Cynthia Foronda and colleagues discuss the positive results of virtual simulation in teaching interprofessional communication.

Miscommunication is a leading cause of patient death in hospitals. Using virtual simulation to enhance clinical skills is a potential solution. Dr. Cynthia Foronda and colleagues share their experience at Johns Hopkins.

Miscommunication in hospitals is a leading cause of patient death (TJC, 2015b). Communication is linked to patient complaints as well as patient outcomes (Liaw, Zhou, Lau, Siau, & Chan, 2014; Harnof et al., 2013). Leading organizations in healthcare have indicated that improving communication is a priority (IPEC, 2011; Kohn, Corrigan, & Donaldson, 2000; TJC, 2015c; WHO, 2011). Consequently, agencies across the world have been striving to improve patient safety education for health professions students (IPEC, 2011; WHO, 2011). Across health professions, communication and teamwork are now identified core competencies in the patient safety curriculum (IPEC, 2011; WHO, 2011).

In response to global directives, educational institutions are revolutionizing training models and content to better prepare their graduates for practice. Some institutions have chosen individual online modules, videos, or large lecture format to teach key concepts. However, there is a movement to provide interdisciplinary experiences to more closely mimic practice conditions. Many educators would agree that simulation is the gold standard of teaching interprofessional education (IPE) as students can learn by doing in a safe environment that facilitates mastery of skills without compromising patient safety (Efstathiou & Walker, 2014). However, many institutions struggle with the logistics, resources, and space needed to offer interprofessional simulations experiences on a regular basis. The aim of this paper is to suggest the use of virtual simulation to teach interprofessional communication.

Communication Failures

In current health care systems, delivery processes involve numerous interfaces and patient handoffs among multiple health care providers with varying levels of educational and occupational training (Hughes, 2008). Dingley, Derieg and Persing (2008) indicate, “Ineffective communication among health care professionals is one of the leading causes of medical errors and patient harm.” A review of reports from The Joint Commission reveals that communication failures were at the root of over 70% of sentinel events” (TJC, 2015a). Furthermore, “the growing body of literature on safety and error prevention reveals that ineffective or insufficient communication among team members is a significant contributing factor to adverse events” (Dingley et al., 2008, p. 1). Of the most frequently identified root causes of sentinel events, “communication” was listed as one of the top three reasons consecutively from 2012 to 2014 (TJC, 2015b). Clearly, health professions educators are being called to improve teaching efforts to address this dire problem.

Barriers to IPE Through Conventional Simulation

There are a number of barriers that have precluded widespread implementation of IPE. The first barrier is a shortage of resources. Mannequin-based simulations require expensive resources including personnel, simulators, equipment, and space. Simulation centers often are designed to meet the needs of only one school; thus, they have space restrictions that are difficult to overcome when two or three schools attempt to unite their students. A second barrier relates to faculty development and training. Running multiple patient simulations with learners representing various disciplines requires specialized training to ensure all students’ learning objectives are met. Further, scheduling is a major hurtle. When attempting to coordinate sessions with various schools such as medicine, nursing, pharmacy, physical therapy, social work, and others that already have packed and diverse schedules, the challenge can be daunting.

Beyond resources, space, training, and scheduling, geographic barriers may be present. For example, medical campuses may be geographically dispersed from nursing schools, and some institutions offering nursing courses are not affiliated at all with a medical program or pharmacy program (Foronda & Bauman, 2014). This reality is especially true for community colleges or institutions limited to offering associate degrees. Thus, when interprofessional education is implemented, it is often offered in a one-dose, mass-gathering effort rather than threaded throughout the curriculum. The challenge that many educational institutions are facing is how to integrate IPE within their curricula.

Virtual Simulation Spans Boundaries

A potential solution to increasing IPE lies within virtual simulation technologies. Advances in technology have resulted in products such as CliniSpace™ (www.clinispace.com), manufactured by Innovation in Learning, Inc. (Los Altos Hills, CA), that allow for multiple players to login virtually, use avatars, and speak in real time. Sophisticated digital learning environments may replicate the clinical environment and foster similar types of decision-making and critical thinking skills encountered in the clinical setting. This technology has the ability to display a patient’s imaging results, reflect the patient’s electrocardiogram wave form, fluctuate vital signs, as well as present audible and realistic heart and lung sounds. Further, an electronic health record is presented for students to explore and document. There are a number of skills that can potentially be taught and learned in this virtual setting. Perhaps, most impressive, students can access this learning environment from the convenience of their homes.

