, dos direitos humanos, dos avanços tecnológicos e do conhecimento científico. Justifica-se o uso da simulação no ensino de enfermagem a partir da perspectiva da dignidade da pessoa humana, da não instrumentalização da pessoa humana, da igualdade, e da não discriminação. Além disso, são apontados alguns princípios fundamentais da bioética e sua relação com a simulação. Discute-se ainda, as contribuições dessa estratégia de ensino e aprendizagem na perspectiva do doente/usuário, do estudante, da universidade, e das instituições de saúde. Ao considerar esses aspectos, é imprescindível pensar numa prática formativa que incorpore essas dimensões nos seus processos de formação dos futuros enfermeiros.

Resumen: 22. El objetivo es reflexionar sobre la simulación en la enseñanza de enfermería a la luz de la bioética y de los derechos humanos. Se trata de un ensayo reflexivo que parte de la premisa que el contexto formativo actual en salud y enfermería debe contemplar en sus procesos estrategias de enseñanza y aprendizaje que tengan en cuenta las diversas cuestiones éticas y bioéticas de los derechos humanos, de los avances tecnológicos y del conocimiento científico. Se justifica el uso de la simulación en la enseñanza de enfermería desde la perspectiva de la dignidad de la persona humana, de la no instrumentalización de la persona humana, de la igualdad y de la no discriminación. Además, se señalan algunos principios fundamentales de la bioética y su relación con la simulación. Se discute además las contribuciones de esta estrategia de enseñanza y aprendizaje en la perspectiva del paciente / usuario, del estudiante, de la universidad y de las instituciones de salud. Al considerar estos aspectos, es imprescindible pensar en una práctica formativa que incorpore esas dimensiones en sus procesos de formación de los futuros enfermeros.

Abstract: 26. The aim of this paper is to reflect about the use of simulation in training nurses based on bioethics and human rights approaches. This is a reflexive essay based on the assumption that the current training context in health and nursing must include in the process teaching and learning strategies which take into account diverse ethical and bioethical questions about human rights, technological development and scientific knowledge. The use of simulation in training nurses is justified on human dignity, not in the instrumentalization of the person, equity and not discrimination. Furthermore, some fundamental principles of bioethics and their relation to simulation are pointed out. Moreover, the contributions of this teaching and learning strategy are discussed under the perspectives of patient/user, student, university and health care institution. Considering these issues, it is essential to plan a training practice incorporating these dimensions in the training process of future nurses.

Values and value in simulated participant methodology: A global perspective on contemporary practices.

This article has been written for the 40th year of the publication of Medical Teacher. While we celebrate the contribution of simulated participants (SPs) to health professions education through values and value-based learning, we also offer critical reflection on elements of our practice, commencing with language. We argue for the use of the term simulated rather than standardized and acknowledge the dominant role of the SP as patient and the origins of the methodology. These shifts in terms and their implications in practice reflect changes in the conceptualization of SP-based methodology. Recently published standards for those who work with SPs (SP practitioners) are noted as an important milestone in our community's development. We consider contemporary practices addressing the complex notions of values and value in SP-based learning. We simultaneously refer to the work of SPs and SP practitioners. Phases of educational design including identifying learning objectives, scenario design, implementation, feedback and debriefing are used to illustrate methodological shifts. Within each of these phases, there are relational issues that have to date often gone unchecked and are under reported in literature. Finally, using the metaphor of a murmuration, we celebrate contemporary practices of the global SP practitioner community.

Simulated Mortality-We Can Do More.

High-fidelity simulation (HFS) is a relatively new teaching modality, which is gaining widespread acceptance in medical education. To date, dozens of studies have proven the usefulness of HFS in improving student, resident, and attending physician performance, with similar results in the allied health fields. Although many studies have analyzed the utility of simulation, few have investigated why it works. A recent study illustrated that permissive failure, leading to simulated mortality, is one HFS method that can improve long-term performance. Critics maintain, however, that the use of simulated death is troubling and excessive. Given the controversy regarding simulated death, we consider the data about the educational value and the emotional harms associated with them, expecting that evidence could be useful in resolving the question. The goal of this narrative review is to explore the argument against simulated mortality and provide educators with an imperative as to why it can be safely utilized.

A Multispecialty Evaluation of Thiel Cadavers for Surgical Training.

BACKGROUND: Changes in UK legislation allow for surgical procedures to be performed on cadavers. The aim of this study was to assess Thiel cadavers as high-fidelity simulators and to examine their suitability for surgical training. METHODS: Surgeons from various specialties were invited to attend a 1 day dissection workshop using Thiel cadavers. The surgeons completed a baseline questionnaire on cadaveric simulation. At the end of the workshop, they completed a similar questionnaire based on their experience with Thiel cadavers. Comparing the answers in the pre- and post-workshop questionnaires assessed whether using Thiel cadavers had changed the surgeons' opinions of cadaveric simulation. RESULTS: According to the 27 participants, simulation is important for surgical training and a full-procedure model is beneficial for all levels of training. Currently, there is dissatisfaction with existing models and a need for high-fidelity alternatives. After the workshop, surgeons concluded that Thiel cadavers are suitable for surgical simulation (p = 0.015). Thiel were found to be realistic (p < 0.001) to have reduced odour (p = 0.002) and be more cost-effective (p = 0.003). Ethical constraints were considered to be small. CONCLUSION: Thiel cadavers are suitable for training in most surgical specialties.

Simulation as an ethical imperative and epistemic responsibility for the implementation of medical guidelines in health care.

Guidelines orient best practices in medicine, yet, in health care, many real world constraints limit their optimal realization. Since guideline implementation problems are not systematically anticipated, they will be discovered only post facto, in a learning curve period, while the already implemented guideline is tweaked, debugged and adapted. This learning process comes with costs to human health and quality of life. Despite such predictable hazard, the study and modeling of medical guideline implementation is still seldom pursued. In this article we argue that to systematically identify, predict and prevent medical guideline implementation errors is both an epistemic responsibility and an ethical imperative in health care, in order to properly provide beneficence, minimize or avoid harm, show respect for persons, and administer justice. Furthermore, we suggest that implementation knowledge is best achieved technically by providing simulation modeling studies to anticipate the realization of medical guidelines, in multiple contexts, with system and scenario analysis, in its alignment with the emerging field of implementation science and in recognition of learning health systems. It follows from both claims that it is an ethical imperative and an epistemic responsibility to simulate medical guidelines in context to minimize (avoidable) harm in health care, before guideline implementation.

Deception and simulation education: issues, concepts, and commentary.

STATEMENT: The use of deceptive methodology in simulation education is an emerging ethical controversy. At the 2014 International Meeting on Simulation in Healthcare, arguments for and against its use were debated by simulation experts. What emerged from this discussion was an apparent disconnect between current practice and existing empiric research on this subject. At present, no framework exists to guide the simulation community's exploration of this issue of deception.After reviewing the relevant psychological literature, we propose a framework delineating discrete elements and important relationships, which enables a comprehensive view of the factors germane to simulations that use deception. We further comment on key pedagogical and psychological issues in the context of this framework and define an agenda for further research. Educators are encouraged to use this framework when determining whether, when, and how deception might be used and, if used, how it can be ethically justified and carefully implemented.