Assessment of the patient's head in CliniSpace

Visual and auscultation of the heart (with monitor including vitals signs and wave form in left upper corner display.)

Using virtual simulation as a pedagogy, faculty members of health professions schools can more readily schedule virtual simulations. Because there is no need to physically meet at a simulation center, virtual simulations may increase opportunity for students in various disciplines to meet. From a conservation and financial perspective, fewer resources such as equipment are needed with virtual simulation. Geographically, this technology enables real time collaboration both nationally and internationally (Foronda & Bauman, 2014). For schools not affiliated with multiple disciplines, this method would facilitate the opportunity for a joint venture.

Virtual Simulation to Teach Interprofessional Communication

Research has suggested that virtual simulation is an effective way to teach teamwork (Caylor, Aebersold, Lapham, & Carlson, 2015) and communication skills (Foronda, Gattamorta, Snowden, & Bauman, 2014). While some may argue that a virtual environment would be limiting in terms of non-verbal communication, there are advantages to this modality. First, for those who are timid, the virtual environment provides a layer of anonymity through the avatar that may decrease anxiety and enhance learning. Second, many communications in healthcare take place over the phone, with health care providers lacking physical gestures and non-verbal cues. The type of communication offered in virtual simulation through voice-over-internet protocol is similar to phone communications, a common form of communication in the practice setting. Third, the virtual environment enables the participants to practice and make mistakes without harmful patient consequences, a benefit of any simulation. Finally, students have expressed appreciation for the level of engagement in virtual simulation as well as being able to participate in a potential teaching method of the future (Foronda, Lippincott, Gattamorta, 2014).

Today and Tomorrow’s Learner

Anecdotally speaking, today’s student is arriving already prepared with strong technological skills and a higher level of comfort with technology than previous generations. Many have grown up playing video games and regularly video-chat with friends all over the world using various methods. Communication is a skill that is changing rapidly due to influences such as social media, email, and texting. Delivering proficient verbal communication in healthcare is paramount and warrants attention in health education. Virtual simulation is a pedagogy that possesses a strong fit with current and future generations’ skills and lends itself as a platform to teach cognitive skills. We predict that, in time, this form of serious gaming will become increasingly attractive to students and faculty, superseding many traditional methods of teaching.

Next Steps

For faculty members interested in trialing virtual simulation to teach IPE, a series of steps should be considered. First, a team of faculty champions from each discipline with interest in the topic should be recruited. Faculty members and members of the support team (i.e. instructional design, information technology) should be trained on the technology. Next, a simulation scenario with sound objectives should be developed. The pre-brief and debriefing are especially important to set the stage and reflect on what was observed and what could be improved. Students will benefit from having an instructional video on the virtual simulation technology to familiarize themselves with how to navigate, assess, auscultate, and perform interventions. It is suggested that students be given the opportunity to log in successfully and practice up to one week prior to the group virtual simulation activity as initial access is often the largest obstacle to overcome.

Although the CliniSpace platform allows for ten avatars at once, we recommend use of six players (students) simultaneously with a facilitator to lead the pre-brief, assure access of all students, role play the patient, and lead the debriefing. With this arrangement, three students would observe while the other three students practiced as healthcare providers. After the first part of the simulation, the roles are switched so that all have a chance to actively participate in the decision-making and critical thinking involved in the simulation. Although some would argue against evaluation, as it may cause student anxiety, we recommend use of a rubric to guide students as well as evaluate their communication performance. The use of rubrics, having demonstrated reliability and validity, is suggested to measure student learning achieved in simulated settings (Foronda, et al., 2015). The National Center for Interprofessional Practice and Education (2015) website is a reputable resource offering additional measurement instruments.

Future Research

Research in virtual simulation for the purposes of IPE is in the infancy stage. There is much work to be completed as technology and teaching methods improve. Research is needed to evaluate the effectiveness of virtual simulation. It would be advantageous to compare virtual simulation to mannequin-based simulation. A cost-benefit analysis of the use of virtual simulation would be helpful to guide administrators in making purchasing decisions. Investigating student learning outcomes achieved after repeated virtual simulations (using a time-series design) would be useful to determine best practices in virtual simulation. Furthermore, faculty members would benefit from exposure and training to the possibilities of what and how to teach with virtual simulation so that the research in this area can expand.

Conclusion

Virtual simulation is a relatively new yet promising pedagogy for education in the health sciences. In a time where the need for IPE is burgeoning, yet logistical challenges are prevalent, virtual simulation presents a viable solution. Virtual simulation spans boundaries and unites students of various disciplines from the convenience of their homes. Improving communication skills of healthcare providers is a priority in healthcare education. We recommend that simulation educators explore the possibilities of using virtual simulation to address this need.

We wish to express sincere gratitude and acknowledge Parvati Dev, PhD and Dr. Wm. LeRoy Heinrichs, MD, PhD, of Innovation in Learning, Inc., for development and trial of CliniSpace.

About the Authors

Cynthia Foronda, PhD, RN, CNE, ANEF is an Assistant Professor at the Johns Hopkins University School of Nursing in Baltimore, Maryland. She specializes in cultural humility and educational technology including simulation, virtual simulation, and distance learning. She received the International Association for Clinical Simulation & Learning Excellence in Research Award in 2015. She is a Fellow in the National League for Nursing Academy of Nursing Education and was in the National League for Nursing Leadership Development Program for Simulation Educators in 2014. She was an Armstrong Institute for Patient Safety and Quality Leadership Fellow in 2014-2015. Dr. Foronda has been awarded three international teaching awards for her innovative and creative online teaching including two Blackboard Exemplary Course Awards (2012, 2013) and the 2012 Sloan-C Excellence in Online Teaching Award. Her current research projects involve interprofessional communication, simulation, virtual simulation, and cultural humility. She has been invited to present nationally and internationally. Dr. Foronda serves on the editorial boards for Clinical Simulation in Nursing, Nurse Educator, and Advances in Simulation. She has experience teaching internationally and working in developing countries.

Irene Jung, MSN, MSHCA, RN is an Associate Director of Quality Integration at Harbor-UCLA Medical Center in Torrance, California. Ms. Jung works with departments and programs to augment quality and process improvement activities throughout the medical center. Ms. Jung's primary responsibilities include the Quality Council, the Core Measures Program, coordinating bi-annual Quality & Safety Town Hall and Quality and Safety Boards in each nursing unit, participating in various committees within the organization and at the Department of Health Services, and serving as a panelist for Clinical Quality Data Management. Ms. Jung holds a Bachelor of Science in Nursing degree from University of Virginia, and a Masters Science in Nursing and Health Care Administration from California State University at Long Beach. She is currently enrolled in the Doctor of Nursing Practice (DNP) Program and the Nurse Educator Certificate Option (NECO) program at the Johns Hopkins University School of Nursing in Baltimore, Maryland.

Anne Belcher, PhD, RN, FAAN, ANEF is Associate Professor and co-Director, Office for Teaching Excellence, at the Johns Hopkins University School of Nursing. She has more than 40 years of experience in nursing education, having taught at the baccalaureate, Masters and doctoral levels. She has held numerous administrative and educator positions throughout her career. Dr. Belcher’s area of expertise is oncology nursing and her research interest is psychosocial aspects of cancer, with a focus on spiritual care. Dr. Belcher holds a Bachelor of Science in Nursing from the University of North Carolina, a Master of Nursing degree from the University of Washington, and a PhD from the Florida State University. She is a member of Nu Beta chapter, Sigma Theta Tau International; is a Fellow in the American Academy of Nursing, and is a Fellow in the Academy of Nursing Education.

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Addendum

Foronda, C., Gattamorta, K., Snowden, K., & Bauman, E. (2014). Use of virtual clinical simulation to improve communication skills of baccalaureate nursing students: A pilot study. Nurse Education Today, 34(6), e53-57. doi:10.1016/j.nedt.2013.10.007